Experience With The Finger Fracture Technique To Achieve Intra-Hepatic Hemostasis In 75 Patients With Severe Injuries Of The Liver
- 1 June 1983
- journal article
- Published by Wolters Kluwer Health in Annals of Surgery
- Vol. 197 (6), 771-778
- https://doi.org/10.1097/00000658-198306000-00017
Abstract
The most important concept emerging from the management of complex hepatic trauma is that direct suture ligation of severed blood vessels and bile ducts is the most effective treatment. Three essential maneuvers are necessary: (1) the use of the finger fracture technique to expose the laceration widely, so that individual ligation of severed blood vessels and bile ducts can be accomplished under direct vision; (2) occluding the portal triad for 20 to 60 minutes; (3) closure of the hepatic incision over a viable omental pedicle. Two hundred consecutive patients with hepatic injuries were treated at the Trauma and Shock Unit of Bellevue Hospital between July 1976 and January 1982. One hundred and twenty-five injuries (63%) could be managed by superficial suture and drainage alone; 75 (37%) more extensive injuries required additional therapy; 47 of the 75 injuries required inflow occlusion for periods of up to 60 minutes, with the mean occlusion time of 30 minutes. All patients were pretreated with 30 to 40 mg/kg of Solu-Medrol prior to cross-clamping the portal triad. In addition, the liver was cooled to 27-32 degrees C topically by pouring 1 liter of iced Ringer's lactate directly on the liver surface, monitoring the temperature with an intra-hepatic probe. Ischemia time exceeded 20 minutes in 70%, 30 minutes in 40% and 60 minutes in 7% of patients. This approach, with complex hepatic trauma, has been dramatically effective. There were only four deaths (5.3%). One (1.3%) patient required reoperation for bleeding; three patients (4%) developed perihepatic abscesses; and two patients (3%) developed biliary fistulae that spontaneously closed. An extended right hepatectomy was necessary in the one patient who required reoperation for bleeding. This represents the only case of a formal hepatic resection in this series. Hepatic artery ligation was not employed in any case. These experiences strongly endorse the direct approach to the treatment of major hepatic lacerations by opening a lacerated liver sufficiently to ligate lacerated blood vessels and bile ducts, followed by closure over an omental pedicle. The wide-spread adoption of this technique will probably lower the mortality from massive liver injuries to 5-10%.Keywords
This publication has 35 references indexed in Scilit:
- Atrial-caval Shunting (ACS) after TraumaPublished by Wolters Kluwer Health ,1982
- AN EXPERIMENTAL-STUDY OF SURVIVAL AFTER 2 HOURS OF NORMOTHERMIC HEPATIC ISCHEMIA1980
- FACTORS DETERMINING THE MORTALITY AND MORBIDITY IN HEPATIC INJURIES - ANALYSIS OF 108 CASES1979
- Tolerance of the Human Liver to Prolonged Normothermic IschemiaArchives of Surgery, 1978
- The mythology of hepatic trauma—or babel revisitedThe American Journal of Surgery, 1978
- Management of 1,590 Consecutive Cases of Liver TraumaArchives of Surgery, 1976
- Selective ligation of the hepatic artery for trauma of the liver.1975
- Major Hepatic Resection Using Vascular Isolation and Hypothermic PerfusionAnnals of Surgery, 1974
- Management of Liver Trauma In 811 Consecutive PatientsAnnals of Surgery, 1974
- Management of Blunt Trauma to the Liver and Hepatic VeinsArchives of Surgery, 1968