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LIVER TRAUMA

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LIVER TRAUMA

  1. 1. Liver Trauma Souradeep Dutta INDIA
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. Post-operative course ● Remained haemodynamically stable ● MRI brain: confirmed small contusion near internal capsule
  6. 6. Case 2: Penetrating trauma ● 24 year old male ● Stab wounds – Three in upper abdomen – Left side of neck
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Anatomy of the injury
  13. 13. 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.
  14. 14. Liver segments • Divided vertically by the 3 main hepatic veins and transversely by the right and left portal branches.
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. Example of a grade 3 injury Subcapsular hematoma Parenchymal hematoma and laceration
  20. 20. Angiography ● May be useful in localizing the site of haemorrhage in stable patients ● Transcatheter embolization of bleeding sites
  21. 21. Treatment ● Conservative – Blunt liver trauma, – Haemodynamically stable – No other injuries requiring surgery ● Surgical – Penetrating injuries – Haemodynamically unstable – Other injuries requiring surgery
  22. 22. Surgical management ● Full laparotomy ● Pringles manoeuvre to occlude the portal triad ● Packing of the liver ● Treat other intra-abdominal injuries as appropriate
  23. 23. 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

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