Abdomen and Pelvis

Biliary and Vascular Anatomy of the Liver

A. This drawing depicts the anatomy of the gallbladder and porta hepatis. Although many variations may exist, review of this area can be helpful prior to operating on an injury in this location.

B. This drawing illustrates the vascular anatomy of the liver.

Hepatic Segments

These are the eight segments of the liver, defined by their portal circulation. Note that there are at least three major venous outflows from the liver. Not shown here are several direct venous outflows directly from the liver to the retrohepatic IVC.

The Pringle Maneuver

Using a noncrushing (vascular) clamp, the entire porta hepatis can be occluded to decrease bleeding from an injured liver. This is a temporary occlusion of the portal vein, hepatic artery, and common bile duct. It is accomplished by palpating the foramen of Winslow and precisely placing the clamp on only the desired structures.

Perihepatic Packing

Temporary packing of a bleeding liver is the prime example of damage control. Laparotomy packs are placed above and below a bleeding area in the liver, making a "liver sandwich." Care is taken not to obstruct the inferior vena cava or to produce too much constriction, leading to liver necrosis.

Hepatorrhaphy

Using a large, special blunt "liver" needle on an absorbable suture, a deep figure-of-eight suture can stop troublesome bleeding. Sutures should be tied loosely, rather than snug and tight, since the liver swells postoperatively, and tight sutures can cause hepatic necrosis.

Hepatotomy

Gross, large ligatures to the liver may cause liver necrosis and postoperative fever. The injury is unroofed by performing a hepatotomy, with direct ligation of the biliary and vascular structures.

Omental Pedicle Packing of Hepatic Laceration or Hepatotomy Site

The left side of the omentum is mobilized off of the transverse colon, preserving a vascular pedicle from the right side of the omentum. The sutures attaching the omentum to the liver are loosely applied, so as not to strangulate the omentum.

Hepatic Balloon Tamponade

A custom, temporary balloon is fashioned using a Penrose drain and a rubber catheter, sealing off the ends of the drain placed over the catheter. After insertion into the body of the liver, the catheter is then filled with saline.