This document provides an overview of liver anatomy, physiology, and management of liver trauma. It describes the surface anatomy, blood supply, ligaments, segments, and imaging appearance of the liver. Factors making the liver prone to injury are discussed. Grades of liver injuries based on the Moore scale are outlined with examples. Non-operative and operative management strategies are reviewed, including criteria for each approach and techniques for temporary and definitive control of hemorrhage. Complications of non-operative management and indications for failure are also summarized.

1. Dr. Aisha Al-Zuhair
General Surgery
KFHU – Khobar – Saudi Arabia
Dec 16, 2009

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

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.

14. Blood Supply
Portal vein
Hepatic artery
Hepatic vein

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

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]

25. Radiological anatomy

26. Radiological anatomy

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.

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.

43. Management
Operative
vs
Non-Operative

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

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

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

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

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
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