Liver Suture Research Articles

Rare Complication of Cardiopulmonary Resuscitation-Liver Injury.

Background and Objectives: Liver injury is a rare complication of cardiopulmonary resuscitation. Correct and early diagnosis and treatment are essential. The clinical signs of injury may be masked by the cardiac arrest. We present a single-centre retrospective observational study of traumatic liver injury after cardiopulmonary resuscitation. Materials and Methods: A retrospective analysis of the patients treated for liver injury after cardiopulmonary resuscitation was conducted. Demographic data, the cause of resuscitation, the duration of restoration of spontaneous circulation (ROSC), and the surgical approach were analysed. Results: We have treated nine patients with severe liver injury after cardiopulmonary resuscitation. The diagnosis was made on the basis of cardiopulmonary instability, a fall in the erythrocyte count in eight cases, and was confirmed by CT or ultrasound examination. The last one was diagnosed accidentally on MR. Surgery, in cases of unstable patients, was followed immediately after a diagnosis. We combined liver sutures and intra-abdominal packing with a planned second-look surgery. Five of the nine patients survived. Conclusions: Liver injury after cardiopulmonary resuscitation is rare and is associated with high mortality. The recurrence of cardiopulmonary instability and/or a low or falling red blood cell count are the main signs of this injury. Bedside ultrasound and CT scans are the most important methods to confirm the diagnosis. The rule of surgical repair is the same as in all liver injuries, regardless of aetiology. The key factors for survival include early diagnosis, together with the length of restoration of spontaneous circulation (ROSC).

Surgical Techniques for Severe Liver Injury: A Comprehensive Review of Current Approaches and Advancements

In abdominal trauma, the liver is the most injured organ and treatment is usually determined by hemodynamics. Severe liver injury with extensive parenchymal injury and uncontrollable bleeding may rapidly evolve into the lethal triad of death (acidosis, hypothermia, and coagulopathy), requiring damage control surgery (DCS). Damage control resuscitation for trauma treatment reduces the need for DCS by enabling rapid control of massive bleeding. Thus, definitive surgery can be completed in one operation. Despite the systematic application of damage control resuscitation, definitive surgery cannot be achieved in severe, and extensive liver injuries. Therefore, understanding, and acquiring damage control surgical techniques is necessary to achieve DCS for severe liver injury. The Western Trauma Association and the World Society of Emergency Surgery have proposed algorithms for the nonoperative and operative management of blunt hepatic trauma. The algorithms list several surgical skills, including electrocautery or argon beam, manual compression, perihepatic packing, the Pringle maneuver, liver suture, omental packing, selective hepatic artery ligation, balloon tamponade, hepatic vascular isolation, and the shunt operation. These techniques require a multidisciplinary approach and individual honing of skills by the surgeon. Trauma surgeons, even hepatobiliary surgeons, must practice damage control techniques in severe liver injury models (animals or cadavers).

Successful Resuscitation Using Extracorporeal Membrane Oxygenation of 2 Patients With Severe Liver Rupture: A Case Report

Extracorporeal membrane oxygenation is a rescue treatment for respiratory or cardiac failure. Its use is limited in patients predisposed to bleeding due to heparin administration. We present 2 patients with deranged coagulation after liver rupture successfully treated by extracorporeal membrane oxygenation. One patient with cardiac arrest developed a liver laceration during resuscitation. Liver suture was performed, but acute respiratory distress syndrome (PaO2/fraction of inspired oxygen, 50) necessitated venovenous extracorporeal membrane oxygenation. The other patient suffered hemothorax, thoracic aorta dissection, and liver rupture. Liver segments VI and VII were resected. Endovascular aneurysm repair of aortic dissection and venoarterial extracorporeal membrane oxygenation were performed. Both patients survived without neurological sequelae.

ON THE THRESHOLD OF VIRTUAL ANATOMY

The lack of a sufficient amount of anatomical material in Ukrainian medical universities has led to the fact that medical students have to work with the bodies of long-dead people whose condition is of a low educational value. Therefore, animal organs are becoming increasingly important in teaching anatomical disciplines. For example, when studying the eyeball at the department of human anatomy, a bull's eye is used; organs of pigs and rats (larynx, trachea, bronchi, lungs, heart, etc.) are used for the purpose of comparative anatomy. Working with the heart of animals, students can learn to suture wounds of the heart using various surgical techniques, perform mitral commissurotomy. To put various types of liver sutures and to perform on liver resection at practical classes, pork or beef liver can be successfully used. Isolated stomach and intestines are indispensable for developing skills of surgical interventions on the hollow organs of the gastrointestinal tract. When studying a human skeleton, it is very helpful to use mock-ups that were obtained using a 3D printer that arouses the interest of students and increases the effectiveness of practical training. In the absence of anatomical material, medical students use the latest computer technology that allows them to study the human body in three dimensions. However, technical means make it possible to obtain only visual information, ignoring the volumetric and spatial characteristics of the objects under study that is their considerable drawback.

Gossypiboma: Is it always what it appears to be? A Rare Complication in Everyday Practice

Background: While the management of liver injury is usually conservative, the major indication for surgery remains hemodynamic instability. Different techniques are described for hemostasis in cases which require surgery. Several commercial hemostatic agents are readily available and can be used as an adjunct after the repair of the liver injuries. One of the most well-known local agents is gelfoam, which is used in multiple fields of surgery. The aim of this work is to present a very rare complication while using gelfoam, mimicking gossipiboma.
 Design: A case study describing a hemodynamically unstable patient who suffered from a penetrating liver injury. Hemostasis was achieved by liver suture and Gelfoam with subsequent angioembolization. In the post-operative period, the patient demonstrated signs of intraabdominal sepsis due to liver abscess. Repeated attempts of percutaneous drainage failed, and all cultures were negative. Due to a strong suspicion of a forgotten abdominal pad (gossipiboma), the patient was operated on and the object was removed. The final pathological report showed no textile in the specimen, the findings were compatible with a piece of gelfoam without any signs of absorption.
 Discussion and Conclusions: Commonly used hemostatic agents are made of gelatin gelfoams, microfibrillar collagen, thrombin, and fibrin sealant. Gelfoam is available in sponge or powder form. The sponge can be left in place and is supposed to be completely absorbed in four to six weeks. We found in the relevant literature only one case of gelfoam use related to granuloma formation. In our case, the radiologic findings in the liver were interpreted as an abscess. The suspicion of a foreign body was raised only during his second admission and thus forced us to operate. There is no clear reason why the piece of gelfoam wasn’t absorbed in that time period. Our assumption is that post angiography liver ischemia may have disturbed the process of fibrin destruction. The possibility of such condition should be considered when liver angioembolization is performed adjunct to surgical hemostasis using gelfoam.

An Integrated Suture Simulation System with Deformation Constraint Under A Suture Control Strategy

Current research on suture simulation mainly focus on the construction of suture line, and existing suture simulation systems still need to be improved in terms of diversity, soft tissue effects, and stability. This paper presents an integrated liver suture surgery system composed of three consecutive suture circumstances, which is conducive to liver suture surgery training. The physically-based models used in this simulation are based on different mass-spring models regulated by a special constrained algorithm, which can improve the model accuracy, and stability by appropriately restraining the activity sphere of the surrounding mass nodes around the suture points. We also studied the kinematic model to update the status of suture points in real time, according to an external force exerted by the operators, which can sense synchronous force feedback in return as well. Moreover, in case that the sutured wounds tear open again, a suture control strategy is designed to ensure the stability of the whole suturing procedure. Several experiments are carried out to validate the model performance in terms of model accuracy, suture control effects, and comprehensive training effects. The experiment results show that the proposed models have realistic visual and haptic feedback, stable control on the suture, as well as good training effects as an integrated liver suture surgery system compared to other suture simulation systems which only simulate suture on a single kind of soft tissue.

Surgical treatment of combined thoraco-abdominal injury of liver with the mechanism of the hydrodynamic shock (case report)

This article presents a clinical case of successful multilevel treatment the combined gunshot wound of liver with the mechanism of hydrodynamic shock using «damage control» tactic. The patient received a combined thoraco-abdominal injured as a result of warfare on the east of Ukraine. The blind fragmental penetrating trauma of the chest cavity led to the rupture of the right dome of diaphragm and liver (S3–S6) by the mechanism of hydrodynamic kick (fragments the wreckage and input/output openings in the abdominal cavity were not found). The «damage control» tactic was implemented as follows. On the second level of medical care the rupture of the liver parenchyma eliminated by repeated firmwares with omentopexy. The post-traumatic period proceeded with the several consecutive complications: cutting the liver sutures, the arrosive bleeding from the right hepatic artery and the irreversible ischemia of the liver S5-S6. These complications were liquidated gradually on the IV level of medical care by the transpupillary choledochal stenting, vascular suture and the imposition of a typical anatomical resection of liver S5–6. Successful treatment of patients with the severe fragmental gunshot thoraco-abdominal injuries should be based on a clear understanding of the stages of traumatic disease and expected complications of parallel conduct medical evacuation, using «damage control» tactic on the all levels of medical care.

Pedicled omentum hepatorrhaphy in blunt hepatic trauma

Background: The liver is the most common solid viscera injured in motor vehicle accidents. Advances in radiological diagnostic techniques and critical care have increasing trend towards the nonoperative management. Still operative management is needed if there is continuous bleed or haemodynamic instability. The omentum commonly known as policeman of abdomen as it reaches intra-abdominal injury site. It is known to adhere to the site of injury and seals it. It increases the vascularity and starts neoangiogenesis. This produces haemostasis and promotes wound healing.Methods: In this study 24 patients were managed by this technique of pedicled omentoplasty. These patients were in the age group of 22 to 42 years. There was male dominance, 22 patients were males (91.7%) while only 2 patients were females (8.3%). The use of omentum in packing is described here. The omentum is converted to a pedicled flap based on right omental artery by tailoring it. The active bleeding vessels can be ligated. The whole length of pedicled omentum is packed in liver cavity. Using liver sutures two or more sutures are applied for stabilization.Results: On exploration, the hepatic injury was assigned grade as per AAST liver injury scale. Out of 24 patients included in this study; two (8.33%) were grade I patients, three (12.5%) were grade II patients, nine (37.5%) were grade III patients and ten (41.67%) were grade IV patients. Patients with grade V and grade VI were dealt by perihepatic packing as damage control surgery were excluded from this study.Conclusions: Pedicled omentoplasty in blunt hepatic trauma can be used irrespective of the grade of liver injury. It should be used in combination with other procedures like debridement, segmental or unsegmental resection, control of active bleeding vessels, use of Pringles manoeuvre, selective hepatic artery ligation and even with deep mattress suturing. This helps in haemostasis, early healing and rapid recovery with minimum complications.

Surgical management of bull horn injury

Background: Bull horn injuries are very frequent, especially in areas with a strong bullfighting tradition professional or amateur all over the world though it is uncommon in India. Methods: A retrospective study of patients admitted to department of general surgery in IGGMC, Nagpur which is tertiary care hospital in central India with the diagnosis of wound by bull horn, between January 2002 and March 2016 was done. Sixty seven patients with bull horn injury were included prospectively. Results: The vast majority of patients were male (80%), with only 13 women (20%). Male: Female ratio was 4:1. The mean age was 34 years for men and 28 years for women. The commonest site of injury was in the abdomen followed by the perineum, back and lower limb. The repair includes, 3 mesentric tear , 2 ileal perforation primary closure, 1 liver suture, 1 splenectomy, 1 gastric perforation primary closure, 1 bladder rupture primary closure, 1 primary closure of sigmoid perforation with proximal colostomy,1 primary repair of anorectal tear with functioning colostomy and 1 femoral vein repair. Perineal wound treated by primary repair and a de-functioning colostomy. The patient with partial avulsion of the scrotum was treated by a secondary closure. The average hospital stay was 7.9 days. Overall wound infection rate was 12.9%. Conclusions: In rural India, bull is very useful animal for domestic and farming purpose. Early surgical treatment is required to prevent further morbidity and mortality.

Electronic Poster Presentations, Maternal Fetal Medicine

Electronic Poster Presentations, Maternal Fetal Medicine

The Evolution of Liver Injury Diagnosis and Treatment in the Past 50 Years

ABSTRACTBackgroundDuring the past 50 years many changes have occurred in treating liver injury. Nonoperative therapy (NOT) for blunt penetrating injuries is now common.Study designThis report highlights the current therapy of liver injury.ResultsComplications of NOT include early rebleeding requiring prompt operative intervention; intrahepatic hematoma which becomes infected necessitating drainage; bile peritoneum requiring exploration and drainage; and hemobilia requiring embolization, hepatotomy with ligation, or resection. Operative exposure through a midline incision which can be extended as a median sternotomy is preferred. Prehepatic and intrahepatic packs are helpful. Full mobilization of the right and left triangular ligaments augments exposure. Hemostasis for both blunt and penetrating, usually, is obtained by hepatorrhaphy using the 2’ blunt tipped needle swedged onto a 2-O chromic suture. Through-and-through injuries may require hepatotomy with intrahepatic ligation of cross-linking vessels. Locally destructive wounds may require nonanatomic debridement to the point of healthy liver tissue which is then sutured. Formal segmentectomy, or lobectomy, is seldom needed. Hepatic artery ligation controls deep arterial not involving the portal venous supply. The retrohepatic caval atrial shunt will facilitate hemostasis from central liver injuries involving the hepatic veins or retrohepatic cava.Debridement of emacerated liver tissue should be extended to good liver parenchyma where deep liver sutures help with approximate the edges.Drainage is not used for minor injuries. Closed suctions are best for larger wounds. Common duct drainage should be avoided.ConclusionMost liver injuries are treated by NOT. Operative therapy involves hemostasis, debridement when necessary, and selective drainage.How to cite this articleLucas CE. The Evolution of Liver Injury Diagnosis and Treatment in the Past 50 Years. Panam J Trauma Crit Care Emerg Surg 2014;3(3):124-131.

The Past and Present of Liver Suture

Since the first attempts at resecting parts of diseased livers in the late nineteenth century, hemorrhage has been the main obstacle for surgeons. One of the first hemostasis techniques in liver resection was liver suture. The idea of suturing the liver in order to perform resection was proposed by a team of Russian and Polish surgeons from Kharkiv University in today's Ukraine. The liver suture became widely popular and has been used in various forms throughout the surgical world. Further into the twentieth century, it has lost much of its popularity; however, over more than 100 years of existence it has seen several peaks in interest. Currently, it is still being used by some liver surgeons as it is one of the cheapest ways of obtaining a bloodless liver parenchyma transection.

Embolização arterial no tratamento de hemobilia pós-trauma hepático: relato de caso

Hemobilia é causa rara de hemorragia digestiva e complicação incomum no trauma hepático. Ocorre devido à comunicação entre ductos biliares e vasos intra-hepáticos. Os autores relatam um caso de paciente vítima de ferimento penetrante abdominal que evoluiu, após três meses da hepatorrafia, com dor, icterícia e hemorragia digestiva. Foi realizada angiografia, que demonstrou pseudoaneurisma de artéria hepática direita, e efetuada embolização com sucesso.

Management of Patients with Traumatic Rupture of the Diaphragm

BackgroundTraumatic rupture of the diaphragm is an unusual type of trauma. In addition, it is difficult to diagnose because it can be accompanied by injuries to other organs. If it is not detected early, the mortality rate can increase due to serious complications. Diaphragmatic rupture is an important indicator of the severity of the trauma. The aim of this study was to investigate the factors affecting the incidence of complications and mortality in patients who had surgery to treat traumatic rupture of the diaphragm.Materials and MethodsThe subjects were patients who had undergone a diaphragmatic rupture by blunt trauma or stab wounds except patients who were transferred to other hospitals within 3 days of hospitalization, from January 2000 to December 2007. This study was a retrospective study. 43 patients were hospitalized, and 40 patients were included during the study period. Among them, 28 were male, 12 were female, and the average age was 42 (from 18 to 80). Outcome predictive factors including hypoxia, ventilator application days, revised trauma score (RTS), injury severity score (ISS), age, herniated organs, complications, and the mortality rate were investigated.ResultsCauses of trauma included motor vehicle crashes for 20 patients (50%), falls for 10 (25%), stab wounds for 8 (20%), and agricultural machinery accidents for 2 (5%). Most of the patients (36 patients; 90%) had wound sites on the left. Diagnosis was performed within 12 hours for most patients. The diaphragmatic rupture was diagnosed preoperatively in 27 patients (70%) and in 12 patients (30%) during other surgeries. For surgical treatment, thoracotomy was performed in 14 patients (35%), laparotomy in 11 (27.5%), and a surgery combining thoracotomy and laparotomy in 15 patients (37.5%). Herniated organs in the thoracic cavity included the stomach for 23 patients (57.5%), the omentum for 15 patients (37.5%), the colon for 10 patients (25%), and the spleen for 6 patients (15%). Accompanying surgeries included splenectomy for 13 patients (32.5%), lung suture for 6 patients (15%), and liver suture for 5 patients (12.5%). The average hospital stay was 47.80±56.72 days, and the period of ventilation was 3.90±5.8 days. The average ISS was 35.90±16.81 (11~75), and the average RTS was 6.46±1.88 (1.02~7.84). The mortality rate was 17.5% (7 patients). Factors affecting complications were stomach hernia and age. Factors affecting the mortality rate were ISS and RTS.ConclusionThere are no typical symptoms of the traumatic rupture of the diaphragm by blunt trauma. Nor are there any special methods of diagnosis; in fact, it is difficult to diagnose because it accompanies injuries to other organs. Stab wounds are also not easy to diagnose, though they are relatively easy to diagnose compared to blunt trauma because the accompanying injuries are more limited. Suture of the diaphragm can be performed through the chest, the abdomen, or the thoracoabdomen. These surgical methods are chosen based on accompanying organ injuries. When there are many organ injuries, there are a great number of complications. Significant factors affecting the complication rate were stomach hernia and age. ISS and RTS were significant as factors affecting the mortality rate. In the case of severe trauma such as pelvic fractures, frequent physical examinations and chest X-rays are necessary to confirm traumatic rupture of the diaphragm because it does not have specific symptoms, and there are no clear diagnosis methods. Complications and the mortality rate should be reduced with early diagnosis and with treatment by confirming diaphragmatic rupture in the thoracic cavity and the abdomen during surgery.

Alterações morfológicas do fígado após secção hepática parcial e omentoplastia

A omentoplastia é um método útil para o tratamento de traumas hepáticos graves. Apesar dos bons resultados dessa tática operatória para controlar a hemorragia, seus efeitos sobre a arquitetura hepática ainda não são bem conhecidos. Dessa forma, o presente trabalho teve como objetivo verificar a influência da omentoplastia em trauma experimental do fígado. Este estudo foi realizado em dez ratos submetidos a secção parcial do lobo hepático direito. Um segmento de omento maior foi introduzido dentro da ferida hepática, que foi suturada com fio de categute simples 5-0. Os animais foram seguidos durante sete (n=5) ou 21 (n=5) dias. Decorridos esses períodos, os aspectos macro e microscópicos do fígado foram avaliados. Todos os ratos suportaram a operação e sobreviveram durante o período estudado neste experimento. Os principais achados foram, no sétimo dia, necrose e abscessos do fígado distal à secção hepática. No 21° dia, a parte distal do fígado tornara-se fibrótica. Concluindo, a omentoplastia é de grande ajuda para controlar sangramentos hepáticos intensos decorrentes de trauma; porém, em ratos, a parte distal de uma ferida profunda muda suas características morfológicas.

Societal impact on surgical education in trauma.

Societal and demographic changes within Detroit have affected the incidence of trauma treated at the Detroit Medical Center. Using liver injury as an index, this phenomenon was studied by comparing 122 patients treated in 1972 with 38 patients treated in 1981. During 1972 76 patients had major injuries, compared to 13 patients in 1981. Intraoperative hemostasis of an actively bleeding liver in 1972 was achieved by liver suture (43 patients), resectional debridement through a nonanatomic plane (three patients), hepatic artery ligation (three patients), anatomic segmentectomy or lobectomy (four patients), and intrahepatic packing with later removal (one patient). During 1981, 13 patients had persistent bleeding requiring intraoperative hemostasis by liver suture (12 patients) or resectional debridement (one patient). This decline in trauma reflects a reduced city population, the dilutional effect of a four-quadrant emergency medical service begun in the mid 1970's, the implementation of a state gun law, and reduced citizen compliance to violence. These changes likely are not unique to Detroit and highlight the need for a National Trauma Registry which would not only help program directors design a meaningful trauma rotation but also help hospital planners accommodate to changes in patient exposure.

Prospective evaluation of hemostatic techniques for liver injuries.

The methods of hemostasis used for liver injuries were evaluated prospectively in 637 patients treated at Detroit General Hospital during a 5-year period. Variables evaluated included severity of injury, presence or absence of bleeding, and methods of hemostasis, The liver injury was either not bleeding or was controlled by temporary pack compression during laparotomy in 325 patients: none of these patients, including the 284 in whom no hemostatic procedure was used, rebled postoperatively. Active bleeding at laparotomy was directly related to the severity of liver injury, and required some hemostatic procedure in 312 patients. The methods of hemostasis were liver sutures (244 patients), nonanatomic resection (30 patients), anatomic resection (21 patients), hepatic artery ligation (nine patients), hepatotomy with intraparenchymal vascular control (five patients), and temporary internal pack with later re-operation (three patients). Rebleeding occurred in eight of the 243 patients who survived (seven after liver sutures and one after nonanatomic resection) and four required re-operation for control of bleeding. Sixty-nine patients with active bleeding died. Death on the table in 38 patients was related primarily to uncontrolled bleeding from liver and major vessel injury. Postoperative rebleeding from the liver occurred in 14 of 31 patients who died after surgery: following initial control by liver sutures (seven patients); anatomic resection (four patients); and hepatic artery ligation (three patients). There was no apparent relationship between any hemostatic procedure and the subsequent appearance of the hepatic ischemia or parahepatic abscess. Based on this experience, the merits and detriments of individual hemostatic procedures are presented.

The Treatment of Ruptured Liver with Absorbable Hemostatics

SURGERY of the liver has lagged behind surgical operations on the other abdominal viscera, mainly because of the difficulty of controlling hemorrhage. However, with the recent development of absorbable hemostatic substances in the form of sponges and packs, control of hemorrhage from the liver can be obtained. The purpose of this paper is to present 3 cases of traumatic rupture of the liver in which hemorrhage was controlled with oxycel and gelfoam. Historical Review In 1888 Langenbuch,1 with mass ligatures, controlled severe liver hemorrhage following partial resection. Kousnetzoff and Penski,2 in 1896, devised a special needle for liver suture. The . . .