This document discusses liver trauma resulting from blunt and penetrating injuries. It describes two case studies, one involving a car accident and the other a stabbing. The car accident patient had liver lacerations that were managed surgically, while the stabbing victim had a liver wound and duodenal injury repaired during an emergency laparotomy. Most liver injuries can be successfully treated without surgery if the patient is hemodynamically stable. Surgical management may involve packing the liver or angiographic embolization of bleeding sites. Following initial resuscitation, imaging can help evaluate the severity and location of liver injuries.

1. Liver Trauma
Souradeep Dutta
INDIA

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. 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. 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. Post-operative course
● Remained haemodynamically stable
● MRI brain: confirmed small contusion near
internal capsule

6. Case 2: Penetrating trauma
● 24 year old male
● Stab wounds
– Three in upper abdomen
– Left side of neck

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. 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. 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. 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. 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. Anatomy of the injury

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. Liver segments
• Divided vertically
by the 3 main
hepatic veins and
transversely by the
right and left portal
branches.

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. 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. 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. 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. Example of a grade 3 injury
Subcapsular hematoma
Parenchymal hematoma
and laceration

20. Angiography
● May be useful in
localizing the site of
haemorrhage in stable
patients
● Transcatheter
embolization of
bleeding sites

21. Treatment
● Conservative
– Blunt liver trauma,
– Haemodynamically stable
– No other injuries requiring surgery
● Surgical
– Penetrating injuries
– Haemodynamically unstable
– Other injuries requiring surgery

22. Surgical management
● Full laparotomy
● Pringles manoeuvre to occlude the portal
triad
● Packing of the liver
● Treat other intra-abdominal injuries as
appropriate

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