2. Operative management
Immediately to Theatre: 2 ASSISTANTS / 2 scrub nurses
Prepare from chin to mid-thigh / two large suction devices
Midline incision + suction + quick gentle inspection
- Split lig. teres hepatis (not Falciform ligament !)
Firstly, assess the hepatoduodenal ligament (for portal bleeding),
Secondly, assess the liver
(1) If it is bleeding from Portal Vein:
compress vein anatomically with fingers of L hand (50% JOB DONE);
use a pack/compression (as the alternative) / tourniquet
(2) NOT from Portal Vein: pack peri-hepatically / compress / wait
TEMPORAL CONTROL achieved: relax a moment and think
2
6. Hepatic bleeding control
• The goal: temporal (+ definitive) control
manual compression (use assistant’s hand)
packing (use lap pads) + manual compression
sutures
other methods possible but
close abdomen (pressure!)
Re Inflow occlusion:
avoid, if possible
if ‘yes’: Pringle maneuvre (tourniquet or Satinsky)
6
11. Liver mobilization: to do or not to do
• Suspected vv. hepaticae injury
– DO NOT do it / compression pack
• Suspected subhepatic IVC injury:
know what you can / DO it
– mobilize the right hemiliver, if
needed, and repair the IVC (RRV)
– if can’t: compression packing
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12. Other techniques:
to control arterial bleeding from the liver
• Ligate right, medial or left hepatic artery
– when direct injury to the pre-hepatic / intrahepatic
artery is identified during surgery
• Immediate angiography with selective
embolization as a hemostatic adjunct in the
operative theatre or in IR suit (hybrid surgery)
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13. Other techniques:
to control bleeding from the liver
Filling parenchymal defects with omentum (?)
Hepatotomy with selective vascular ligation
Ballon tamponade: Blakemore tube (for GSW) (?))
Resection
– debridement: anatomic vs non-anatomic
– delayed hemihepatectomies / sectionectomies (if non-viable)
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14. GRADE 6 (full avulsion)
1st TASK:
forget the liver
Control of bleeding from major vessels
2nd TASK:
deal with the liver for (liver surgeon)
1st choice: Replantation of liver or survived hemiliver
2nd choice: Liver transplantation within 24-48 h
Problem: availability of liver graft
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24. Specifically, for GSW: Ballon tamponade
using Sengstaken – Blackmore tube
temporal / definitive control
24
25. Liver avulsion (gr. 6)
Pack and compress the site
Identify structures of hepatoduodenal ligament
CLAMP PV AND PROPER HEPATIC ARTERY
Right-sided visceral medial rotation (Cattell–Brasch)
Clamp IVC above renal vessels
CLAMP IVC above hepatic veins
Sternotomy / any ‘tomy’ to expose IVC
Clamp it above hepatic vessels
RELAX as MAIN JOB DONE (bleeding stopped)
Wait other surgeons: Liver AND / OR Vascular
IF NOT COMING IN 30-40 MIN
Please insert large plastic drain (Robinson No. 30)
with the side holes in both ends of it via right atrium
WAIT AS 2 OPTIONS REMAIN:
1. Liver/hemiliver re-implantantion (1st choice)
2. Liver allograft transplantation: within 24-48 h
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26. The last thing to
remember (56 PVs,
by research paper)
Management of injury to PV
(if a patient is lucky enough to be
brought to Acute Care Hospital in a
few minutes from the moment of a
traumatic event)
1. No panic
2. Manual compression, firstly
3. Apply Pringle, secondly
4. Repair of the trunk of PV
5. If you can’t: ligate both ends
6. If you can’t: compress packing
Never think about medico-legal
consequences because of one
reason:
ONLY YOU THE ONE
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