livertrauma-1702171

1. Management of Traumatic
Liver Injuries
1
Dr Junaid Ahmad Sofi
Surgical Resident
Dept. of General & Minimal Invasive Surgery
SKIMS

2. Liver Anatomy

3. Surface anatomy
 In RUQ
 5th ICS in midclavicular line to the Rt costal
margin.
 Weighs 1400 g n women and 1800g n men .
 Span 10 cm +/-2

4. Surface anatomy
 Superior, anterior, and right lateral surfaces 
 fit diaphragm.
 Falciform ligament
 Posterior surface 
 Rt lobe: colon, right kidney, and duodenum
 Lt lobe: stomach

7.  The liver covered by fibrous
capsule that reflects on the
diaphragm and post abdominal
wall
 Leaving a bare area that
connects the liver to the
retroperitoneum directly

8. Ligaments
Liver supported by:
 Coronary lig
 Rt & Lt Triangular lig
 Falciform lig

9. Fissures

10. Segmental anatomy
 Classically; liver divided to 4 lobes:
 Right lobe
 Left lobe
 Caudate lobe
 Quadrate lobe

11. Segmental anatomy
 Functionally; on the basis of the distribution of vessels and ducts within
the liver  segments.
 Cantlie’s line.

12.  Cantlie's line runs from
the middle of the
gallbladder fossa
anteriorly to the inferior
vena cava posteriorly.
12

14. Blood Supply
 Portal vein
 Hepatic artery
 Hepatic vein

15. Blood Supply – Portal Vein
 Superior Mesentric and Splenic veins
 Posterior to hepatic artery and bile duct at the hepatodudenal junction.
 Valveless
 75% of total blood supply the liver
 Pressure 3-5 mmHg

16. Blood supply – Hepatic artery
 Intrahepatic anatomy; part of portal tried follows segmental anatomy.
 Extrahepatic anatomy; highly variable:
 Commonest ( in 60%) anatomy: abdominal aorta celiac trunk  CHA proper
hepatic art  Rt and Lt hepatic artery
 LHA  seg 1,2,3 and  middle hepatic artery  seg 4.
 RHA  cystic art , Rt liver

22. Blood supply – Hepatic vein
 Rt hepatic vein  Drain seg 5,6,7,8  vena cava.
 Middle hepatic vein  Drain seg 4,5,8
 Lt hepatic vein  Drain seg 2,3
[ seg 1 drain by short hepatic  vena cava]

24. Radiological anatomy

25. Radiological anatomy

26.  Right hepatic vein divides the
right lobe into anterior and
posterior segments.

Middle hepatic vein divides the
liver into right and left lobes (or
right and left hemiliver). This
plane runs from the inferior vena
cava to the gallbladder fossa.

The Falciform ligament divides
the left lobe into a medial-
segment IV and a lateral part -
segment II and III.
 The portal vein divides the liver
into upper and lower segments.
The left and right portal veins
branch superiorly and inferiorly to
project into the center of each
segment. 26

27. Liver Injury

28. Introduction
 It is the 2nd commonest organ injured in blunt
abdominal trauma and the commonest injured in
penetrating trauma.
 1%-8% of pt with multiple blunt trauma sustain a
liver injury.
 During last 3 decades, liver injury increased. This
inc could be actual or artificial d/t better diagnostic
modalities.
 Exsanguination represents the leading cause of
death in liver injuries
Richardson JD. Ann Surg. 2000;232:324-330.
Lucas CE. Am Surg. 2000;66:337-341.

29. While small lacerations of the liver substance may be, and
no doubt are, recovered from without operative
interference:
If lacerations be extensive and vessels of any magnitude are
torn, hemorrhage will, owing to the structural
arrangement of the liver, go on continously.
JH Pringle,
1908

30. History of Liver Trauma
 WW1
 WW2
 Vietnam
 Mortality 66%
 -- 28%
 -- 15%

31. Factors making the liver prone to injury:
1. The large size of the liver,
2. its friable parenchyma,
3. its thin capsule, and
4. Its relatively fixed position in relation to the spine and ribs.

32. Diagnostic Modalities In Liver Trauma
 DPL
--fast, sensitive, accurate and simple to perform
--invasive, cannot diagnose retroperitoneal injury
--DPL is positive when
-more than 10 ml of frank blood in the aspirated fluid
-fecal matter or bile
- >100,000 RBC/micL
- >500 WBC/micL
 X-ray
--nonspecific, but useful in showing the extent of associated skeletal trauma & elevation
of diaphragm
 Ultrasonography (FAST)
--fast, accurate, noninvasive, a good initial screening test
--sensitivity 88%, specificity 99%, accuracy 97%
 CECT
32

33. CECT
The standard evaluation method
Performed with water soluble oral and intravenous contrast
Prerequisite for non operative management
33

34. Grading of liver injury by a system
brought by:
AAST (American Association for
the Surgery of Trauma)

35. Advance one grade for multiple injuries up to grade III
35

36. Grade 1
I-Subcapsular hematoma<1cm, superficial laceration<1cm deep.
A stabbing injury to the RUQ of the abdomen
Contrast CT demonstrates a small, crescent-shaped subcapsular and
parenchymal hematoma less than 1 cm thick.

37. Grade 2
II-Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick.
A blunt abdominal trauma
CT scan at the level of the hepatic veins shows a subcapsular hematoma 3
cm thick.

38. Grade 3
III-Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm
diameter.
A blunt abdominal trauma
Contrast CT shows a 4-cm-thick subcapsular hematoma associated with
parenchymal hematoma and laceration in segments 6 and 7 of the right
lobe of the liver..

39. Grade 4
IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction
A blunt abdominal trauma
CT scan of the abdomen demonstrates a large subcapsular hematoma
measuring more than 10 cm. The high-attenuating areas within the lesion
represent clotted blood

40. Grade 4
A blunt abdominal trauma
Contrast CT shows a large parenchymal hematoma in segments 6 and 7
of the liver with evidence of an active bleed. Note the capsular laceration
and large hemoperitoneum.

41. Grade 5
V- Global destruction or devascularization of the liver.
A motor vehicle accident
CT demonstrates global injury to the liver. Bleeding from the liver was
controlled by using Gelfoam.

42. Grade 6
VI-Hepatic avulsion

43. Management
Operative
vs
Non-Operative

44. Changing Times…
 NOM=Nonoperative management
 86.3% of hepatic injuries are now managed without operative
intervention
 Now the standard of care for hemodynamically stable patients with
blunt hepatic trauma
44

45. Changing times…
 The severity of liver injuries has been universally classified according to the
American Association for the Surgery of Trauma (AAST) grading scale.
 In determining the optimal treatment strategy, however, the haemodynamic
status and associated injuries should be considered.
 Thus the management of liver trauma is ultimately based on the anatomy of
the injury and the physiology of the patient. The paper presented by the
World Society of Emergency Surgery (WSES) gives classification of liver trauma
and the management Guidelines.
45

46. Liver trauma: WSES position paper
World Society of Emergency Surgery (WSES) classification of liver trauma
and the treatment Guidelines
 In many cases there is no correlation between AAST grade and patient physiologic
status.
 In determining the optimal treatment strategy, the AAST classification should be
supplemented by hemodynamic status and associated injuries.
 Most liver injuries are grade I, II or III and are successfully treated by
observation only (Non operative Management, NOM).
 In contrast two thirds of grade IV or V injuries
necessitate laparotomy (Operative Management, OM)
46

47. 47

48. The WSES classification considers either the AAST
classification OR the hemodynamic status and the associated
lesions
48

49. Recommendations for NOM in Blunt Liver Trauma (BLT)
 NOM should only be attempted in centers capable of a precise diagnosis of the
severity of liver injuries (CT)and capable of intensive management (close clinical
observation and haemodynamic monitoring in a high dependency/intensive care
environment(SICU), including serial clinical examination and laboratory assay, with
immediate access to diagnostics, interventional radiology and surgery and
immediately available access to blood and blood products(Blood Bank)
1. Blunt trauma patients with hemodynamic stability and absence of other internal injuries
requiring surgery, should undergo an initial attempt of NOM irrespective of injury grade
2. NOM is contraindicated in the setting of hemodynamic instability or peritonitis
3. NOM of moderate or severe liver injuries should be considered only in an environment that
provides capability for patient intensive monitoring, angiography, an immediately available OR
and immediate access to blood and blood product
4. In patients being considered for NOM, CT-scan with intravenous contrast should be performed
to define the anatomic liver injury and identify associated injuries
5. Angiography with embolization may be considered the first-line intervention in patients with
hemodynamic stability and arterial blush on CT-scan 49

50. How to manage conservatively
Grade I II III IV
ICU 0 0 0 1
Hospital stay
(d)
2 3 4 5
Activity
Restriction (w)
3 4 5 6

51. Follow up
There is no evidence supporting routine imaging (CT or US) of the hospitalized,
clinically improving, hemodynamically stable patient.
Nor is there evidence to support the practice of keeping the clinically stable
patient at bed rest.
2003 Eastern Association For The Surgery of Trauma

52. Recommendations for NOM in
Penetrating Liver Trauma (PLT)
1. NOM in penetrating liver trauma could be considered only in case of
hemodynamic stability and absence of: peritonitis, significant free air,
localized thickened bowel wall, evisceration, impalement (absence of other
internal injuries requiring surgery,) should undergo an initial attempt of
NOM irrespective of injury grade
2. NOM in penetrating liver trauma should be considered only in an
environment that provides capability for patient intensive monitoring,
angiography, an immediately available OR and immediate access to blood
and blood product
3. CT-scan with intravenous contrast should be always performed to identify
penetrating liver injuries suitable for NOM
4. Serial clinical evaluations (physical exams and laboratory testing) must be
performed to detect a change in clinical status during NOM
5. Angioembolisation is to be considered in case of arterial bleeding in a
hemodynamic stable patient without other indication for OM
6. Severe head and spinal cord injuries should be considered as relative
indications for OM, given the inability to reliably evaluate the clinical status
52

53. NOM cont.. Complications
occur in 12–14 % of patients
 in the presence of abnormal inflammatory response, abdominal pain, fever, jaundice or
drop of hemoglobin level, CT-scan is recommended
 Bleeding, abdominal compartment syndrome, infections (abscesses and other infections),
biliary complications (bile leak, hemobilia, bilioma, biliary peritonitis, biliary fistula) and
liver necrosis are the most frequent complications associated with NOM
1. Re-bleeding or secondary hemorrhage are frequent (as in the rupture of a
subcapsular hematoma or a pseudoaneurysm). In the majority of cases (69 %), “late” bleeding
can be treated non-operatively
“Late” bleedings generally occur within 72 h after trauma, incidence - 0 % to 14 %.
 Unlike the splenic injuries, liver lesions behave predominantly in two ways: either with a c
opious
hemorrhage at the beginning requiring an OM, or with no active bleeding that can be safely
managed with NOM
 Posttraumatic hepatic artery pseudoaneurysms are rare (1.2 %, with the 70–80 % extra-
hepatic and 17–25 % intra-
hepatic) and they can usually be managed with selective embolization 53

54. 2 .Biliary complications – 1/3 of cases.
 ERCP and stenting, percutaneous drainage and surgical intervention (open or
laparoscopic) are - to manage biliary complications
 intrahepatic bilio-venous fistula (frequent associated with bilemia) ERCP represents an
effective tool
 CT-scan or ultrasound-guided drainage are in peri-hepatic abscesses (incidence 0–7 %)
3.The trauma related thromboembolic diseases are
considered the third cause of death in patients who survive the first 24hr after trauma
 Deep venous thrombosis is found in 58 % of cases and the risk of pulmonary
embolism ranges from 2 to 22 %
 DVTProphylaxis is safe and effective if initiated within 48 h from hospital admission
 an initial treatment with sequentialcompression devices and as soon as possible (when th
e hemoglobin level variations are ≤ 0.5 g from theprevious draw) the introduction of DVT
P in addition to the compression device 54

55.  necrosis and devascularization of hepatic segments
surgical management would be indicated
 Lastly, the liver compartment syndrome is rare and has
been described in some case reports as a consequence of
large sub-capsular hematomas. Decompression by
percutaneous drainage or by laparoscopy
55

56. Criteria of failure of NOMLI
 Increasing fluid requirements to maintain normal hemodynamic status
 Failed angio embolization of A-V fistulae/pseudoaneurysm
 Transfusion requirements to maintain Hct/Hgb and normal hemodynamic
status
 Increasing hemoperitoneum associated with hemodynamic liability
 Peritoneal signs/rebound tenderness

57. Recommendations for Operative
Management (OM) in liver trauma (blunt and
penetrating)
1. Patients should undergo OM in liver trauma (blunt and penetrating) in
case of hemodynamic instability, concomitant internal organs injury
requiring surgery, evisceration, impalement
2. Primary surgical intention should be to control the hemorrhage, to
control bile leak and to institute an intensive resuscitation as soon as
possible
3. Major hepatic resections should be avoided at first, and considered
subsequently (delayed fashion) only in case of large devitalized liver
portions and in centers with the necessary expertise
4. Angioembolisation is a useful tool in case of persistent arterial bleeding
57

58. 58

59. Operative
technique/options
 Initial   Explorative Laparotomy
 Temporary control of hemorrhage:
 Why temp?
 Ongoing hemorrhage, life threatening, no time to
restore circulatory volume.
 Liver injuries not highest priority

60. Operative
technique/options
 How?
 Manual compression
 Perihepatic packing.
 Pringle maneuver.
 Tourniquet
 Hepatic vascular isolation
 Placement of atriocaval shunt
 Moore-Pilcher balloon
commonest
Juxtahepatic
venous injury

61. Operative Management
 bleeding may be controlled by compression alone or with electrocautery, bipolar
devices, argon beam coagulation, topical hemostatic agents, or omental packing
 major haemorrhage more aggressive procedures can be necessary. These include first
of all hepatic manual compression and hepatic packing, ligation of vessels in the
wound, hepatic debridement, balloon tamponade, shunting procedures, or hepatic
vascular isolation
 Temporary abdominal closure can be safely considered in all those patients when the
risk of developing abdominal compartment syndrome is high and when a second look
after patient’s hemodynamic stabilization is needed( RELOOK)
 Anatomic hepatic resection can be considered as a surgical option .In unstable
patients and during damage control surgery a non-anatomic resection is safer and
easier
 If repair is not possible a selective hepatic artery ligation
 In case of right or common hepatic artery ligation, cholecystectomy should be
performed to avoid gallbladder necrosis
61

62. 62

64. • Pringle Manure
– Occludes hepatic artery & portal
vein
– If bleed persists, then it is hepatic
venous bleed

66. SUTURED LIVER LACERATION
66

67. liver packing and hemostatic fibrin gel on liver surface
67

68. omental patch for liver
trauma 68

69. Harmonic scalpel

70. 70

71. Argon Coagulation
71

72. Ultrasonic dissector

73. Tissue link TM for hepatic resections
Parenchymal tissue fragmentation and skeltonization of vascular-biliary structures with ultrasonic dissector

74. Mesh rapping
74
 new technique for grade
III,IV laceration,
tamponading large
intrahepatic hematomas
 not indicated where
juxtacaval or hepatic vein
injury is suspected

75. 75

76. Temporary closure of the
abdomen entails covering
the bowel with a fenestrated
subfascial 45 × 60 cm sterile
drape (A), placing Jackson-
Pratt drains along the fascial
edge (B), and then occluding
with an Ioban drape (C, D).
76

77. Other Operative interventions
 Omental packing
 Intrahepatic tamponade with penrose drains/ Inflated Foleys
 Fibrin glue
 Retrohepatic venous injuries
--Complete Vascular isolation of the liver
--venovenous bypass
--Atriocaval shunting
 Liver transplantation
77

78.  Post-operative angioembolization is a viable option
 After artery ligation, in fact, the risk of hepatic necrosis, biloma and abscesses
increases
 Portal vein injuries should be repaired primarily. The portal vein ligation should be
avoided
 Liver Packing and a second look or liver resection are preferable
 Where Pringle maneuver or arterial control fails, and the bleeding persists from
behind the liver, a retro-hepatic caval or hepatic vein injury could be present
 Three therapeutic options exist: 1) tamponade with hepatic packing, 2) direct repair (with or
without vascular isolation), and 3) lobar resection
 LIVER PACKING IS THE MOST SUCCESSFUL METHOD OF MANAGING SEVERE VENOUS
INJURIES
 When hepatic vascular exclusion is necessary, different types of shunting procedures
have been described
 veno-veno bypass (femoral vein to axillary or jugular vein by pass
 atrio-caval shunt bypasses the retro-hepatic cava blood through the right atrium
 In the emergency, in cases of liver avulsion or total crush injury, when a total hepatic
resection must be done, hepatic transplantation has been described
78

79. Embolization principles
• Coeliac trunk must be analyse before embolization
• selective embolization = microcatheter
• Embolic material: – Temporary or definitive
Results
• NOM – Success 82% to 100%. (US trauma centers) –
Complications- bile leaks, hemobilia, bile peritonitis, bilious ascites,
hemoperitoneum, abdominal compartment syndrome, missed injuries, hepatic
necrosis, hepatic abscess, and delayed haemorrhage
complication rate increases with the grade of injury
• Embolization – success rate is 95%
Hepatic necrosis is rare – First complication is gallbladder necrosis
79

80. Thank You!
 sofijunaid@gmail.com