Liver damage. Symptoms and consequences of liver injury: rupture, bruise and knife wound A bullet wound to the liver is fatal

One of the most severe and deadly injuries is liver rupture. After all, it is a vital organ, its damage always poses a threat to life. Especially if a blow to the liver provokes peritonitis, in which a large amount of blood and bile enters the peritoneum. Only urgent transportation of the victim to a medical facility and qualified actions of personnel can prevent death.

Types of liver ruptures

The cause of the rupture is injuries due to a car accident. A liver bruise occurs when falling from a height or when a person hits sharp objects, a direct blow to the liver. Other provocateurs are a gunshot wound, a knife wound, squeezing the body with heavy objects, which often happens during explosions in residential premises and earthquakes. Sometimes the liver can be torn due to a very strong cough, during labor during childbirth. The injury pattern looks like this: compression, bruise, counter-impact. Depending on the cause of the injury, there are closed liver injuries (without violating the integrity of the skin) and open ones (the integrity of the skin is broken). The following types are known:

Type of break	What's happening?
Subcapsular	A hematoma forms with strong turns or bending of the body. Hematomas can be subcapsular or central. Particles of parenchyma may be found in them.
Parenchymal	In the parenchyma ( soft fabric) cracks, deep tears or crushing are formed. Particles of the organ may separate from it. It is especially often combined with rib injury.
With damage to the gallbladder and liver	Possible intoxication of the body due to the spillage of bile into the liver or peritoneum.
Open	The main danger is open heavy bleeding.
Spontaneous	Occurs due to changes in the structure of the liver when the parenchyma loses its resistance. Cause of condition - chronic diseases(hepatitis, syphilis, cancer, fatty degeneration, long-term alcohol abuse) and pregnancy.
Combined	Damage to the liver is combined with injuries to the spleen, sternum organs, arms, legs, and head.

Symptoms and complications

Peritonitis can occur due to liver injury.

Liver rupture is always a serious condition. Closed injuries are dangerous because in most cases they do not manifest themselves in any way other than a feeling of numbness in the skin at the site of the injury. This happens because there are no nerve endings in this organ.

Therefore, bruises can be diagnosed only in the later stages, when serious and fatal changes begin in the organ. The patient cannot lie on his back, more often on the right side, curled up, the stomach is swollen. A few days after the injury, peritonitis may occur due to hemorrhage. An open liver injury is easier to detect, but life counts in minutes. Liver damage, especially open ones, is always dangerous due to large blood loss or peritonitis and ends in death. The following signs indicate that the liver has ruptured:
frequent shallow breathing;
poorly palpable pulse;
slow heartbeat;
pale skin and mucous membranes;
vomiting or nausea; a fall;
blood pressure
dizziness or loss of consciousness;
severe bleeding from open ruptures;
severe pain with movement or palpation;
retracted stomach;

state of shock.

Complications of injury are quite serious. Abscesses may develop, fistulas or cysts may form, and bleeding may occur. A ruptured liver provokes colic, jaundice, gastrointestinal bleeding - hemobilia. Symptoms of renal and hepatic failure may be observed, as well as the breakdown of organ cells due to the activity of its own enzymes or necrosis. A fatal outcome cannot be ruled out.

Diagnostics

Coagulogram is an indicator of blood clotting. A patient with a rupture must be immediately taken to the hospital. Open wounds are easy to diagnose. Closed ones are more difficult. Used for diagnostics laboratory methods . These include: general analysis

blood, general urine test, biochemical blood test, liver tests, coagulogram (blood clotting test), lipidogram (determines the amount of cholesterol). The diagnosis is made based on changes in indicators. Hardware methods are also used. These include:	Method
What does it show?	Laparotomy
The most informative method. The peritoneum is cut, examined, then surgery follows.	Radiography
Determines how damaged the liver is, as well as the amount of free fluid in the peritoneum.	Tomography: magnetic resonance or computer
Determines the amount of blood accumulated in the peritoneum, whether there is a liver hematoma, what is the length and depth of the damage.	A vinyl chloride catheter is inserted, with the help of which even small ruptures where bleeding progresses are diagnosed. Highly effective method.
Needle paracentesis	The research technique allows you to determine the presence of blood in the peritoneum, even if the patient is unconscious.

Treatment

Treatment of liver injury is carried out in a hospital. His life depends on how quickly the victim is brought there, otherwise he will die from loss of blood. The primary assistance to the patient is to give him a semi-sitting position with his legs bent. During transportation, it is necessary to remove clothing, apply cold to the injured area and inject adrenaline. The patient must not eat or drink. Treatment is only surgical, even if the bruise is closed and symptoms are not expressed. Resection of non-viable areas of the organ and tamponade are performed. Foreign objects are removed from the wound: remnants of clothing, blood clots and stitches are applied. If necessary, other affected organs are also operated on. The operation looks like this:

ruptures are sutured;
using an aspirator, blood is sucked out from the peritoneum;
the surgical incision is sutured;
drainage tubes are removed (they are needed to pump out fluid from the peritoneal cavity).

Liver injuries are divided into closed and open. The symptoms of liver damage consist of shock and internal bleeding, and later symptoms of gallstones are added. Liver damage is characterized by pale skin, cold, adynamia or, conversely, agitation, soreness and muscle tension in the right hypochondrium, dullness in the sloping areas of the abdomen, and a positive Shchetkin-Blumberg symptom. Treatment boils down to urgent laparotomy with suturing of the liver and the site of rupture with a pedicle or muscle flap. The spilled blood should be completely removed from the abdominal cavity; in the absence of damage to hollow organs, autotransfusion is indicated.

Liver surgery is difficult. It is necessary to take into account the segmental structure of the organ, the course of the hepatic and portal veins. In case of extensive crush injuries to the liver, non-viable tissue within the segment is removed, and the common bile duct is also drained.

There are closed (with the abdominal wall intact) and open (with penetrating wounds) liver injuries.

Closed damage liver are not common. They can arise from a direct blow, compression and counter-impact. With a direct blow to the liver area, its ruptures are most often localized on the lower surface or on the upper and lower, and only occasionally only on the upper surface. With compression, on the contrary, the upper surface of the liver is more often damaged and only in some cases the lower surface.

During counter-impact, it is mainly the upper surface of the liver that is affected. If you fall from a great height onto your legs or buttocks, the liver may be separated from its ligamentous apparatus. The end of a broken rib at the time of injury can penetrate into the liver parenchyma and cause its severe destruction. If there are pathological changes in the parenchyma, especially if the liver volume is increased (malaria, alcoholism, amyloid degeneration, the presence of neoplasm metastases), even a minor injury leads to liver rupture. Liver damage can occur in newborns during artificial respiration.

Rice. 24. Multiple cracks in the diaphragmatic surface of the liver (according to Nikolaev).

Various liver ruptures are observed. 1. Subcapsular ruptures with subcapsular or deep (central) hematomas. The latter usually develop at the moment of a sharp rotation of the body around the longitudinal axis or with a sharp and strong bending of the body due to displacement of the layers of the liver parenchyma. In this case, the hematoma mass often contains torn pieces of parenchyma. 2. Ruptures with damage to the capsule: single or multiple cracks (Fig. 24), cracks with deep breaks in the parenchyma, crushing of areas of parenchyma remaining connected to the organ, complete separation of sections of the liver. 3. Liver ruptures in combination with damage to the gallbladder and external biliary tract(G.F. Nikolaev). Rarely there are ruptures that penetrate the entire thickness of the organ.

Closed liver injuries are characterized by a rapidly progressing severe condition from the first minutes after the injury - a combination of symptoms of shock and internal bleeding. Soon reflex disturbances in breathing (thoracic type) and blood circulation occur; symptoms of acute blood loss begin to predominate more and more - increasing pallor of the integument, cold sweat, adynamia, often unresponsiveness, increased heart rate up to 120-140 beats per minute, drop in blood pressure. The faster the heart rate increases, the worse the prognosis. Pain in the right hypochondrium increases quite quickly, often radiating to right shoulder, but there are no very sharp pains in the abdomen at first. Their presence rather indicates the simultaneous rupture of one of the hollow organs. These cases are especially difficult from the very beginning. Palpation in the liver area becomes more and more painful, and a progressive limited tension of the abdominal wall is established here. Dullness appears when percussing the right iliac region. The Shchetkin-Blumberg symptom is not positive in all cases. The amount of hemoglobin and the number of red blood cells drop rapidly with an early and rapid increase in leukocytosis (from 15 to 30 thousand).

Despite the characteristic picture, it can be difficult to make a correct diagnosis, especially with a central hematoma. In the event that liver damage was not recognized in the first 1-2 days and the victim did not die from ongoing bleeding, a picture of peritonitis develops, most often biliary. Cases of subcapsular, especially central, hematomas proceed more favorably, but after 1 - 3 days of a relatively favorable course, the hematoma may rupture with profuse hemorrhage into the free space. abdominal cavity(biphasic liver ruptures). Children and the elderly are particularly susceptible to even relatively minor liver damage.

The prognosis depends primarily on the timeliness of the operation, as well as on the severity of blood loss, the age of the victim, and the presence or absence of concomitant damage to other organs.

Treatment is only surgical, with the exception of relatively rare cases when there is no certainty about the presence of a liver rupture, and the phenomena of blood loss are insignificant and do not increase. It must be remembered that due to a drop in blood pressure, bleeding from the liver may stop and resume after a day or two (biphasic bleeding); in doubtful cases, the patient must be operated on. You cannot operate if the victims are delivered in an extremely serious and inoperable condition.

Rice. 25. Kuznetsov-Pensky seam.

The abdominal cavity is opened along the midline, if necessary, with an additional intersection of the right rectus muscle. The inspection of the liver begins with its convex surface. Small cracks and breaks in the parenchyma can be easily sutured with conventional interrupted sutures. If there are deep ruptures and significant bleeding, before suturing, larger damaged vessels are ligated or sutures are applied according to Kuznetsov-Pensky (Fig. 25), or the edges of the liver wound are sutured with mattress sutures (Fig. 26). When a separate section of the liver or even a lobe of it is crushed, liver resection is performed according to the method of P. G. Kornev and V. A. Shaak (Fig. 27). If, however, parenchymal bleeding continues, then tamponade of the liver wound with an omentum, muscle (biological tamponade) or a hemostatic sponge is recommended. In case of difficult to stop bleeding, it is proposed to squeeze the liver vessels, that is, the hepatoduodenal ligament (Fig. 28) with your fingers for a few (no more than 10-12) minutes and at this time suture the bleeding vessels. The crushed areas of liver tissue are cut off after ligating or stitching the “leg”. The blood that has spilled into the abdominal cavity along with the torn pieces of the liver is removed. Antibiotics in a solution of novocaine are injected into the abdominal cavity and the wound is sutured tightly in layers if there is confidence that the bleeding has stopped. Otherwise, the area of the liver wound must be tamponed. The operation is performed with continuous drip blood transfusion. If the hollow organs are intact, it is possible to successfully reinfuse blood collected in the abdominal cavity, having previously filtered it through several layers of gauze.

Rice. 26. Mattress sutures for deep liver ruptures (according to Torek).

Rice. 28. Temporary clamping of the hepatoduodenal ligament to stop bleeding from the hepatic artery (according to Minogot).

Rice. 27. Liver resection according to the Kornev and Shaak method: 1 - first moment; 2 - second moment.

Open damage. Stab wounds of the liver are often combined; the transverse colon, stomach, and lungs are simultaneously injured (thoraco-abdominal wounds). The wound surface of the liver is smooth, even, and bleeds much more strongly than with ruptures and crushing. Particularly severe bleeding is observed with damage to the lower surface of the liver, which occurs with wounds much more often than with closed injuries. The picture of shock is much more severe when blood flows, in addition to the abdominal blood, into the chest cavity.

The prognosis is especially difficult with combined injuries and worsens sharply with delayed operations.

Treatment is only surgical - laparotomy with suturing of the liver wound, and in case of thoracoabdominal wounds, diaphragm wounds. In these cases, blood is removed from the pleural cavity, the chest wound is sutured tightly after treatment, and then air is sucked out of the pleural cavity.

Gunshot wounds to the liver during the Great Patriotic War Patriotic War accounted for 20% of all abdominal wounds. The clinical picture of gunshot wounds of the liver is basically similar to that of closed liver injuries, but with bilocular and combined injuries, symptoms of damage to other organs are superimposed. Treatment is surgical; the operation is performed as early as possible, without waiting for the shock to be eliminated, with a blood transfusion already started.

The volume and types of interventions on the liver are basically the same as for closed ruptures and stab wounds. Some surgeons insist on careful surgical treatment the gunshot wound of the liver itself, giving particular importance to excision of areas of non-viable liver parenchyma, removal foreign bodies from its tissue, etc. In case of extensive gunshot injuries to the anterior-superior surface of the liver, it is recommended to suture its edge to the anterior abdominal wall, which makes it easier to stop bleeding and form adhesions.

Of the complications in the postoperative period with liver injuries, the most commonly observed are peritonitis, postoperative shock, suppuration of the surgical wound, primary biliary fistulas, which are associated with damage to large intrahepatic bile ducts, and secondary ones as a result of suppuration or bedsores of a large bile duct with tight tamponade of the liver wound or from a fragment of a shell or bullet.

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Among injuries to the abdominal organs, liver ruptures represent a relatively difficult and complex task in diagnostic and therapeutic terms. Despite its fairly dense consistency, the liver is easily damaged, even with a slight impact on it. The liver is covered by peritoneum except for its posterior surface. The peritoneal cover does little to protect it from mechanical stress. Once this covering is damaged, the loose liver tissue is easily torn in any direction. This explains the fact that with closed abdominal injuries, liver rupture occurs relatively often. Due to its sufficient density and low elasticity, bleeding and leakage of bile may occur when a small incision or puncture is made with a needle.

The liver can also be damaged by chest injuries and lumbar region. This is due to the anatomical position of the liver, its large mass and limited movement, its ligamentous apparatus [ML. Aliev, 1997; Yu.V. Biryukov et al., 1997; E.S. Vladimirova et al., 1997]. Being weakly elastic and fixed between the ribs and the spine, it is damaged relatively often in case of closed injuries compared to other organs of the abdominal cavity, especially when it is affected by a pathological process (syphilis, malaria, fatty degeneration, amyloidosis). If there are pathological changes in it, even when exposed to a slight external force, it ruptures.

Classification. There are closed and open, isolated and combined with other organ injuries.

Based on the severity of liver damage, they are divided into 4 degrees:
1) rupture of the liver capsule with light bleeding that does not stop spontaneously or after suturing the capsule; with such damage, the integrity of the liver parenchyma is not impaired;
2) rupture of the parenchyma, in which the bleeding stops after suturing it;
3) deep ruptures of the liver, accompanied by profuse bleeding and symptoms of shock;
4) simultaneous ruptures of the liver, large vessels and IVC; With this type of injury, patients often die at the scene.

Damage to the liver is often combined with damage to other organs of the abdominal cavity, chest, skull and musculoskeletal system.

Closed liver injuries

Such injuries are noted when there is a blow to the right hypochondrium or epigastric region, as well as when there is compression between two objects and debris, ruins, a fall from a height, etc. If there are pathological changes in the liver and a sharp increase in intra-abdominal pressure, even with a minor injury, its rupture may occur. Among abdominal injuries, subcutaneous ruptures of the liver account for 13.2-24.3% [Yu.V. Biryukov et al., 1987; Yu.M. Pantsyrev et al., 1988; Yu.I. Gallinger, 1996; E.I. Galperin, 1999]. Liver injury ranks third among all closed abdominal injuries. In peaceful conditions, liver damage often occurs in car and train accidents. It should be noted that statistical data regarding the number of closed liver injuries is less than their actual number, since a significant proportion of victims die at the scene of the incident or during transportation to a medical facility, and often in medical institutions with an unclear diagnosis.

Rib fractures play an important role in the mechanism of closed liver injuries. This often causes damage right lobe liver. Closed liver injuries are often found in men of working age (18-40 years). The nature of liver damage depends on the mechanism of its occurrence. When mechanical force is applied to a limited area of the liver, crushing of it and adjacent organs and tissues occurs. When falling from a height or with strong pressure on the liver, extensive crushing, tearing off of its individual sections, and damage to other organs of the abdomen and chest can occur.

Pathological anatomy. Liver ruptures can be isolated and combined with neighboring organs (stomach, duodenum, transverse circulatory system). With thoracoabdominal injuries, the chest organs may also be damaged along with the liver. Liver ruptures are often accompanied by damage to the gallbladder and extrahepatic bile ducts. Liver damage can be accompanied by a violation of the integrity of the capsule or without it (Figure 7, 8).

Figure 7. Liver rupture (crack)

Figure 8. Liver crush

In some cases, the liver tissue may be crushed or individual parts of it may be torn off. Injuries to the liver without compromising the integrity of the capsule are called subcapsular ruptures. The latter may take the form of central hematomas.

Clinical picture and diagnosis. The clinical picture of closed liver injury is determined by the nature of the damage. In this case, relatively mild and severe courses are noted. The severity of the patient is mainly determined by the amount of intra-abdominal bleeding and traumatic shock. With subcapsular hematomas and superficial ruptures, the patient's condition can be relatively satisfactory. In case of significant or multiple ruptures, crushing or separation of individual parts, the condition of the victims can be very serious. Immediately after the injury, symptoms of shock predominate, and later symptoms of internal bleeding develop: pallor, cold sweat, tachycardia and hypotension. During the erectile phase of shock, patients are restless, scream excitedly, and often change position. Breathing is rapid, shallow, blood pressure is normal or elevated, the skin and visible mucous membranes are pale.

Some patients experience a forced position, changing which causes the pain to intensify ("stand-up" syndrome). Immediately after the injury, the abdomen is tense and retracted. When examining a patient, abrasions, hemorrhages, rib fractures, etc. are sometimes noted in the liver area. Patients are very restless and complain of severe abdominal pain. The pulse progressively increases, blood pressure drops. The level of blood pressure depends on the severity of the lesion and the amount of blood lost. Feeling the abdomen can be painful, especially in the area of injury. When percussing the abdomen, a dullness of the percussion sound is noted, its location changes when the patient’s position changes (symptom of movement). The amount of blood poured into the abdominal cavity can reach 2-3 liters. Bleeding does not stop spontaneously, since mixing bile with blood reduces coagulability. As a result of the absorption of bile pigments, bradycardia may occur. With closed liver injuries, it is not always possible to make a diagnosis and determine the nature of the damage before surgery. Despite this, the overall clinical picture is dominated by damage to the intra-abdominal organ, which requires urgent surgical intervention.

If intra-abdominal bleeding is suspected, it is recommended to perform a puncture of the abdominal cavity and laparoscopy, especially in the presence of multiple injuries, when shock is superimposed on the clinical picture of liver damage. If blood is detected in the abdominal cavity, emergency surgery is indicated. RI also helps in diagnosis. In this case, indirect signs are revealed (high position of the diaphragm, limitation of its mobility, rib fractures, etc.).

Subcapsular hematoma of the liver develops gradually. IN initial stage it shows almost nothing. However, reaching large sizes, clinical signs become more pronounced. With minor stress or injury, a so-called two-stage liver rupture can occur. This usually occurs 8-15 days after the injury. Liver ruptures are accompanied by bleeding into the free abdominal cavity, and after some time diffuse peritonitis usually develops, even in the absence of damage to the hollow organs. With massive damage to the liver from the absorption of decay products of its parenchyma, NP can often develop.

Clinical picture. The clinical picture of liver damage varies. Frequently occurring phenomena include shock and intra-abdominal bleeding. In severe cases, collapse and loss of consciousness develop. The patient lies on the right side or is in a forced semi-sitting position. He cannot maintain a horizontal position and immediately assumes a semi-sitting position. With combined damage to hollow organs, this phenomenon is accompanied by the picture of peritonitis. The condition of the victims is progressively deteriorating. The pulse quickens and is weakly filled, and sometimes barely noticeable, blood pressure drops. The abdomen is moderately swollen and tense, especially in the area of the right hypochondrium. When accumulated in the abdominal cavity, relatively large quantity There is dullness in the blood in sloping areas. With isolated liver damage, the symptom of peritoneal irritation is relatively less pronounced than with its combined damage with hollow organs.

The diagnosis is made on the basis of a carefully collected medical history, examination, degree of blood loss (determination of hematocrit and blood volume), blood pressure, fluoroscopy data, abdominal puncture, laparoscopy using the articulated catheter method.

Diagnosis is significantly difficult with subcapsular hematomas. With such damage, mild symptoms are observed in the first days. However, a few days after the injury, the patient’s condition may deteriorate sharply, severe pain appears, and clinical picture intra-abdominal bleeding.

Diagnosis of liver damage becomes significantly more difficult when drunkenness injured or unconscious after a traumatic brain injury. In such cases, there is a need to more carefully examine the patient and establish more active monitoring of him.

Treatment. If a closed injury (rupture) of the liver is suspected, emergency surgery is indicated. The latter is less dangerous for the patient than late surgery, since every hour of waiting increases the risk of an unfavorable outcome. If a liver rupture is detected, the damaged area can be tamponed with a greater omentum (biological tamponade). If the liver tissue is crushed, resection of this area is performed.

Open liver injuries

They are inflicted by various piercing and cutting objects, as well as firearms. Accordingly, puncture wounds and gunshot wounds are distinguished. The latter, in turn, can be blind, end-to-end and tangential. Gunshot wounds, as a rule, are combined with injuries to other abdominal organs. With stab and cut wounds, the size of the liver damage is relatively small, as with gunshot wounds, but with simultaneous damage to the lungs, stomach or intestines, the course of the damage becomes more severe and becomes dangerous. When wounds are inflicted with cold steel, the wound surface of the liver is smooth, its dimensions often correspond to the dimensions of the external opening of the wound.

Gunshot wounds are characterized by the presence of multiple ruptures of the liver. The wound canal is usually filled with blood clots and pieces of liver tissue. In the presence of perforating wounds, the size of the exit hole is usually larger than the entrance. In case of liver injuries, the severity of bleeding depends on the size of the damage and the nature of the damaged vessels. Along with bleeding, there is also a leakage of bile, which often becomes the cause of the development of biliary peritonitis. In a later period, necrosis of damaged areas of the liver parenchyma deprived of nutrition develops.

Clinic and diagnostics. The clinical picture of open liver injuries differs little from the clinical picture of closed injuries. It depends on the nature of the injury, the amount of blood lost and the time that has passed since the injury. The clinical picture is dominated by symptoms of shock, especially with combined injuries. A reliable sign of liver injury is the outflow of clear or bloody bile from the wound. After a rupture of the liver, the development of a catastrophe in the abdominal cavity is indicated by internal bleeding, the presence of symptoms of peritonitis, pain, tension in the abdominal wall, the presence of a positive Blumberg-Shchetkin symptom, the lag of the abdominal wall from the act of breathing, chest type of breathing, etc. The presence of these phenomena gives reason to think about liver damage. The course of the wound channel, the presence of other characteristic clinical signs also provide grounds for diagnosing liver rupture before surgery. There are abdominal, thoracoabdominal and abdominothoracic wounds. In the second type of injury, the liver wound is usually localized on its convex surface, rarely also on the anterior or lower surface.

By the location of the wounds, you can approximately determine the location of liver damage and thoracoabdominal wounds. When localized on the anterior parts of the chest and epigastric region, damage to the central segments of the liver can be assumed. Wounds localized in the posterolateral parts and subcostal areas indicate damage to the peripheral parts of the liver. When localizing wounds in the epigastric and mesogastric areas, it is necessary to think about damage to the lower surface of the liver. This injury is often accompanied by damage to the gastrointestinal tract, often the stomach. The size of the skin wound in victims in most cases corresponds to the size of the liver wound. When large vessels are damaged, circulatory disturbances in large areas of the liver develop. At the same time, the color of the liver quickly changes. When the PA is damaged, it is grayish in color, the BB is dark purple, and when the PV is damaged, it is a dark brown hue. It is also necessary to remember about penetrating liver damage. During the operation, the opposite surface should be examined or felt, otherwise serious complications may occur.

With combined thoracoabdominal injuries, the clinical picture consists of symptoms of damage to the liver, other abdominal organs and chest. Unlike closed liver injuries, there are no special diagnostic difficulties with open liver injuries. If there is a wound in the liver area, there is no need to carry out additional research to clarify the diagnosis.

Treatment. Even if there is the slightest doubt about a liver rupture, it is necessary to immediately operate on the patient, without waiting for all the symptoms to develop. characteristic symptoms. Depending on the location of the injury, the operation begins with laparotomy or thoracolaparotomy. The nature and extent of surgical interventions on the liver depend on the type of damage. For open liver injury, the choice operational access due to the location of the wound. If it is necessary to perform manipulation on the posterior diaphragmatic surface of the liver, the incision is extended to the right side, cutting through the rectus abdominis muscle. For thoracoabdominal and combined injuries of the abdominal organs, the incision begins with a right-sided thoracotomy along the VIII intercostal space and continues to the midline of the abdomen.

During surgery, first of all, measures are taken to stop bleeding. In case of severe bleeding, you can temporarily turn off the liver from the general circulation by clamping the hepatoduodenal ligament and the PA and IV located in it (Figure 9) for no more than 10-15 minutes. After the bleeding has stopped, the liver wound is treated and the blood and bile that have accumulated there are removed. It is necessary to remove blood clots, non-viable tissue and foreign bodies from the liver wound. The wound is sutured with a round needle using mattress or U-shaped sutures (Figure 10), and a pedunculated omentum is placed under the sutures. If the patient's condition is very serious and there is a large rupture of the liver, when it is impossible to suture the wound, it is considered acceptable to limit oneself to the usual packing with an omentum or gauze swab. If the rupture is localized on the diaphragmatic or costal surface, it is considered advisable to suture this area of the liver to the diaphragm. In case of damage to the main vessels and bile ducts, as well as massive burns of the liver, it is recommended to decompress the bile ducts using their external drainage. Atypical liver resection is often performed. In this case, it is necessary to take into account the structure of the liver and avoid damage to the segmental artery and vein. For incised wounds, it is considered acceptable to stitch the wound without excision of its edges.

Liver injury is a medical emergency. It is almost always complicated by intra-abdominal bleeding, often massive, as well as a state of shock. Consequences include the development of peritonitis and death.

If there are any signs to suspect liver damage, the victim should be urgently taken to the nearest medical institution surgical profile to clarify the diagnosis, and carry out urgent and resuscitation surgical treatment.

According to statistics, liver injuries occur in almost 25% of cases of abdominal trauma. At the same time, closed ones are observed in 30–50% of victims, stab wounds – in 45–70%, gunshot injuries – up to 5–7%.

Almost four times more often, it is the stronger sex who receives various injuries, and most often these are open wounds - stab wounds or gunshots. Women often suffer closed injuries in road accidents.

So, there are closed and open damage. With closed injuries, the integrity of the abdominal wall is not broken, and open ones, accordingly, are penetrating.
Let's take a closer look at these damages.

The causes are: direct blow to the liver, compression or counter-impact.
The most common cause of liver damage today is a motor vehicle accident (40–45% of cases). In this case, very often the damage is direct, such as a blow or bruise.

With a direct blow to the liver area or its bruise, ruptures occur mainly on the lower surface of the organ, sometimes on both: upper and lower. They are observed extremely rarely on the upper surface exclusively.

When the torso is compressed, especially in the chest and abdomen, between two planes during various types of disasters, destruction of buildings, etc., sometimes quite severe damage to organs occurs. In this case, lesions will most often be on the upper surface, rarely on the lower. Sometimes crushing of the liver tissue and separation of its parenchyma may occur.

When falling from a great height to lower limbs or the pelvic area, liver damage occurs according to the principle of counter-impact. In this case, lesions occur most often on the upper surface of the organ. Sometimes there is a complete or partial separation of the organ from its ligamentous apparatus.
If a rib fracture occurs at the same time, the end of the damaged rib sometimes penetrates into the thickness of the liver tissue and causes additional injury.

In some diseases (alcoholism, hepatitis, amyloidosis, neoplasms, etc.), a morphological change in the parenchyma occurs, which impairs the resistance of liver tissue. In these cases, even the slightest injury to the liver causes serious damage. Sometimes even spontaneous rupture of the organ occurs.

Cases of spontaneous liver rupture in pregnant women have been described, especially in the presence of severe late gestosis. This can happen in the last months of pregnancy, during or after childbirth.

In children and the elderly, the resistance of liver tissue is also quite low. For example, in newborns, severe damage can occur during cardiopulmonary resuscitation (with asphyxia), and even during childbirth - if it is pathological.

Liver ruptures occur:

Subcapsular rupture. Hematomas are formed, which can be located in the same place, subcapsular, or located more deeply - central. Hematomas located in deeper layers often occur when the body is sharply bent or turned.
Ruptures in which the integrity of the capsule is compromised. In this case, cracks form in the parenchyma: one or several. Cracks can be combined with fairly deep tissue tears. Sometimes crushing of areas of the parenchyma occurs, and they may remain connected to the organ or a complete separation of these areas occurs.
Liver rupture accompanied by injury to the gallbladder and biliary tract.

Quite rarely there are ruptures that penetrate the entire thickness of the organ.

A more detailed and unified classification was proposed by I.A. Krivorotov back in 1949:

bruises with small hemorrhages into the capsule and under it without disruption of the parenchyma;
bruises with hemorrhages under the capsule, as well as into the parenchyma;
superficial ruptures of the capsule without damage to the parenchyma;
superficial breaks in the parenchyma;
deep ruptures of the parenchyma with damage to the bile ducts of the liver;
ruptures and hemorrhages in the center of the organ with minor damage to the surface;
bruises and ruptures of the liver simultaneously with ruptures of the gallbladder;
bruises and ruptures of the liver simultaneously with ruptures of the hepatic and common bile duct;
isolated gallbladder ruptures.

Open liver injuries

Usually they are combined with other adjacent organs (diaphragm, lungs, stomach, etc.).

When injured by cold weapons (stab wounds), the wound surface is flat, smooth, and severe external bleeding occurs. In the vast majority of cases, the lower surface of the liver is affected.

When injured by a firearm, the damage is often similar to that of closed injuries: massive lesions with ruptures and contusion (bruising) of the organ.
Diagnostics

First of all, you should find out your medical history. As a rule, there are indications of a traumatic agent: a bruise in the liver area, a blow to the liver, a bruise of the anterior abdominal wall, a fall, an accident, etc.
Sometimes diagnosis seems difficult with multiple and combined lesions, severe alcohol intoxication, severe traumatic or hemorrhagic shock, etc.

Symptoms common to all liver damage are: pallor of the skin and mucous membranes, increased heart rate, cold sweat, drop in blood pressure, i.e. symptoms indicating acute significant blood loss.

The patient's position is usually forced immobile due to severe pain syndrome. Pain and muscle protection are also detected during palpation in the right hypochondrium, as well as positive symptoms of peritoneal irritation.

With closed lesions, rapid progression and increasing symptoms of massive bleeding are observed. There is a direct connection between the progression of increased heart rate (tachycardia) and more negative consequences.

Pain in the right hypochondrium usually increases gradually. If there is acute and sharp pain in the first minutes after injury, one should suspect a simultaneous rupture of one of the hollow organs of the abdominal cavity. Symptoms of peritoneal irritation may not be detected in all cases.

It is sometimes difficult to give a correct assessment of the patient’s condition and make the correct diagnosis for closed liver injuries, despite quite characteristic signs. However, if assistance is not provided in the first hours and the patient does not die from severe bleeding, then after 1–3 days peritonitis develops, in most cases biliary.

So-called biphasic liver ruptures also occur - with hemorrhage of an undiagnosed hematoma 1-4 days after the incident. This occurs due to a decrease in blood pressure in the first time after injury, when, as a result of compensatory vasoconstriction, a temporary stop of bleeding occurs. Then it resumes, sometimes with greater intensity.

Open liver injuries, as a rule, do not present difficulties for diagnosis. It should be noted that bleeding from such injuries is much more profuse, and the symptoms of acute blood loss are more severe and develop faster, especially with combined damage to several organs.
In peripheral blood tests, increasing anemia and leukocytosis are observed.

Additional diagnostic methods include ultrasound, CT scan, magnetic nuclear tomography. In controversial cases, diagnostic laparoscopy is used, which allows an accurate diagnosis.

Treatment

Treatment of almost all liver injuries is only emergency surgery.
It is extremely rare that a wait-and-see approach is possible when there is no firm certainty of the presence of a liver rupture, while the phenomena of acute blood loss are absent or insignificant and do not progress. Of course, observation is carried out only in a hospital setting.

Surgical treatment is performed in the form of emergency laparotomy. The scope of the operation is often limited to suturing the liver wounds. If extensive crushed areas of parenchyma are visualized, they are removed within healthy tissue. The spilled blood from the abdominal cavity is also removed.

For open injuries, treatment is only and exclusively surgical. The liver wound is sutured, and in case of combined injuries, other damaged organs are sutured. For gunshot wounds, treatment begins as early as possible. A thorough inspection of the liver is carried out for the presence of foreign bodies in its tissue, non-viable, crushed areas of parenchyma, etc. If they are detected, excision and removal are performed.

In parallel, anti-shock measures and blood transfusion of donor blood or its components are carried out. In the absence of damage to the internal hollow organs, the blood that has spilled out and accumulated in the abdominal cavity is collected and used for autohemotransfusion.

Forecast

The prognosis for liver injuries depends on the following factors:

Age of the victim - in children and the elderly, even minor injuries are more difficult to bear;
Severity of blood loss;
Timely surgical treatment – you should especially not hesitate in case of open injuries;
The presence or absence of combined damage to other organs.

Liver contusion is a severe injury characterized by damage to the soft tissue of the hepatic lobes. This severity is due to the importance of the functions of the organ itself, the difficulty of diagnosis and the complexity of treatment. The liver, as an organ, is protected only by a thin capsule. The organ itself consists of two lobes: left and right.

Despite the security chest, the liver also often succumbs to bruises, like any other structure of the body. The causes of this injury are:

Bruise from a blow to the abdominal area;
Liver bruise from a fall from a height;
Bruise due to compression of the ribs on the organ.

Symptoms

Signs of soft tissue injury to the liver include:

Pain. Any injury is first of all accompanied by a feeling of sharp pain, which later turns into aching pain. However, the feeling of pain may not accompany the injury at all. Pain appears directly at the site of impact and can spread to neighboring areas of the body. Any movement or tension of the muscles surrounding the organ provokes an increase in the unpleasant sensation;
Organ injury is accompanied by the formation of abrasions and hemorrhages. When passing vessels are damaged, the degree of bruising increases, which can lead to serious consequences such as shock. This condition is characterized by mental disorientation and lethargy;
Heart dysfunction. Liver contusion is a severe stress for the body, and, as is known, stress is a general reaction of the body, accompanied by a set of nonspecific symptoms, including: decreased blood pressure, increased number of heartbeats per minute, cooling of the extremities;
Externally unusual position of the abdomen. Trauma causes the abdomen to become retracted or distended. In the case when the bruise damaged not only the liver, but also the intestinal elements, the abdomen will swell, and upon palpation, tension in the anterior group of abdominal muscles will be observed;
Shchetkin-Blumberg symptom. If you put your hand on the area of the right hypochondrium and quickly release it, severe pain will appear in this area. However, this symptom is not decisive, since it is also positive in acute appendicitis;
Kulenkampf's sign. This symptom is accompanied severe pain in a stomach;
The patient cannot change the position of his body. Any attempt to turn leads to increased pain;
Temperature increase. This manifestation indicates inflammatory processes in the liver;
Jaundice;
Hepatomegaly is an increase in liver volume.

First aid

The problem with this pathology is the inability to fully provide first aid to the victim. However, with a few steps you can still alleviate his current condition.

Call ambulance. Only experts can adequately assess general state patient and find ways to provide assistance;
Place the victim in a horizontal position. He is forbidden to move or even strain. Any movement can provoke increased bleeding;
Place ice or any other cold object (cold bottle, frozen meat) on the impact site;
Periodically check whether the patient is conscious or not. To do this, he is asked questions about his last name, place of residence, his hobbies, and who is next to him.

Treatment

The hospital treatment stage begins with an immediate diagnosis of the condition of the organ. Therapy for liver contusion is classified as follows:

Surgery;
Drug therapy;
Rehabilitation.

If there is heavy bleeding, specialists perform surgery. During the operation, surgeons assess the condition of the liver and conduct additional diagnostics. Liver cracks are sutured, bleeding vessels are tied up, grossly damaged areas are excised.

In case of severe bleeding, reinfusion is performed into the abdominal cavity - a transfusion of the patient's own blood. After all the actions, surgeons wash the abdominal cavity and suture the tissue. After surgery, the patient is prescribed drug therapy, which includes drugs that strengthen the liver and infusion. ethnoscience in case of such injury it is contraindicated.

Thank You for rating this article. Published: August 18, 2017