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LIVER CONTUSIONS: PRINCIPLES OF SURGICAL TECHNIQUE AND TACTICS  [PDF]
C. Letoublon,Catherine Arvieux
Jurnalul de Chirurgie , 2005,
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
LIVER CONTUSIONS. DECISIONS AT ARRIVALS: THE RESUSCITATION AND EVALUATION OR LAPAROTOMY  [PDF]
C. Letoublon,Catherine Arvieux
Jurnalul de Chirurgie , 2005,
Abstract: The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury. The liver is the second most commonly injured organ in abdominal trauma, but damage to the liver is the most common cause of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle accidents in most instances. In the past, most of these injuries were treated surgically. However, surgical literature confirms that many of liver injuries have stopped bleeding by the time surgical exploration is performed, and some operations performed for blunt abdominal trauma are nontherapeutic. Imaging techniques and non-operative management, have made a great impact on the treatment of patients with liver trauma, and use of these techniques has resulted in marked reduction in the number of patients requiring surgery and nontherapeutic operations
Liver Trauma: Operative and Non-operative Management  [cached]
Moosa Zargar,Marjan Laal
International Journal of Collaborative Research on Internal Medicine & Public Health , 2010,
Abstract: Background: The liver is the second most commonly injured organ in abdominal trauma, but liver damage is the most common cause of death after abdominal injury. Although urgent surgery continues to be the standard for hemodynamically compromised patients with hepatic trauma, there has been a paradigm shift in the management of patients who have stable hemodynamic. A marked change toward a more conservative approach in the treatment of abdominal trauma has been noted during the last decades. Modern treatment of liver trauma is increasingly non-operative. Purpose: To find the epidemiology, etiologies and managements of liver trauma in a population based study in Iran. Material and Method: A study including 16,287 trauma patients referred to the main hospitals of seven cities with different geographic patterns was done in Iran. Eighty-four patients with hepatic trauma during the 1-year period ending March 2000 included in this Cross-Sectional study. We determined the incidence, etiology and management of the patients suffering liver injury. Analysis was done using SPSS 18. Statistical significance was set at P<0.05. Results: Out of 16287 trauma patients 84 (0.5%) had hepatic trauma with male predominance 68(81%). The most type of trauma was blunt and the main cause was motor vehicle crashes. Thirty patients (35.7%) managed non-operatively. There was no significant difference in hospital stay between patients operated and managed non-operatively. There was no mortality in the patients managed non-surgically. Conclusion: In this study hepatic trauma was in 3.7% of abdominal trauma patients. This study concluded non-operative management of hepatic injuries is associated with a low overall morbidity and does not result in increases in length of stay. Non-operative management is a safe approach for the patients of liver trauma with stable hemodynamic.
Indications and Contraindications for Liver Transplantation  [PDF]
Vibha Varma,Naimish Mehta,Vinay Kumaran,Samiran Nundy
International Journal of Hepatology , 2011, DOI: 10.4061/2011/121862
Abstract: Patients with chronic liver disease and certain patients with acute liver failure require liver transplantation as a life-saving measure. Liver transplantation has undergone major improvements, with better selection of candidates for transplantation and allocation of scarce deceased donor organs (according to more objective criteria). Living donor liver transplantation came into existence to overcome the shortage of donor organs especially in countries where there was virtually no deceased donor programme. Advances in the technical aspects of the procedure, the intraoperative and postoperative care of both recipients and donors, coupled with the introduction of better immunosuppression protocols, have led to graft and patient survivals of over 90% in most high volume centres. Controversial areas like transplantation in alcoholic liver disease without abstinence, acute alcoholic hepatitis, and retransplantation for recurrent hepatitis C virus infection require continuing discussion.
Indications and Contraindications for Liver Transplantation  [PDF]
Vibha Varma,Naimish Mehta,Vinay Kumaran,Samiran Nundy
International Journal of Hepatology , 2011, DOI: 10.4061/2011/121862
Abstract: Patients with chronic liver disease and certain patients with acute liver failure require liver transplantation as a life-saving measure. Liver transplantation has undergone major improvements, with better selection of candidates for transplantation and allocation of scarce deceased donor organs (according to more objective criteria). Living donor liver transplantation came into existence to overcome the shortage of donor organs especially in countries where there was virtually no deceased donor programme. Advances in the technical aspects of the procedure, the intraoperative and postoperative care of both recipients and donors, coupled with the introduction of better immunosuppression protocols, have led to graft and patient survivals of over 90% in most high volume centres. Controversial areas like transplantation in alcoholic liver disease without abstinence, acute alcoholic hepatitis, and retransplantation for recurrent hepatitis C virus infection require continuing discussion. 1. Introduction Liver transplantation is a life-saving procedure for patients with chronic end stage liver disease and selected patients with acute liver failure (ALF) [1–3]. Over the years, the technique of the operation has undergone major changes. Together with this, there has been an improvement in the understanding of pre- and posttransplantation physiology and the introduction of newer and more effective immunosuppressive drugs and strategies for preventing posttransplantation infections so that, in the United States, the one year patient survival has now reached 87.6% and graft survival 82.4% [4]. Liver grafts for transplantation can be obtained either from deceased donors (DDs) or living donors (LDs). Living donor liver transplantation (LDLT) was introduced because of the increasing demand for donor organs and the widening gap between the resource (deceased donor) and demand (recipient). It is very important to prioritize the patients for organ allocation in a deceased donor liver transplantation (DDLT) programme. This is, however, different in a programme which is based mainly on LDLT where the prospective donor is usually a close relation. However, in both the situations, a measure such as a scoring system is important in prognosticating the outcome following transplantation. There has to be a balance between the patient’s medical reserves to withstand a major operation like liver transplantation and its probable outcome. For DDLT organ, allocation was initially based on the location of the patient (at home, in hospital or in an intensive care unit) and the time on
Operative treatment of proximal humeral fractures in children: Indications and results  [cached]
Odehouri KTH,Gouli J,Ouattara O,Kouame D
African Journal of Paediatric Surgery , 2008,
Abstract: Background: In most children proximal humeral fractures are treated non-operatively with generally good results. This review discusses the indications of operative treatment and assesses the treatment results. Materials and Methods: The charts of 20 patients (14 girls; mean age: 12.3± 2.8 years; range: 7-16 years) with proximal humeral fractures who were operated on at our institution were reviewed from 1992 to 2002. Results: There were five metaphyseal fractures and 15 physeal injuries which were angulated according to Neer-Horowitz score as grade III in four cases and grade IV in 16 cases with a mean angulation of 47.8±39.1 degrees (range: 6-148 degrees). Associated lesions comprised open fracture and head trauma in two cases each. Patients with associated injuries were operated on primarily and the 16 others by secondary intention. All but one were reduced via an anterior approach with internal fixation. They were assessed for clinical and radiological healing at a mean follow up of 3.6 years ranging from 1.2 to 7.8 years. Conclusion: Based on our study, surgical option is indicated for severely displaced and unstable fractures in older children and adolescents.
Arthroscopic Surgery of the Elbow; Indications, Contra-Indications, Complications and Operative Technique  [PDF]
Frank Theodoor Gabriel Rahusen, Orthopedic Surgeon, Denise Eygendaal
Surgical Science (SS) , 2011, DOI: 10.4236/ss.2011.25049
Abstract: Arthroscopy of the elbow was first described by Burman in 1931. In this first article about arthroscopy of the elbow in the journal of bone and joint surgery, he concluded that the elbow joint was not suitable for arthroscopy; the joint was too small and the neurovascular structures in the anterior compartment of the elbow were close. In 1932 he revised his original article with some technical modifications and slowly arthroscopy of the elbow was performed more often. In the late 1980’s arthroscopic surgery of the elbow became more and more popular. In this article an overview is given of the indications for elbow arthroscopy, the surgical technique is described in detail and the possible complications are highlighted.
Vascular clamping in liver surgery: physiology, indications and techniques
Elie K Chouillard, Andrew A Gumbs, Daniel Cherqui
Annals of Surgical Innovation and Research , 2010, DOI: 10.1186/1750-1164-4-2
Abstract: Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.Efforts to reduce or eliminate operative bleeding, have been the primary focus throughout the history of liver surgery. For years the degree of hemorrhage has remained a major prognostic factor after liver resection. Vascular clamping is an efficient tool to minimize bleeding during parenchymal transection. This has been made possible by the liver's known tolerance to normothermic ischemia. Different types of clamping methods have been described including total (i.e. Pringle maneuver) and partial or selective (i.e. selective clamping of the part of the liver to be resected) (APPENDIX 1). In addition, clamping can be applied to the inflow only, or to both inflow and outflow (hepatic vascular exclusion). Clamping may also be either continuous or intermittent.The indication, as well as the type of clamping, depends mainly on the size and the location of the lesions to be resected, the quality of the liver parenchyma, the surgeon's preferences, and the unexpected operative events. Ideally, the type of clamping is decided preoperatively. Operative hemodynamic and fluid management differs according to the type of clamping. For example, in the absence of inferior vena cava clamping, fluid expansion must be limited
The main indications and techniques for vascular exclusion of the liver
Chaib, Eleazar;Saad, William Abr?o;Fujimura, Ikurou;Saad Jr., Willian Abr?o;Gama-Rodrigues, Joaquim;
Arquivos de Gastroenterologia , 2003, DOI: 10.1590/S0004-28032003000200013
Abstract: background: the purpose of vascular clamping during the course of liver resection is to reduce bleeding and subsequent complications. aim: to show both step-by-step surgical techniques for vascular exclusion of the liver and their indications. methods: it is described the following techniques: clamping of the hepatic pedicle, ''pringle'' maneuver; intermittent clamping of the hepatic pedicle; intermittent vascular exclusion of the liver, without vena cava clamping, and hepatic vascular exclusion with vena cava clamping. also metabolic and homodynamic consequences as well as the technical failure of the application of each of them are discussed. conclusions: the choice of technique to use for clamping during hepatectomy depends on the surgeon's judgment. dogmatic or systematic attitude, is prejudiciable for the patient and liver surgeon must be able to use all kinds of clamping.
The main indications and techniques for vascular exclusion of the liver
Chaib Eleazar,Saad William Abr?o,Fujimura Ikurou,Saad Jr. Willian Abr?o
Arquivos de Gastroenterologia , 2003,
Abstract: BACKGROUND: The purpose of vascular clamping during the course of liver resection is to reduce bleeding and subsequent complications. AIM: To show both step-by-step surgical techniques for vascular exclusion of the liver and their indications. METHODS: It is described the following techniques: clamping of the hepatic pedicle, ''Pringle'' maneuver; intermittent clamping of the hepatic pedicle; intermittent vascular exclusion of the liver, without vena cava clamping, and hepatic vascular exclusion with vena cava clamping. Also metabolic and homodynamic consequences as well as the technical failure of the application of each of them are discussed. CONCLUSIONS: The choice of technique to use for clamping during hepatectomy depends on the surgeon's judgment. Dogmatic or systematic attitude, is prejudiciable for the patient and liver surgeon must be able to use all kinds of clamping.
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