الفهرس 
live Surgical anatomy of the rOnly 14 pages are availabe for public view
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Abstract
Despite its relatively protected location, the liver is the most commonly injured organ following blunt abdominal trauma. Blunt liver trauma is usually due to road traffic accidents, assaults, or falls from heights, and results in deceleration injuries with lacerations of liver tissue from shearing stresses.
In the past, most of these injuries were treated surgically. However, surgical literature confirms that as many as 86% of liver injuries have stopped bleeding by the time surgical exploration is performed, and 67% of operations performed for blunt abdominal trauma are nontherapeutic laparotomies. The management of liver injury has evolved greatly over the last decade. There have been many technical advances in medicine that now allow us to better diagnose and treat liver injuries both operatively and nonoperatively.
However, surgical literature now confirms that the successful use of nonoperative management of blunt liver injuries in a hemodynamically stable patient has become the standard of care.
The severity of liver trauma ranges from a minor capsular tear, with or without parenchymal injury, to extensive disruption involving both lobes of the liver with associated hepatic vein or vena caval injury.
Resuscitation of blunt liver trauma victim follows standard advanced trauma life support principles: maintenance of a clear airway, urgent fluid resuscitation, ventilatory and circulatory support, and control of bleeding and volume replacement started immediately.
The patient’s blood is grouped and crossmatched, and blood samples should be sent for urgent analysis of haemoglobin concentration, white cell count, blood gas pressures, and urea, creatinine, and electrolyte concentrations. Patients should also have a nasogastric tube and urinary catheter inserted.
The most important decision after initial resuscitation is whether urgent surgery is needed or not.
• Patients who respond to fluid resuscitation and remain stable can be observed closely, investigated, and re-evaluated.
• Patients who remain shocked after 3 litters of intravenous fluid usually have continued bleeding and require urgent laparotomy.
Imaging techniques, particularly computed tomography (CT) scanning, contrast-enhanced CT, Spiral CT an Multidetector-row CT have made a great impact on the treatment of patients with liver trauma, and use of these techniques has resulted in marked reduction in the number of patients requiring surgery and undergoing nontherapeutic operations. Angiography and embolisation have been successfully employed as an extension of resustation in the non-operative management of patients with blunt hepatic injuries.
Non-operative management of blunt liver trauma has been shown to be safe , thereby reducing the number of unnecessary laparotomies. Of all the variables evaluated, haemodynamic stability appears to be the most crucial and has become the decisive factor that favors undertaking non-operative management.
While hemodynamic stability, rather than either CT grade of in¬jury or the presence of periportal tracking, determines which patients can be managed nonoperatively, the sub¬group of patients with complex hepatic injuries (grades IV to V) are at greater risk for treatment failure and should be carefully monitored in critical areas.
Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury.
The intraoperative management of complex hepatic injuries remains a formidable challenge for the surgeon. Based on the clinical experience from large trauma centers, the evolution in management has included early mobilization of the liver and extended portal occlusion times. The preferred operative techniques are resectional debridement, hepatetomy and direct suture ligation or perihepatic packing. Deep liver sutures, anatomical resection, hepatic artery ligation and retrohepatic caval shunts have a limited, more defined, role for selected injuries. Finally, increasing emphasis has been placed on the importance of recognition and avoidance of complications to improve patient outcome.
Although blunt liver trauma accounts for 15-20% of abdominal injuries, it is responsible for more than 50% of deaths resulting from blunt abdominal trauma. The mortality rate is higher with blunt abdominal trauma than with penetrating injuries.
During the management of liver trauma, it is imperative to keep these key points in mind when managing patients with these particu¬lar injuries, as they can be quite devastating. Only through careful attention to detail, we can improve the overall mor¬bidity and mortality following major hepatic and biliary trauma.