Grading of liver injuries and Kidney injuries

1. GRADING OF LIVER AND
KIDNEY INJURIES
DR. PRAMESH PRASAD SHRESTHA
FCPS RESIDENT (1ST YEAR)
DEPARTMENT OF GI SURGERY AND DIGESTIVE DISEASES

2. KIDNEY INJURY
• AAST KIDNEY INJURY SCALE, 2018
• The most recent update incorporates Vascular Injuries, such as
Pseudoaneurysm, arteriovenous fistula

3. Classification of Kidney Injury
• GRADE I
• Subcapsular hematoma or contusion without laceration

4. Classification of Kidney Injury
• GRADE II
• Superficial laceration ≤1 cm depth not involving the collecting
system (no evidence of urine extravasation)
• Perirenal hematoma confined within the perirenal fascia

5. Classification of Kidney Injury
• GRADE III
• laceration >1 cm not involving the collecting system
(no evidence of urine extravasation)
• vascular injury or active bleeding confined within the
perirenal fascia

6. Classification of Kidney Injury
• Grade IV
• laceration involving the collecting system with urinary
extravasation
• laceration of the renal pelvis and/or complete ureteropelvic
disruption
• vascular injury to segmental renal artery or vein
• segmental infarctions without associated active bleeding
(i.e. due to vessel thrombosis)
• active bleeding extending beyond the perirenal fascia
(i.e. into the retroperitoneum or peritoneum)

7. Classification of Kidney Injury
• Grade V
• shattered kidney
• avulsion of renal hilum or laceration of the main renal artery
or vein: devascularisation of a kidney due to hilar injury
• devascularised kidney with active bleeding

8. Classification of Kidney Injury
• Additional notes:
• advance one grade for multiple/bilateral injuries up to grade III

9. Management of Kidney Injury
• History: Mode and mechanism of injury
• Examination:
• Features of shock: heavy retroperitoneal bleed,
• Ecchymosis in the flank or upper quadrants of abdomen
• Diffuse abdominal tenderness
• Lower rib fractures
• Urethral Catheterization may reveal hematuria.

10. Management of Kidney Injury
• Laboratory investigations:
• Hemoglobin: may be decreased in large bleeding
• Renal Function Tests: may be deranged usually if there is bilateral kidney
injuries
• Urine Analysis: Hematuria
• Imaging:
• Plain X-ray: Bony injuries
• USG abdomen and pelvis, FAST scan
• IVU
• CECT abdomen and pelvis/ CT IVU – gold standard
• MRI

11. Management of Kidney Injury
• One Shot IVP
• In unstable patients requiring immediate operative interventions
• Done on the operating table
• Technique:
• Bolus intravenous injection of contrast 2ml/kg
• Followed by a single plain film taken after 10 minutes
• Advantage: can assess kidney function, extravasation of urine and injuries to
collecting systems

12. Management of Kidney Injury
• Angiography
• Most common indication: non visualization of the kidney on IVP when CT is
not available.
• Test of choice for renal venous injuries
• Indicated in stable patients to
• assess pedicle injury if CT findings are unclear
• For those patients who are candidate for radiological control of hemorrhage

13. Management of Kidney Injury
• Non Operative Management
• Grade 1-4 blunt renal trauma, stable patients should be managed
conservatively with:
• Bed rest
• Prophylactic antibiotics
• Continuous monitoring of vital sings until hematuria resolves
• Persistent bleeding represents the main indication for renal
exploration and reconstruction

14. Management of Kidney Injury
• Indications for Exploration
• Hemodynamic instability due to renal hemorrhage is an absolute indication
• Grade 5 renal injury in a stable patient
• Expanding or pulsatile perirenal hematoma seen at laparotomy done for
associated injuries

15. Management of Kidney Injury
• Surgery:
• Goal is to control hemorrhage and renal salvage
• Approach is trans-peritoneal
• Early control of renal pedicle
• Temporary occlusion of the pedicle during exploration of kidney reduces blood loss
without increasing post operative morbidity

16. Management of Kidney Injury
• Renorraphy and partial nephrectomy for parenchymal laceration
• Nephrectomy is the best option for Repair of Grade 5 renal injury
except in cases of solitary Kidney
• Retroperitoneal Drainage should be done following renal exploration

17. Management of Kidney Injury
• Post trauma care and follow up
• Repeat Imaging recommended for all hospitalized patients within 2-4 days of
significant renal trauma, especially in cases of fever, flank pain, or falling
hematocrit
[Blankenship JC, Gavant ML, Cox CE, et al. Importance of Delayed Imaging for Blunt Renal Trauma.
World J Surg 2001 Dec; 25 (12): 1561-4]
• Nuclear Scintigraphy can be done before discharge for documenting
functional status

18. Complications
• Within the First Month:
• Bleeding
• Infection
• Perinephric abscess
• Sepsis
• Urinary Fistula
• Hypertension
• Urinary Extravasation
• Urinoma

19. Complications
• Late Pathologic Findings:
• Urinoma: results from deep lacerations that are not repaired with persistent
urinary extravasation; may later develop hydronephrosis and abscess
formation
• Hydronephrosis: Large hematomas with perinephric fibrosis may engulf PUJ
causing hydronephrosis over time.
• Arteriovenous fistula: May occur after penetrating Injuries but are not
common
• Renal Vascular Hypertension: occlusion of blood flow in renal vein

20. Complications
• Page Kidney/ Page Phenomenon:
• Systemic hypertension secondary to extrinsic compression of kidney by a subcapsular
collection such as hematoma, seroma or urinoma
• May present acutely after an inciting event or following a delay
• Pathology: Compression of the kidney results in compression of the intrarenal vessels,
which leads to decreased blood flow to the renal parenchymal tissues and induction of
RAAS system, resulting in hypertension
• Management:
• Medical management
• Vascular reconstruction
• Total Nephrectomy

21. Special Cases
• Pediatric Renal Trauma
• Children are more prone to renal trauma
• Kidneys are lower in the abdomen
• Less protected by the lower ribs and muscles
• More mobile
• Less perinephric fat
• Proportionately larger in the abdomen
• Hypotension is a less reliable sign and patient may have a significant injury
despite stable blood pressure

22. Livery Injury
• One of the most Common Organ to be injured

23. Classification of Traumatic Liver Injury
• AAST Liver injury scale
• GRADE I:
• HEMATOMA: Subcapsular, <10%
surface area
• Laceration: Capsular tear, < 1cm
parenchymal depth

24. Classification of Traumatic Liver Injury
• AAST Liver injury scale
• GRADE II:
• hematoma: subcapsular, 10-50%
surface area
• hematoma: intraparenchymal <10
cm diameter
• laceration: capsular tear 1-3 cm
parenchymal depth,
<10 cm length

25. Classification of Traumatic Liver Injury
• AAST Liver injury scale
• GRADE III:
• hematoma: subcapsular, >50%
surface area of
ruptured subcapsular or parenchymal
hematoma
• hematoma: intraparenchymal >10 cm
• laceration: capsular tear >3 cm
parenchymal depth
• vascular injury with active bleeding
contained within
liver parenchyma

26. Classification of Traumatic Liver Injury
• AAST Liver injury scale
• GRADE IV:
• laceration: parenchymal
disruption involving 25-75%
hepatic lobe or involves 1-3
Couinaud segments
• vascular injury with active
bleeding breaching the liver
parenchyma into the peritoneum

27. Classification of Traumatic Liver Injury
• AAST Liver injury scale
• GRADE V:
• laceration: parenchymal
disruption involving >75% of
hepatic lobe
• vascular: juxtahepatic venous
injuries (retrohepatic vena cava /
central major hepatic veins)

28. Classification of Traumatic Liver Injury
• AAST Liver injury scale
• GRADE VI:
• Hepatic Avulsion

29. Management of Liver Injuries
• Non operative management
• 86.3% of hepatic injuries can be managed without surgical
interventions
• Surgical intervention relies on the hemodynamic stability of the
patient rather than the grade of Injury

30. Management of Liver Injuries
• Thus WSES (world society of Emergency Surgery give a classification
of liver trauma mand management guidelines, incorporating AAST
Classification within.
• WSES classification: (3 classes, 4 grades)
• Minor hepatic Injuries, WSES grade I includes AAST Grade I and II
• Moderate Hepatic Injuries, WSES grade II, includes AAST Grade III
Severe Hepatic Injuries,
• WSES Grade III, includes AAST Grade IV-VI
• WSES Grade IV, Includes AAST Grade I-VI

31. Management of Liver Injuries
• In WSES classification, Grade I-III can be managed with Non surgical
treatment
• Grade IV requires surgical intervention
• However, Non surgical Management should only be attempted in
centers capable of precise diagnosis of the severity of liver injuries
and capable of intensive management, with immediate access to
diagnostics, interventional radiology, surgery and blood and blood
products

32. Management of Liver Injuries
• Surgical Management
• Goal: control hemorrhage, control biliary leak
• Angioembolization is an useful tool in case of persistent arterial
bleeding

33. • Surgical Technique:
• Exploratory Laparatomy
• 1st Priority is to Control hemorrhage rather than liver repair

35. Moore Pilcher Balloon
Pringle Maneuver

36. Placing an Cuffed ET Tube Clamping of
Supra Hepatic Vena Cava
Venous Bypass

37. Treatment of Liver Injuries:

38. • Mesh Wrapping
• For Grade III and IV laceration ,
tamppnading large intrahepatic
hematomas
• Not for juxtacaval or hepatic vein
injuries

40. • Post operative angioembolization in a viable option
• Portal vein injuries should be repaired primarily
• Liver packing is the most successful method of managing even severe
venous injuries
• In cases of liver avulsion or total crush injuries, when total hepatic
resection must be done, hepatic transplantation has been described

41. •Thank you!!