Hepatic Trauma

Adegbesan Adeniyi

Case 1: Blunt trauma

29 year old female

Driver of a car, wearing seatbelt

Collision heavy vehicle

Airbags activated

Managed as per ATLS protocols

GCS 15 /15, haemodynamically stable

RUQ pain, left wrist fracture-dislocation

Radiology

Bi-malleolar left ankle fracture Ultrasound abdomen: free fluid, splenic

contusion CT abdomen

– oblique tear through right lobe of the liver– right adrenal gland contusion – blood in peritoneum

Management

Transferred to ICU with IV fluids & blood

Ankle dislocation reduced, back slab applied

Laparotomy: full assessment performed– Large volume of intraperitoneal blood– 2 liver lacerations – Small haematoma at splenic hilum– Small contusion of tail of pancreas– No active bleeding

Surgicel to splenic hilum and liver lacerations

Washout performed and drains placed

Post-operative course

Remained haemodynamically stable

MRI brain: confirmed small contusion near internal capsule

Case 2: Penetrating trauma

24 year old male

Stab wounds – Three in upper abdomen – Left side of neck

Clinical findings

GCS 13/15, haemodynamically stable 3cm wound over the right zygoma 1.5cm wound zone 2 left side of the neck Abdomen: 1.5cm wound over the right and left

upper quadrants breaching rectus sheath and muscles

Managed as per ATLS protocol IV Fluids, Catheterized Hb = 13.5

Management

Chest x-ray normal

Ultrasound abdomen: No free fluid

Admitted to ICU pre laparotomy

Became haemodynamically unstable with increasing abdo pain

Responded to IV fluids and blood transfusion

Emergency laparotomy findings

Haemoperitoneum

Wound in the right upper quadrant obliquely traversed both lobes of liver, through the 1st part of duodenum into pancreas

Bleeding from D1 and pancreas

Haemostasis achieved

Duodenum repaired with interrupted PDS

Wash out performed, drain placed

Anatomy of the injury

Management

Neck wound: fascia breached but no vascular injuries, closed in layers

Managed with NG tube, antibiotics and parenteral nutrition

Developed bile leak, conservatively managed

Small pelvic collections were managed with antibiotics

Discharged on 31st post-operative day

Background

Largest solid abdominal organ, fixed position

Liver injury is the most common cause of death after abdominal trauma

Blunt injury due to road traffic accidents most common

80% adults, 97% children have successful conservative management

Liver injured more easily in children

Liver anatomy

Cantile described main divisions along axis from gallbladder fossa to the IVC

This divides the liver into equal halves

Couinaud divided the liver into 8 segments.

Liver segments

• Divided vertically by the 3 main hepatic veins and transversely by the right and left portal branches.

Types of liver injuries

Haematoma: subcapsular or intrahepatic Laceration Contusion Hepatic vascular disruption Bile duct injury 86% of injuries have stopped bleeding at time of surgical

exploration Transfusion requirements are reduced with conservative

management

Management

Initial resuscitation as per ATLS protocol

It is important to note the mechanism of injury

Clinical picture may vary from mild RUQ pain through to peritonism to haemorrhagic shock

Stable patients undergo CT imaging

Unstable patients require resuscitation and laparotomy

CT Scans

Accurate in localizing the site of liver injury and any associated injuries

Used to monitor healing

CT criteria for staging liver trauma uses AAST liver injury scale

Grades 1-6

Classification

I- Subcapsular hematoma<1cm or superficial laceration<1cm deep

II- Parenchymal laceration 1-3cm deep or subcapsular hematoma1-3 cm thick

III- Parenchymal laceration >3cm deep and subcapsular hematoma >3cm diameter

IV- Parenchymal/supcapsular hematoma >10cm in diameter, lobar destruction or devasularization

V- Global destruction or devascularization of the liver

VI- Hepatic avulsion

Example of a grade 3 injury

Subcapsular hematoma

Parenchymal hematoma and laceration

Angiography

May be useful in localizing the site of haemorrhage in stable patients

Transcatheter embolization of bleeding sites

Treatment

Conservative– Blunt liver trauma,– Haemodynamically stable– No other injuries requiring surgery

Surgical– Penetrating injuries– Haemodynamically unstable– Other injuries requiring surgery

Pachter et al, Annals of Surgery 1994Pietro padalino, European Journal of Trauma and Emergency Surgery July 2009

Surgical management

Full laparotomy

Pringles manoeuvre to occlude the portal triad

Packing of the liver

Treat other intra-abdominal injuries as appropriate

Learning points!

Liver injuries frequently are associated with multiple other injuries

Most liver injuries can be managed conservatively

Essential Skills: Laparotomy, Pringles, Ligament mobilisation and liver packing

As with all trauma, the ATLS protocol is the foundation of treatment