In this presentation, I discussed the mechanism of injury, grading, clinical features, diagnosis, and treatment of liver injuries.

1. LIVER INJURY
DR.B.SELVARAJ MS;Mch;FICS;
‘Surgical Educator’
MALAYSIA
BLUNT ABDOMINAL TRAUMA

2. LIVER INJURY
• Etiology
• Pathology
• Clinical features
• Workup/Investigations
• Differential diagnosis
• Liver CT injury grading
• Treatment
• Complications
• Treatment algorithm for Liver injury
LEARNING OBJECTIVES

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• The liver is the 2nd most frequently injured solid organ in blunt
injury 0f the abdomen after spleen.
• Hepatic injury is more common in patients with penetrating injuries
(30%) than in patients with blunt abdominal trauma (15% to 20%).
• The overall mortality of liver trauma is approximately 10%. Blunt
injuries are usually more complex and result in mortality
approaching 25%.
• Most deaths occur in the early postoperative period (< 48 hours) from
shock and transfusion-related coagulopathies.
OVERVIEW

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• H/O Blunt abdominal or lower thoracic trauma
• Penetrating trauma to Right Hypochondrium and
epigastric areas
• Blunt injury produces contusion, laceration and
avulsion injuries to the liver, often in association
with splenic, mesenteric or renal injury.
• Penetrating injuries, such as stab and gunshot
wounds, are often associated with chest or
pericardial involvement.
• Blunt injuries are more common and have a
higher mortality than penetrating injuries.
ETIOLOGY
• Injury types
• Subcapsular hematoma
• Lacerations (± disruption of hepatic
lobes/ segments)
• Deeper injuries + vascular (IVC/
hepatic vein) injuries
• Mechanism of injury
• Crushing
• Deceleration
• Sudden increase in intra abdominal
pressure because of seat belt

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• The main immediate consequence is hemorrhage.
• The amount of hemorrhage may be small or large,
depending on the nature and degree of injury.
• Many small lacerations, particularly in children,
cease bleeding spontaneously.
• Larger injuries hemorrhage extensively, often
causing hemorrhagic shock. Mortality is
significant in high-grade liver injuries.
PATHOLOGY

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CLINICAL FEATURES

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• Other causes for hemoperitoneum
• Splenic injury
• Ruptured ectopic pregnancy
• Ruptured abdominal aortic aneurysm
• Acute hemorrhagic pancreatitis
DIFFERENTIAL DIAGNOSIS

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INVESTIGATIONS

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INVESTIGATIONS- CECT
 CT is the procedure of choice for diagnosis and
estimation of the degree of liver injury in the
hemodynamically normal patient.
 Contrast blush (intraparenchymal hyperdense
contrast collection)suggests active hemorrhage and
is associated with failure of nonoperative
management in all solid organ injuries.

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INVESTIGATIONS
SELECTIVE CELIAC ARTERIOGRAPHY
 Angiography may be
used in patients
demonstrating a
contrast blush on CT
scan to identify and
treat a vascular
abnormality with
angioembolisation

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INVESTIGATIONS DPA/DPL

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AAST – CT GRADING

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TREATMENT
Nonoperative management
 Requires ICU monitoring in a dedicated
trauma center and immediate ability to
convert to operative management should
that become necessary
 Isolated blunt hepatic injury is increasingly
managed nonoperatively.
Indications
 Hemodynamic stability
 Minimal evidence of blood loss, < 2 units
packed red blood cells as transfusion
requirement
 Absence of active contrast extravasation on
CT scan
 Absence of other indication for laparotomy
 Length of intensive care unit (ICU) monitoring is generally
24 to 48 hours initially, with serial hematocrit evaluation
and continuous hemodynamic monitoring
 Blood transfusion is limited to 2 units of packed red blood
cells. If the patient has an ongoing transfusion
requirement of more than 2 units, operative management
should be performed
 The majority of pediatric hepatic trauma is successfully
managed nonoperatively.
 Recovery recommendations include restricted activity in
terms of contact sports, running, or similar stresses for 3
months following injury.
 Angiography is performed in patients who are
hemodynamically normal and have a blush on initial CT
scan.

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TREATMENT
Operative management
 Initial management to combat
hypothermia
- Have a warmed operating room available
- Give warm IV fluids
- Heating pad on the operating room table
- Convection heater prepared for use
 Prepare and drape from the neck to the
mid thigh to allow access to the chest via a
sternotomy or thoracotomy and to allow
access to the upper leg for harvesting a
saphenous vein for a vascular injury.
 Prophylactic antibiotics are given and a
midline incision from the xiphoid to the
pubis is used
 All intraperitoneal blood should be quickly evacuated and
bleeding sources controlled with packs
 Simple injuries (grades I and II)
- The majority of hepatic injuries (blunt 60% and
penetrating 90%) are minor and will have stopped bleeding or,
if not, can be managed by simple techniques. These include
suture ligatures, electrocautery or argon beam coagulation,
and application of topical agents.
- For 1- to 3-cm deep bleeding lacerations, suture
hepatorrhaphy using horizontal mattress sutures of 0 chromic
on a large blunt needle are used to loosely approximate liver
parenchyma.
- Topical agents (i.e., Surgicel or Avitene) are useful once
major hemorrhage is controlled.
- Fibrin glue is also used as a topical hemostatic agent

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TREATMENT
Operative management
 Complex hepatic injuries (grade III or
greater) in 10% of penetrating and 40% of
blunt trauma
 Initial management should be the control
of the hemorrhage with manual
compression of the injury using
laparotomy pads.
 Prior to definitive hemostatic control of
the liver injury, the portal triad is occluded
with manual compression, a Rummel
tourniquet, or an atraumatic vascular
clamp (the Pringle maneuver)
 Liver can tolerate up to 90 minutes of
warm ischemia
 Hepatotomy with selective vascular ligation is the most
widely used method to control extensive bleeding
 After hemorrhage is controlled and necrotic parenchyma
debrided, the resulting hepatotomy site can be filled with a
pedicle of omentum based on the right gastroepiploic vessel
 The liver edges are then loosely approximated with 0
chromic liver sutures.
 Omentum will tamponade minor oozing, decrease dead
space, and increase absorption of small amounts of blood
and bile.

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TREATMENT
Operative management
 Resectional debridement (do not confuse
this with anatomic resection) is indicated
when there is partially devascularized
tissue
 Hepatic resection refers to anatomic
removal of a segment (or lobe) and is
reserved for patients with total
destruction of a segment (or lobe)
 Selective hepatic artery ligation can be
used to control arterial hemorrhage from
the liver parenchyma. This maneuver is
usually tolerated because of the high
oxygen saturation of the portal blood and
can be performed without subsequent
hepatic necrosis.
 Perihepatic packing is indicated in patients with extensive
uncontrolled lacerations, expanding subcapsular
hematomas. This is typically referred to as damage control,
where hemorrhage and contamination are controlled.
 Packing should be removed after the patient has stabilized
hemodynamically after 24 to 72 hours

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TREATMENT
Operative management
 Internal tamponade for penetrating
injuries using red rubber catheter and a
Penrose drain tied at each end.
 Injuries to the retrohepatic IVC or hepatic veins are
frequently lethal. Total vascular isolation of the liver
(clamping the hepatoduodenal ligament, suprarenal IVC
and suprahepatic IVC sequentially; Heaney technique)
After the shunt is in place, the
hepatic ligaments are taken down
and the repair can be accomplished

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COMPLICATIONS
 Recurrent bleeding in 3% of cases which can be managed by
therapeutic embolisation
 Intra-abdominal abscesses occur in 2% to 10% of all hepatic trauma
which can be treated by CT guided drainage
 Biliary fistula: drainage of >50ml bile for > 2 weeks in 1 to 10% of cases
which can be managed conservatively or ERCP stenting
 Hemobilia: Rare. Classic triad of right upper quadrant pain,
gastrointestinal tract hemorrhage, and jaundice. “Quincke’s triad”
Can be treated by therapeutic embolisation

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Treatment Algorithm