Liver damage

Liver damage are divided into open and closed ones. Symptoms of liver damage is the sum of the phenomena of shock and internal bleeding, and later joined the symptoms of biliary peritonitis. When liver damage is characterized paleness of skin, cold sweat, weakness, or, conversely, agitation, tachycardia, pain and muscular tension in palpation of the right hypochondrium, dullness in sloping areas of the abdomen, positive symptom Shchetkina - Blomberg. The treatment is reduced to emergency laparotomy with stitches for wounds liver and tamponade rupture flap seal on the leg or arm. Poured out the blood should be removed from the abdominal cavity; if no damages hollow organs shows autotransfuzii.
Liver surgery difficult. You must consider the segmental structure of authority, the course of liver and portal veins. With extensive razmesheniya of the liver is removed non-viable tissue within the segment and make drainage of the common bile duct.

There are closed (when an integrity of the abdominal wall) and open (when penetrating wounds) liver damage.
Closed damage the liver is not frequent. They may arise from direct impact, compression and protivoparaz. A direct blow to the region P. breaks it most often localized on the bottom surface or on the top and bottom and only occasionally only on the upper surface. In case of compression, on the contrary, often damaging the top surface P. and only in some cases - of the lower.
When protivogaze suffers mainly the upper surface of P. When falling from a great height in feet or buttocks can be a separation of P. from her ligaments. The end of broken ribs at the time of injury can be introduced in the parenchyma P. and call it heavy destruction. If there are pathological changes parenchyma, especially if the volume of P. increased (malaria, alcoholism, amyloid rebirth, the presence of metastatic tumors), even a small force trauma leads to breaking P. Damage P. may occur in newborns in the production of artificial respiration.


Fig. 24. Multiple cracks diaphragmatic surface of the liver (Nikolaev).

There are various gaps liver. 1. Podepsaly breaks with podepsaly or deep (Central) bruising. The latter usually develop at the time of steep turn the trunk around the longitudinal axis or sharp and strong inflection of a trunk as a result of shifting layers of the hepatic parenchyma. At the same time in the mass of bruises are often cut out pieces of the parenchyma. 2. Breaks with damage capsules: single or multiple cracks (Fig. 24), cracks with deep gaps parenchyma, crush areas parenchyma, remaining in connection with the authority, a complete withdrawal of plots P. 3. Breaks P. combined with damage to the gallbladder and external biliary tract (G. F. Nikolayev). Rare breaks, getting through the entire thickness of the body.
For closed liver damage is characterized by rapidly progressive condition from the first minutes after injury - a combination of the symptoms of shock and internal bleeding. Soon come reflex breathing disorder (breast-type) and circulation; become more prevalent symptoms of acute blood loss - growing pallor of the skin, cold sweat, weakness, often reaktivnost, increased heart rate to 120-140 beats per 1 min., a drop in blood pressure. The faster increases in pulse rate, the worse the prognosis. Quickly growing pain in the right hypochondrium, often with irradiation in the right shoulder, but very sharp pain in my stomach at first does not happen. Their presence speaks sooner about the simultaneous rupture of one of hollow organs. These cases from the very beginning proceed especially hard. Palpation in the area of P. becomes more painful, here is set progressive limited tension of the abdominal wall. Appears stupidity with percussion right iliac region. Symptom Shchetkina - Blomberg positive in all cases. Decreases rapidly as the number of hemoglobin and the number of erythrocytes in early and rapid growth leukocytosis (15 to 30 thousand).
Despite a characteristic picture to make the correct diagnosis can be difficult, especially when the Central hematoma. In case if the damage on, are not recognized in the first 1-2 days and the victim is not killed by the ongoing bleeding, develops a picture of peritonitis, more bile. More favorable flow of the cases subcapsular, especially Central haematomas, but after 1 to 3 days a relatively favorable currents can occur gap hematomas with abundant bleeding in the free abdominal cavity (two-phase breaks P.). Children and the elderly are particularly difficult to carry even a relatively small liver damage.
The Outlook depends primarily on the timeliness of operations, and the severity of blood loss, the age of the victim, the presence or absence of collateral damage to other organs.
Treatment only operational, except for the relatively rare cases when there is no confidence in the gap P. and phenomena blood loss is small and not growing. We must remember that in connection with the fall in blood pressure bleeding from P. can stop and resume after a day or two (two-phase bleeding); in doubtful cases, the need to operate on the patient. Can't operate, if the victims are delivered in a very difficult inoperable condition.

seam Kuznetsova - Pensky
Fig. 25. Seam Kuznetsova - Pensky.

The abdomen is opened on the middle line, if necessary with additional intersection of the right direct muscles. Revision P. begin with a convex surface. Small cracks and breaks parenchyma easily sutured normal interrupted sutures. If deep gaps and significant bleeding before suturing bandage larger damaged vessels or stitched up by Kuznetsov - Pensky (Fig. 25), or stitch the wound edges P. mattress seams (Fig. 26). When razlozhenii individual parcel P., or even share it produce liver resection method, P. Kornev and C. A. Shaka (Fig. 27). If parenchymatous bleeding continues, it is recommended tamponade wounds P. gland, muscle (biological tamponade) or hemostatic sponge. If you have a hard stop bleeding proposed on several (not more than 10-12 minutes to pinch your fingers vessels P., i.e. liver-duodenal sheaf (Fig. 28) and at this time to make edging bleeding vessels. Crushed tissue P. cut off after ligation or flashing "legs". Shed abroad in the abdominal cavity blood together with detached pieces P. removed. In the abdominal cavity injected antibiotics in the solution of Novocain and the wound is sutured in layers tightly, if there is confidence that the bleeding stopped. Otherwise, the area of the wound P. have to DAB. Operation is carried out in continuous drip blood transfusion. When the history of hollow organs can be successfully produce reinfusion blood collected in the abdominal cavity, preliminary having filtered it through several layers of gauze.


Fig. 26. Mattress seams with a deep rupture of the liver (on Tareku).

Fig. 28. Temporary clamping of the liver-duodenal sheaf to stop bleeding from the hepatic artery (Minogue).
liver resection
Fig. 27. Resection of liver way Korneva and Shaka: 1 - first, 2 - a second time.

Open injuries. Stab wounds liver are often combined simultaneously ranada transverse colon, stomach, lungs (of thoraco-abdominal injuries). The wound surface P. smooth, even, much stronger bleeds than during the breaks and razmesheniya. Especially heavy bleeding occurs when damage the surface P. occurring if the injuries are more often than with closed injury. Picture of shock much harder when the blood is poured out, in addition to abdominal, thoracic cavity.
The Outlook is especially heavy when combined injuries and rapidly deteriorating at a belated operations.
The treatment is only operative - laparotomy with suturing wounds of the liver, and with thoracoabdominal injuries and wounds of the diaphragm. In these cases, from the pleural cavity remove the blood, the wound of the chest after processing tightly sewn, then from the pleural cavity sucked off the air.
Gunshot wounds., in the years of the great Patriotic war was 20% of all injuries of the abdomen. The clinical picture of gunshot wounds P. basically the same as it is in closed injuries P., but when two and combined injuries layered symptoms of damage to other organs. Operative treatment; operation is carried out as early as possible, without waiting for the elimination of shock, when the already started transfusion.
The volume and types of intervention P. basically the same as with closed gaps and stab wounds. Some surgeons insist on a thorough surgical treatment of the most gunshot wounds liver, giving special importance to the excision of areas unsustainable parenchyma P., removal of foreign bodies from its fabric and so on, When extensive fire damage to the front upper surface P. recommended podselenie its edges of the anterior abdominal wall, which makes it easier to stop bleeding and the formation of growths.
Of complications in the postoperative period when the damage P. the most frequently observed peritonitis, post-operative shock, operating festering wounds, primary biliary fistula, which are connected with damage of a large intrahepatic bile ducts, and secondary result in abscesses or large bedsore gall turn to tight tamponade wounds P. or from a shell or bullet.