Surgical techniques for managing hepatic injury
- David G Jacobs, MD
David G Jacobs, MD
- Professor of Surgery
- University of North Carolina at Chapel Hill Medical School
- Ashley Britton Christmas, MD, FACS
Ashley Britton Christmas, MD, FACS
- Assistant Professor
- University of North Carolina at Chapel Hill Medical School
The liver is the most frequently injured abdominal organ. Most hepatic injuries are minor and heal spontaneously with nonoperative management, which consists of observation and the adjunctive use of arteriography and embolization. However, about 14 percent of patients with hepatic injury will require surgical intervention [1-4].
When surgery is needed, a systematic approach is used to control bleeding while conserving liver parenchyma; hepatic resection is reserved for severe injuries. The use of damage control techniques during the initial laparotomy, specifically perihepatic packing, reduces the extent of subsequent surgical procedures.
The surgical management of hepatic injury will be reviewed here. The diagnosis and nonoperative management of hepatic injury is discussed in detail elsewhere. (See "Management of hepatic trauma in adults".)
The liver is divided into two lobar segments (right and left), and further subdivided into eight segments based upon the vascular or bile duct distribution (figure 1). Access to these segments can only be achieved through complete mobilization of the organ by incising its various ligamentous attachments (coronary ligament, left and right triangular ligaments) (figure 2).
The liver has a dual blood supply from the portal vein and the hepatic arteries (figure 2). The portal vein, which is a confluence of the splenic and superior mesenteric veins, supplies about 80 percent of the blood to the liver, while the remainder of the blood is supplied by the hepatic arteries.
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- LIVER ANATOMY
- Injury grading
- APPROACH TO SURGICAL MANAGEMENT
- LIVER EXPOSURE AND MOBILIZATION
- TECHNIQUES FOR LIVER HEMOSTASIS
- Manual compression
- Portal clamping (Pringle maneuver)
- Perihepatic packing
- Topical hemostatic agents
- Parenchymal vessel ligation
- Direct liver suturing
- SEVERE INJURY
- Hepatic artery ligation
- Liver resection
- Juxtahepatic venous injuries
- Liver transplant
- OTHER CONSIDERATIONS
- Abdominal closure
- Perihepatic drainage
- Postoperative imaging
- SUMMARY AND RECOMMENDATIONS