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