Editing Liver injury (section)

== Management ==

* Requirements for non-op management
** Haemodynamic stability
** Not necessarily inappropriate for higher grade injuries
** Best if patients can provide a reliable physical examination
** Often, grade I or II injuries require no intervention
* Non-op management
** Bed rest one day longer than the grade of injury (this is an historic recommendation - modern says ambulation is safe)
** Serial examination, Hb
** Need the ability to closely observe and manage with laparotomy if deterioration - consider transfer to such a facility
* Interventional radiology
** Embolisation indications
*** Stable patient with clear active haemorrhage on CT
** Combined theatre can be very effective
* Indications for operation
** Unstable
** Historically, any penetrating liver injury - however this dogma has been challenged, and stable patients with localised tenderness and reliable exam do not necessarily need exploration
** Free intra-abdominal haemorrhage
*** Free blood in paracolic gutters, pelvis, or tracking along periportal triads is evidence of significant hepatic injury and almost mandates exploration
* Immediate laparotomy
** Preparation:
*** Consider REBOA
*** MTP
*** Should have large bore central venous access from top half of torso (in case retrohepatic caval injury)
*** Equipment
**** Topical haemostatic agents
**** APC
**** Cell saver
**** Good assistant
** Aims of liver bleed laparotomy:
*** Stop the bleeding
*** Remove obviously devitalised liver tissue
*** Stop or control bile leaks
** Positioning
*** Prep and drape from clavicles to knees
** Incision
*** If high-grade injury is known or suspected, chevron incision
*** Otherwise generous midline
** Manoeuvres
*** Pringle - umbilical tape around porta hepatis, or insert a finger through the foramen of Winslow and apply a Satinsky clamp or non-crushing intestinal clamp. Limit to 15 minutes if you can, but Schein's says technically safe for up to 60 mins.
*** Cattell-Braasch - medial visceral rotation on right side of abdomen
*** Heaney - total vascular exclusion of the liver in extensive liver/IVC injuries
** Assessment
*** Pack four quadrants beginning with suspected site of haemorrhage
*** Liver packing - posterior paracaval, lateral anterior, and posteroinferior. Don't usually pack within liver tears, which can cause worsening of bleeding when they are pulled out.
*** Anaesthesia catch up
*** Temporise spillage or contamination - 5-20% of major hepatic injuries are associated with hollow viscous injury
*** May need to mobilise liver along falciform and triangular ligaments - but think about this carefully if you suspect a retrohepatic venous injury, as the tamponade can be released causing massive bleeding

=== Stepwise approach to liver bleeding ===

*** '''Initial move in all patients with liver bleeding:'''
**** Pack and allow anaesthetist to catch up
**** When resuscitation is optimised, remove packs
**** If still bleeding, perform Pringle manoeuvre. If bleeding persists, either there is aberrant arterial circulation or this is hepatic vein/IVC bleeding (which should be packed and left alone by non-HPB surgeons).
**** Explore liver gently to identify and control injuries
*** '''Superficial injury:'''
**** '''Haemostatic agents''' e.g. Tisseel, Surgicell
***** Good for large raw areas
**** '''Suture repair''' (hepatorrhaphy)
***** Large suture, can be absorbable or non-absorbable depending on who you read.
***** Tight enough to achieve haemostasis but not too tight to pull through tissue.
***** Requires a gentle touch and somewhat intact capsule
***** Need to avoid overzealous ligation
***** Ligation of specific branches of PV or HA is rarely needed, but can be done
**** '''APC'''
*** '''Deep injury'''
**** Packing as damage control is often the right way to start off, allowing resuscitation and later definitive management
***** Pack behind, above and below
**** Can do finger fracture deep into wound to look for actively bleeding vessels, but try not to make the situation worse
**** '''Clipping''' of lacerated vessels
**** '''Tractotomy''' for penetrating hepatic trauma
***** Could also tamponade the tract using something like a Penrose drain dragged through the laceration
**** '''Mesh wrap''' for compression
**** Lobectomy is not really performed for trauma
***** Can do debridement of devitalised liver tissue to facilitate vascular control, though
*** Frequently there will be persistent oozing after control of specific bleeding sites - can use an '''omental patch''', this is especially useful for large raw liver surfaces resulting from debridement or tractotomy
*** '''Decide on damage control or definitive'''
**** The simplest approach is just to pack tightly, leave the abdomen open and come back with more experienced surgeons (this is the old-fashioned approach to liver trauma too)
**** If packs are holding, but patient needs resuscitation (cold/coagulopathic/other issues) then best to pack and leave abdomen open
***** Especially when temp gets <32 and acidosis. Large vessel bleeding needs to be controlled prior to this.
**** If just pack the abdomen and leave open, often do a CT and check for anything you can embolise (small venous bleeders will be stopped by the packs, while arterial bleeders will continue)
**** In most patients, further exploration and potential repair is appropriate