Liver Trauma

Souradeep Dutta INDIA

Case 1: Blunt trauma

● 29 year old female

● Driver of a car, wearing seatbelt

● Collision heavy vehicle

● Airbags activated

● Managed as per ATLS protocols

● GCS 15 /15, haemodynamically stable

● RUQ pain, left wrist fracture-dislocation

Radiology

● Bi-malleolar left ankle fracture● Ultrasound abdomen: free fluid, splenic

contusion● CT abdomen

– oblique tear through right lobe of the liver– right adrenal gland contusion – blood in peritoneum

Management

● Transferred to ICU with IV fluids & blood● Ankle dislocation reduced, back slab applied

● Laparotomy: full assessment performed– Large volume of intraperitoneal blood– 2 liver lacerations– Small haematoma at splenic hilum– Small contusion of tail of pancreas– No active bleeding

● Surgicel to splenic hilum and liver lacerations● Washout performed and drains placed

Post-operative course

● Remained haemodynamically stable

● MRI brain: confirmed small contusion near internal capsule

Case 2: Penetrating trauma

● 24 year old male

● Stab wounds – Three in upper abdomen – Left side of neck

Clinical findings

● GCS 13/15, haemodynamically stable● 3cm wound over the right zygoma● 1.5cm wound zone 2 left side of the neck● Abdomen: 1.5cm wound over the right and left

upper quadrants breaching rectus sheath and muscles

● Managed as per ATLS protocol● IV Fluids, Catheterized● Hb = 13.5

Management

● Chest x-ray normal

● Ultrasound abdomen: No free fluid

● Admitted to ICU pre laparotomy

● Became haemodynamically unstable with increasing abdo pain

● Responded to IV fluids and blood transfusion

Emergency laparotomy findings

● Haemoperitoneum● Wound in the right upper quadrant obliquely traversed

both lobes of liver, through the 1st part of duodenum into pancreas

● Bleeding from D1 and pancreas● Haemostasis achieved● Duodenum repaired with interrupted PDS● Wash out performed, drain placed

Management

● Neck wound: fascia breached but no vascular injuries, closed in layers

● Managed with NG tube, antibiotics and parenteral nutrition

● Developed bile leak, conservatively managed

● Small pelvic collections were managed with antibiotics

● Discharged on 31st post-operative day

Background

● Largest solid abdominal organ, fixed position

● Liver injury is the most common cause of death after abdominal trauma

● Blunt injury due to road traffic accidents most common

● 80% adults, 97% children have successful conservative management

● Liver injured more easily in children

Anatomy of the injury

Liver anatomy

● Cantile described main divisions along axis from gallbladder fossa to the IVC

● This divides the liver into equal halves

● Couinaud divided the liver into 8 segments.

Liver segments

• Divided vertically by the 3 main hepatic veins and transversely by the right and left portal branches.

Types of liver injuries

● Haematoma: subcapsular or intrahepatic● Laceration ● Contusion ● Hepatic vascular disruption ● Bile duct injury● 86% of injuries have stopped bleeding at time of surgical

exploration● Transfusion requirements are reduced with conservative

management

Management

● Initial resuscitation as per ATLS protocol

● It is important to note the mechanism of injury

● Clinical picture may vary from mild RUQ pain through to peritonism to haemorrhagic shock

● Stable patients undergo CT imaging

● Unstable patients require resuscitation and laparotomy

CT Scans

● Accurate in localizing the site of liver injury and any associated injuries

● Used to monitor healing

● CT criteria for staging liver trauma uses AAST liver injury scale

● Grades 1-6

Classification

● I- Subcapsular hematoma<1cm or superficial laceration<1cm deep

● II- Parenchymal laceration 1-3cm deep or subcapsular hematoma1-3 cm thick

● III- Parenchymal laceration >3cm deep and subcapsular hematoma >3cm diameter

● IV- Parenchymal/supcapsular hematoma >10cm in diameter, lobar destruction or devasularization

● V- Global destruction or devascularization of the liver

● VI- Hepatic avulsion

Example of a grade 3 injury

Subcapsular hematoma

Parenchymal hematoma and laceration

Angiography

● May be useful in localizing the site of haemorrhage in stable patients

● Transcatheter embolization of bleeding sites

Treatment

● Conservative– Blunt liver trauma,– Haemodynamically stable– No other injuries requiring surgery

● Surgical– Penetrating injuries– Haemodynamically unstable– Other injuries requiring surgery

Surgical management

● Full laparotomy

● Pringles manoeuvre to occlude the portal triad

● Packing of the liver

● Treat other intra-abdominal injuries as appropriate

Learning points!

● Liver injuries frequently are associated with multiple other injuries

● Most liver injuries can be managed conservatively

● Essential Skills: Laparotomy, Pringles, Ligament mobilisation and liver packing

● As with all trauma, the ATLS protocol is the foundation of treatment