Protocol final

1. Liver Trauma Management Protocol
‫شمــــــس‬ ‫عين‬ ‫جامعــــــة‬ ‫مستشفيات‬
Ain Shams University Hospitals

3. Ain Shams University Hospitals
Department of General Surgery
Hepatobiliary Unite
CONTRIBUTORS
Scientific Writing, Conceptualization &
Methodology
Amr Emam Elgazar, MD
Revised & Reviewed by:
Prof. Dr. Mohamed Fathy, MD
Prof. Dr. Mohamed Bahaa, MD
Prof. Dr. Hany Said, MD
Assist. Prof. Dr. Hatem Sayed, MD
Supervision
Prof. Dr. Mohamed Fathy, MD
Approval
General Surgery department board of
Ain Shams University
Prof. Dr. Mohey Elbanna, MD

4. Table of Contents
Topic PageNo.
 Abbreviations_____________________________________________________5
 Introuduction_____________________________________________________6
 Definitions_________________________________________________________7
 AAST classification_______________________________________________8
 WESE classification_______________________________________________9
 General approach________________________________________________10
 Algorithm hemodynamic unstable____________________________11
 Non-operative management____________________________________12
 Operative management__________________________________________16
 Complications_____________________________________________________20
 References_________________________________________________________21

5. Abbreviations
WSES: World Societyof EmergencySurgery NOM: Non –operative management
OM: Operative Management DSC: Damage control Surgery
AG: Angiography AE: Angio-embolization
BT: Blunt trauma PT: Penetrating trauma
GSW: Gunshot wounds SWS: Stab wounds
LWE: local wound exploration VTE: Venous thromboembolism
PE: Pulmonary embolism DVT: Deep venous thrombosis
LMWH: Low molecular weight heparin
REBOA: Resuscitative endovascularballoon occlusionof the aorta
REBOVC: Resuscitative endovascularballoon occlusionof the vena cava
AAST: American Associationforthe Surgery of Trauma
FAST: FocusedAssessment with Sonography in Trauma

6. The liver is one of the mostcommonly involvedorgansin traumatized
patients.Earlydiagnosis and managementof hepatic traumais very
crucial to safe the severelytraumatizedpatientspresentedto the
Emergencydepartment(ER).
This necessitatesa multidisciplinaryapproachtodeal withthe
complexity of moderateand severeliver injuries.
Ourgoal in Ain-ShamsUniversityhospitalsis to providea provisional
frame-workandevidencebasedguidelines that shouldbe followed in
general Surgerydepartmentto deal with any kind of livertraumain a
systematicapproach, whichmaybe also subjectedto futureadjustments
and modificationsin the view of continuousadvancementin the field of
the traumaSurgery.
ThisProtocolfollows the recommendationsofWorldSociety of
EmergencySurgery(WSES)guidelinespublishedin 2020.
Introduction
6

7.  Hemodynamically unstable patient:
1. Systolicblood pressure is < 90 mmHg with clinical evidence of hemorrhagicshock with skin
vasoconstriction(cool,clammy, decreased capillaryrefill),altered level of consciousness
and/or
2. Shortness of breath with respiratoryrate >20/min and/or
3. Systolicblood pressures is > 90 mmHg but requiring:bolus infusions(1-to 2 L or small boluses
of 250mL of crystalloids untilavailabilityofcolloids /multiple transfusions and/or
vasopressordrugs and/or
4. Base deficit > 5 mmol/l and/or
5. Transfusion requirement ofat least > 4 units of PRBCs within the first 8 hrs.
 Transient responder:
Patients are those showingan initial response to adequate fluid resuscitation,but then subsequent
signs of ongoingblood loss and perfusion deficits.These patients havean initial response to
therapybut do not reach sufficient stabilization level to undergo the Non –operativemanagement
(NOM).
Important Definitions
7

8. AAST classification
8

9. The WSESclassificationdividesliver injuriesinto fourclasses
consideringthe (AAST)classificationandthe hemodynamicstatus:
WSES Classification
9

10. General Approach Algorithm
10

11. Algorithm for hemodynamically unstable patients

12.  Treatment of choice for all hemodynamically stable patients: minor(WSES I), moderate (WSES II),
and severe (WSES III) in the absence of other internal injuries requiring surgery.
1. ICU admissionis required for moderate (WSES II) and severe (WSES III) lesions for at least 48 to 72hrs.
2. Tri-phasic CT scan
3. AG/AE is done as a first-line interventionin hemodynamicallystable patients with arterial blush on CT scan.
4. Serial clinical evaluations (physicalexams, laboratory testing and Ultrasound) must be performed
to detect a change in clinical status during NOM
- Baseline full laboratory tests are done in the first day.
- In first 24hrs CBC is done every 6hrs, then every 12hrs in the first week as long as the patient is
hemodynamicallystable, in the next week it is done every other day.
- Follow up liver enzymes; INR and lactate are done every day in the first week, then every other
day in the next week.
- Baseline Pelvi-abdominalU/S & duplex is done in the first day then every 24hrs as long as the
patient is hemodynamicallystable and no progressionin abdominal collectionin follow ups;
otherwise it is done every 12 hrs.
5. Bed rest with bathroom privileges for the first day. After 24 hours, patients are allowed to ambulate
and do light activityas long as they are stable.
Non-Operative Management
12

13. 6. Sequential compression devices forinitialprophylaxis against DVT in patients with no
contraindications.As soonas the patient had stable hemoglobin (stable hemoglobin defined as a
decrease in the laboratory value of < 0.5 g from the previous draw); LMWH prophylaxis (40 mg
once daily by SC injection) is usedin additionto the sequentialcompressiondevices.
7. Early enteral feeding is associatedwithimproved clinicaloutcomes when administeredwithinthe first 72 hrs
from admissioninICU, and it should be delayed only in cases of uncontrolled shock, use of vasopressor
therapy, uncontrolled hypoxemia and acidosis,uncontrolled upper GI bleeding, gastric aspirate > 500 ml/6 h,
bowel ischemia,bowel obstruction,abdominalcompartment syndrome,and high-output fistula without distal
feeding access.
8. Follow up Tri-phasic CT scan is done after 7 to 10 days.
9. Discharge of the patient from hospitalis done after 72 hrs after stabilization.
10.On discharge,patients after moderate and severe liver injuries are instructed to refrain from contact sports
for 3 months.
13
Non-Operative Management

14. 11.During the recovery phase,patients should be encouragedto not remainalone for long periods and to return
immediatelyto the hospitalin case of increasing abdominalpain, lightheadedness,nausea, or vomiting.
12.Mandatory late follow-up imaging is not indicated,and it should be used only if the patient’s clinical condition
and/or symptoms indicating a complicationrequire it for diagnosis.
13.In selectedcases where an intra-abdominalinjury is suspectedin the days after the initialtrauma, interval
laparoscopic exploration may be consideredas an extensionof NOM strategy.
Non-Operative Management
14

15. Penetrating Trauma
 The concept of liver trauma management is valid for both: blunt and penetrating trauma (including
Stab and GSWs whether high or low energy) as long as the patient is hemodynamically stable. It is
mandatory to diagnose all associated injuries and to provide intensive and strict follow up.
 Distinction between low- and high-energy penetrating traumas is mandatorywhen deciding for OM or
NOM.
 Low-energy PT (such knives, axes, glass and pellets) may be safely treated with NOM
 High-energy PT(gunshots, bullets, and other ballistic injuries) are less amenable to NOM, and
in 90% of cases, OM is required
 CT- scan is needed in GSWs to determine the trajectory. The accuracyof CT scan in SWs has
been questioned,even in the presence of a negative CT scan,laparotomy may be necessary.
 In anterior abdominalSW, local wound exploration(LWE) is generally accurate in evaluating penetration
depth; small external wounds may be enlarged for precise LWE and determinationofanterior fascia
violation.LWE, however, may be misleading,and patients should be admittedfor observationif
equivocal.
 Wounds close to the inferiorcostal marginshould be evaluated by LWE with caution and only if strictly
necessary.
Non-Operative Management
15

16.  For Hemodynamically unstable and non-responderpatients (WSES IV).
1. Primary surgical intentionshould be to control the hemorrhage and bile leak and initiationof
damage control resuscitationas soonas possible.
2. Exploratory laparotomy± Right subcostalextension by Hepatobiliarysurgeon, packing all four
quadrants and manual compression of the liver using both hands for 15–20 minutes.
3. Then remove the lower quadrant packing first, followed by left upper quadrant and finally right
upper quadrant, if the spleen is activelybleeding, splenectomyshould be performed.
4. Assess the liver laceration and identify the bleeding vessel
5. if no major bleeding is present, compressionalone or electrocautery, bipolar devices,argon beam
coagulation,topicalhemostatic agents,simple suture of the hepatic parenchyma, or omental
patching maybe sufficient to stop the bleeding
6. If bleeding continues,go for perihepatic packing then perform the Pringle maneuver if necessary
(The clamp can be safely applied for 15 minutes/time upto 4 times),and call HPB unite.
Operative- management
16

17. 7. If bleeding is controlled after perihepatic packing and/or Pringle maneuver, then check for lesions in PV, HA or
intra parenchymal vessel.
8. Portal vein injuries should be repaired primarily.
9. Portal vein main branch ligationshould not be consideredand should be avoidedbecause of the high risk of
liver necrosis or massive bowel edema.If no other optionexists,ligationcan be used, but only in patients with
an intact hepatic artery.
10.Liver packing or liver resection should be preferred to ligationin case of lobar or segmental/sub-
segmental portal venous branch injuries.
11. If the injury is on the right or left branches of the proper hepatic artery, selective ligationis advisable.If the
right or commonhepatic artery must be ligated, cholecystectomy should be performed to avoidgallbladder
necrosis.
12. Whenever Pringle maneuver or arterial control fails and bleeding persists,the presence of an aberrant
hepatic artery should be considered.
Operative- management
17

18. 13. If bleeding is not controlled after perihepatic packing and/or Pringle maneuver and the bleeding comes from
behind the liver, retro-hepatic-caval or hepatic vein injury should be highly suspectedand two viable
options exist for the management:
 Tamponade with hepatic packing; least risky method.
 Direct repair with or without vascular isolation/exclusion.
 Hepatic vascular exclusionconsists of performing a Pringle maneuver, and clamping of the inferior
vena cava above and below the injury. Superiorly, the inferior vena cava can be isolatedjust below
the diaphragm or through extending the incisionto a median sternotomy or clam shell thoracotomy
and inferiorly, just above the renal veins. This approach allows direct repair of the vascular injury.
Aortic clamping is not recommendedfor the vena caval or hepatic vein injury.
13.In cases of liver avulsionor total crush injury, when a total hepatic resectionis indicated, hepatic
transplantation has been described.
14.During the operative repair, if the patient develops coagulopathy,acidosis,or hypothermia,
damage control surgery should be considered:perihepatic packing (place six folded laparotomy
pads to be placed between the liver and the abdominal wall to obtaintamponade) with temporary
abdominalclosure then transfer to ICU. The timing of re-explorationdepends upon the correction
of acidosis,coagulopathyand hypothermia.Usually, 24 hours is the safe periodfor re-exploration
and formal completionof the surgery.
Operative- management
18

19. 15.Non-Anatomic hepatic resection is safer and easierin unstable patients & major hepatic resections should
be avoidedat first and only consideredin subsequent operations,in a resectionaldebridement fashionin
cases of large areas of devitalizedliver tissue done by experiencedsurgeons.
16.REBOA may be used in hemodynamicallyunstable patients as a bridge to other more definitive procedures
for hemorrhage control, REBOA catheterin zone I (Supra-celiac) should be consideredif despite all damage
control procedures, there is still active surgical bleeding. Togetherwith REBOVC at the level of the retro-
hepatic vena cava to achieve proximal and distal vascular control of a possible retro-hepatic/ supra-hepatic
vessel injury with the REBOVC and ultimately obtaining complete combinedendovascular/openliver
isolationwith the Pringle maneuver.
17. Two principal indications for post-operative (AG-AE):
 After initialoperative hemostasis,instable patients with contrast blush at completionCT scan
 As adjunctive hemostatic toolin patients with uncontrolled suspected arterial bleeding despite
emergency laparotomyand hemostasis attempt.
Operative- management
19

20.  Intrahepatic abscesses; CT scan or ultrasound-guidedpercutaneous drainage is
the treatment of choice
 Delayed hemorrhage without severe hemodynamic compromise maybe managed
at first with AG/AE.
 Hepatic artery pseudo- aneurysm; managed with AG/AE to prevent rupture.
 Most traumatic bilomas regress spontaneously;Symptomatic, infected or enlarged
bilomas should be managed with percutaneous drainage.
 Combinationof percutaneous drainage and endoscopic techniques maybe
considered in managing post-traumatic biliarycomplications not suitable for
percutaneous management alone.
 Free Biliary peritonitis has been usually treatedwith laparotomy.
- Combination of laparoscopicirrigation/drainage and endoscopicbile duct stent
placement may representa validalternative.
 In the presence of necrosis and de-vascularization of hepatic segments,surgical
management may be indicatedwhenever affecting patient condition
Complications
20

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