LIVER TRAUMA Muhammad Syazwan Mohd Hasim 31a
LIVER TRAUMAMuhammad Syazwan Mohd Hasim31a
INTRODUCTION• It is the 2nd commonest organ injured in blunt abdominal
trauma and the commonest injured in penetrating trauma. • 1% - 8% of patient with multiple blunt trauma sustain a liver
injury.
FACTORS• The large size of the liver• Its friable parenchyma • Its thin capsule • Its relatively fixed position in relation to the spine and ribs
ANATOMY
CLASSIFICATIONI - Close Injury
1. According to mechanism of injury: Direct hit, fall from a height, compression between two objects, Road traffic injuries
2. According to the type of damage: rupture of the liver with damage of the capsule subcapsular hematoma, damage of extrahepatic bile ducts and blood vessels of the liver
3. According to the degree of damage: surface cracks and rupture to a depth of 2 cm, rupture to half thickness of the liver, rupture depth of more than half of the liver
4. Localization: Damage lobes or segments of the liver.
5. Character: With damage of extra- and intrahepatic vessels and bile ducts.
II - Open Injury
1. Gunshot: bullet, shrapnel, the shot.
2. Machetes: stab
III - The combination of blunt trauma injury to the liver
GRADING
GRADING OUTCOMES• Grade I,II - minor injuries, represent 80-90% of all injuries, require
minimal or no operative treatment
• Grade III-V - severe,require surgical intervention
• Grade VI - incompatible with survival
CLINICAL PICTURE• Pain• Signs of blood loss• Hematoma• Tenderness upon palpation• Dullness during percussion
DIAGNOSTICSUltrasonography - fast, accurate, noninvasive, a good initial screening test - sensitivity 88 %, specificity 99 %
DPL - fast, sensitive, accurate and simple to perform - invasive, cannot diagnose retroperitoneal injury
Computed tomography - The standard evaluation method for stable patient . Performed with dilute water soluble oral contrast agent and intravenous contrast
X-ray- nonspecific, but useful in showing the extent of associated skeletal trauma.
CLASSIFICATION (AAST)
I - Subcapsular hematoma <1cm, superficial laceration<1cm deep
II - Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick
III - Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter
IV - Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction
V - Global destruction or devascularization of the liver
VI - Hepatic avulsion
MANAGEMENT
CONSERVATIVE :
1. 86% of liver injuries stopped bleeding by the time of surgical exploration
2. 67% of operations performed are nontherapeutic
• Criteria - hemodynamically stable - simple hepatic parenchyma laceration of intrahepatic
hematoma - absence of active hemorrhage - hemoperitoneum of less than 500ml - limited need for liver related blood transfusions (12U) - absence of peritoneal sign - absence of other peritoneal injuries that would otherwise
require an operation
OPERATIVE :
• Initial hemostasis 1. Packing 2. Pringle maneoevre 3. Bimanual liver compression 4. Cross clamping aorta above celiac trunk
• Hepatotomy with direct suture ligation
- using the finger fracture technique, electrocautery or an ultrasonic dissector to expose damaged vessels and hepatic duct which ligated , clipped or repaired
- low incidence of rebleeding, necrosis and sepsis - effectives following blunt liver trauma requires further
evaluation
• Resection debridement
- removal devitalized tissue - rapid compared with standard anatomical resection, which
are more time consuming and remove more normal liver parenchyma
- reduced risk of post-op sepsis secondary hemorrhage and bile leakage
• Anatomical resection
- reserved for deep laceration involving major vessels or bile ducts, extensive devascularization and major hepatic venous bleeding
• Perihepatic packing
- Indication: coagulopathy, irreversible shock from blood loss (10u),
hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries
• Mesh rapping
- new technique for grade III,IV laceration, tamponading large intrahepatic hematomas
- not indicated where juxtacaval or hepatic vein injury is suspected
• Omental packing• Intrahepatic tamponade with penrose drains• Fibrin glue• Retrohepatic venous injuries - Total vascular exclusion - venovenous bypass - Atriocaval shunting• Liver transplantation