Sunday, August 28, 2016

Step 2 CK: Management of liver laceration


Say you have a hemodynamically unstable patient with a gunshot wound or blunt trauma to the RUQ.
Why shouldn't you simply suture and close deep liver lacerations?

Because of the risk of hemobilia and abscess formation.

Here's what a surgeon must do:

Penetrating injury: If the patient is unstable or deteriorating in the emergency room, patients should be taken to the operating room within 15 minutes. Activation of massive blood transfusion protocol, four quadrant packing, direct compression and rapid control of fecal contamination are the initial steps. Debridement, ligation of the bleeding vessel, lobectomy and repair of venous injury under total vascular isolation are the best strategies with good outcome. If the triad of coagulopathy, acidosis and hypothermia are encountered during this phase of the repair, perihepatic packing and temporary closure of the abdominal incision with transfer to intensive care unit (ICU) should be the priority. The patient should be taken back to operating room as soon as the metabolic derangement is corrected and rewarming has occurred.

Blunt injury: Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods.

That's all!

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