Traumatic Liver Injuries

By

Dr. Monsif Iqbal

Surgical Unit II

CASE PRESENTATION

PATIENT’s PROFILE:

• Name: XYZ• Age: 17 yrs.• Sex: Male• Address : Wah Cantt.• D.O.A: 18-04-2011• M.O.A: ER

PRESENTING COMPLAINTS

• H/O RTA, Patient while on motor bike struck against the concrete block of an electric pole – 2 hrs

• Sustaining injury to the lower chest and abdomen

• Complain of severe chest and abdominal pain• 2 episodes of Vomiting• Drowsiness

PHYSICAL EXAMINATION:

On Examination» Pulse: 103/min» B.P: 84/60 mm of Hg» Oxygen Sat: 99%» GCS 15/15» Abrasions right lower chest and epigastrium

On Abdominal Examination– sever tender epigastrium– mild generalized tenderness

INVESTIGATIONS:

1. Blood CP: • Hb ---- 11.3 gm/dl• TLC ---- 24.6x103/ul• PLT ---- 434x103/ul

2. ALT: 573. RFTs: Urea: 34, Creatinine 0.75

sodium : 139Potassium : 4.0Chloride : 101

Management

• 2 large bore IV lines• IV fluids rushed• IV antibiotics and Analgesics started• Blood sample sent for grouping and cross matching• Patient shifted to ITC, there B.P. 70/45mmHg, Pulse 125/min• USG FAST carried out– Gross intraperitoneal fluid collection– Left lobe of the liver ---- ill defined– Suspicion of liver injury

Management (cont.)

• Patient shifted to OT and urgent exploratory lapratomy carried out, the findings were– Laceration of the left lobe of the liver– Massive blood in the peritoneum– A 3 cm perforation in the left hemidiaphram

• Left lobectomy, bleeding vessels underun, perihepatic packing, perfortion in the diaphram sealed, drain put in RUQ, abdomen partially closed, and left sided chest intubation done

• 3 units of blood transfused peroperatively

Management (cont.)

• After 48 hours, the pateint was shifted again to OT, abdomen opened, perihepatic packs removed, no active bleeding, hemotama around the raw area,,,, the abdomen was closed in the layers and the drain remained there…

• The patient weaned off the ventilator support after 48 hours,the recovery uneventful, drain output NIL and removed at 7th day posoperatively..

Traumatic Liver Injuries

Anatomy

Segmental Anatomy

Clinical Presentation

• Histroy• RTA• Fall• Penetrating injuries

• Clinical Findings:• Bruises on the epigastrium or entry wound• Tachycardia• Tachypnea• Shock

Diagnostic Modalities• DPL --fast, sensitive, accurate and simple to perform --invasive, cannot diagnose retroperitoneal injury --DPL is positive when

-more than 10 ml of frank blood in the aspirated fluid-fecal matter or bile- >100,000 RBC/micL- >500 WBC/micL

• X-ray --nonspecific, but useful in showing the extent of associated skeletal

trauma• Ultrasonography (FAST) --fast, accurate, noninvasive, a good initial screening test --sensitivity 88%, specificity 99%, accuracy 97%

Ultrosonography

• CT Scan– The standard evaluation method for stable pt

– Performed with water soluble oral and intravenous contrast

Management Algorithm

American Association for the surgery of trauma organ injury scale :liver

*Advance one grade for multiple injuries, up to grade III.

Management according to the Grade

• 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

Non Operative Management

• Criteria --hemodynamically stable --absence of active hemorrhage --hemoperitoneum of less than 500ml --absence of peritoneal sign --absence of other peritoneal injuries that

would otherwise require an operation

Non Operative Management

• Criteria (continued) --good quality CT scans --experienced radiologist --intensive care setting• Currently believe that ultimate decisive factor

should be the hemodynamic stability at presentation or after initial resuscitation, irrespective of the grade of injury on CT or the amount of hemoperitoneum

Non Operative Management• Complications --Delayed hemorrhage ‧ most common, usual indication for a delayed operation ‧under strict guidelines, the incidence ranges from 0-5%, and blood transfusions are required in fewer than 20% ‧ common errors:

(1)assuming that the hemorrhage is not related to the liver

(2)multiple(more than four)blood transfusions in the hope that it will stop (3)misreading CT and underestimating hemoperitoneum and active bleeding

Non-operative management

• Complications --biliary fistula and liver abscess ‧ranges from 0.5-20 ‧nasobilaiary or percutaneous tranhepatic drainage or

endoprothesis insertion . If fails, then needs surgical resection of affected segment

--Hemobilia ‧1%, iatrogenic causes most common ‧injury causes communication between the biliary tract and blood vessels ‧abdominal trauma, jaundice, RUQ colicky pain and blood in vomitus or stool point to this diagnosis ‧managed by percutaneous selective hepatic a. embolization or surgical intervention

• Complications --bilihemia ‧rare complication of severe decelerationon injury, in which the

hepatic venules and the intrahepatic bile ducts rupture ‧excessive bilirubin level ‧endoscopic sphincterotomy and biliary endostenting --Extrahepatic bile duct stricture ‧ Endobiliary ballon dilatation or stenting ‧ usually require surgical correction using Roux-en-Y

hepatodochojejunostomy• Mortality rate --7-13% with most resulting from associated injuries --0-0.4% resulting from liver itself

Operative interventions

Operative interventions

• Initial control of bleeding achieved with temporary tamponade using packs, portal triad occlusion(Pringle manoeuvre), bimanual compression of the liver or even manual compression abdominal aorta above celiac trunk

• If hemorrhage is unaffected by portal triad occlusion(Pringle manoeuvre) by digital compression or vascular clamp, major vena cava injury or atypical vascular anatomy should be expected

Operative interventions (cont.)

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

Perihepatic packing

Operative interventions (cont.)

• 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

Operative interventions (cont.)

• 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

Operative interventions (cont.)

• Mesh rapping

--new technique for grade III,IV laceration, tamponading large intrahepatic hematomas

--not indicated where juxtacaval or hepatic vein injury is suspected

• Anatomical resection --reserved for deep laceration involving major

vessels or bile ducts, extensive devascularization and major hepatic venous bleeding

Mesh rapping

Other Operative interventions

• Omental packing• Intrahepatic tamponade with penrose drains• Fibrin glue• Retrohepatic venous injuries --Complete Vascular isolation of the liver --venovenous bypass --Atriocaval shunting• Liver transplantation

Operative management

• Complications --Hemorrhage,sepsis --Biliary fistula --Respiratory problems --Liver failure --Hyperpyrexia --Acalculous cholecystitis --Pancreatic, duodenal or small bowel fistula

THANKS