SURGICAL MANAGEMENt Of LIvER tRAUMA

Liver is the largest abdominal organ that is often affected by injuries due to blunt or penetrating trauma (1). Road traffic accidents and violence are responsible for the majority of liver injuries (2). A high incidence of liver trauma currently is secondary to a dominant role of mechanized transportation and increasing violent behaviour (3). Blunt injuries are dominant in Europe (4, 5, 6), while in The United States of America and Republic of South Africa penetrating injuries are more common, especially gunshot wounds (7-13). Liver trauma are rarely isolated, they are frequently associated with injuries of other abdominal organs (spleen, pancreas, kidney), chest and head injuries (1, 4, 5, 6, 9, 10, 11, 14). Liver wounds are generally minor and do not require surgical intervention, while major wounds, both isolated and associated with other injuries, are difficult to manage and concerned with a high risk of death (1). There are two mechanisms causing blunt liver injuries: deceleration and a direct blow (2, 15). Deceleration occurs during road traffic accidents and falls from height when on impact the liver remains still in move, what results in a laceration of its relatively thin capsule and parenchyma at the sites of their attachment to the diaphragm (2). A parenchymal laceration is usually caused by shearing stresses (16). The liver usually tears between the posterior sector (segments VI and VII) and anterior sector (segments V and VIII) of the right hepatic portion (2). In contrast, a direct blow to the abdomen, by a fist or other blunt object, can lead to crush injury with damage of the central portion of the liver (segments IV, V and VIII) (2). Blunt injuries can also cause disruption of the hepatic parenchyma underneath an intact Glisson’s capsule, causing a subcapsular or intraparenchymal hematoma (2). As the largest abdominal organ, the liver is also particularly susceptible to the ability of compressive abdominal injuries to rupture its relatively thin capsule (3). Penetrating liver injuries are generally secondary to gunshot or stab wounds, with the former usually causing more tissue damage due to the cavitation effect as the bullet traverses the liver parenchyma (2). Because of the rich vascularization of the organ, posttraumatic hemorrhage from the liver can be massive (3). The severity of liver trauma ranges from a minor capsular tear, with or without parenchymal injury, to extensive disruption involving both liver portions with the associated injuries of the hepatic veins and inferior vena cava (2). The liver is partially protected from injury by the overlying ribs of the lower chest (3). However, this location implicates a possibility of producing a characteristic injury called „bear claw” which occurs when the ribs are compressed into the liver and cause typical, curvilinear lacerations across the dome and anterior surface of the right lobe (17). This injury is quite frequent in patients who were involved in a traffic collision as a passenger when the car was hit from the side, because the right portion of the liver is very susceptible to compression by the lateral ribs (17). It is necessary to remember that hepatic injuries can involve not only the liver parenchyma, but also the porta hepatis, hepatic veins and retrohepatic inferior vena cava.