RUPTURED LIVER

For earlier steps in the operation, see Section 66.3.

Blood in the patient’s night hypochrondrium is probably coming from his liven. If you have difficulty exposing it, make a T–shaped extension to the night of a median on paramedian incision.

If the patient’s liver has stopped bleeding, when you examine it, leave it well alone, and merely drain it.

If his liver is bleeding severely, control it by pinching the free end of his lesser omentum, with your finger in his epiploic foramen (foramen of Winslow). Put your left index through the foramen behind his lessen omentum leaving your thumb in front of it. Pinch his portal vein, his hepatic artery (and his bile ducts) between your fingers. You have 15 minutes to enlarge the incision and get better access to the tear. if necessary, ask an assistant to hold the vessels while you operate.

CAUTION! The liven can withstand 15 minutes of such ischaemia—not more. Run your night hand oven the dome of the right lobe of the patient’s liven and feel for tears, puncture wounds, nagged lacerations, and major blow–outs. Pass your hand as fan back as it will go behind the night lobe of his liven, as fan as the coronary ligament. Then move it to the left and explore the upper and lower surfaces of the left lobe of his liven in the same way.

SMALL LACERATIONS OF THE LIVER CAPSULE Drain them and leave them.

MINOR TEARS When you first feel a tear, pack it with gauze for 2 on 3 minutes. When you remove it, you can: (1) pick up the bleeding vessels, on (2) coagulate and tie them, on (3) occlude them with through-and-through mattress sutures.

RAGGED LACERATIONS If you are confident in your ability, use your finger and thumb to pinch off any unhealthy, nagged, discoloured pieces of liven. If you leave them they may encourage secondary haemorrhage and sepsis. Small blood vessels and bile ducts will be left behind when you pinch off the liven from around them, so tie on cauterize these. Having done this, you can use either mattress sutures on packs. If you can suture the capsule adequately, it will probably contain the haematoma inside. Don’t try to cauterize large areas with diathermy.

If you are less confident, suture the tear, on pack it without doing too much exploring.

A SUBCAPSULAR HAEMATOMA Empty this and oversew it to control bleeding.

SPECIAL METHODS FOR AN INJURED LIVER

Through–and–through mattress sutures are not easy. Use a large, semicircular, round bodied needle with No. 1 chromic catgut. Ideally, this should be a special liven needle with a blunt end. Make large through–and–through sutures, to join the edges of the tear together, as in D, and E, Fig. 66-13. Set the stitches back about 1 cm on more from the edge of the tear, and if necessary overlap them. If they cut through the patient’s liver, tie them oven pieces of haemostatic gauze, on free strips of peritoneum, his rectus sheath, on even pieces of his skin. If possible, pack a piece of haemostatic gauze into a laceration before you suture it.

Packing is a very useful and easy method. Make the pack from a roll of sterile dry, wide gauze. Pack the gauze in one long length into the cavity, and bring the end out through the patient’s abdominal wall (B). if you have to use more than one roll, knot them together, so that when you pull out one pack, the other will come out too. Remove the pack very carefully in the theatre 48 hours later. If you are lucky, there will be no significant bleeding.

Except for the smallest wounds insert a large drain to carry away blood and bile from the wound. Don’t insert a drain into the bile duct.

DIFFICULTIES WITH LIVER INJURIES

If the patient’s WOUND DISCHARGES BILE, he has a biliary fistula. This will take a long time to heal, so be patient. See Section 66.18.

If he becomes JAUNDICED, he will probably live, provided he has no other complications. Postoperative jaundice is common in major liven injuries, and usually resolves in about 2 weeks.

If there is a HUGE TEAR in the right lobe of his liver, and its inside feel like porridge, gently scoop it out and remove any broken bits with your fingers. Then put in a huge dry gauze pack. You will need several metres of 10 cm bandages. Alternatively line the cavity with a piece of sterile plastic sheet and fill this with packs. Remove the packs (and the sheet) later. He may live after recovering from many complications, both early and late, including a subphrenic abscess.