Liver Trauma (Liver Injury)

52
Liver Trauma Dr. D. Shamrai, Surgical club Armata manus

Transcript of Liver Trauma (Liver Injury)

Page 1: Liver Trauma (Liver Injury)

Liver Trauma

Dr. D. Shamrai, Surgical club Armata manus

Page 2: Liver Trauma (Liver Injury)
Page 3: Liver Trauma (Liver Injury)
Page 4: Liver Trauma (Liver Injury)

• Решение оперировать проникающее ранение живота при наличии перитонита, геморрагического шока, эвисцерации не требует дальнейшего подтверждения УЗИ, КТ, лапароскопии – ни один из этих методов обследования не может изменить решение об операции.

Page 5: Liver Trauma (Liver Injury)

Повреждения печени

Page 6: Liver Trauma (Liver Injury)
Page 7: Liver Trauma (Liver Injury)
Page 8: Liver Trauma (Liver Injury)
Page 9: Liver Trauma (Liver Injury)
Page 10: Liver Trauma (Liver Injury)

Типы закрытой травмы печени

1) Deceleration (shearing) injuries occur in motor vehicle accidents and in falls from a height where there is movement of the liver in its relatively fixed position;

2) Crush injuries follow direct trauma to the abdomen over the liver area.

Page 11: Liver Trauma (Liver Injury)

• Deceleration (shearing) injuries → lacerations between the right posterior section (segments 6 and 7) and the right anterior section (segments 5 and 8), which can extend to involve major vessels;

• Crush injuries → damage to the central portion of the liver (segment 4, 5 and 8) and also may cause bleeding from the caudate lobe (segment 1).

Page 12: Liver Trauma (Liver Injury)
Page 13: Liver Trauma (Liver Injury)
Page 14: Liver Trauma (Liver Injury)
Page 15: Liver Trauma (Liver Injury)

Grade 1

A stabbing injury to the RUQ of the abdomen

Contrast CT demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.

Page 16: Liver Trauma (Liver Injury)

Grade 2

A blunt abdominal trauma

CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.

Page 17: Liver Trauma (Liver Injury)
Page 18: Liver Trauma (Liver Injury)

Grade 3A blunt abdominal trauma

Contrast CT shows a 4-cm-thick subcapsular hematoma associated with parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver..

Page 19: Liver Trauma (Liver Injury)

???

Page 20: Liver Trauma (Liver Injury)

Grade 4A blunt abdominal trauma

CT scan of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-attenuating areas within the lesion represent clotted blood

Page 21: Liver Trauma (Liver Injury)

Grade 4A blunt abdominal trauma

Contrast CT shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the capsular laceration and large hemoperitoneum.

Page 22: Liver Trauma (Liver Injury)

Grade 5A motor vehicle accident

CT demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam.

Page 23: Liver Trauma (Liver Injury)
Page 24: Liver Trauma (Liver Injury)

Степень повреждения печени?

Page 25: Liver Trauma (Liver Injury)
Page 26: Liver Trauma (Liver Injury)

Метод исследования?

Page 27: Liver Trauma (Liver Injury)
Page 28: Liver Trauma (Liver Injury)

Management• Nonoperative management (NOM) for blunt liver trauma (1985,

Тrunkey):

Haemodynamic stability

Absence of peritoneal sign

Availability of CT

Monitor in ICU

Facility of immediate surgery

Absence of other organ injuries

Page 29: Liver Trauma (Liver Injury)

Non-op management (NOM)• При NOM требуют оперативного вмешательства 5-

15% пациентов;• 1-3% пропущенных повреждений кишечника;• Для тупой травмы живота NOM – общемировая

практика с 1987;• Для проникающей травмы живота NOM с 1994 года;• Появление исследований про NOM огнестрельных

ранений печени в последние годы;

НО: «CT scan was mandatory before adopting the NOM».

Page 30: Liver Trauma (Liver Injury)

Operative management• Доступ: срединная лапаротомия или

билатеральный подреберный доступ;• Минимальная мобилизация печени;• DCS (Damage control surgery).

Page 31: Liver Trauma (Liver Injury)

Мобилизация печени

Page 32: Liver Trauma (Liver Injury)
Page 33: Liver Trauma (Liver Injury)

Operative technique/options

– How?• Manual compression• Perihepatic packing. • Pringle maneuver.• Tourniquet • Hepatic vascular isolation • Placement of atriocaval shunt

common

Juxtahepatic venous injury

Page 34: Liver Trauma (Liver Injury)

• Временные способы остановки кровотечения:

- Прием Прингла;- Тампонирование;- Бимануальная компрессия;- Атриокавальный шунт.

Page 35: Liver Trauma (Liver Injury)

Тампонирование

Page 36: Liver Trauma (Liver Injury)

Perihepatic packing

Page 37: Liver Trauma (Liver Injury)
Page 38: Liver Trauma (Liver Injury)
Page 39: Liver Trauma (Liver Injury)

Прием Pringle• До 1 часа;• Длительная компрессия ОЖП опасна;• Если кровотечение из паренхимы печени не

остановлено, значит имеет место повреждение ретропеченочного отдела НПВ.

Page 40: Liver Trauma (Liver Injury)
Page 41: Liver Trauma (Liver Injury)

Venovenous bypass

Page 42: Liver Trauma (Liver Injury)

Мобилизация печени

Page 43: Liver Trauma (Liver Injury)

• Окончательная остановка кровотечения:- катетер Фолей;- баллон Погетти (Poggetti);- резекции печени (секциоэктомии,

атипичные резекции печени, гемигепатэктомии)

Page 44: Liver Trauma (Liver Injury)

by Poggetti

Page 45: Liver Trauma (Liver Injury)

Foley Catheter

Page 46: Liver Trauma (Liver Injury)
Page 47: Liver Trauma (Liver Injury)

Через 9 месяцев после правосторонней гемигепатэктомии

Page 48: Liver Trauma (Liver Injury)
Page 49: Liver Trauma (Liver Injury)
Page 50: Liver Trauma (Liver Injury)
Page 51: Liver Trauma (Liver Injury)
Page 52: Liver Trauma (Liver Injury)

Thank you for attention

Support lecturer by the like armata-manus.comvk.com/armata_manusfacebook.com/armatamanus

Dr. D. Shamrai, [email protected], facebook.com/dmitriy.shamrai