1) Liver trauma is the second most common organ injured in blunt abdominal trauma and the most common injured in penetrating trauma, occurring in 1-8% of patients with multiple blunt trauma. 2) The liver is susceptible to injury due to its size, friable parenchyma, thin capsule, and fixed position near the ribs and spine. 3) Liver injuries are classified based on the mechanism of injury, type and degree of damage, localization within liver lobes/segments, and whether associated vessels or bile ducts are damaged. Grades I-II are minor injuries while Grades III-V require surgical intervention and Grade VI is incompatible with survival.

1. LIVER TRAUMA
Muhammad Syazwan Mohd Hasim
31a

2. INTRODUCTION
• It is the 2nd commonest organ injured in blunt abdominal
trauma and the commonest injured in penetrating trauma.
• 1% - 8% of patient with multiple blunt trauma sustain a liver
injury.

3. FACTORS
• The large size of the liver
• Its friable parenchyma
• Its thin capsule
• Its relatively fixed position in relation to the spine and ribs

4. ANATOMY

5. CLASSIFICATION
I - Close Injury
1. According to mechanism of injury:
Direct hit, fall from a height, compression between two objects, Road traffic injuries
2. According to the type of damage:
rupture of the liver with damage of the capsule subcapsular hematoma, damage of
extrahepatic bile ducts and blood vessels of the liver
3. According to the degree of damage:
surface cracks and rupture to a depth of 2 cm, rupture to half thickness of the liver,
rupture depth of more than half of the liver
4. Localization:
Damage lobes or segments of the liver.
5. Character:
With damage of extra- and intrahepatic vessels and bile ducts.

6. II - Open Injury
1. Gunshot: bullet, shrapnel, the shot.
2. Machetes: stab
III - The combination of blunt trauma injury to the liver

7. GRADING

9. GRADING OUTCOMES
• Grade I,II
- minor injuries, represent 80-90% of all injuries, require
minimal or no operative treatment
• Grade III-V
- severe,require surgical intervention
• Grade VI
- incompatible with survival

10. CLINICAL PICTURE
• Pain
• Signs of blood loss
• Hematoma
• Tenderness upon palpation
• Dullness during percussion

11. DIAGNOSTICS
Ultrasonography
- fast, accurate, noninvasive, a good initial screening test
- sensitivity 88 %, specificity 99 %
DPL
- fast, sensitive, accurate and simple to perform
- invasive, cannot diagnose retroperitoneal injury
Computed tomography
- The standard evaluation method for stable patient . Performed with
dilute water soluble oral contrast agent and intravenous contrast
X-ray
- nonspecific, but useful in showing the extent of associated skeletal
trauma.

12. CLASSIFICATION (AAST)
I - Subcapsular hematoma <1cm, superficial laceration<1cm
deep

13. II - Parenchymal laceration 1-3cm deep, subcapsular
hematoma1-3 cm thick

14. III - Parenchymal laceration> 3cm deep and subcapsular
hematoma> 3cm diameter

15. IV - Parenchymal/supcapsular hematoma> 10cm in diameter,
lobar destruction

16. V - Global destruction or devascularization of the liver

17. VI - Hepatic avulsion

18. MANAGEMENT
CONSERVATIVE :
1. 86% of liver injuries stopped bleeding by the time of surgical
exploration
2. 67% of operations performed are nontherapeutic

19. • Criteria
- hemodynamically stable
- simple hepatic parenchyma laceration of intrahepatic
hematoma
- absence of active hemorrhage
- hemoperitoneum of less than 500ml
- limited need for liver related blood transfusions (12U)
- absence of peritoneal sign
- absence of other peritoneal injuries that would otherwise
require an operation

20. OPERATIVE :
• Initial hemostasis
1. Packing
2. Pringle maneoevre
3. Bimanual liver compression
4. Cross clamping aorta above celiac trunk

21. • Hepatotomy with direct suture ligation
- using the finger fracture technique, electrocautery or an
ultrasonic dissector to expose damaged vessels and hepatic
duct which ligated , clipped or repaired
- low incidence of rebleeding, necrosis and sepsis
- effectives following blunt liver trauma requires further
evaluation

22. • Resection debridement
- removal devitalized tissue
- rapid compared with standard anatomical resection, which
are more time consuming and remove more normal liver
parenchyma
- reduced risk of post-op sepsis secondary hemorrhage and bile
leakage

23. • Anatomical resection
- reserved for deep laceration involving major vessels or bile
ducts, extensive devascularization and major hepatic venous
bleeding
• Perihepatic packing
- Indication:
coagulopathy, irreversible shock from blood loss (10u),
hypothermia(32C), acidosis(PH7.2), bilobar injury,large
nonexpanding hematoma, capsular avulsion, vena cava or
hepatic vein injuries

25. • Mesh rapping
- new technique for grade III,IV laceration, tamponading large
intrahepatic hematomas
- not indicated where juxtacaval or hepatic vein injury is
suspected

27. • Omental packing
• Intrahepatic tamponade with penrose drains
• Fibrin glue
• Retrohepatic venous injuries
- Total vascular exclusion
- venovenous bypass
- Atriocaval shunting
• Liver transplantation