A fifteen-year experience with automotive hepatic trauma

CT scanning in acute abdominal injuries

Computed tomography has become an important adjunct in the evaluation of the patient with blunt abdominal trauma. It provides quantitative information about hemoperitoneum as well as qualitative information about the source of hemoperitoneum. CT scanning also evaluates the retroperitoneal organs and retroperitoneal hematoma more accurately than any other available imaging technique. Like any other diagnostic tool, the CT scan must not be overused or abused. This technique should be applied only to stable patients and only in institutions with up-to-date equipment, a committed radiology and surgery staff, and appropriate monitoring equipment in the CT suite. If proper technique is used, then high-quality scans can be obtained which, if interpreted by experienced personnel in the light of the clinical findings, can improve our management of selected trauma patients.

Liver replacement after massive hepatic trauma

Two patients sustained massive hepatic injuries from blunt trauma in motor vehicle accidents. At the time of operation, nonreconstructable injuries to the porta hepatis were found in addition to destruction of the right lobe. Life-threatening hemorrhage was controlled, but both patients were left with nonfunctional or inadequate hepatic remnants. Liver transplantation was performed. Both patients recovered after liver replacement. One died 7 weeks later of cytomegalovirus infection. The other recipient is well 16 months later. Liver transplantation is a reasonable option in patients with lethal hepatic injuries or unreconstructable injuries to the porta hepatis.

Evaluation of experimental blunt and penetrating hepatobiliary trauma by sequential peritoneal lavage

Peritoneal lavage, when used in the standard way to detect hemoperitoneum, gives no information regarding site or nature of injury. We think that it would be useful for the surgeon to be more able to characterize intraabdominal injuries preoperatively, and that this may be possible by extending the scope and duration of the technique of peritoneal lavage. To test this hypothesis, we investigated the use of sequential peritoneal lavage with extended chemical analysis to precisely define the nature and extent of hepatobiliary trauma in an animal model. Thirty-six dogs were divided randomly among one control and four experimental groups in which sham laparotomy, blunt thoracoabdominal trauma, direct laceration of the liver, liver laceration plus bowel perforation, and gallbladder perforation were carried out. Sequential peritoneal lavage was performed over a six-hour experimental period with simultaneous serum and lavage samples analyzed for red and white blood cells, bile, and enzyme activity (GOT, GPT, and alkaline phosphatase) at four test intervals up to six hours post injury. Our results demonstrate that enzyme activity is easily detectable in lavage effluent after blunt hepatic injury but not after penetrating trauma, and seems to correlate with the extent of hepatocellular disruption. Lavage white cell counts in excess of those anticipated for hemorrhage alone are present only in association with an inflammatory stimulus other than blood or bile. A lavage-to-serum-bilirubin ratio of one or more can be expected after gallbladder or extrahepatic biliary perforation. This information may be valuable in the emergency assessment of the trauma patient.

Liver injuries in sydney: a 20-year experience

One hundred and twenty consecutive liver injuries treated at the Royal Prince Alfred Hospital have been studied prospectively. The overall mortality of 17.5% and the mortality for blunt injury of 23% compare quite favourably with figures in other reported series of similar injuries. The surgeon who treats liver injury must have a repertoire of procedures appropriate for different circumstances and must remain flexible in his approach. Simple suture haemostasis and the provision of adequate drainage will cope with most injuries. Debriding resections are safe, allow adequate haemostasis to be achieved, and give reasonably good access to the retrohepatic vena cava and hepatic veins. Formal lobectomy is very rarely indicated. Drainage of the common bile duct is to be avoided, but cholecystostomy has some marginal advantages and appears safe. The problems of retrohepatic vena caval injury and major hepatic vein tears have not all been solved.

[Surgical management of liver trauma (author's transl)]

Surgical management and follow up of 85 patients with liver trauma are reported. 20 patients had only liver trauma, all others were polytraumatised. Letality was 20% in patients with sole liver trauma, the overall letality was 43%. In most cases death resulted from prolonged circulatory shock. Most of the other casualities resulted from septical complications of biliary peritonitis. Prognosis was mainly correlated with the interval between trauma and surgical treatment as well as with the amount of blood lost. The main features of the operative technic were access to the liver through a subcostal and sometimes transdiaphragmal incision, temporary tamponade of the bleeding source, compression of the hepatoduodenal ligament, of the vena cava (intrapericardial) to minimize blood loss. Instead of hemihepatectomy, resection of liver tissue was limited to the smallest amount possible, and followed by extensive drainage.

Management of liver trauma in children

The charts of 203 consecutive children undergoing emergency laparotomy for management of an acute liver injury were reviewed. Although drainage was all that was required in the majority of cases, massive hemorrhage, usually arising from disrupted hepatic veins, appeared to demand liver resection (as performed in 17 children, with a mortality of 18%) during earlier years of the survey. Control of exsanguinating bleeding from such liver wounds by packing with viable autogenous tissue (pedicled omentum) subsequently eliminated almost entirely the need for resection. Fatalities resulting from either hemorrhagic shock or loss of liver substance then became relatively rare. Additional significant problems were associated organ injuries, postoperative wound and intra-abdominal sepsis, bleeding diatheses, and late instances of hemobilia. The overall mortality was 6%.