4. Historia
Mitología.- Prometeo.
En 1870 Burns describio un paciente que
sobrevivio a una lesion en el higado por
arma de fuego.
Reseccion hepatica por tumores (1887 Carl
Lagenbuch); (1891 William Keen).1902 se
usa sutura absorbible en vez de seda
1908 maniobra de Pringle (Clampaje
completo y en bloque del hilio hepático).
Uso empacado descendio la mortalidad de 30
a 17% despues de la Segunda Guerra Mundial
24. Lesiones Asociados
Lesión esplénica 45%
Fracturas costales 33%
Lesion de duodeno, pancreas asociado
a lesion del lobulo derecho 15%.
Lesion hepatica aislada <50%.
25. Clasficación
Grado Descripción Mortalidad
(%)
I
Hematoma Subcapsular menor 10%, Laceración
menor 1 cm de profundidad
~ 0
II
Hematoma Subcapsular de 10 a 50% o 10 cm,
Laceración: 1 a 3 cm profuncdiada
< 10
III
Hematoma subcapsular mayor 50%, hemamotoma
intraparenquimtoso de más de 10 cm de diametro o
expasnsvios. Laceración mayor de 3cm
10 a 25
IV
Hematomas intraparquimotosos con sangrado activo,
disrrupcion de 25 a 75 % de un lobulo o 1-3
segmentos.
45%
V Disrrupcion de mas 75% de un lóbulo o más de 3
segmentos. Lesiones suprahépaticas. 80%
VI Avulsion de las venas suprahepaticas, grandes
arterias o venas del parenquima hepatico ~100
26. Clínica
Historia Clinica y Antecedentes
Marca del Cinturón
Irritacion peritoneal.
Dolor en cuadrante superior derecho.
Perdida de sangre
Irritación Peritoneal.
Laboratorio: Aumento de enzimas
hepaticas.
35. Manejo Conservador
50% de las lesiones hepáticas ceden
Paciente Pediatricos
Capacidad de cicatrización
Avances de Tomografía
88 a 99% de Exito
6 a 20% Biliomas o Fugas
5%
5
43. Angiografía
80-90 % de exito
Resangrado luego de empacamiento
8-28% de Mortalidad
Yi-Chieh Huang, M.D.a, Shih-Chi Wu, M.D.b Tomographic findings are not always predictive of
failed nonoperative management in blunt hepatic injury.jTh American Journal fo Surgery.2011.01.031
54. Empacado
Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and
effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma
American Journal of Surgery (2011) 201, e5–e14
55. Empacado
Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and
effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma
American Journal of Surgery (2011) 201, e5–e14
56. Empacado
Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and
effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma
American Journal of Surgery (2011) 201, e5–e14
57. Empacado
Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and
effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma
American Journal of Surgery (2011) 201, e5–e14
81. Decisiones Críticas
Operar cuando esta indicado
Pacientes inestables, si el sangrado se
detiene, empacar y terminar la cirugía
Si se va realizar una reseccion, tomar
la decisión temprano
En las resecciones: la experticia
clinica/técnica, y rápidez son
esenciales
82. Reintervenciones
Lactato menor 2.5mmo/L
Deficit de Base menor 4.0 mmol/L
INR menor de 1.25
Temperatura mayor de 35
48 horas
Salomone Di Saverio, Fausto CAtena Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing
perihepatic packing: Single institution 14 years experience at European trauma centre Injurey Int. Care Injured Jana 2012
89. Pronostico
W.L. Sikhondze, T.E. MadibaPredictors of outcome in patients requiring
surgery for liver traumaInjury, Int. J. Care Injured (2007) 38, 65—70
90. Pronostico
W.L. Sikhondze, T.E. MadibaPredictors of outcome in patients requiring
surgery for liver traumaInjury, Int. J. Care Injured (2007) 38, 65—70
91. Bibliografía
1. Greta L. Piper, MDa, Andrew B. Peitzman Management of Hepatic
TraumaSurg Clin N Am 90 (2010) 775–785
2. W.L. Sikhondze, T.E. MadibaPredictors of outcome in patients requiring surgery
for liver traumaInjury, Int. J. Care Injured (2007) 38, 65—70
3. Plackett, T; Bamparas G. The Journal of TRAUMA® Injury, Infection, and
Critical Care • Volume 71, Number 6, December 2011
4. C. Pilgrim, Usatoff Val Role of Laparoscopy in Blunt Trauma ANZ J. Surg. 2006;
76: 403–406
5. Salomone Di Saverio, Fausto CAtena Predictive factors of morbidity and mortality
in grade IV and V liver trauma undergoing perihepatic packing: Single institution
14 years experience at European trauma centre Injurey Int. Care Injured Jana 2012
6. Yu-Chung Chan, Naofumi Nagasueg, Simplified Hepatic Resections With
the Use of a Chang’s NeedleAnn Surg 2006;243: 169–172)
92. Bibliografía
7. Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique
of perihepatic packing: a safe and effective surgical hemostasis and
multidisciplinary approach can improve the outcome in severe liver trauma
American Journal of Surgery (2011) 201, e5–e14
8. Yi-Chieh Huang, M.D.a, Shih-Chi Wu, M.D.b Tomographic findings are not
always predictive of failed nonoperative management in blunt hepatic
injury.j.amjsurg.2011.01.031
9. M.M. Beitner et al. / Injury, Int. J. Care Injured 43 (2012) 119–122
10.Trauma Sociedad Panamaricana de Trauma Segunda Edicion
Notas del editor
1,2,3 70 a 90% no sangran en la lpe
4 y 5 10 a 30% siguen sangrando
mayoria sangrado venoso
mortalidad 56% por hemoarrgai
dos veces mayor al ALT y AST
A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma.
Hemobilia presents as gastrointestinal bleeding with or without abdominal pain and jaundice caused by bile ducts occluded by blood clots. It has been reported immediately after the initial trauma or up to 4 months later,
92% de fallo de manejo conservador
si esta ausente 2% de fallo
96 min de duracion
The associa- tion of DCS strategy with early packing followed by angioembo- lization in patients with grade IV–V injury, resulted in a significant decrease of overall and liver specific mortality rate compared to immediate definitive surgery with resection, sutures or other complex haemostatic attempts (0% vs 36.7% for overall and 0% vs 23% for liver specific mortality) with shorter operative time (92 min vs 127 min)
12 porciento de mortalidad en lesiones grado IV y V vs 36%
69 pacientes ... 11 pacientes manejo conservador solo lesiones 1 y 2
6 u de GRE , 4 PFC y una aferesis de plaquetas mejoran la mortalidad
Tiene que ser usando las marcas antomicas y sobre la el diafragma
All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
controla sangrado de vena porta y arteria hepatica
si el sangrado persiste oscuro y profuso de cara anterior puede ser una suprahepatica3
30 min por 15 de descanso
Reseccion Anatomiaca 50% de mortalidad
Blood loss during parenchyma transection was reduced in 11 right lobectomies (652 mL), 1 3-segmentectomy (300 mL), 14 bisegmentectomies (252 mL), 7 segmentectomies (104 mL), 12 subsegmentectomies (19 mL), 5 wedge resections (7 mL), 18 left lateral segmentectomies (110 mL), and 1 hepatorrhaphy (minimal). There was no procedure-related mortality. A mild bile leakage occurred in 1 case (1.5%) but healed spontaneously.
Vascular isolation may be achieved with atriocaval shunting to bypass the bleeding caval segment, as first described by Schrock et al. in 1968 or femorocaval shunting, as introduced by Pilcher et al. in 1977. However, the non-shunt approach to these injuries resulted in better survival in several studies, including that by Buechter.14 Other methods of vascular isolation include intrahe- patic vascular clamps,15 sequential16 or concurrent17 vascular clamping of the suprarenal cava, suprahepatic cava and portal triad, with or without aortic cross-clamping,13 and interventional endovascular isolation.18 However, total vascular isolation results in prohibitively high mortality and is not recommended.1
apuñalado
la ventaja es que no hay que abrir el trayecto que puede provocar mas coagulopatia
suturas el extremo distal y proximal es dificil
The new protocol (Fig. 1) mandated angiography in all adult patients with liver injury OIS grades 3—5
and in any patient with clinical suspicion of ongoing bleeding, defined as falling haemoglobin and tachy- cardia, or any transfusion requirement where the liver could not be ruled out as a significant bleeding source.
