July 7, 2009 | In: TRAUMA
OPERATIVE MANAGEMENT OF LIVER INJURY
11. How are acute liver injuries classified?
Show answer
Liver wounds are generally graded on a scale of I to VI according the depth of parenchymal laceration and involvement of the hepatic veins or retrohepatic portion of the inferior vena cava. Optimal methods of obtaining hemostasis vary with the severity of the injury.
12. Do all patients with a traumatic liver injury require surgery?
Show answer
No. Nonoperative treatment is the standard for victims of blunt trauma who remain hemodynamically stable (approximately 85% of patients). One third of such patients require blood transfusions, but if the volume exceeds 6 units in the first 24 hours, angiography should be done. CT scan should be repeated in 5-7 days for grade IV and V injuries. Complications, including perihepatic infection, biloma, and hemobilia, have been reported in 10% of nonoperative patients.
13. What are the options for temporary control of significant hemorrhage in victims of hepatic trauma?
Show answer
Ongoing hemorrhage leads to the vicious cycle of acidosis, hypothermia, and coagulopathy. Manual compression, perihepatic packing, and the Pringle maneuver are the most effective temporary strategies.
14. What is the Pringle maneuver?
Show answer
The Pringle maneuver is a manual or vascular clamp occlusion of the hepatoduodenal ligament to interrupt blood flow into the liver. Included in the hepatoduodenal ligament are the hepatic artery, portal vein, and common bile duct. Failure of the Pringle maneuver to control liver hemorrhage suggests either (1) injury to the retrohepatic vena cava or hepatic vein or (2) arterial supply from an aberrant right or left hepatic artery (see question 9).
15. What is the finger fracture technique?
Show answer
Finger fracture hepatotomy or tractotomy is the method of exposing bleeding points deep within liver lacerations by blunt dissection. Pushing apart the liver parenchyma enables points to be identified and ligated. This method is most commonly required for penetrating injuries.
16. What is the role of selective hepatic artery ligation in securing hemostasis in patients with a major liver injury?
Show answer
Deep lacerations of the right or left hepatic lobe may result in bleeding that cannot be completely controlled by suture ligation of specific bleeding points within the liver parenchyma. In this situation, either the right or left artery can be ligated for control of the bleeding with little risk of ischemic liver necrosis.
17. Why is retrohepatic vena caval laceration lethal?
Show answer
Exposure requires either extensive hepatotomy, extensive mobilization of the right lobe, or right lobectomy, or transection of the vena cava. The large caliber and high flow of the inferior vena cava results in massive hemorrhage during surgical exposure, whereas clamping of the inferior vena cava often results in hypotension attributable to an abrupt decrease in venous return to the heart.
18. What is the physiologic rationale for use of a shunt in attempted repair of retrohepatic vena caval injuries?
Show answer
Hemorrhage control requires maintenance of venous return to the heart while both antegrade and retrograde bleeding through the laceration is stopped. These requirements are met by shunting blood through a tube spanning the laceration between the right atrium and lower inferior vena cava.
19. What is the intrahepatic balloon tamponading device?
Show answer
For transhepatic penetrating injuries, a 1-inch Penrose drain is sutured around a red rubber catheter. This forms a long balloon that is threaded through the bleeding liver injury and inflated with contrast media through a stopcock in the red rubber catheter. The balloon tamponades liver hemorrhage. The catheter is brought out through the abdominal wall, deflated, and removed 24-48 hours later.
20. What are the indications for perihepatic packing?
Show answer
Liver packing with planned reoperation for definitive treatment of injuries in patients who have hypothermia, acidosis, and coagulopathies is a life-saving maneuver. Laparotomy pads (> 20) are packed around the liver to compress and control hemorrhage. The skin of the abdomen is then closed with towel clips (abbreviated laparotomy), and the patient’s metabolic abnormalities are corrected with planned reoperation within 24 hours.
21. What is the abdominal compartment syndrome?
Show answer
The abdominal compartment syndrome is a potentially lethal complication of perihepatic packing. It may occur when intraabdominal pressure exceeds 20 cmH2O. Intraabdominal pressure increases because of bowel and liver edema secondary to ischemia and reperfusion injury or continued hemorrhage into the abdominal cavity. As pressure increases beyond 20 cmH2O, venous return, cardiac output, and urine output decrease, but ventilatory pressures increase. Patients must return promptly to the operating room for decompression of the abdomen. A manometer attached to the Foley catheter is useful in following intraabdominal pressure.
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