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LIVER CONTUSIONS: PRINCIPLES OF SURGICAL TECHNIQUE AND TACTICS

Keywords: LIVER , TRAUMA , EMERGENCY LAPAROTOMY , DAMAGE CONTROL , PRINGLE MANEUVER

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Abstract:

The prognostic of the liver trauma is conditioned by the type of the hepatic injuries. Their anatomic and hemorhagic characteristics will influence the kind of treatment: emergency laparotomy or non-surgical treatment. The most important condition for a non-surgical treatment of the liver trauma is a stable patient. Operative option is indicated for unstable patients, when there are other visceral injuries or when the surgical unit hasn't accurate imagistics posssibilities. For optimal operative management of the liver trauma, some principles need to be followed: 1) the patient is positioned with the arms at right angles on arm boards, wich allowes better access to intravenous or intraarterial lines; 2) skin preparation is for a toarco-abdominal approach; 3) the primary incision is a midline one wich can be branched with a right transverse. After laparotomy there are two situations: liver injuries without or with active haemorrhage. For the first situation, evacuation of the hemoperitoneum, lavage and drainge are the only procedures indicated. For the second types of injuries we also describe favorable and unfavorable injuries. When the hand compression of the liver is effective and hepatic injury is anterior, the hemostasis after clampage of the hepatic pedicle (Pringle maneuver) is indicated. Perihepatic packing is indicated in case of choagulopaty. Hepatic resection it isn't recommended. The unfavorable situation is association of acidose-hypotermia and choagulopaty wich cause a "biological hemorrhage". In this cases are indicated"abbreviated laparotomy" with perihepatic packing (damage control) and planned reoperation or arterial embolisation (interventional radiology). When the clampage of the hepatic pedicle it isn't efficient, probably a hepatic vein is injured and a a perihepatic packing is also indicated. The unefficiency of the perihepatic packing, the clampage of the hepatic pedicle + inferior vena cava (under and above the liver) ± aorta it is necessary to stop the active bleeding. The closure of the laparotomy it is necessary to be made very fast, especially for the "abbreviated laparotomy". In the case of trauma of the main hepatic duct an external billiary drainage it is recommended. The reoperation it is indicated in some cases: intraabdominal hyperpression syndrome, perihepatic packing, other intraabdominal complications. Conclusion: The prognostic of the liver trauma depends by the anatomical type of the injuries. Operative management of the liver trauma is very difficult. The clampage of the hepatic pedicle (with or without vena cava

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