The liver
Surgical anatomy- Largest solid organ 1200-1800gPosition: wedge shape from RT hypochondrium-epigastric- LT hypochondrium. surfaces (2 ) parietal & visceralLesser omentum: fold of peritoneum connect lesser curvature of stomach with the visceral surface of liver. The free border contains :CBD- hepatic A- portal vein. Blood supply & venous drainage :- hepatic A from coeliac trunk- portal vein formed by union of SMV &splenic V.- Three hepatic V drains into IVC Lymphatic drainage: LN at porta-hepatis – coeliac LN– some--- thoracic duct.Surgical physiology- liver is a busy organ-1.5 L of blood/ min. 2/3 portal V – 1/3 hepatic A.Functions :1- formation & secretion of bile.2- CHO, protein & fat metabolism.3- metabolism of many drugs & hormones .4- removal of ammonia.5- liver is the storage house of glycogen, vit.B12, vit.A, iron & copper.6- reticuloendothelial cells clear the blood from bacteria that can escape from the intestine to the portal circulation.
INVESTIGATIONSA– Liver function tests: 1- total serum bilirubin. Direct & indirect.2- AST serum aspartate aminotransferase.3- ALT serum alanine aminotransferase.4- alkaline phosphotase.5- serum albumin.6- prothrombin time.B–Imaging of liver: US- CT- MRI- arteriography C– Liver biopsy: per cutaneous –laparoscopy- laparotomy.
Liver trauma - 2nd common solid organ after spleen. - associated injury: ribs, pleura, lung, colon & spleen. Aetiology: 1- accidental trauma: blunt (RTA) & penetrating (bullet, stab). 2- iatrogenic injury: percut biopsy , PTC. 3- spontaneous rupture (eclampsia, hepatic tumour). Types of injury: 1- small subcapsular hematoma. 2- small superficial tear or tears. 3- large subcapsular or intrahepatic hematoma. 4- large deep tear or tears. 5- shattered liver. 6- vascular injury : most difficult hepatic V Consequences: 1- bleeding. 2- hematobilia.
Clinical features & diagnosis: 1- history of trauma. 2- abdominal pain. 3- abdominal tenderness & rigidity. 4- lower rib fractures. 5- massive bleeding--- hemorrhagic shock. 6- minor bleeding---DPL , US, CT. 7- during laparotomy. Treatment: 1- minor hemorrhage & small tear can be conservatively followed by regular CT. 2- continuous bleeding calls for surgical interference. 3- serious liver injuries require urgent laparotomy.
Principles of surgical management :1- adequate exposure– longitudinal incision.2- arrest bleeding.-small tear---spontaneous.-brisk liver hemorrhage --- packing--- Pringle`s maneuver (clamp, finger) for 20 min.-tying sutures over pedicled omentum , deep transverse mattress sutures using special liver needle.3- hematoma– explore– ligation damaged vessels & ducts & excise dead tissue.4- shattered lobe --- excise the lobe.5- firm packing of inaccessible & difficult bleeding areas e.g hepatic veins.Mortality rate 15-20% & this percentage increase if there are associated injuries.