الفهرس 
ANATOMY OF THE LIVEROnly 14 pages are availabe for public view
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Abstract
THE LIVER IS THE ORGAN MOST COMMONLY INJURED AFTER ABDOMINAL TRAUMA. THE INTERNAL ARCHITECTURE OF THE LIVER IS COMPOSED OF SERIES OF SEGMENT COMBINED TO FORM SECTOR SEPARATED BY SCISSURAE CONTAINING THE HEPATIC VEINS, TOGETHER OR SEPARATELY THEY CONSTITUTE THE VISIBLE LOBES.
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.
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.
Injury to intra-abdominal structures can be classified into two primary mechanisms of injury-compression or concussive forces and deceleration forces. The liver and spleen seem to be the most frequently injured organs, reflecting increased use of CT scanning and concomitant identification of more injuries.
Evaluation and decision making are far more difficult in blunt trauma than in penetrating trauma.
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 chemistries, serum amylase, urinalysis, coagulation studies, blood type and match, arterial blood gas, blood ethanol, urine drug screens, and a urine pregnancy test (for females of childbearing age).
Emergency department ultrasonography seems destined to play an increasing role in decision making in patients with liver trauma, its advantages include its non-invasiveness.
Focused assessment with sonography of patients in hypotensive blunt trauma state for determining the source of hemorrhage is the first priority. In contrast, a negative FAST does not exclude intraperitoneal hemorrhage or organ injury.
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 condoned by the ATLS course can be applied to all cases of critically ill patients, acute care surgery, and trauma.
Fortunately, the majority of blunt liver injuries are not severe and operative management of these patients often results in nontherapeutic exploration because the liver has stopped bleeding. These injuries account for 70-90% of hepatic wounds. The remaining 10-30% of these injuries, however, challenge even the most experienced surgeon.
More significant liver injuries, however, are much more difficult to manage both operatively and non-operatively. Nonoperative management 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.
The operative management of these injuries can be as demanding as deciding whether or not the patient needs an operation following blunt trauma. Despite excellent results with non-operative management, patients with the most severe life-threatening abdominal injuries need emergency surgical treatment.
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.
Conclusion:
* Hepatic trauma is increasing nowadays due to increase motor vehicle accident mostly blunt type.
* Most of blunt hepatic trauma patients can be treated in anon operative way provided that the patient is heamodinamecly stabl.
* Operative management of blunt hepatic trauma, in spite of a method of treatment but carry high incidence of complications.