Liver rupture

　　The liver is the largest solid organ in the abdominal cavity, with fragile texture and easy to be injured. In various abdominal injuries, liver laceration accounts for 15-20%. Liver laceration is divided into primary liver laceration and secondary liver laceration. The bleeding from liver laceration is mostly due to primary liver cancer laceration, but there are still a small number of cases due to liver benign lesions and liver cirrhosis nodules. This disease is often caused by external force or trauma after the liver itself is damaged.

　　Liver laceration can be complicated by severe hemorrhagic shock.

　　Hemorrhagic shock is a rare disease characterized by acute onset of severe shock, encephalopathy, and other symptoms in previously healthy children, leading to death or extremely severe neurological damage. It mainly occurs in infants aged 3 to 8 months (with an average age of 5 months). There are also reports of occurrence at the age of 15.

　　After liver laceration, there may be bile leakage into the peritoneal cavity, so abdominal pain and peritoneal irritation are more obvious. After liver laceration, blood may sometimes enter the duodenum through the bile duct, causing melena or hematemesis (i.e., biliary hemorrhage).

　　1. Subcapsular liver laceration

　　Only right upper quadrant pain, which can radiate to the right shoulder and back, with expansion of the liver dullness.

　　2. Complete liver laceration

　　Manifested as hemorrhagic shock, due to the entry of blood and bile into the peritoneal cavity, and the stimulation of the peritoneum is more obvious, with abdominal pain, muscle tension, tenderness, and rebound pain; there is mobile dullness, disappearance of bowel sounds, and abdominal puncture can withdraw blood mixed with bile.

　　3. Occasionally, blood enters the digestive tract through the bile duct, causing hematemesis or melena.

　　The prevention of liver laceration mainly involves avoiding injury factors or preventing liver laceration after injury.

　　1. Rest in bed, control diet, use painkillers, hemostatic agents, and antibiotics, and closely observe the pulse, respiration, blood pressure, and overall condition.

　　2. In the case of open wounds, clean cloth should be used to pack and bandage to stop bleeding first.

　　3. For shock patients, they should be placed in a flat lying position with the head slightly lower, attention should be paid to keeping warm and maintaining a clear respiratory tract, and they should be rushed to the hospital for rescue.

　　4. After the above emergency treatment, the patient should be sent to the hospital for emergency surgical treatment as soon as possible.

　　Patients with liver laceration can choose the following examinations according to the condition of the disease:

　　1. Laboratory examination: When there is bleeding from a ruptured solid organ in the abdomen, the values of red blood cells, hemoglobin, and hematocrit decrease significantly, and the white blood cell count may slightly increase. In the case of a ruptured hollow organ, the white blood cell count increases significantly.

　　2. B-ultrasound examination.

　　3. X-ray examination.

　　4. CT examination.

　　5. Radioisotope scanning.

　　6. Diagnostic abdominal puncture and lavage.

　　7. Laparoscopy.

　　For liver laceration patients, especially pay attention to avoiding the consumption of stimulating foods, and focus on light diet.

　　1. Pay attention to rest for liver laceration patients, avoid spicy, stimulating, high-fat and greasy foods, eat light diet, eat more vegetables and fruits and coarse grains, and supplement vitamins, proteins, and trace elements.

　　2. Strengthen nutrition, pay attention to rest, drink more water, and can take oral protein powder, and a small amount of fish and shrimp can also be eaten. Choose high-protein, high-vitamin, low-fat diet from liquid diet to regular diet, from small meals to normal diet. Pay attention not to eat difficult-to-digest and spicy foods.

　　The clinical treatment methods are different according to the symptoms and manifestations of liver laceration.

　　1. Surgical management

　　1. Temporarily control bleeding. As soon as the injury situation is determined, the abdomen should be rapidly opened to gain control over bleeding time. The surgical incision should be sufficiently large to fully expose the liver. After entering the abdominal cavity, it is often due to the copious bleeding that affects the exploration of the injury. At this time, the operator should quickly wrap a thin catheter or a thin strip around the hepaticoduodenal ligament, tighten it to occlude the blood flow into the liver. At the same time, the first assistant uses a suction device to remove the accumulated blood in the abdominal cavity. Rapidly cut open the round ligament and falciform ligament, and explore the visceral and diaphragmatic surfaces of the left and right lobes of the liver under direct vision. It should be pointed out that during the exploration process, it is necessary to avoid excessive forceful traction of the liver to prevent deepening the lacerations on the liver and causing more bleeding. If there is still a large amount of bleeding from the liver laceration even after complete occlusion of the blood flow into the liver, it indicates that there is an injury to the hepatic vein or inferior vena cava. Fill the wound with gauze pads to stop the bleeding and quickly cut open the coronary ligament and triangular ligament on the injured side of the liver. Expose the second or third hepatic portal and investigate it. Then, according to the condition of liver injury, decide on the appropriate surgical method. In the surgical management of liver trauma, temporarily occluding the blood flow into the liver at normal temperature is the simplest and most effective method of temporarily controlling bleeding, which has been widely used in clinical practice. In normal individuals, the safe time limit for occluding the blood flow into the liver at normal temperature can reach about 30 minutes; when the liver has pathological changes (such as liver cirrhosis), the time limit for occluding the blood flow into the liver should not exceed 15 minutes.

　　2. For simple liver lacerations with a depth less than 2cm, debridement is not necessary. Simple suture repair is sufficient. For severe liver trauma, thorough debridement and hemostasis are one of the key steps in surgery. Because there may be necrotic liver tissue at the wound site, there may be liver tissue fragments or foreign bodies in the wound, and there may be active bleeding deep in the wound. If thorough debridement is not performed to remove necrotic liver tissue and foreign bodies, it may lead to adverse consequences. During debridement, it is usually necessary to temporarily occlude the first hepatic portal at room temperature, then cut the damaged edge of the liver capsule with an electrosurgical knife, and use finger dissection to separate the necrotic liver tissue until normal liver substance is reached. After clearing the damaged liver substance, the injured blood vessels and bile ducts at the liver断面 can be exposed, clamped, and ligated or sutured. For larger blood vessels (portal vein, hepatic vein) branches or bile duct injuries, 5-0 non-traumatic suture is used for repair. After releasing the hepatic portal occlusion, observe for 3-5 minutes. Confirm that the wound has been thoroughly debrided and completely hemostasis before placing a pedicled omentum strip into the liver wound and then performing a mattress suture around the liver edge.

　　3. If the liver injury is severe, a debridement liver resection should be performed to retain as much normal liver tissue as possible, reducing the mortality rate and the incidence rate of postoperative complications.

　　4. The method of packing with gauze blocks still has certain application value. Recent experience shows that in some cases, such as when it is not possible to perform thorough hemostasis surgery for severe liver trauma due to the conditions or technical capabilities of the hospital, in order to control the bleeding from the liver wound as soon as possible and save the patient's life, it is necessary to use gauze packing to win time for the transfer to a higher-level hospital. For example, due to a large amount of blood loss and a large amount of transfusion of stored blood, there is a disorder of the coagulation mechanism, and the liver wound bleeds extensively and is difficult to control. In this case, it is necessary to immediately pack and compress the wound to stop bleeding and terminate the operation. In the past, it was believed that in order to prevent secondary infection, the gauze used for packing and hemostasis should be gradually removed within 3-5 days after the operation. Now it seems that this period is too short and is an important reason for rebleeding after the gauze is removed. As a gauze used for packing and hemostasis, it can be gradually removed 7-15 days after the operation. When packing the gauze, 2-3 drainage tubes can be placed around it to timely drain the exudate around the liver wound, which is an effective measure to prevent local secondary infection.

　　Second, non-surgical treatment

　　Indications for non-surgical treatment:

　　1. Upon admission, the patient is conscious and can correctly answer the doctor's questions and cooperate with physical examinations.

　　2. Hemodynamic stability, systolic blood pressure above 90mmHg, and heart rate below 100 beats per minute.

　　3. No signs of peritonitis.

　　4. Ultrasound or CT examination determines that the liver injury is mild (Ⅰ～Ⅱ degree).

　　5. No other internal organ injuries were found. During the conservative treatment process, it is also necessary to clarify the following two points:

　　(1) After receiving 300-500ml of intravenous infusion or blood transfusion, the blood pressure and heart rate quickly return to normal and remain stable.

　　(2) Repeated ultrasound examinations prove that the liver injury condition is stable and the amount of blood in the abdominal cavity has not increased or has gradually decreased. However, when the indications for non-surgical treatment are not clear or there is not much confidence, it is necessary to be cautious.