Liver trauma conference presentation

1. LIVER TRAUMA MANAGEMENT EXPERIENCE AMONG A
CLUSTER OF PATIENTS PRESENTING WITHIN A MONTH
Muhammad Saaiq
Surgical Grand Round, Pakistan Institute of Medical
Sciences (PIMS), Islamabad.
September 29, 2006.

2. What prompted this presentation ?

3. Case No. 1
 Male aged 18 , presented with H/O
RTA and blunt trauma abdomen.
 Exploratory Laparotomy revealed :
i) About 4 cm long and 1cm deep liver
laceration just on the left side of the FL.
ii) Another 4cm long and 4 cm deep
irregular laceration just lat. to L. Teres
with a bleeder spurting blood.
iii) 800cc blood
AAST grade III Liver trauma.

5. Case No. 2
Male aged 19 ,
presented with H/O FAI Rt. Lower
rib cage / chest.
Exploratory Laparotomy revealed :
*Sealed firearm wound on the frontal
surface of Rt lobe ( B/w segments V
and VIII) corresponding to a similar
wound on posterior surface of liver.
* About 200 cc free blood.
AAST Grade III Liver trauma.

9. Case No. 3
 Male aged 15 presented with H/O FAI abdomen / Lt.
lower back.
 Exploratory Laparotomy revealed :
i) Firearm exit wound epigastrium / Lt hypochondrium with
omentum coming out through it .
ii) Fragmented Spleen.
iii) Parenchymal disruption of Lt lobe of liver involving > 50 %
of the lobe. iv) Two lacerations ( about 6 cm each) in the
stomach.
v) 3 cm rent in diaphragm leading to the Firearm entry
wound near inferior angle of Lt scapula.
vi) Irregular laceration of Lt costal margin with diaphragm
separate from costal margin over an area of 4 cm.
vii) About 2000 cc free blood in the peritoneal cavity.
AAST Grade IV Liver trauma.

15. Case No. 4
Male aged 20 presented with H/O Stab Rt
flank.
 Exploratory Laparotomy revealed :
i) One Litre free blood in the peritoneal cavity.
ii) Irregular laceration of the abdominal wall
communicating with the outside stab wound.
iii) 3 cm long and 5 cm deep laceration on
segment V communicating with a 1 cm
wound just lateral to the Gall bladder fossa.
iv) A small rent in the peritoneal reflections over
the duodenum with bruising of the adjoining
area.
AAST Grade III Liver trauma.

20. Liver Trauma
Anatomical Considerations

24. FUNCTIONALLY LIVER HAS :
2 Lobes
4 Sectors
8 Segments

26. Etiology / Mechanisms :
Blunt trauma :
Deceleration
Compression
Secondary penetrating injury from spicules
of fractured ribs / bones
Penetrating trauma :
Low energy trauma
high energy trauma

27. American Association for Surgery
of Trauma (AAST )
Grading system

28. Grade I :
Hematoma ; Subcapsular, non-expanding < 10 % surface
Laceration ; Capsular tear, Non-bleeding, < 1 cm
parenchymal depth
Grade II :
Hematoma ; Subcapsular, Non-expanding, 10-50 % surface
area Or intraparenchymal, Non-expanding, < 2 cm in
diameter.
Laceration ; Capsular tear, active bleeding, 1-3 cm deep,
< 10 cm in length.
Grade III:
Hematoma ; Sucapsular, > 50 % surface area Or
Ruptured subcapsular hematomea with active bleeding
Or Intraparenchymal hematoma > 2 cm or expanding.

29. Laceration ; > 3 cm parenchymal depth.
Grade IV:
Hematoma ; ruptured intrparenchymal hematoma with
active bleeding.
Laceration; Parenchymal disruption involving 25-50 % of
hepatic lobe
Grade V :
Laceration; Parenchymal disruption involving over 50 % of
hepatic lobe
Vascular; Juxtahepatic venous injuries(major hepatic veins,
retrohepatic vena cava)
Grade VI : Vascular; Hepatic Avulsion

30. Diagnostic Issues
 Active Management and Diagnostic investigations
if any should proceed simultaneously.
 No investigation should delay the proper treatment.
 Penetrating Vs blunt and whether the patient is
hemodynamically stable or not will rationalize the
route of investigations as well as management.
 Confirmation of hemoperitoneum may be done
with DPL or four-quadrant aspiration or FAST U/S.
 Ct scan abdomen and chest helps to determine
the Nature and Extent of liver injury plus any other
associated injuries.

31. MANAGEMENT :
Initial Resuscitation.
Definitive measures for Liver trauma.

32. Initial Resuscitation
A
B
C
D
E
F ?

33. Definitive
Management

34. Surgical Options :

35. Suture Hepatorrhaphy

36. Suture Hepatorrhaphy with
. Omental Buttressing

37. Perihepatic Packing

38. Perihepatic Packing

39. Hepatic Artery Ligation

40. PRINGLE MANOEUVRE

41. Application of Bioadhesives

42. Mesh Hepatorrhaphy

43. Major Vascular Injuries

44. Arterial Embolization

45. Liver Resection
Liver transplantation

46. Interventional radiology
Re-emergence of Perihepatic
packing with
Temporary abdominal closure
Recent Advances

47. Intra-hepatic Packing

48. Immediate Postoperative
Concerns

49. Common Problems
Hemorrhage
Sepsis
Bile leak
Coagulopathy

50. Lethal Triangle ( a.k.a Bloody
vicious cycle of trauma)
Core Hypothermia
Metabolic Acidosis
Coagulopathy

51. Other Complications of Liver Trauma
Bile collection
Liver abscess
Biliary fistula
Hepatic artery aneurysm
Arteriovenous Fistulation
Arterio-biliary Fistulation
Biliary tract strictures

53. LIVER TRAUMA
 Muhammad Saaiq
 Unit-I , Department of
Surgery.
LIVER TRAUMA