Liver trauma: indications for and principles of surgery

1. Liver trauma: operative
management
Raimundas Lunevicius
Consultant Surgeon
Liverpool University Hospitals NHS FT, Aintree Site
Mersey and Cheshire Major Trauma Centre
University of Liverpool
19th July 2018
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2. Operative management
Immediately to Theatre: 2 ASSISTANTS / 2 scrub nurses
Prepare from chin to mid-thigh / two large suction devices
Midline incision + suction + quick gentle inspection
- Split lig. teres hepatis (not Falciform ligament !)
Firstly, assess the hepatoduodenal ligament (for portal bleeding),
Secondly, assess the liver
(1) If it is bleeding from Portal Vein:
compress vein anatomically with fingers of L hand (50% JOB DONE);
use a pack/compression (as the alternative) / tourniquet
(2) NOT from Portal Vein: pack peri-hepatically / compress / wait
TEMPORAL CONTROL achieved: relax a moment and think
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3. Bleeding from portal vein
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4. Portal bleeding control:
anatomical temporal finger compression
(1) Repair without liver
inflow occlusion (side)
(2) Repair with in-liver
inflow occlusion
Pringle maneuver
Tourniquet
30 min
15 +5 rule
never 45 min in trauma
(3) If no ways / no help:
CLAMP / LIGATE it
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5. Bleeding from the liver
(hepatic bleeding)
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6. Hepatic bleeding control
• The goal: temporal (+ definitive) control
manual compression (use assistant’s hand)
packing (use lap pads) + manual compression
sutures
other methods possible but
close abdomen (pressure!)
Re Inflow occlusion:
avoid, if possible
if ‘yes’: Pringle maneuvre (tourniquet or Satinsky)
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7. Retrohepatic bleeding control
Vena Cava / Hepatic vein injury
(the least accessible vascular structures)
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8. Retrohepatic bleeding control:
Vena Cava / Hepatic vein injury
Potentially mortal injuries especially if the supporting structures of the
veins – ligaments, diaphragm, liver parenchyma – are disrupted
(free bleeding and ex-sanquination)
Three main strategies to deal with:
1. Tamponade: perihepatic packing (do NOT mobilize the liver, plug
the hole just)
2. Direct repair without or with vascular isolation, if possible
3. Repair via a lobar / section resection or just a lobar / section
resection (or resectional debridement)
HOWEVER, if the source of bleeding is below the liver:
immediate IVC (renal vein injury is also possible) repair is necessary
(do not play with atriocaval shunts, venovenous bypasses…)
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9. The role of sternotomy / thoracotomy
and the clamp of aorta and IVC
Depends on the case:
In most of the cases: unnecessary
especially in case of IVC injury around or below
renal veins
However, do when it is necessary to control
massive bleeding
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10. Technicalities
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11. Liver mobilization: to do or not to do
• Suspected vv. hepaticae injury
– DO NOT do it / compression pack
• Suspected subhepatic IVC injury:
know what you can / DO it
– mobilize the right hemiliver, if
needed, and repair the IVC (RRV)
– if can’t: compression packing
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12. Other techniques:
to control arterial bleeding from the liver
• Ligate right, medial or left hepatic artery
– when direct injury to the pre-hepatic / intrahepatic
artery is identified during surgery
• Immediate angiography with selective
embolization as a hemostatic adjunct in the
operative theatre or in IR suit (hybrid surgery)
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13. Other techniques:
to control bleeding from the liver
Filling parenchymal defects with omentum (?)
Hepatotomy with selective vascular ligation
Ballon tamponade: Blakemore tube (for GSW) (?))
Resection
– debridement: anatomic vs non-anatomic
– delayed hemihepatectomies / sectionectomies (if non-viable)
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14. GRADE 6 (full avulsion)
1st TASK:
forget the liver
Control of bleeding from major vessels
2nd TASK:
deal with the liver for (liver surgeon)
1st choice: Replantation of liver or survived hemiliver
2nd choice: Liver transplantation within 24-48 h
Problem: availability of liver graft
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15. NB! 1
In brief, the best procedures
The best universal procedures for temporal and
definitive control (when surgery required):
Manual compression
Perihepatic packing
Other surgical maneuvers are rare:
Liver inflow occlusion (no more than 30 min)
Plus other procedures on liver parenchyma or major
vessels
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16. NB! 2
Perihepatic packing
Do not forget to close peritoneum-fascia
– as high intraabdominal / perihepatic pressure is crucial
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17. Injury specific complications
Postop haemorrhage or re-bleeding
If in 7-10 days: usually arterial
IR is the best option; avoid laparotomy
Hemobilia: UGI bleeding 2-4 weeks after injury
Bilhemia: ERCP, identify leaking bile duct
Biloma: fever and jaundice: PD
Biliary fistula (leak)
Other fistulae (thoracobiliary fistulae)
False aneurysm of injured (any) hepatic artery
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18. Illustrations of surgical maneuvers
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19. Manual compression:
method of temporal intraoperative control
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20. Perihepatic packing:
method of temporal & definitive control of bleeding
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21. Liver inflow occlusion:
Pringle maneuver is time sensitive (temporal control)
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22. Hepatotomy with selective ligation
for deep lacerations
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23. Omentum packing:
maneuver per se or after hepatotomy (rare)
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24. Specifically, for GSW: Ballon tamponade
using Sengstaken – Blackmore tube
temporal / definitive control
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25. Liver avulsion (gr. 6)
Pack and compress the site
Identify structures of hepatoduodenal ligament
CLAMP PV AND PROPER HEPATIC ARTERY
Right-sided visceral medial rotation (Cattell–Brasch)
Clamp IVC above renal vessels
CLAMP IVC above hepatic veins
Sternotomy / any ‘tomy’ to expose IVC
Clamp it above hepatic vessels
RELAX as MAIN JOB DONE (bleeding stopped)
Wait other surgeons: Liver AND / OR Vascular
IF NOT COMING IN 30-40 MIN
Please insert large plastic drain (Robinson No. 30)
with the side holes in both ends of it via right atrium
WAIT AS 2 OPTIONS REMAIN:
1. Liver/hemiliver re-implantantion (1st choice)
2. Liver allograft transplantation: within 24-48 h
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26. The last thing to
remember (56 PVs,
by research paper)
Management of injury to PV
(if a patient is lucky enough to be
brought to Acute Care Hospital in a
few minutes from the moment of a
traumatic event)
1. No panic
2. Manual compression, firstly
3. Apply Pringle, secondly
4. Repair of the trunk of PV
5. If you can’t: ligate both ends
6. If you can’t: compress packing
Never think about medico-legal
consequences because of one
reason:
ONLY YOU THE ONE
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