Liver trauma
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Transcript of Liver trauma
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