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Sun Jan 11 05:59:30 GMT 2009

30 yo male status post motor vehicle crash who arrived complaining of abdominal pain / hemodinamically stable. CT abdomen revealed a Grade IV liver laceration extending threw segments 7 & 8 with active extravasation of contrast, and moderate amount of hemoperitoneum. Taken immediately to angio where a distal right hepatic artery branch was successfully embolized. Next morning patient presents with an elevated WBC / worsening acidosis and increase abdominal tenderness for which patient is taken to the operating room for exploratory laparotomy to rule out any other missed injury. During laparotomy no other injuries found, abdominal washout is performed and hepatorraphy with several interrupted zero chromic liver mattress sutures.
Two weeks post op patient presents with a sudden drop in his hemoglobin and a repeat CT abdomen is essentially negative. 
Four weeks post op patient presents with an abrupt episode of cardiac arrest following a melenotic stool. A rapid EGD is performed during CPR protocol to rule out a hepato-biliary or upper GI source. EGD was negative. FAST was negative. An acute abdominal compartment syndrome developed as a consequence of the aggressive IVF and blood product resuscitation during CPR. The abdomen was opened at the bedside in the TICU, and no hemoperitoneum was noted. CPR is continued and a significant and distinct cyanosis of the shoulders/neck /and head developed all of a sudden. A presumptive diagnosis of an acute superior vena cava syndrome is considered for which bilateral chest tubes are placed. Lt chest tube resulted no air or blood. Right chest tube decompressed a massive hemothorax of greater than 2 liters. An immediate right antero-lateral thoracotomy was performed with packing of the right chest and the patient was transferred from the TICU to the OR with
 ongoing CPR.
In the OR both chest and abdominal incisions were united and the diaphragm was transected following the ligament of Teres down to the suprahepatic vena cava. Complete liver isolation was performed by placing vessel loops on the hepatoduodenal ligament (Pringle), the suprahepatic inferior vena cava and the suprarenal subhepatic vena cava.The liver is encased with a plastic bag ( "Seattle Bag") and then packed. All vascular controls were released and liver bleeding was controlled. Both the abdomen an the chest are left open and a poor mans VAC were placed on each cavity.Patient was taken back to the TICU for rewarming and correction of coagulapathy.Patient stabilizes overnight and is taken to the angio suite the next morning to coil any possible intrahepatic pseudo aneurysm, any persistent intrahepatic arterial bleeding and possibly prophylactic embolization of the right hepatic artery in preparation for planned surgical resection. Angiogram
 revealed a blush of the right medial hepatic artery that was then successfully embolized. 48 hours later patient was taken back for packing removal and a subtotal right hepatectomy/cholecystectomy. Patient eventually undergoes thoracotomy and abdominal wall closure with alloderm. Patient recovers and is transferred to a rehab facility.

Michael W. Parra, MD 
Trauma Research Director
Broward General Medical Center
Fort Lauderdale, Fl

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Delayed Hepatic Rupture