الفهرس 
SURGICAL ANATOMYOnly 14 pages are availabe for public view
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Abstract
The management of hepatobiliary trauma has evolved through the years, as we demonstrated in this Essay. Successful management of hepatic injuries requires attention to detail and sound judgment. A number of points we men¬tioned in this essay regarding management schemes and techniques cannot be over emphasized.
The liver is the organ most commonly injured after abdominal trauma. Management schemes for significant hepatic injury have changed throughout the years, al¬though the primary goal of reducing morbidity and mortal¬ity from hemorrhagic shock and sepsis has remained un¬changed. Fortunately, the majority of blunt liver injuries are not severe and operative management of these patients often results in nontherapeutic exploration because the liver has stopped bleeding. These injuries account for 70-90% of hepatic wounds. The remaining 10-30% of these injuries, however, challenge even the most experienced surgeon.
Nonoperative management of blunt hepatic trauma has been the primary method of treatment in the pediatric population for a number of years but only recently has gained popularity in the adult population. A number of in¬vestigators have published retrospective reviews of non-operative management for blunt hepatic injury and have demonstrated good results for lower-grade injuries. This is not particularly surprising based on the previously de¬scribed operative findings and the high incidence of non-therapeutic laparotomy. Therefore, there is little debate relative to the nonoperative management of these minor liver injuries following blunt hepatic trauma.
More significant liver injuries, however, are much more difficult to manage both operatively and non-operatively. Although there may be poor correlation with CT grading of hepatic injuries compared to operative findings, recent data have demonstrated that nonoperative manage¬ment is the treatment of choice for blunt hepatic injury, providing the patient is hemodynamically stable. In fact, nonoperative management can be employed regardless of severity of hepatic injury and regardless of the amount of hemoperitoneum that may be present in the abdominal cavity. Basing nonoperative management on hemodynamic stability alone, and excluding those patients who are unsta¬ble or have other obvious indication for laparotomy follow¬ing trauma, one may expect about a 90% success rate. This is obviously beneficial to these patients because they re¬quire fewer blood transfusions and thus are spared laparo¬tomy. It is imperative, however, that all transfusions be explained, and that prolonged blood and fluid resuscitation in a patient with significant hepatic injury mandates opera¬tion. Separating liver-related transfusions from associated injury transfusions, however, can be extremely difficult in the multiply injured patient. Nonoperative management also results in a significant decrease in abdominal morbidity when compared to similarly injured operated patients. Thus, following blunt abdominal trauma, nonoperative therapy is the treatment of choice in the hemodynamically stable patient.
The operative management of these injuries can be as demanding as deciding whether or not the patient needs an operation following blunt trauma. Regarding penetrating trauma, the issue is clear. Gunshot wounds to the abdomen should be explored. Selective management following stab wounds may be employed; however, if there is any doubt, patients with penetrating trauma should be managed by op-eration. Regardless of the mechanism of injury, the most important first step in the operative procedure is manual compression of the liver in order to control hemorrhage. One technical point that is often overlooked in the opera¬tive management of significant liver injury is mobilization of the liver. To completely mobilize the right lobe, one must take down the triangular ligaments and the coronary ligaments in addition to dividing the peritoneal attach¬ments on the posterior surface of the right lobe. When the right lobe is adequately mobilized, one can visualize the right hepatic vein, the lateral wall of the retro-hepatic vena cava, and the right lobe of the liver can then be completely delivered into the wound. This is necessary for adequate exploration of the hepatic laceration. The left lobe may be similarly mobilized; however, it is technically much easier. When dealing with persistent hemorrhage from the hepatic laceration, a number of options are available, as outlined in this essay. Occlusion of the porta hepatis can stop hem¬orrhage from the portal vein and hepatic artery. However, it will not stop bleeding from the hepatic veins. In in-stances in which there is significant hepatic vein hemor¬rhage, individual suture ligation of the bleeding vessels is the treatment of choice. If this is unsuccessful, then gauze packing of the abdomen should be performed and the ab¬domen then closed with a temporary device so that coagulopathy can be corrected and the patient returned to the operating room, usually within 24-48 hours. When hem¬orrhage is under control, a viable tongue of omentum can be mobilized and packed into the hepatic laceration. The viable omental pack has a number of advantages. It pro¬vides some immunologic support to the wound that is part of the inherent properties of the omentum. More impor¬tantly, however, it provides a tamponade from within the hepatic laceration. This viable omental tongue should be placed into the hepatic laceration and then sewn into place with a running, large monofilament suture. This will dis-tribute the tension of the suture along the lacerated edges of the liver fairly evenly. Care must be taken, however, not to incorporate a large amount of hepatic tissue within the stitch, because these types of hepatic sutures may damage previously uninjured liver and contribute to the develop¬ment of hepatic artery pseudoaneurysm with hemobilia. Thus, the key points for operative management of the liver injury are:
• Manual compression of the liver
• Extensive mobilization
• Direct repair of bleeding vessels
• Viable omental packing
• Gauze packing of the abdomen
Closed suction drains can then be brought out through a separate stab incision to collect bile as it drains temporarily from the hepatic laceration.
During the management of liver and biliary tract trauma, it is imperative to keep these key points in mind when managing patients with these particu¬lar injuries, as they can be quite devastating. Only through careful attention to detail, can we improve the overall mor¬bidity and mortality following major hepatic and biliary trauma.