This document summarizes information about liver trauma, including: - Epidemiology of liver injuries, which often occur with other injuries like spleen or rib fractures. - Relevant anatomy of the liver, including its large size, friable tissue, and location making it prone to blunt trauma. - Classification system for grades of liver injuries from 1 to 6 based on severity. - Modern management primarily involves conservative non-operative treatment using CT scans and angiography, reserving surgery for more severe bleeding or injuries. - Key concepts discussed are damage control surgery, the "death triangle" of hypothermia, coagulopathy and acidosis to avoid, and total vascular exclusion for severe bleeding control

1. LIVER TRAUMA
Dr. D.K.Sharma
M.S., MCh. (GI Surgery)
Prof. & Head, Deptt. Of Surgery
RNT Medical College, Udaipur, Raj.

2. Synopsis

3.  Epidemiology
 Relevant Anatomy
 Pathophysiology
 Mechanisms of Injury
 Grades of Liver Trauma
 Clinical Features
 Investigations
 Treatment
 Important Concepts
 DPL
 FAST / eFAST
 ALTS
 DCS
 Death Triangle
 Total Vascular Exclusion

4. Epidemiology

5. Associations
 Isolated liver injury occurs in less than 50% of
patients.
 Blunt trauma 45% with spleen
 Rib fracture  33% with Liver injury
 Bowel injuries
 Pancreatic Injuries
 Gall Bladder & Bile Duct Injuries
 Rare
 Contusions, avulsions, lacerations or perforations.

6. Relevant Anatomy

8. Pathophysiology

9. Why the liver…
 Large organ
 Friable parenchyma, thin capsule, fixed position in
relation to spine  prone to blunt injury
 Wide bore, thin walled blood vessels with high
blood flow  Excessive blood loss
 Right lobe larger, closer to ribs  more injury
 In children:
 compliant ribs
 transmitted force

10.  Mild injuries heal in 3 months.
 Moderate injuries heal in 6 months.
 Severe injuries in 9-15 months.
Healing

11. Classification & Grading

12. Grade VI Hepatic Avulsion

14. Clinical Features

15.  Blood Loss
 Peritonism
 Symptoms
 Abdominal Pain
 Radiation to shoulder
 Altered Sensoium
 Signs
 Hypotension
 RUQ tenderness, and guarding
 Generalized Peritonism
 Hemoperitoneum
 Biliary Peritonitis
 Delayed – Intra-abdominal
abscess

16. Investigations

17. Labs & Radiology
 Hematologic
 Elevated LFTs
 DPL -- high sensitivity
 CT scan is the diagnostic procedure of choice.
 USG
 MRI ??
 Diagnostic Laparoscopy

18. USG
 FAST
 eFAST

19. Angiography
 Active bleeding
 Transcatheter embolization
 Embolization & stenting for fistulas.

20. CT Scan
 Localization.
 Monitor healing.
 Grades 1-6

21. Management

22. Management
 In the Past vs Now treatment of blunt liver trauma
 Stopped bleeding at Laparotomy- 86%
 Non-therapeutic explorations- 67%
 Conservative Management-
 Adults-80%
 Children-97%
 Reasons
 MDCT
 TAE
 Liver regenerative capacity
 Improved Critical Care
 Operative / Non-Operative
 CT scan diagnosis and follow up

23.  Remember associated injuries
 Spleen
 Pancreas
 Bowel
 Resuscitate
 Consider Cryoprecipitate, FFP
 Assessment of injury
 Spiral CT
 Laparotomy
♦ Treatment
♦ OM
♦ NOM
Management

24.  Damage Control Surgery
 Perihepatic packing
 Hepatorrhaphy
 Mesh Wrapping
 Enough Tension
 Anchoring
 Hepatotomy & Selective Vascular Ligation
 Resection
 Non-anatomical
 Anatomical
 Intrahepatic Balloon Tamponade
 Total Vascular exclusion
 Liver Transplantation

26. Post-Operative Complications
 Hemorrhage
 Correct coagulopathy
 TAE
 Operative Control
 Remove perihepatic packing bet 36-72 h
 Sepsis & Abscess
 Percutaneous drainage
 Surgical Drainage
 Biliary Complications
 Biloma
 Biliary Ascites
 Biliary Fistulae

27. ATLS
 Advanced Trauma Life Support
 Aggressive fluid resuscitation
 CVP
 UO Monitoring
 Avoidance of “Death Triangle”
 Hypothermia
 Coagulopathy
 Acidosis

28. Damage Control Surgery
 Stone (1980); Univ. of Pennsylvania (1983)
 To avoid or deal with Danger Triad
 Early recognition
 Already at physiologic limit
 Concepts & Sequence
 Control of Hemorrhage & Contamination
 Temporary closure & Return to ICU
 Deal with the Triad
 Return to OT Definitive repair

29. Death Triangle
 Danger Triad; Bloody Vicious Cycle
 Components
 Hypothermia
 Decreasing Temp
 <34 C
 Coagulopathy
 Non-surgical Oozing
 PT > 50% of normal
 Acidosis
 <7.2 despite adequate volume resuscitation

30.  surgeryclasses.blogspot.in

31. Thank you