الفهرس 
Anatomy Of The LiverOnly 14 pages are availabe for public view
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Abstract
The liver is the center of metabolic homeostasis and serves as the regulatory site for energy metabolism by coordinating the uptake, processing, and distribution of nutrients and their subsequent energy products. The liver also synthesizes a large number of proteins, enzymes, and vitamins that participate in a tremendously broad range of bodily functions. Lastly, the liver detoxifies and eliminates many exogenous and endogenous substances, serving as the major filter of the human body.
Liver trauma defined as any parenchymal damage to the liver secondary to trauma, including hematoma, laceration or avulsion, as well as damage to vascular or biliary structures. Motor vehicle accidents (MVAs) continue to account for the majority of blunt hepatic injuries. Blunt injuries account for approximately two thirds of all hepatic injuries.
Signs and symptoms of blunt hepatic trauma include: Upper right quadrant pain, Abdominal wall muscle rigidity, spasm or involuntary guarding Rebound tenderness, Hypoactive or absent bowel sounds, Signs of hemorrhage and/or hypovolemic shock.
In recent years, laboratory evaluation of trauma victims has been a matter of significant discussion. Commonly recommended studies include serum glucose, complete blood count (CBC), serum amylase, coagulation studies, blood type and match, arterial blood gas, blood ethanol, urine drug screens, and a urine pregnancy test (for females of childbearing age).
The right liver and the left liver are respectively drained by the right and the left hepatic ducts whereas the dorsal lobe (caudate lobe) is drained by several ducts joining both the right and left hepatic ducts. The intra-hepatic ducts are tributaries of the corresponding hepatic ducts which form part of the major portal triads which penetrate the liver invaginating Glisson’s capsule at the hilus.
Emergency department ultrasonography seems destined to play an increasing role in decision making in patients with liver trauma, its advantages include its non-invasiveness.
Abdominal CT has become the method of choice for the evaluation of the stable patient with suspected blunt liver trauma. Hepatic parenchymal injuries may be defined in terms of: 1.Sub-capsular hematoma, 2.Intra-hepatic hematoma, 3.Laceration, 4.Vascular injury, and/or, 5. Active hemorrhage. Angiography is an extremely valuable adjunct in the management of patients with blunt hepatic trauma.
Magnetic Resonance Imaging is an attractive option for diagnosis. However, lengthening imaging time and limitation with spread availability have previously precluded the utilization of MRI in the workup of blunt hepatic trauma patients.
Diagnostic peritoneal lavage (DPL) is an invasive, rapid, and highly accurate test for evaluating intraperitoneal hemorrhage. DPL plays a role in both blunt and penetrating abdominal trauma. Today DPL is performed less frequently, as it has been replaced by other non-invasive methods.
Diagnostic laparoscopy remains a controversial approach in the setting of suspected liver trauma.
The management of hepatic trauma has evolved through the years. Successful management of hepatic injuries requires attention to detail and sound judgment. A number of points we men¬tioned in this essay regarding management schemes and techniques cannot be over emphasized.
It is clear that the primary goal in the stabilization of trauma and critically ill surgical patients is correction of physiologic derangements. The sequential approach to patients identify by the ATLS course can be applied to all cases of critically ill patients, acute care surgery, and trauma.
The liver is the organ most commonly injured after abdominal trauma. Management schemes for significant hepatic injury have changed throughout the years, al¬though the primary goal of reducing morbidity and mortal¬ity from hemorrhagic shock and sepsis has remained un¬changed. Fortunately, the majority of blunt liver injuries are not severe and operative management of these patients often results in nontherapeutic methods because the liver has stopped bleeding.
Nonoperative management of hepatic injury can be employed regardless of severity of hepatic injury and regardless of the amount of hemoperitoneum that may be present in the abdominal cavity. Thus, following blunt hepatic trauma, nonoperative therapy is the treatment of choice in the hemodynamically stable patient.
Evaluation and decision making are far more difficult in blunt trauma than in penetrating trauma.
Liver hemorrhage can usually be initially controlled by direct pressure using packs. Additional techniques include: Pringle maneuver (digital compression of the portal triad), Bimanual compression of the liver, Manual compression of the aorta above the celiac trunk.
The liver is the most common abdominal organ injured by penetrating trauma. Penetrating trauma of the liver may be caused by bullets, shrapnel, knives, and other sharp objects. In most centers, surgery for stab wounds is performed only in patients in whom internal injury is strongly suspected. Complications from liver trauma occur in approximately 20% of patients and include delayed rupture (very rare), hemobilia, arterio-venous fistula, pseudoaneurysm, biloma and abscess formation.
High-velocity gunshot wounds can be devastating and will require resectional debridement or lobectomy. Isolation of the liver can be temporarily achieved by using Satinsky clamps on the suprahepatic inferior vena cava, , and the porta hepatis.
Severe lesions in the liver are associated with a high mortality rate. Alternative surgical techniques such as the use of an intrahepatic balloon may be effective and reduce mortality in severe hepatic lesions. This study aimed to demonstrate the experience of a university hospital in the use of the Sengstaken -Blakemore balloon in patients with transfixing penetrating hepatic injury as an alternative way to treat these challenging injuries