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Tue Jan 13 14:02:30 GMT 2009

Saboor,

Excellent questions!

If the liver laceration was not bleeding at the time of laparotomy on day 2 (having embolised a posterior sectoral RHA), why was 'hepatorraphy' performed? 
During initial laparotomy no other injuries were identified except the grade IV liver injury with persistent venous bleeding from the organ. The angiogram only managed the arterial hepatic bleeding but the vast parenchymal disruption with transected biliary ducts and portal branches were not addressed. If the patient had been managed nonoperatively and the possibility of an associated injury had not been considered, then I agree with you that most of the time these injuries have the potential on healing on their own. In this case, we decided to open too rule out other injuries, and on evaluating the liver injury it was considered that it required "traditional" surgical repair.
What was the drop in Hb. at two weeks? Did he need a transfusion? Has the CT been reviewed again to check for missed findings, such as intra-hepatic hematoma?
It was a three point drop and we transfused two units of PRBC's.On retrospective review of the CT there were no additional findings suggestive of intrahepatic parenchymal bleeding. 
At four weeks the patient arrests suddenly - presumably from a RHA bleed 
(?Ruptured pseudo-aneurysm of right hepatic artery, with a small haemobilia prior to that). I can only postulate that he bled into his chest from an associated (?missed) diaphragmatic rupture? From the account it would seem that there was no source in the chest, and he did not bleed from an associated vena caval / right hepatic vein laceration?
Correct
 A complete vascular isolation has tremendous haemodynamic consequences in a 'non-compromised' patient, would you recommend this manoeuvre in a similar situation again?
Yes, this patient developed cardiac arrest from an abrupt delayed hepatic ruture with exsanguination via the right chest. This maneuver is essential in controlling the blood loss in these extreme cases.
 If the liver was placed in 'Seattle bag' and packed, then clamps were released - how was the bleeding from the liver controlled, which was now under a pack and swabs? Could you please tell us about the Seattle bag and its use in hepatic trauma?

The Journal of Trauma: Injury, Infection, and Critical Care:Volume 57(4)October 2004pp 884-886. The Liver Bag: Report of a New Technique for Treating Severe, Exsanguinating Hepatic Injuries. Sattler, Scott MD; Gentilello, Larry M. MD

>From the Department of Surgery, Harborview Medical Center, University of Washington (S.S.), Seattle, Washington, and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School (L.M.G.), Boston, Massachusetts.
Embolisation of RHA does not mandate a right hepatic resection. I am unclear why a hepatic resection was deemed 'necessary'. In the great majority of patients who undergo RHA ligation (trauma or iatrogenic) do not progress to hepatic parenchymal necrosis because of dual blood supply. Personally, I think it was an overkill where you had already achieved haemstasis?
I agree with you that embolization of the RHA does not mandate a right hepatic resection and that they do not geenrally progress to hepatic parenchymal necrosisbecause od dual blood supply. But I do disagree in this case that this was an overkill because of the following reasons:
1. Patient had already failed miserably the first attempt of traditional open surgiacal repair with embolization and repeating the same therapeutic option seemed unsafe and unwise.
2. Patient had massive disruption of the parenchyma of the right lobe which in turn comprimises significantly the concept of dual blood supply.
3. The end result of a patient recovering such an event with no further complications.   

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Delayed Hepatic Rupture