idea about liver trauma

1. LIVERTRAUMA
The liver is the second most common organ injured
in abd.Trauma. being big , central & vascular

2. Background
 Largest solid abdominal organ,fixed position
 Second most common injured, but most common cause
of death after abdominal trauma
 Blunt MVA most common
 80% adults, 97% children-conservative rx

3. Pathophysiology
 Friable parenchyma, thin capsule, fixed position in
relation to spine.
 Right lobe gets hit more since its larger, and closer to
ribs.
 85% injuries involve segments 6,7,8 from compressioin
against ribs, spine, abd wall.
 Shear forces at attachments to diaphragm
 Transmission thru right hemithorax.

4.  Liver injured easily in children since ribs are compliant,
force transmitted.
 Liver not as developed in children, with weaker
connective tissue framework.
 Iatrogenic injuries by biopsies, biliary drainage, TIPS,
can cause capsular tears and bile leaks, fistulas,
hemoperitoneum.

8. (3) Injury to blood vessels and
biliary structure :
May occur in both type of trauma
The liver have two
vascular pedicle

9. A- Inflow pedicel : Portal vein , H. artery.
easy accessible in hepato duod. Lig & controlled by Pringle: maneuver
B – Out flow pedicle Hepatic vein , retro hepatic v. cava
inaccessible .Total vascular isolation of the liver may be needed !
(4) Spontaneous rupture
e.g primary carcinoma , haemangioma , blunt trauma

10. Liver injury scale (AMercian ASSocitation of the surgery of trauma (AAST)

11. 1. Superficial parenchymal wound: simple suture , diathermy
2. Deep or extensive parenchymal injury : → Paking
3. Deep injury involving major vascular structure → Require
special maneuver to achieve hemostasis ( poor prognosis)
AAST SUMMURIZESTHE LIVER INJURY SCALE INTO 3TYPES

12. Diagnosis
A. Clinical :
1. Pt with blunt abd. trauma & Hypotension
2. Contusion over the lower chest
3. Fracture of Rt Lower ribs (9-12 ribs)
4. Penetrating injuries to the Rt lower chest (below the fourth
intercostal space
5. Sign of hoemoperitonium

13. B. Taping
Diagnostic
Negative tape does not rule out intra
peritoneal organ damage
C. Laboratory investigation
Blood picture
 leuko cytosis
 HB concentration
Liver function
Of little value in first 24h
D. Imaging
X Ray abd. And chest
Elevated RT copula of the diaphragm
Fracture lower sibs
E. Ultra sound
Nan invasive & can be repeated
Highly sensitive in detecting >200ml of intra
peritoneal fluid

14. F. Computed tomography (CT Scan )
Delineate the anatomy of injured sold organ & grading of the injuries
Used in haemodynamically stable Pt. suitable for non operative management )

15. G . Selective angiography
Should be considered in Pt with active contrast extravasations into the
peritoneum seen on CT scan

16. Management
Hemodynamic stability of the pt.
Types of injury
Blunt
Stable
Conservative non
operative regardless
the grade or extent of
injury
Un stable
Urgent laparotomy
penetrating
Stap wound
stable Unstable
Gun shot
Usually operative
conservative ( careful
selected case)

17. Complication of Non operative management
1- Ongoing Bleeding
Stable
Repeat CT
Extravasations
Selective
angiographic
embolization
Unstable
Urgent
laparotomy
Hypotension
↓ HB
↑ liver size

18. 2- Biloma
3- Biliary fistula
T. Drainage under U/S guide
Failed
ERCP
( Endoscopic papillotomy & stending

19. 4. Intra Abd. abscess
5. Hepatic abscess
6. Haemobilia
• Delayed rupture of false aneurysm of branch of H. artery into biliary tree
• c/p → jaundice / biliary colic, upper G.I. Hge
• Treatment angiographic Embolization (treat. of choice)
t. drainage under U/S guide

20. 7. Liver necrosis
Small area Large area
No treatment
Difficult to
diagnose
May become infected
May need resectional
debridement & drainage

21. 8.Missed Hollow viscus injury
• Rare, difficult in diagnosis
• RepeatedCT
• Laparotomy
• Failure to achieve the source ⇛ Death

22. laparotomy
Superficial
Simple suture
Local Homeostasis
Deep injuries
Packing
Control
Removed after 48h
POST operative angiography
for selective embolization
Uncontrolled
Inflow occlusion
Bringle maneuver
Unstable

24. Pringle maneuver for reducing bleeding in the liver surgery has stood the test of time for over a
century.The medial free edge of the hepatoduodenal ligament contains the portal vein,
hepatic artery, and the common duct. By inserting one’s index finger through the foramen of
Winslow and compressing the portal triad between the thumb and index finger, all of the
inflow to the liver can be occluded with the rare exception of an anomalous hepatic artery
coursing outside the pinched area.This occlusion can alternatively be performed with a
nontraumatic instrument or touniquet. C caudate lobe of the liver, P portal vein, hepatic
artery, and common duct, D duodenum, IVC inferior vena cava

25. Bringle maneuver
Bleeding stop Not stop
Consider injuries
H. vein
Retro hepatic IVC
Abberant H artery
. Special technique .Total
Hepatic isolation
. Mobilization of the liver
. Mortality high

26. Summary
1. Blunt hepatic injury in stable Pt ⇛non op. management with adjunctive
measures to manage sequelae & complication
2. Missed Hollow Viscous is unusual & carry high mortality with the
conservative strategy

27. 3. Haemodynamically unstable patient ⇛ emergency laparotomy &
managed first by Paking
4. Rarely Pt . With injury to hepatic vein or retro hepatic vena cava ⇛ needs
proximal & distal vascular control & even in most experienced hand the
mortality rate is high.