3. Surface anatomy
In RUQ
5th
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
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]
28. Introduction
It is the 2nd
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:
1. The large size of the liver,
2. its friable parenchyma,
3. its thin capsule, and
4. Its relatively fixed position in relation to the
spine and ribs.
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.
45. Non-Operative Management of
Liver Injury
An absolute increase in the incidenceof
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 onimmediately, 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 adverseevents 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
injuriesand not the liver.
Fluid and blood requirements, the degreeof injury
severity, and the presence of other abdominal
organinjuries may help predict failure.
51. Complications of NOMLI
Biliary (bile peritonitis, bile leak, biloma, hemobelia..)
Infection (liver abscess, necrosis, abdominal sepsis,
SIRs)
Abdominalcompartment 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
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, 8th
ed.
http://www.netterimages.com/
http://www.adhb.govt.nz
http://emedicine.medscape.com/article/370508-overview
http://www.east.org
Editor's Notes
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.
