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Liver Trauma

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  • The superior, anterior, and right lateral surfaces of the liver are smooth and convex, fitting against the diaphragm. The posterior surface has indentations from the colon, right kidney, and duodenum on the right lobe and the stomach on the left lobe
  • Common resections acc to the segmants: Right hemihepatectomy (segments 5 to 8, or right hepatectomy, right hepatic lobectomy) Right trisectionectomy (segments 4 to 8, or right lobectomy, trisegmentectomy of Starzl) Left hemihepatectomy (segments 1 to 4, or left hepatectomy, left hepatic lobectomy) Left lateral sectionectomy (segments 1 to 3, or left lobectomy, left lateral segmentectomy).
  • Common resections acc to the segmants: Right hemihepatectomy (segments 5 to 8, or right hepatectomy, right hepatic lobectomy) Right trisectionectomy (segments 4 to 8, or right lobectomy, trisegmentectomy of Starzl) Left hemihepatectomy (segments 1 to 4, or left hepatectomy, left hepatic lobectomy) Left lateral sectionectomy (segments 1 to 3, or left lobectomy, left lateral segmentectomy).
  • The 8 liver segments (namely 1, 2, 3, 4a, 4b, 5, 6, 7, 8) are numbered clockwise on the frontal view.
  • The 8 liver segments (namely 1, 2, 3, 4a, 4b, 5, 6, 7, 8) are numbered clockwise on the frontal view.
  • Transcript

    • 1. Dr. Aisha Al-Zuhair General Surgery KFHU – Khobar – Saudi Arabia Dec 16, 2009
    • 2.  
    • 3. Surface anatomy
      • In RUQ
      • 5 th ICS in midclavicular line to the Rt costal margin.
      • Weighs 1400 g n women and 1800g n men .
      • Span 10 cm +/-2
    • 4. Surface anatomy
      • Superior, anterior, and right lateral surfaces 
        • fit diaphragm.
        • Falciform ligament
      • Posterior surface 
        • Rt lobe: colon, right kidney, and duodenum
        • Lt lobe: stomach
    • 5.  
    • 6.  
    • 7.
      • The liver covered by fibrous capsule that reflects on the diaphragm and post abdominal wall
      • Leaving a bear area that connects the liver to the retroperitoneum directly
    • 8. Ligaments
      • Liver supported by:
      • Coronary lig
      • Rt & Lt Triangular lig
      • Falciform lig
    • 9. Fissures
    • 10. Segmental anatomy
      • Classically; liver divided to 4 lobes:
        • Right lobe
        • Left lobe
        • Caudate lobe
        • Quadrate lobe
    • 11. Segmental anatomy
      • Functionally; on the basis of the distribution of vessels and ducts within the liver  segments.
      • Cantlie’s line.
    • 12.  
    • 13.  
    • 14. Blood Supply
      • Portal vein
      • Hepatic artery
      • Hepatic vein
    • 15.  
    • 16. Blood Supply – Portal Vein
      • Superior Mesentric and Splenic veins
      • Posterior to hepatic artery and bile duct at the hepatodudenal junction.
      • Valveless
      • 75% of total blood supply the liver
      • Pressure 3-5 mmHg
    • 17. Blood supply – Hepatic artery
      • Intrahepatic anatomy; part of portal tried follows segmental anatomy.
      • Extrahepatic anatomy; highly variable:
        • Commonest ( in 60%) anatomy: abdominal aorta  celiac trunk  CHA  proper hepatic art  Rt and Lt hepatic artery
        • LHA  seg 1,2,3 and  middle hepatic artery  seg 4.
        • RHA  cystic art , Rt liver
    • 18.  
    • 19.  
    • 20.  
    • 21.  
    • 22.  
    • 23. Blood supply – Hepatic vein
      • Rt hepatic vein  Drain seg 5,6,7,8  vena cava.
      • Middle hepatic vein  Drain seg 4,5,8
      • Lt hepatic vein  Drain seg 2,3
      • [ seg 1 drain by short hepatic  vena cava]
    • 24.  
    • 25. Radiological anatomy
    • 26. Radiological anatomy
    • 27.  
    • 28. Introduction
      • It is the 2 nd commonest organ injured in blunt abdominal trauma and the commonest injured in penetrating trauma.
      • 1%-8% of pt with multiple blunt trauma sustain a liver injury.
      • During last 3 decades, liver injury increased. This inc could be actual or artificial d/t better diagnostic modalities.
      Richardson JD. Ann Surg. 2000;232:324-330. Lucas CE. Am Surg. 2000;66:337-341.
    • 29.
      • While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference:
      • If lacerations be extensive and vessels of any magnitude are torn, hemorrhage will, owing to the structural arrangement of the liver, go on continously.
      JH Pringle, 1908
    • 30. History of Liver Trauma
      • WW1
      • WW2
      • Vietnam
      • Mortality 66%
      • -- 28%
      • -- 15%
    • 31. Factors making the liver prone to injury:
      • The large size of the liver,
      • its friable parenchyma,
      • its thin capsule, and
      • Its relatively fixed position in relation to the spine and ribs.
    • 32.  
    • 33. 1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4
    • 34. Grade 1
      • A stabbing injury to the RUQ of the abdomen
      Contrast CT demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.
    • 35. Grade 2
      • A blunt abdominal trauma
      CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.
    • 36. Grade 3
      • A blunt abdominal trauma
      Contrast CT shows a 4-cm-thick subcapsular hematoma associated with parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver..
    • 37. Grade 4
      • A blunt abdominal trauma
      CT scan of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-attenuating areas within the lesion represent clotted blood
    • 38. Grade 4
      • A blunt abdominal trauma
      Contrast CT shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the capsular laceration and large hemoperitoneum.
    • 39. Grade 5
      • A motor vehicle accident
      CT demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam.
    • 40.  
    • 41.  
    • 42.  
    • 43. Management
      • Operative
      • vs
      • Non-Operative
    • 44.  
    • 45. Non-Operative Management of Liver Injury
      • An absolute increase in the incidence of nonoperatively managed liver injuries (NOMLI) is unequivocal.
      • Multiple studies have shown that NOMLI is effective
      Knudson MM. Surg Clin North Am. 1999;79:1357-1371. Malhotra AK. Ann Surg. 2000;231:804-813. Maull KI. World J Surg. 2001;25:1403-1404. Pachter HL. Am J Surg. 1995;169:442-454. Sherman HF J Trauma. 1994;37:616-621. Schweizer W. Br J Surg. 1993;80:86-88. . Miller PR. J Trauma. 2002;53:238-242. Goan YG. J Trauma. 1998;45:360-364. Brasel KJ. Am J Surg. 1997;174:674-677. . Ochsner MG.. World J Surg. 2001;25:1393-1396.
    • 46. Criteria for NOMLI
      • No indications for laparotomy (physical examination signs/symptoms or other injuries)
      • Hemodynamically normal after resuscitation with crystalloid
      • No injuries that preclude physical examination of the abdomen (e.g., CHI, spinal cord injury)
      • No transfusion requirements (PRBC)
      • Constant availability of surgical and critical care resources
    • 47.
      • Liver injury score of patients is not as important as the hemodynamic status for determining conservative management
    • 48. High Success With Non-operative Management of Blunt Hepatic Trauma
      • Arch Surg.  2003;138:475-481
      • Hypothesis   Nonoperative management of liver injuries (NOMLI)   is highly successful and rarely leads to adverse events.
      • Setting   High-volume academic level I trauma center
    • 49. Cont.
      • Results
      •   78 patients
      • 23 (29%) were operated on   immediately, but only 12 (15%) for bleeding from the liver. NOMLI failed in 8 for reasons unrelated to the liver injury.
      • The success rate of NOMLI was 85% (47 of 55 patients),   but the liver-specific success rate was 100%.
      • No adverse   events were attributed to NOMLI .
    • 50. Cont.
      • Conclusions    
      • NOMLI   is safe and effective regardless of the grade of liver injury.
      •   Failure of NOMLI is caused by associated abdominal injuries   and not the liver.
      • Fluid and blood requirements, the degree   of injury severity, and the presence of other abdominal organ   injuries may help predict failure.
    • 51. Complications of NOMLI
      • Biliary (bile peritonitis, bile leak, biloma, hemobelia..)
      • Infection (liver abscess, necrosis, abdominal sepsis, SIRs)
      • Abdominal   compartment syndrome 
      • Hemorrhage
      • Hepatic necrosis &/or Acalculous Cholecystitis
    • 52. Failure of NOMLI
      • Usually attributed to reasons unrelated to liver injury
      • Other injuries can be missed in a blunt trauma victims, such as:
        • Bowel
        • Pancreas
        • Diaphragm
        • Bladder
        • Which can lead to failure of NOMLI
    • 53. Criteria of failure of NOMLI
      • Increasing fluid requirements to maintain normal hemodynamic status
      • Failed angio embolization of A-V fistulae/pseudoaneurysm
      • Transfusion requirements to maintain Hct/Hgb and normal hemodynamic status
      • Increasing hemoperitoneum associated with hemodynamic liability
      • Peritoneal signs/rebound tenderness
    • 54. How to manage conservatively Grade I II III IV ICU 0 0 0 1 Hospital stay (d) 2 3 4 5 Activity Restriction (w) 3 4 5 6
    • 55. Follow up
      • There is no evidence supporting routine imaging (CT or US) of the hospitalized, clinically improving, hemodynamically stable patient.
      • Nor is there evidence to support the practice of keeping the clinically stable patient at bed rest.
      2003 Eastern Association For The Surgery of Trauma
    • 56.  
    • 57. Indications
      • In Blunt Trauma
      • In Penetrating Trauma
      • Hemodynamic instability
      • Transfusion> 2 blood volume or > 40 ml/kg
      • Devitalized parenchyma
      • Sepsis / biloma
      • Exploratory lapratomy is indicated in any penetrating trauma in with peritoneal penetration
    • 58. Operative technique/options
      • Initial   Explore Laparotomy
      • Temporary control of hemorrhage:
        • Why temp?
          • Ongoing hemorrhage, life threatening, no time to restore circulatory volume.
          • Liver injuries not highest priority
    • 59. Operative technique/options
        • How?
          • Manual compression
          • Perihepatic packing.
          • Pringle maneuver.
          • Tourniquet
          • Hepatic vascular isolation
          • Placement of atriocaval shunt
          • Moore-Pilcher balloon
      commonest Juxtahepatic venous injury
    • 60.  
    • 61.  
    • 62.  
    • 63.  
    • 64. Operative technique/options
      • Definitive management of the injuries:
    • 65. 1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4
    • 66.  
    • 67.  
    • 68.  
    • 69.  
    • 70.  
    • 71.  
    • 72. Hepatic segments Resections
      • Right hemihepatectomy (segments 5 to 8 );
        • AKA as Right hepatectomy or right hepatic lobectomy
      • Right trisectionectomy (segments 4 to 8 );
        • AKA as Right lobectomy or Rrisegmentectomy of Starzl
      • Left hemihepatectomy (segments 1 to 4 );
        • AKA as Left hepatectomy or Left hepatic lobectomy
      • Left lateral sectionectomy (segments 1 to 3 );
        • AKA as Left lobectomy or Left lateral segmentectomy
    • 73.  
    • 74.  
    • 75. References
      • Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease,  8th ed.
      • Sabiston Textbook of Surgery, 18th ed.
      • Khatri: Operative Surgery Manual, 1st ed.
      • ACS Surgery principles and Practice 2006.
      • Cameron; current surgical therapy, 8 th ed.
      • http://www.netterimages.com/
      • http://www.adhb.govt.nz
      • http://emedicine.medscape.com/article/370508-overview
      • http://www.east.org