Hydrodynamic rupture of liver in combat patient: a case of successful application of “damage control” tactic in area of the hybrid war in East Ukraine
The patient was a 22-year-old male soldier who received severe injury in the battlefield area next to the village of Krasnohorivka in the Donetsk oblast of Ukraine. On December 16, 2016, the patient received multifragmental combined with thoraco-abdominal injuries as a result of shelling from MLRS “Grad”. The wounds were detected mainly on the right side of the patient due to fragments penetrating the chest and causing hemopneumothorax (Fig. (Fig.1); firearm fracture of 5–7, rupture of right dome of the diaphragm, as well as ruptures of the liver’s parenchyma due to “hydrodynamic shock”. The entrance wound was detected in the region of 5–7 ribs between the anterior and the posterior right axillary lines, whereas an exit wound was not detected.
Figure 1. Presentation of the combat patient after being injured by multiple-launch rocket system “Grad” (first hours after injury). The entrance wound from the shrapnel channel is marked by the arrow
The patient received first medical aid immediately at the place of injury from other soldiers of his team. This included superimposed aseptic dressings and painkillers. Then, the patient was subsequently evacuated by sanitary transport to the second level of medical care to get primary surgical aid. The time taken between injury and evacuation was less than 60 min; thus, the principle of the “golden hour” was achieved.
To receive basic surgical aid, the patient was transported to the Military Medical Hospital #66 at Pokrovsk of the Donetsk oblast. At this level, the patient was diagnosed with having a penetrating thoracic wound. The blood loss was approximately 1500 ml, indicating hemorrhagic shock. The blood product transfusion of red was applied by using red blood cells and blood plasma.
Thoracentesis was performed to eliminate the right hemopneumothorax. Taking into consideration the absence of an exit wound, it was not possible to be sure about the path of the wound channel; therefore, penetrating thoraco-abdominal injury was suspected and laparocentesis was performed. A hemorrhagic content was received at the laparocentesis; thus, laparotomy was performed. At the revision of the abdominal cavity, we detected a rapture of the right dome of the diaphragm as well as the ruptures of 3–6 segments (S3–6) of the liver. The entrance wound was detected only in chest area, whereas the exit wound was not identified neither in chest, nor in abdomen wall. Therefore, a conclusion was made that damage of the liver was in result of “hydrodynamic shock”. Considering the severity of the patient, minimal surgical treatment was applied, which included suturing of liver ruptures as well as excision of necrotic tissues and suturing of gunshot wounds of limbs. However, in an early post-operative period, a hemorrhage and bile were detected on drainage. Relaparotomy was performed and liver damage within the area of gallbladder fossa was detected. Given the doubts about the viability of the liver S3–6, the question was whether or not liver resection should be applied for possibly ischemic segments. However, the severity of the patient and principles of DC tactic were taken into consideration. Thus, cholecystectomy was performed to get access to damaged liver in the area of gallbladder fossa (coagulation and suturing), and patch of omentum was used to fill the gap in injured S3–6 of liver (Fig. 2).
Figure 2. Demonstration of liver damage (second day after injury): damaged tissues were sutured and omentopexy was applied (marked by the arrow)
For further treatment, the patient was transported to the Mechnikov Regional Clinical Hospital in Dnipro, where further resuscitation was continued. Antibacterial therapy was administrated as well as other symptomatic therapy and daily dressings were applied.
Three days after the level III, the patient was transported to the ICU at the National Military Medical Clinical Center of Ukraine in Kyiv. The general condition of the patient remained severe. Drainage from the subhepatic area showed daily bile volume up to 300 ml. Such a volume of bile was caused by the intrahepatic biliary hypertension as a result of post-traumatic edema of liver parenchyma. In order to eliminate biliary hypertension (sixth day after the combat injury), the following intervention was performed: endoscopic papillosphincterotomy, endoscopic retrograde cholecystopancreatography, and stenting of the common bile duct. To provide enteral nutrition, the feeding tube was placed behind the Treitz ligament. Implementation of endoscopic decompression of the bile duct had resulted in gradual reduction of bile volume from the subhepatic drainage from up to 50 ml per day as compared to 300 ml before the decompression.
At post-operative period, a computed tomography (CT) scan of the abdomen was performed. At CT analyses showed the liver to demonstrate zones with ischemic lesions (Fig. 3). Considering liver CT data, a liver resection of the affected segment was planned to prevent further necrosis and abscess formation according to DC tactic. However, on the 16th day after the injury, intra-abdominal bleeding was diagnosed and urgent laparotomy was performed. At revision, erosion of the right hepatic artery was detected (Fig. 4) as a result of the chronic inflammation of the artery wall and continuous contact to the bile. Erosive defect was sutured and stable hemostasis was achieved (Fig. 4b). At revision of sutured areas of the liver, we found it to be covered with fibrin, partial failure of sutures and bile leakage were observed. Furthermore, tissue softening and color changes of liver S5–6 parenchyma were detected, indicating ischemic failure (Fig. 5a). In order to stop bile leakage and to prevent liver failure, a decision was made to perform anatomic resection of the liver S5–6 (Fig. 5b). Due to the critical status of the patient and considering DC approach, we postponed the surgery for stabilization of hemodynamics by resuscitation and transfusion of one-group packed red blood cells. At the ninth day after the liver resection, the patient was transferred to the surgery ward from ICU.
Figure 4. Photograph illustrating erosive defect of right hepatic artery after suturing. a The area of erosive defect of right hepatic artery is marked by an arrow; the turnstile is placed under the artery (marked by 1). b Sutured right hepatic artery (suture line marked by the arrow): 1 – right hepatic artery; 2 – left hepatic artery on the turnstile
Figure 5. Intraoperative photograph illustrating liver at relaparatomy on the 16th day after the injury. a Damaged area of liver is covered with fibrin, bile leakage is seen under the partial failure of sutures. b Liver after the resection of fifth and sixth segments
Apart from the thoraco-abdominal injuries, the patient was also diagnosed with multiple fragmental injuries of soft tissues of the skull, chest, abdomen, as well as extremities. The most serious soft tissue injury was detected at the right lower limb, which was subsequently treated with VAC system (Figure 6.)
Figure 6. Photograph illustrating the damages of soft tissues after multiple-launch rocket system “Grad”. a The shrapnel wounds lateral area of the right thigh with installing of VAC system on the 21st day after the injury. b The shrapnel wounds at the anterior area of the right thigh on the 49th day after the injury. c The overall look of the patient with post-operative and post-injury scars before discharge from the hospital on the 49th day after injury
The patient was discharged from hospital in good condition on the 49th day after receiving injuries (Fig. 6). The patient received 45 days of further rehabilitation according to military medical commission decision before continuing his return to military duties (V level).