| Authors: ARVIEUX C., CARDIN N., MESTRALLET J.P., MORRA I., LAYUN J., FALCON D., SENGEL C., DELANNOY P., RISSE O.,LETOUBLON C. |
| Abstract: Aims of the study: Intra-abdominal Hypertension (IAH) and Abdominal Compartment Syndrome (ACS) can occur in a variety of surgical conditions, particularly in trauma patients with major life-treatening hemorrhage, massive volume resuscitation and coagulopathy (1). They have also been documented in the context of major burns (2). We describe herein the case of a patient with a major hepatic trauma and full-thickness burns of the abdominal area, who developed ACS treated successfully by lateral escharotomy, vacuum pack technique, and skin autograft .
Patient and methods: during a car crash, a 28 years-old man was ejected and jammed under his car, just under the exhaust pipe. At the admission he was CGS15, pale and hypotensive, and he had 20X20 cm2 80% full-thickness burn of the anterior wall of his abdomen. Ultra-sound statements showed a right liver trauma and one litre of free fluid in the cavity. Emergency hepatic angiography and embolization performed for a grade IV liver injury were successful, and non operative management was decided. He improved rapidly, but 16 hours after the admission he developed IAH. During laparotomy, 2 litres of blood were retrieved but the surgeon found no active bleeding from the liver. Because of the pathologic rigidity of the inferior anterior abdominal wall, she decided an excision of the burned tissues, a right vertical 30 cm escharotomy and partial cutaneous-only closure. He improved promptly after surgery. At day 6 the patient developed an evisceration and closure was done with the vacuum pack system (3). At day 14 he developed a peri-hepatic biloma and a septic syndrome, treated by an elective sub-hepatic incision and drainage. The vacuum pack was removed and replaced by the great omentum which was sutured around the abdominal muscle. At day 21 he had coverage with a skin autograft. He was discharged at day 44.
Discussion: The rigidity of the burned abdominal wall increases the risk of IAP in severe liver trauma, and imposes, in some case, large parietal resection. The aim of the surgical management of patients carrying IAH and defect of the parietal wall is to prevent the abdominal compartment syndrome and to contain the intra-abdominal viscera. Escharotomy (2), Vacuum pack technique (3) and skin autograft are useful and appropriate techniques in those cases.
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