Editing Liver injury (section)

=== 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