Operative management of complex liver injury

Operative management of complex liver injury

dplor nis~nn~$uuas6u~n'mlAds:uin~foua: 5 uas ~ 4 a u ~ f l ~ ~ w ~ w ~ ~ i s u n i s ~ n ~ ] i $ u ~ s s ~ u i u i a . Y

&nun(]) idaaainriut8ueaa:uuin1wi odl&~iulnrsun 1duniua:dii;nmruin~$uI4niau~~n~'~

blunt injury ua: penetrating injury l u~o9Gunis inwin is~ in~$uuos~~~dapd Iw~b~un is5"n~ i

imuds:~udls:nos an:linlA~afilu~4audini~ui~i$uuos~u~~oj~us ~n&n.lr'iiia&aa:nix~nnis 2 P, d B

inu i lumsuin~tuuns~~~~d~~iw"muiu1nuuziswal~~dwsini~san?1aw~1~su aPioiiabdrnn nir

12 - 15 iiu ~.~S¶JIRL$UWFIS~¶J~:~PI IV iln: V, "15

w Por uinduunn8ui8nn iia;niruiniiuuTnm portal triad ~uusuonnnirwiudgr nisl?iulahnis%ai

' d 9 , ~~ lanmr i i~~s~du? isww~wiua~a :u"sns~n is~nwio t i i sP i~ i~os lu~~~ f lu

A n i s ~ i i ~ ~ a n s : ~ u u o s n i s u i n ~ ~ u u o ~ 6 ~ 1 ~ : n a i u d i ~ ~ ~ o d ~ : d ~ 1 ~ n i w u a s n i s ~ ~ i a ~ n ~ ] i ~ns%&binis

A ,or PU

s:6uwiuwa"nvas The American Association for the Sugery of Trauma wnnsu (2)

Grade Injury Description

I Haeniatoma Si~bcapsular, <10% si~rface area

Laceration Capsular tear, <lcm parenchymal depth

I1 Haerrlatoma Siibcapsular, 10-50% surface area

Intraparenchymal, <lOcm diameter

Laceration 1-3cm parenchymal depth, <lOcm length

111 Haematorna Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematonia 3

Intraparencymal haematoma >lOcm or expanding 3

Laceration >3cm parenchymal depth 5

IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Coinaud's segments in a single lobe 4

V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Coinaud's segments within a single lobe 5

Vascular l~~xtahepat ic venous injuries ie, retrohepatic vena cava/central major hepatic veins 5

I Vascular Hepatic Avulsion C

Advance one grade for multiple injuries to same organ up to Grade 111.

Source : liver injury scale Avialbe from : http://www.trauma.org/archive/scores/ois- liver.htm1

pld plw 1iurnirrnr~~minln~~Insunis~1i~~$u~pdbb~sd~u(3)

1. Recognition of the operative indication %ai~miii$4auo/lunnia:darnnas1~5"u

nisdiiYnwiobi

2. Adequate operative approach and assessment nira~uu$4'iuiin:n1sdi~nb~airu"i

w7iiabweis~gulA~~1uinLtu

3. Temporary control bleeding from liver nim~iu~n'onauu~an~ia

4. Adequate mobilization of the liver

5. Make decision for damage control or definite bleeding control 6. Make good decision and choose the appropriate choice for retrohepatic

vena cava injury 7. Think about the adjacent maneuver to stop bleeding 8. Detection and management of the complication ~disz~nsz?swaiLwsnCoud

K oieo:iihvu

1. Recognition of the operative indication

n i s i n ~ i h n u ~ n i 6 o s d i 6 ~ dunisin~11uims~iu~upo"~~~in~dau~n~~uns~uini~uvos6~1~u

Jagr ju Bariouq 1 9 9 0 n m u y p $ r j ~ m q ~ ~ ~ r m ~ n ~ s d i ~ ~ ~ ~ n ~ o O " u d ~ s q ibu s : ~ u n i s u i n ~ 8 u v o s k ,

n is i i ia"onaon%ubash, naiui9ddlZd~:Gniruini8uuo~a~ua~duq w~oarsa"o i i i bile duct injury

Croce imznm: (4) 1Z~nlnluQ4audlaZi'~1nisuina!u6~os6~]~ns:~~] tin: d3uimuos&lu A 9 1

niodosn' jnun wuidoua: 8 9 uoaQ~ihuiiia"y~imSwi$udnGku i n u i L u l i 6 s a d i 4 ' n *lswdmdii

u i n d u i o r i u a i n blunt injury d h G n i n n i r l n i 8 n n h Q s i i n n u r i u i ~ im:~ninisn~nuosibon~os%u

u?Lamdi i i n~ is tu ds~al; iinislXarisds:no.uuosia"ond~ounii nisFiab$ol~a~osw"as s:u:iaai%unis d

u o u ~ r a w u n n a i G o u n i i ~ n & i i h n r n r m i u u ' a u n i i i u o ~ d ~ s u d u u i i u n i r d i 6 (hua: 4 vs.foua: 7) 91 4 4

i i a : % ~ ~ i i i u : ~ i ~ ~ o i o ~ ~ ~ o s d ~ ~ n b i u a ~ u i a o ~ a ~ ~ u w " a s 3-5 Unit i idnasdi contrast+nhanced

helical CT scan i~eds:~iius:~uvosnisuini8~1, 1 1 ? u i m ~ 8 ~ n l u b o ~ ~ o s , evidence of enteric

injury, active extravasation of constrast iia: asaoni pseudoaneurysm

High grade injury, nisiin"oad?uimuinlu4osw"~s n i s i contrast extravasation i iaz

pseudoaneurysm Alil&~$ubnn~iulunis?npIi1nudlani&o~di6n ai ; i9u~o~iwdinaiuidusQsio:

hlnTnunirlanidisinI~idii~o $4 Malhotra (5) ~m:nmzwuii hua: 14 vo .mmru in~ fuuoshr :k~

IV iia: foua: 22.6 uosnisuini8uvos6us:6u V $ulnids:arunaiudii~o'lunis~nPrilnunis~di6n Ad 9 l Classic criteria uesni~%lnnisuini8uuos6ud1ni~o~~i6n n'o n r w n e d a a i i t Y y y i m S w ~ ~ ~ ~

~ l n ~ o t i i w s i QdaufdnhR, nisuinduuossiur:iYuii (grade 1-111) iia:l&iuiR.onduunii 2 unit ds d B 9 na1ud1i~ovosn1sin~1dnunis~njdi4'n%un1su1ni!us:~u 1-111 dibsonssoua: 95, ~uvm:$r:~u IV

iia: V anasan8ofoua: 7 5 $9 8 0

A d 9 1 2 d 9 n7diin~u~~'ilaudinisui~i!uvos6'uwuvous~nmo~~&~unisdi6~~o (3)

1. ~ n a i u ~ u ~ a w ' w i i m a o w ii.u"o:lZ%nisl~nis~inniiwuLida iia:Gwa FAST w3a DPT,

bfl91uan

2. ~yl2nm~wnsdaimsaowu~n~s~a1navo~ar~sw"uis~o~n6u$u~n~!~i ia: lniar iuis~i~

angiographic embolization 16' d 2- 2 9 4-

3. ~ d a u ~ ~ n 1 ~ u 1 n i o u n ~ u n a 1 s i i ~ u ~ n ~ 1 h ~ ~ n 1 ~ ~ ~ d 1 6 n i ~ a a u a r ~ ~ i ~ ~ ~ ~ ~ ~ n s d ~ 1 ~ ~ d s n%

16'iuaa"onuinnii 2 units niundsnistYs~nmoin~s

~idnd~sb~miuhnr~$daud~d~a~im~wi~p.idn~~~i~~~uuimi!umu penetrating injury hi nars"n~i%nsSlliiigm idosoinwinwain%unir3Gara"uvosniruim~!uv~snr:~sau baa: nisuimi!uves

r:uueiua:du7 a:dswa~&~~wawrn$oud~uiirsniunn"s

2. Adequate operative approach and assessment

Y

n is i i lasawa~sad Xyphoid auzs pubic symphysis a.rinnfslonl$& subcutaneous

tissue n R d 2 l % s Linea alba n R i 3 IGo'q Preperitoneal fat o<al3ni+iiosdos8at~ Mayo

scissors Iimrdsiaainuatdow~u?batlavouiiwa ~m:mrs:Cmr:km~ui~b~'~~ioCuAiuCiu r i i l l i fn

nr:iwi:iloaia: m n $ d a u ~ a w a i ~ u a ~ n ~ n ~ r i i ~ m ~ a ~ u ~ nfs oia~aisanih~osM"osw1~ bilateral subcostal incision

idoo';lios~~lgA"~ijroidi1d~snumB~nui ioi~~o~oon~inioanYOs'bnuw*i n7odo ntom4sspn

vorbwaa n"sww"sn~i$osroon~n]wi~~iu$isbdo1.;9"b~u~8sw"e,~d%miap.i u<aii 4 quadrant packing 11&

retroperitoneal lgA"&%u buarn:~uniru~mfudr:bnw penetrating wound

nimraam~mia"omoonluIliosw"os r i ibur iou~ ioi laparotomy pad oon %nua~$uioiosnlu 2

u~nm~n'isainu?~a~di$unibnqf;ouidoa:~~i~unizuos~~uiia:~~ud~un~r~~s~uu~nvu ika:iinir

ffiu~a"om I~i~io:i8umsgA"iuaa"om~ansia aio~naiu8i i~ud&ssnmidu~80~ aorta n%nirnnnw"iula"sfl

Tnunirdouuau n~urnnaomb8om~b~unibnqb~omoon

3. Temporary control bleeding from liver

n i ~ ~ i ~ a e ~ m u n ~ s n d ~ d ~ a v ~ s ~ u ~ s a l o s ~ ~ u a : ~ a u u ~ n ~ ~ ~ ~ ~ n i s u ~ m b ~ u v o s ~ u n ~ o ~ ~ bbd&os

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rnmqn~uos~a"onnonui~~n~~~bb<a m r r i ~ m r G ~ u i ~ o m ~ ~ n ~ ~ ~ ~ a n r ~ a .asuaums;

I . Manual compression iilkTnulG~Iliauiiu~$oCudbinni~inin"~~ lina:dauWBomoon41 A

as ~in:r:n~i~~ua"aua~wwu"a:~a~:~~~oon~~nn~r~mn"unr:~sauasa:nd~ado~~l

2. Temporary packing n i r l d ~ ~ i ~ u i s m ~ o i i a : ~ ~ ~ u a:Iliaunmbu"o6uiamn ammsEhiioa

18 ainp.fukdnuriimr~iuia"oml~n~macGwio~d

3. Pringle maneuver a8unis clamp uiaacu portal triad $9 control hepatic artery

aaa: portal vein ansd"e4o first part duodenum nfoo io%#mo catheter n#oa 2 sauaa#a& nisp;ii 1 Pringle maneuver mu1miilGni~i1~aoaaa:iouGui1'$89i~uu aaa:dau~unira~niiadomdoonEpd

u i o i n hepatic artery n"pl Portal vein (a$sao:lna$iasna"seinnisii Pringle maneuver) n i o i i

o i n Hepatic vein (aa"oao:u"snslwaai) nisnGss Portal triad Iiaiuisniia8us~u:aaaiui1ilA d l o,

doqaina:i i lGguvinadem iawwoRiwmnaiu~ viiuIunaiuai;uji nasdo: clamp 20 ui iaabanaiu 5 B 94 uitiawdoamnisuimibomvo~~u (7-8) adinirdn~inu~ln~npriIu~4auiiuau 1,000 s iuunaQihud

d A w uimaaunwu T n u l 8 i i Pringle maneuver a$us:u:aaai 30-60 u d l u ~ i ' a u ~ i high grade liver

injury wuiimuisniil8lmu~niiwaaa'y1sn~ou(9) aiaunis8nprivsa Pachter aaa:nna: lmu8npriIu

Qdaai iuaw 8 I s i u w u i i a i u i s n i i Pringle maneuver 18 7 5 u i i % m u d l l j l i i i significant

morbidity (1 0) lA in i s8npr in "sn i s i i PringIe maneuver aiuu systematic review (1 1) l m u d n ~ i l u 16

p r a p r pr RCT ado ds:aGuuan uonouuosn is i i vascular occlusion s:n4iaGma$o6u iaa:ad?uua~uu~oGi

iia:4oa~us:niianis vascular occlusion tqunfans ia k n i s vascular occlusion ot j~q ioadoa

w u i i n d u d l 6 ? u vascular occlusion i ~ i u i ~ t ~ n a d o o n ~ o u n i i o r i i ~ i ~ u ~ i ~ ~ ~ u a14 liver J enzymes ~ u i n u u n ~ ~ o ~ i a ~ W " u d i ~ ~ a ~ u b ~ u a n " u u ~ ~ i ~ ~ ~ n a i u a a w n ~ i ~ ~ u ~ m s i n i s n i u h a i u wiowa

Li'YIS"40U%1i7

Baunisid~uuatiuus:ni ia vascular occlusion a ~ u n f a n s i a n"pl vascular occlusion oi l ,

hoadoa wuii?i~naiuaamnii~n"uIuAiuiiuauadom~l$ s:u:aaai%wnisii6a ~m=iinisniu ~ m s i n i s a ~ m

Guaiu iiuaua$omdaZu ~aa:s:u:ni~uoul~ ICU

ias:aWdu?8iini5ii Pringle maneuver ~$uw"~lnnis~~~dse~u%pl"~unis~iub$oma~a:~

91*1aaftosGsu

m n ~ ~ w u ~ u ~ u ~ ~ u a a ' o n k n ~ i a a a # a ~ ~ n i u ~ ~ n ~ ~ u a a " o n o i o i j n i ~ ~ ~ q d (3)

I . n i s i 1 packing n 3 o PringIe maneuver d l i n n i o a

2. win41 Pringle maneuver aabaaa'omt'isoona8~8~~nann ap.siooonoinnaenaa"omaamq i naiua~uldl8i1oiooonuioinaA~iaa"o~aama~ina1uijmdn~lu~1a~n aiow"i l iscui i i

supreceliac aortic clamping 3. o' ia$nnt'aonna$uil i in~i oonu1oin~oni1un~avaaGuQ41aupdio:in1su1ma$uvo~

retrohepatic vein o 1 ~ 8 u ~ u ~ n u n i r u o 1 n ~ ~ ~ ~ a a ~ p 1 ~ n ~ m a n ~ o ~ d a u n 1 1 1 1 o - a " n n ~ mnaa'om

loonamaa amna i i i i a : i i n i ru ima~u4~ retrohepatic vein a id nir# iuaa"om~ansiaoio

P;i1~8lmunis~u6uAou~~Iwi~$iu 0 1 0 ~ 1 % # b a ' 8 ~ ~ ~ ~ ~ 1 n 9 ~ 8

4. Adequate mobilization of the liver

iwdon~sds:fiun~ruima~uuoaGudnu~sQd" ha$udo:Waaa1:6uoonoinaa"ua:ru"1aa~u~ awdolnY

nis~iua8omviilioriiaa~ud rnnnisuina$uo~diii~ndan"au4iu nasdu&u;Uhu n i m i i n ligamentum

of teres iba"aGmyn Gm Triangular ligament [an: Coronary ligament 81u~ier%wus:<wx%

Phrenic vein Pslinarwuuitam left posterior coronary ligament

~lnniruima~udun~nrrai $~aunas~uGunZuoaii41uiwisi~uanai~ Imu~auaiwwu"o:~miai:

right triangular ligament its: coronary ligament it~aun6un~uvaibbiwis medial nas

.j:oJ'ms:a"q IVC aia: hepatic vein

5. Make decision of damage control or definitive bleeding control

A msnrwunir i i i Damage control '!%fsidarniouo .a~oia~3u%ai i iuor:d{4auo~luXos

9, Y , riiGn~nun1rwu1u1un19';o~a~n~nai{dau~~qn181uo~~?wui0i1s~ui~ss ii~$uda:n'orl67 damage

control iwdon~~qmi~a:n~n~~u~n1srii6md%4iaaiduiui~u~d ~ e i s ~ ~ u n i s d i damage control

I i i i f i {dauai%unia: shock , acidosis (pH < 7.2), Base deficit < 14 mmol/L (1 2),

hypothermia (gorn41ii i~niu~inii 35 o.mii~at$so), massive transfusion (> 10 Unit of II

pack red ce11)(13), l i?urrisii lunis resuscitate uinni i 10 a"m.j(14), nisFiiGmuiu~n"und7 90

uili I ~ { I Y ~ ~ ~ ~ ~ I C U ~ W ~ ( I 51, serum lactate level > 5 m m o l / ~ , INR or PTT > 50% uo~r i i

d n l Pqlunr~&nun~flunar18?unis damage control

Damage control : liver packing nisv?~ packing idu~~w~~%unl~~iuLa"omainnlsu1m~$uSuLLssuOs~ud~i~unaiupiiuu~iis

A a~winniu vsuon~ini~uni~~1%uE~-imou~isnu~rn1s~~m4os~osiw"0~1uid~~dans1afiouda:disaan1.j

d u A ¶J

uimi$ulu4esw'osuB"a m s i i packing is~i~nsn%~lunir~1uia"on%u{4a~u1mi~~1~ut~ssw~u vslnwa;

hinaiusia.nu (16-22) Tmuknrom~no~d hun: 40 - 80 ~nn' jnui inirr i i perihepatic

packing lu{dasdii~qqiorSw~insdiioiL~rn rnuirodauanksimrmiu?A~s 1 h 3

~mahimisd packing do uhor anterior chest wall, diaphragm and

retroperitoneum i i i ~ u i o q mobilized the liver ImunisJi right iia: left triangular,

coronary ala: falciform ligaments n.~ui i~doiiq'!rr?miu nini$u hematoma %PA ligament 'lu' nara:dibhldi~sqain iia:iininnnduuos vena cava nfo hepatic vein " is mobilization a:

-4 rii%Xia"omoonuinv~-A

ludasd~iaoigdnrdi pack to~l ioon liniiilqrnia"omoon& oiuiroiiiiilqai18Tnums

packing hu??ho.r Feliciano im: Patcher (23)Imunisioi plastic a1rrosu7naiia~utiouds:ais

gdnrdpacking ain$unarv?i temporary abdominal closure rnw"odosiiunis~~m abdominal compartment syndrome

Aydin U imtnor: (24) nu i imr l i i Peri-hepatic packing d~iduswomu~-.ouiu~:i A'

~umsiuuinvu wuii$i~-~u~4'iudlkiumr perihepatic packing dIiriuswe&ii r:u:ianiniruoulu

ICU u iun i i 1~a:iiuaui~om~I8?uuinni1ariisiiGud1~qwison'l i~caii1~msinis~1~Ii~imnoi1s6u

s:u:naidmui:n.uds:ioi packing oon;u& controversy naial riiuiinaium$uiinasmi A

oonwi%ainrnsi~r?!vniat coagulopathy, acidosis uatnia: hypothermia ibda ~11si~~i~u:~3ai

24 - 48 AlusnkrnrriiGm Inn Krige im:i$ouiau.nuwuii (25) mn pack iruiuaiiu 3 i n a:; S X J 9 Tonlatiin perihepatic sepsis I8foua: 83 iinniuoan4i 3 a"odo:wuaiusfoua: 27 a~a:eininis8n~ri

lu 1986 (26) wuii ibn sepsis iviw foua: 10.2 h@au8 to1 packing oonlu 24-48 Alus

Definitve bleeding control in severe parenchymal injury

Directed sutured 4a 4 1dnnira8ulnunrsuosu~~a~~~u~aomoon luniruimliu liver lacerations vosiifoGuioaZn

1dWnas8ntRu 3 .au ~nudu8nas1duuiio6u1mumsd~aui$uuuim1n$daiu~inn"u chromic suture

~uo5d0 a~uisn~ifua~il:~n~&naiu~iuua~u Figure of 8, simple suture wio Horizontal mattress d 44 mass:PJ'ns:a"snis~u~]wantiiuldoubii~nisuin~iuiona~m~a"onniulu6u nlaiui$umasYnaslnl~~uGu i f 3

mniiu liver capsule tau8 n8niiu~nis$uduos~~uwislasJvos~~ulao.i~nta narynliinoailju W m iduauuinau"oriu o i a l l pledget wioiaqo6udarrroslP;lXlnu~in liver capsule

Hepatotomy, Finger fracture and selective vascular ligation %uns~~inisuin~~u~nvimuos~ifo6~1i ia:di~onoondtinsa~aindau~nuo~1ouZn &Gninis

s~imi$plvasu?aatu hepatic artery nia portal system n"ilP;muisnnauqu~a"snoen18?~ni~

directed suturing ~iww6uissiuuu:iil$l%i finger fracture(27) ZoignZnirwal8~fiudauZnvos

rouiindo8iui~onaina.a"uta"an~ims~w"nuim lnukunn Pringle Maneuver ~si$unisfiiu~n"on$ann~ A Y

tioui%~ capsule uo~6uiuhamros~lddib~ot~u~ud1unisb~i~dau8nuositwa bihignnforiulntlmr * Y Y .I Y

9, a a w ii finger fracture technique iiFmul~uauruomu nsawa"sabinaen~dona~a:w'odiZ ainGu~sniu

ua:6nviomdi% riouq iiladounosrnbu~n~a"omoon 1iX3lGclam~ nduyn n"ii$unrr~nvinuosnaon

aZonuuinln$uisriau airnrn6udouTaull Prolypropylene 510 sunr:iswuiiim1i3uos!n a 4a.2

ia"omeon aia"a%G"bisXiu~a"ona+u clips, yn n?oa8udou .asanuoia i i%X~i inn isu inb~uvo~~a~mbZa~

v i o i l ~ Q u q ~ u a i B ~ ~ n?si i lmudnaiwwbdb~tra~i~~ds:nuni~&~s

Omental packing

a~s6uan'mnis~nuin niomuntYsnisii hepatotomy, finger fracture 9nla~a"a oza~n.tios41s 2 92 d a a .I

wluGu m a s i i omentum gn%awuwuiaonoen Stone aia:nm:l~siusiu?iniriwu4iidmr1nismiu

~viusfeua: 8 (28,29) iilnu6maa-1: greater omentum oin transverse mesocolon miuiaua

avascular plain sinhma'ou omentum ain greater curvature Inur:rinr:isniruiniiuioa#~1

iann right gastroepiploic bb~a%~ad~d~uuhtu~~85"uuinb~u~ba:~"ou'~aau fh capsule uns%

Penetrating tract A - A'

ida~niruimduauun:qi~oGu awanannuuo:dn an:aiaauuin8a:dr:~~unisuin1~u6u~s

Enniawa nisld omentum ihladadu?%is?7nds iioi Poggetti i8~~w:ii?lnis%G balloon

tamponade l un r~~ iquuwa penetrating (30)lnumraiq penrose drain l~lnu'oiiimdsuiniinn

oinik114end-~erforated tube iia:m penrose drain iddmu& 2 Gia ain$uh balloon Ra5.r

d l d i t i l d i i i m i a l u tract im: Ida i rM balloon ldanYlu contrast agent mnmuironyni80nl#Z w 44 -4 '4

nxiio-ioi balloon onnhr 24 - 48 b1u.r na:u~uemnnud inan i rg Foley cnth uuin 16 (3 1) v w a u h ~ l d i b i l d l u penetrating tract nh ld& ih balloon niusuiaonoonm.r Foley cath imnqiild

I dd a rnuq.miiiiimusnuiaonoon KiiBonaonoin tract ~imn.riihimdaun1 balloon ~uod8nniim8ii

i8oneon n~rlnir lGod9uii i iwdqdia"on~t~n ain&namur:uiu rnntBo~ny~lkasQiioiaius:~~iu

Ha: Foley cath oonnainsinshq?~a"qnisiitnnfqiisn 3 - 4 i u mnnioquosmruini$uiiuu~inln~

n i l 2 ru. mr lq Senstaken Blakemore tube (3) lriihblluliih id i i i hd grastic balloon 96 wo~~auonm;loonunsiinaido9~i~udau~n"u~Ojl#w'oiunn oin&r iou~ld~i ib id esophageal

balloon nuniii8eniounamyn biianlirnuisnnynl#lnu3~dna'iauiiida oiaiadu8a:losii

hepatotomy aslddohuidon ~ n a r i i n i r i d u B n ~ ~ w " i u u ~ ~ ~ mn:s:niuui#~um~in"nn"ouia"on

uuinlnnjn.iu9utu

Selective hepatic artery ligation

Hepatic aretery injury msuinituuosi#uta"n~u:iam portal triad if n!#oua: 0.07 z-r 0.2 1 uout$d?ug<~mpld

q ~ ~ $ W r n ~ (32,33) nisuini~u~oroiua:u~i~m~id~sinir~iuq.r$~fou: 50 ~dosainhn:ii

portal vein n?o hepatic artery uialu iauhu Kidnisuiniluuosi#ulBoR 2 i#udwu415nsinir

niucs$sfoua: 99

nisuin&uuos hepatic artery l un r~8 i f .u blunt injury i u w u l ~ o u u i n Gnwulu

penetrating im:wuiinirdi selective hepatic artery ligation idnnnisl$foua: 1 uos~d?l?t~dii

rnru1n&uuosguiu8~uiisqffqnun(34) niuimCnmslnunisdi Pringle maneuver uXaXiwuiii

~8eaoonpd"euas iia:~lsaowuii portal vein u"si?ludnih~ ninwuiiiinds~naeuniuisndi primary

repair I $ uibiirnsa8uia"enuin iaa:inis~nwi$~~~lo~oiua:duiauAau aiuisodi hepatic artery

ligation?# idosain+ii collateral vessel uiniauiiuii portal vein ~unisiiursiuiau#au lan in i u d d 9 1

o:in"a severe hepatic dysfunction wa'snis ligation Cupd"ouuin (35) iii8ilunsmwydauiinia:

hypoperfusion t-iounJinisdi hepatic artery ligation oiuiil#ai% liver ischemia iia:

necrosis w?a sepsis miuui"a (36) iisiusiuuos Lucas iia: Ledgerwood wuiiii complete

hepatic necrosis an:iiru??in aiodiqlsdniuk~iinis8nHiodiqqAiau1udrj:i~u~

luilrprju msdi intervention m~k4inln&iilh:lu'11pddodi~ii~udi~~p1i~al~~lunsGd

u"qn9iii8onoon nitma'snis damage control packing ~unis8n~riuss Asensio (37) wuji%unf@

@lau 22 nuAiniluinduuor~ui~uiisq 15 nu l~ i u rn rd i angiographic embolization allnrn

nyai80nl$ lnuald indication imuitnulurnrdi angiogram ~o l# t$dauBlA iu PRC 4 U lu 6

4alu-a n?e.di 6 U 111 24 4alu.r

Portal vein nirnnnihie Portal vein 5msinisiti'uii?mgsm nirs"nnriii!iImu manual

decompression nio pressure packing i;ihimmisuimPaund~p~?ia~d mid portion of the

Hepatodeodenal ligament n i r i i pringle maneuver d o control inflow iaa: outflow

ubaa6iimd.r above aa: below uns?mduiadu aa : rnu isnd i rao~Ai~ retropancreatic

portion 910s portal vein Imunisii distal pancreatectomy Y

~16ibinds~os hemorrhage fiufliolisnn~!& bin: control !ahunisii lateral

venorrhaphy ~ t~wu i i hnmrmn~?mgsd~m (38,39) &ii.$mrduq Iunir repair idu

saphenous vein graft, polytetrafluoroethylene interposition graft, end to end primary repair, iia: portal caval shunt (40) iii~riosiu~snisdr:flunaioldii~o~ou

~ u n r ~ d i n i r ~ i a ~ " o n u i n nisi1 portal vein ligation muimi i?& &l8iisiunubu Child B: lug 1954 afii~a:iinisiwduuuvo~ Portal pressure iiat. systemic pressure anas irimunrisi(arii

collateral %udqn ai i i i inunuIu9 1995 ii Foua: 90 uns$i~'iudU~uniri i portal vein Y

ligation Guidu33m (38) iidoinnis8np~iuas Stone i aa :na :1And ia i i ~ i~~ isn~n~~~mlAF~ua : 80

ninf~ni?u%oi~ portal vein ligation w"od~na"soinwu~~!~f l~u~sndo~i~~~%mu~~ lateral

venorrhaphy !i

Resection nisi1 anatomic resection $uiin"raiiw;naio%uiidasdaiug 1960 $ 9 8 ~ 1970 %mu

McClelland Ha: Shires (4l)lkiunuiiiiknronii?mgsn"sf~ua: 80 i d i i ~mu inunuo ind&

nir~id~siuuisriau41"niilu$iIau~iinis~nui~vosidoGuuinoum'uozn~m, iniruimionun:niimiu d

uosiu"niuu1n adr:uzn~snirsi~i~~Guamaso~nf~t,a: 6 m8o;nua: 3 iuosainmnlii%u$43u~inir

iti'ui8omlnno~u~aa:ii~~rinismiuqsolin igu~nnirdnarni+dus iia:nari~~nuriauibwwo"d!i:un~r Y ,a d l 2

dneuruwisAiuGuii~:wisi~uii~ ~ i a : ~ d ~ : f l ' ~ l n 1 9 6 ~ i ~ l ~ ~

Fibrin sealant Fibrin glue i~uarirdr:naus:niis fibrinogen n"pl thrombin, calcium chloride ua:

aprotinin ~wmsnFisi8u clot di i%s ias (43) aiat.?&wa~$unsG penetrating wound iniswmaaslu . ,

tYmadflma~s WSJ~I?&-~; ii~msinirin4m hypotension %inii, aatYmsiniriduiiom (44-45) %t~%?flu

iin~r~lunraidiiu~ni~uuosduw"au~sm'~~diinisu~n~~u~iu~n i~d iqmnC~i i sn i a~ i~ao ln"u i in i~ : coagulopathy

I K i n i r i n ~ ~ randomized control trial (46) i~oid~uuiiuurrnii~wa'm~m.n"XioliR"~n~i

airJr:nou fibrin (TachoSil) iia: argon beam lunis~iolin'onunr hepatic resection lunr8d

!nj%dqsJ"Smq Fmuinnri%u$iIauiiuau 1 19 siu wuii TachoSil %~iaai%wni~Xiol iR"0~1~Gouni i (3.6

u i i VS. 5.0 uig) ~ m u a i m n i i s h n i i s i G u d i ~ ~ w i s n ~ ~ iiiGmsirnrmiuiia:waaiwrn~~u ?iiamndisr?u

~.mmrdn~ids:Iu'~~Gv~s Fibrin sealant iii~un'oslnlnri~~n~wdoli~ol6oId

Mesh wrap rdu?ar?~unisdiu~$on~no~ian6s~o wuiiaiuisaannisi~uia"on~udma"w~a~s dinisuin~$u

uosGur (47) i i ~ n u d i mesh ~rou~u~~uiiibunn"u101bbda:n~uuoa~ud?~?uuinb!u ainiudi

mesh 1dWniu falciforrn ligament 1~d r : l u~un ro ld i i superficial lacerations uoaGunmu~ d P4d I 9 liwn arilu'?~ds:~unni1uns61"adiiui~b!uuoanaDn1a"on1~$ iinu.nudnii~oaaaGob!uou l % n u a i u

nd.rIuq~~iqGimq~dn (48) dua~nislaY absorbable mesh warpping lu(d3uiiu-~u 4 nuisld

3 n.ff.1990 - 2000 &oiy 18 m'oun"a 15 3 iiiu!&'uuindu~:riu IV-V diinirdui$onuin TRU 3 Y

nu!P?iii~wi: right lobe aiau 1 nu'lP??u wrap Guw"swunwnr41 Hepatic enzymes iia:cj:i'u K bilirubin t~au~i%us:er: 3-7 a"odusn asa:douq anasdsz6udnE b~n:niuna"aaiuisn%~G?m?&dn~ 44 4 1

~ ~ u : ~ i i i b d u ~ a ~ a i u a ~ a : s a n ~ ~ a n-JrGni?u~adiGuiutiriouda:i acidosis an:: hypothermia

Transplantation '44 4 durnsiiion~nmanda~uidauaiauGouTnui~audii~Z$msi overall survival nn u

4 91 ~nn~$ur:uun"uiauhuG~u iinumundaain Philadelphia !R'nliiaoswll3ud'l&?unisii~n hepatic

transplantation barinuol:l8u$d3uoiQ6ou d$uhiidqryierlwo~luino191"dnZ i&~idduui8u

+cyonerGwdlrinsdmunfi aa:lunisdiGmwu avulsion d portal vein ua: proper hepatic artery

(49) iinisuini8uduiim~ubiu98ciiab~ua ?riiiniruini8urnar:uuds:aiw lu'iirnar coagulopathy

iiazaiuisnni donor lAariiasani$a a~bo:isiuaiun"anisds:aunaiudi~~~o~di ~dociisls8miulu'

a1u1cjni11 ATnokald

Gerota's fascia flap Macro (50) i i a : n m : ~ ~ s i o a ~ u ~ a ~ u d ~ ~ ~ a ~ u n ~ s i ~ Gerota's fascia flap IunsGqdau

blunt abdominal injury 4wuiitdu liver injury grade 111 with at segment VI V11 fauriui

ia"onoend?uieruin lEiaiuisnwy~?Aniuna"~n~x~~udou i a l A i i gerota's fascia flap veslmwia J

X i u u a i u u u i n u u u ~daummsn~~nG~mi~n:a~u~xona"u.u"iulA Qadu?~iilmaiBondsda:A~ai

nis~nuisiuaiu~nIuo~~inm

6. Make good decision and choose the appropritate choice for retrohepatic vena cava injury.

n~xuinduuoariud~uura aiuiroriild~Rnniruini$'~~vos inferior vena cava dciitmdab8

I 8 siowuiauiiunir8nuinuoa suspensory ligaments, ns:rjaaunlolifoiu 6aGums exposure 9

d u 4' aobui~dm~nhinL$u~Iaoia i i~~bn'nnis release ternponade im:iiIdiRntBonoonuinuu1A

Buckman ~ia::nol:~~bbu:Cin~siiGm?nui?a" 3 ?Z d u I

1. n-1cji"udauidut$onii~na'i~~numsa 8ia%~mcjniunaonia"onnbu153u~aunio?u'8~~

2. nixGnGun~udinisuinb~uoon

3. nisnnnaonba"onriib~o1~n~n(5 1)

1. nisa"unr?u1mumss n i a i d u u e ~ o u ~ m u m s a ~ m u ~ ~ ~ ! ~ ~ n i s shunt f i o u i u Pachter iia:

Feliciano nd ia la "4 in i sw iu portal vein i a u s u mobilization of the liver f au% medial

rotation tta: I-inger fracture ihldhgm$u~mdu (52) ~au3i;n1r~i' l4knnissom3~mfoua: 66

(6114) ~m:?%f~hen im-nm: ~nusiuiimuirorom3?n!&s"oe,az 50

ni.stdubouwaomia"am~iImuoi8~ shunt Xaui?u8ubwu Schrock iia:nme lug 1 9 6 8 (53) Y d 4

Gu%Ain iswuiu ipJ i i iwo complete vascular control of the liver A a u n i s i i atriocaval shunt

ii14'iQba"amoin infrahepatic venacava bypass Fiiu retrohepatic venacava i&imssrj atrium i s i u a i u l j i ~ i u i s n ~ o w 3 4 m 1 A Qouaz 3 0 o i n l i u a u ~ d a u 200 s i u

lug 1 9 9 7 Pilcher ain:nm: !&siusiunis0iii balloon shunt Imu ldn ia saphenofemoral

junction i i u IVC 1; balloon i$iIdna~iiuwds$ijaa"omoon itn:i~om$uioin IVC o:!wna&i craw 44 atrium 1 n u d i u s h u h . r u o s o i u (54) & u n n n e n 8 n t ~ u a n i r i i thoracotomy ~ m u d i t n : ~ W s i i a i u

ligament son17 6u i i % # n i r tamponade ln i tdu ld(55) iad1u3 1988 the multi-institutional

trial wuljinisssm3?m%oan15%~ balloon shunt i ~ o i f i u u t i u n r artriocaval shunt " a i i s t k 4 94 A Ad "1514 venovenous bypass i3uanaswuswunissiusiunisl4~~onisLtu4ouiL~pJ~aomidon

A i ~ ~ s # u ( 5 6 ) ( 5 7 ) ~ m u d u r i i i i r n ~ 1 u ~ d a u i d d u u n ' i u 6 im:~~~n1rds:~nkoiu1~4%u~dau~3J"~tw~

(58-60)1mulOj8os1$ systemic heparinization venovenous shunt ni2ul$iaa"omban'u!diGal~ 4- 4 l

!&iftoawe iaus:priuia"en~~sW~aua'~s6uosiisni~ aanisuawos6ui n m 3 y w i reperfhion injury 40, 4

ui lno in~usunuaiuuu. rs Biffi anmm:%unisi$uni~%d~ius:uiuia"omoin portal vein twdonmnisuau

nesii1!8 (61) n i s i iGmnn i r i i r nd ia 9 i a u n m 3 r y m n ~ ~ i i i m n a ~ u ~ u 1 a ~ ~ ~ ~ ~ i n ~ n ~ s n ~ u ~ a e m a ~ o m ~ i 9 A d 4 IVC i d ~ l ~ 8 ~ ~ ~ 8 l 8 ~ ~ ~ ~ ~ ~ ~ ~ i u " ~ ~ ~ L ~ ~ ~ i ~ 1 ~ f ? ~ ~ ~ 1 U ~ l ~ l ~ ~ M ~ 1 ~ ~ ~ ~ ~ shunt

n i s i 1 directed clamping techniques % 8 f i n i s s i u a i ~ d e ~ ~ i a Carrillo iaa=nmz b,$siusiu

$snaiudit$o6uesnisi i vascular clamps msau?iasla hepatic-vein-injured ends uazt6 iu t~usouzn

uiauoa6uA2u omentum i m z m r packing (62) i i i 4 i l n u h l d t t i % n i x approaches ? d l i k ; i d n n

~idl~Yuuim&u~ut3ud.r~uin im:n'aiBom1Lin 1wuiaw1-1u~dau~iids:aunisdod"~u

4.4 9. Anatomic resection ~ a B m u n r i i a ~ s r i o u n d i ni~ii6mi~o6u1Ojaiu~iiiilunsni~~daui

f i l ? i a t ~ w ~ n s i n1s6m6uiudoYnlnnianir&ui~~Guio hepatic vein &~l i i i ;o~ni$mtou

d Temponade with containment ~uosainmri~udouwaom~a"om1mumsa n%rnrpisatiGu

noni ;bnn i rmiuqa i11~nis~ln~au~w~adduuiidnaa8un1 pack i a u i i u n i r i i embolization tjn

idanoon ~ w u i 1 1 A w a R ts in~smluo~$dr :u~mfot~a: 14-20.5 (63-64) i m r l l i w u n i s i i i n venous

thrombosis w b s n i s i i packing

Richardson ua:nm: (65) !~s iuaiuni fn~in isuint~u~o.r retrohepatic vena cava v i a

hepatic vein 7 8 n u w u i i i n i s W atriocaval shunt 45 n u i i i i iua 4 n u ~ r e m F i m i11hnmrN 2 d

atriocaval shunt aaaso6isuin i i%X ims%Qnis i t u lmumss w ? o n i s i i packing u invu issuq aka= 44 pl d=. 9,

I&waRuin m s i i packing i i ~ m s i n i s s a m r ~ n s a u a 60 nis%ubmumssi~ms~n~'iro~namroua~ 40

i a u n i r % 4 shunt ii6msinissom33miiu.rQeua: 6.8

d da iinissiusiunisl4 endoluminal stent graf't %u{uiai~uwunisuiai~udo retrohepatic 9

v v : vena cava ZsaimZl2002 Fau watarida (66,67) wuii"aAwai4 niuicjnllr!mws~~qnicj~iii6~

damage control m?o iirisunicjeii~a61niuisoSGaw"u~&fiou iia:%ur:u:m&

Drain ?&i<u~nisais drain vas6uiqaidwa"snfiunsnsiulann!q$nos Fischer i~a:nm:Iffn"pdwu%u'?l

1978 ii wuwrinyuiirnrl$ penrose drain kidugmliniliimi$alunispIiai$~Ivoq~ucj:~u 1-11

(68) aeilunisuimdu2uasqiia:wu~1i4?a h~duho.riinirnq drain i.wdokinnd7uio~ii~

nis%4 closed suction drain l~~unisuou?uoii~i~w~waiu4iiinla:lu~~~qs lug 199 1 14% mrnu~iu i iwu perihepatic abscess lu{d'iuilliiirnus:uiufoun: 6.7 h{iI'il?u$ii closed

suction %ua: 3.5 h{dauil?ub;ii penrose drain (ow: 13 (69) aa:sinnir%wain Charity

hospital wuiiE4nniri5m abscess lu{iI:u~lu'~murruiufoua: 1.8 ~un~u{daudiirnur:uiu

~mu%wufoun: 0 Lin: h{dau~mur:uiaiuui~~foua: 8.3 ~mu%~na iunnn~ i isw iqa~~voqn~u$

iiaiut:uiaiuu~niiuniudIiiinius:uiu (70) aa:lunirlnlnauu review lu{dauhuau 161 nu$

l&?uniruimtduuouriu ~auiSuniudl&lt-i closed suction drain 78 mu lu'lind rnur:uiu 83 n u

(71) wad~in~ i~no~n~u~u ' !~ i ina~u i imne i~suo~~ms~nic jm~u, n i c j i 5 m ~ u ~ ~ ~ ? o biliary fistula a d d

s:miiqnosniu ainwanis8n~i~s%finaiua~ui i nacjazaiq drain ~~insmwivu bile leak qabau bin:

nisdnlnlu?? 1988 uonji(70) n i r i i i la f uos shock ~in:nis!&~ui~omuiniuidu predictive $ Bi6~vssnisi5m perihepatic abscess uinni~n~s~niu~:uiuwioi~?u'~n~us:u~u

d * .A q d i i a:aisniur:uiunnoiunwuniskavo~~i~~miouum:nis~ii~m i~a:nasl$closed

suction drain

7. Think about the adjunct maneurver tostop bleeding

nkrnsdiPmruiai~u~ui~s~vo~~u 1muiam:mrii damage control ih mmGiutboa

rino:i~unisii perihepatic packing na:~~unirfiiuibom.a"ancjia i~nr i i { i Iauoonaindoqi ig~

iiiduhoiopriiiu'i?n~i~a~u intensive care unit dolaulrdluma: gmmp~luiian~ui~Fmu active

warming i i f lu acidosis ~ n u n i r l ~ a i r ~ i d d u i w o iil~aEilam'i:d7uim~iwui:nu ii8lurn3:

coagulopathy siow"oism1 angioprphic embolization 8iibemtYa'sau'mym

8. Detection and management of the complication

d 4 u do, d

wahsi~usainmr?n'uinicjuimaa~~wmu~uiis~umd~

iizh i d u w n w r n ~ o d w u l i n ~ i ~ ~ $swu?&foua: 4-6 uoq n~u{iIauiinlnInun~rei~Zm d A W d 2 4;

vosnisuimiauwmu iilw"s~"nUu:4i%unis%dnius:uiubdos:pIiu~ii4$oiawu~~ma"sii~m 81minuuiasa

uinnii 50 ml da?u uiui5un4i 2 8dmiw" & ~ . d i i i biliary fistula (72) ua:winiiuauuinnii 300-

400 2aSSms aal'd&5"~lni5lGo<uidui~u m~~P9o<u%aunirii fistulograrn, HIDA scan, ERCP,

CT abdomen l u a i u r i o u i n l n T m u n i r i i Roux-en-Y Y ~ i e d u & N d h i l ap l i un iu i ro in ln18bmu

? i ~ o q i i g m i h n i r l i stent diuw~~w"aww"ss'a~~n'un~rlaia~ur:uiu~~uwi~w"a~ J 9 (73) w i o n i r i i

endoscopic retrograde cholangiography(ERC) i i ihlai stent ~ i a m i u 8 a o m r i i .Y 442 sphincterotomy P ~ r n u i r o a n biliary pressure ~ a o : i i l ~ n i ~ ~ ~ v e ~ u i ~ ~ v u ( 7 4 ) m n w u i i m s i ?

44-d $ ve.riiZoenuioiniovuiRidn mr ia i :~ :u i~d iwm~w"awG~ i 8 u ? " s i r i n ~ i w m a n n ~ s

Abscess n i r w u n u o q r o u l $daua:iioinis sepsis, d a n C s , i d o o i m r , 141 liver

function test d ~ m d n l , m u i r n h l n l K T m a n i s i i CT guided drainage a a : m r l h i d i j $ m r id81 A

o i n - ~ s ~ t i $ u mr i i surgical drainage r a i i n a r r:uiunuosoon im:$mi~ouoasiu~miuoenotiia

L ~ u s w o

Hemobilia q f i ~ n ~ r d w u ! $ ~ o u a : 0.3 -1.2 (75) $saiinoin pseudoaneursym ~ia 'a i imndi

biliary system Inu@laufi o i n i r d a a w " o s ~ i u v a i u u iwdos iaun'sJGnia:idonoonluwia~~~ioin~s

d a u u u un:oiaiimarlni<a sepsis(76) o~mroianu!kduiuw~oddn~~wa"~nird~~n n i s i r i a 5 u i i

18%mu side viewing duodenoscopy iw"aoioo:wuademaanoin ampulla of Vater iaa:ii EFWC

(77) ~in:5'6 Technetium-tagged red blood cell scan n i s l g ' 6 selective hepatic artery

angiography i ia:ii embolization i8u?;n-Irluniriria<udZd4~ ~in:aimrn%lni#uia"omd

uimdud~4uniin~dii1lXi~onoon!8 o ia16 '6 percutaneous transhepatic cholangiogram (78) B c~sdauu-Ino:fn~i~ii~aTmu intervention ni.jditne:iilun.j~diinirlmi$o v i o l n j a i u i r n s " n ~ i 1 ~ 0

intervention 7 ; i i T n u d i l i 4 i l d i w d a vessel ligation aiiinu~iub~nirdi~n.46"ouu-In

Bilhemia a;nainmruimi8uvoqp1iqi~u~i~1u~u ia4~6un15uinb~u~~9~a~nba"o~~i~u~u

i~unirfteu~ouoawnomia"on~iibn:w'o~i~~u~u (Biliovenous fistula) mraawuiia:nusiun~qiirn~u d Q nl 1975 wu!$&uslin {daua:fioiniri~n"o.avu a i ~ i r o i i n i ~ ~ ~ ~ ~ u ~ m u n i r i i ERCP (79) r n r i n ~ i i i

44 0,

wmuaa kiirimrii hepatecotmy, mrld T-tube, mr~njIKiuminlnGuii~mrinirmiuB~

a d

i d n f i n i r u i n d u v o a k mrnuiuiumtni.rdd~miau~unir~i~n hidum'?uu$dau, im?uudud

n i r d i r i n aa~wadi ta iRWn51~duqw ua:ranita ii 4 quadrant packing i i m s f i i u i b o n i d o ~ h 1 idu

manual compression, Pringle maneuver, packing idei~uiiim~i.rLa"8m~on1~w"ai~n~l.d1

4 i i 8 u 8 o ~ i i damage control w i s a i u i s a i i definite repair 1; win.Fiois~ii ia"aii i iniruini8uu~~

retroperitoneal vena cave lfi damage control by perihepatic packing aini fu l i ina"uu1

resuscitation i a d ICU i i61v acidosis, hypothermia, ua:biWwym4ia8u80~w"air~i

ernbolization, i f ! o ~ r i i u 72 $aba-run:$dauii~~~im~wdZ$u nasloi laparotomy pad onnoa: Q

adis:~q'swa~awsn4oudoioa:~~nvu

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