66.7 Liver injuries

Injuries to a patient’s liver resemble those of his spleen with one critical difference—you can remove his entire spleen, but not his liver. Either massive bleeding kills him quickly, despite all you can do to resuscitate him, or signs of an intra–abdominal disaster develop more slowly. If blood immediately floods his whole peritoneal cavity, the signs are general; if bleeding is less severe, the signs are mostly on the right. Pain at the tip of his shoulder is less common than with rupture of his spleen.

Figure 66.13: CONTROLLING BLEEDING FROM THE LIVER. You can pinch the vessels in the free edge of a patient’s lesser sac (A), pack his liver (B), or suture a tear (C, D, and E). You can also use horizontal mattress sutures (F).

The right lobe of the liver is injured more often than the left. You may find: (1) A minor tear, usually without serious bleeding. Most stab wounds are like this. (2) Ragged lacerations with severe bleeding. (3) Tears of the patient’s hepatic artery, his portal vein, or his hepatic veins or their major branches. Controlling haemorrhage from these vessels is desperately difficult, and most patients die even in expert hands. If his hepatic veins have been injured, a tape has to be passed round his vena cava above and below their point of entry. They then have to be exposed and sutured—a difficult task.

Happily, not all liver injuries are impossibly difficult. The easier ways of controlling a bleeding liver are: (1) To pinch the vessels in the free edge of the patient’s lesser omentum between your fingers temporarily. (2) To pack the tears with gauze for 24 to 36 hours. The main risk of doing this is that severe sepsis may follow. (3) To bind tears together with deep mattress sutures. (4) To use absorbable haemostatic gauze. Experts can excise large parts of the liver, or tie its arteries, relying on the fact that it has two blood supplies—arterial and portal. Even so, their results are usually bad.

The complications, particularly infection, are grave, but a live patient with complications is better than a dead one. The main way to prevent infection is to insert really adequate sump drains (4 to 6 Ch), so that as few clots as possible remain in the patient’s abdomen to become infected.