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LIVER INJURIES

PROFF. S.FLORET

Abdominal injuries

• For anatomical consideration:

• Abdomen can be divided in four areas

Intra thoracic abdomen

True abdomen

Pelvic abdomen

Retroperitoneal abdomen

ETIOLOGY

• Penetrating Trauma

• Blunt trauma

• Iatrogenic injuries

PENETRATING INJURY

• Stab Wound

• Gun Shot Injury

• Blast Injuries

BLUNT INJURY

• Road Traffic Accidents

• Fall From Height

• Crush Injuries

• Sport Injuries

• Violence

IATROGENIC INJURY

• Endoscopic

• External Cardiac Message

• Peritoneal Dialysis

• Paracentesis

• Liver Biopsy

• Barium Enema

Primary survey

• A‐ Air way management

• B‐Breathing

• C‐Circulation

• D‐Disability

• E‐Exposure

Abdominal Trauma: Examination

• Inspection:‐

Abdominal distension

Movement of Abdominal wall

Discoloration of skin

Record all external marks of injury

Record entry & exit site of bullet injury.

PALPATION

Look for tenderness/rigidity/guarding

Spine tenderness

Pelvic compression test &compression of lower chest wall

Per rectal examination

Examination (cont)

PERCUSSION:

‐ Look for free fluid

AUSCULTATION:

‐ Bowel sounds.

Investigations

Lab investigations:‐

• Haematocrit estimation

• Urine analysis

• Serum Amylase estimation

• Other routine lab test for base line

Radiological Investigations

• X‐ray chest erect for fracture ribs & free gas under diaphragm

• X‐ray Abdomen supine for bowel gas pattern & psoas shadow

Peritoneal Lavage

• INDICATIONS:

‐Unconscious patient ‐Patients with high energy transfer with equivocal physical signs

‐Multiple injury with unexplained shock

‐Pts. With spinal cord injury

‐Intoxicated Pts.

‐Pts. with suspected abdominal injury undergoing surgery for other condition

DPL ‐ CONTRAINDICATIONS

• Previous abdominal surgery

• Pregnancy

• obesity

• Patient with obvious surgical abdomen

DPL

Positive DPLAspiration of gross blood ‐RBC count > 100000/cumm(for stab wound >1000RBC/cumm)

‐WBC count >500/cumm‐Amylase>200 units‐Presence of bile , faces or bacteria

DPL ‐Limitations

• False + ve in 20% of cases mainly in pelvic fractures

• Does not differentiate between solid organ & hallow viscus injuries

CT abdomen

• Indicated in haemodynamically stable patients,

‐ To identify & grade solid organ injuries‐To diagnose retroperitoneal injuries‐To follow patients of solid organ injuries treated conservatively

CT abdomen‐ draw backs

• ‐Expensive

• ‐Requires to Radiology Department

• ‐Low sensitivity to diagnose bowel or diaphragmatic injuries

DIAGNOSTIC LAPAROSCOPY ( gas less laparoscopy )

• To identify peritoneal violation in anterior or flank stab wounds

• To identify diaphragmatic injuries

Ultra sonography (FAST)

• To evaluate presence of haemoperitoneum in blunt abdominal trauma

• FAST means focused abdominal sono tomography

FAST

• Positive FAST in unstable trauma patients indicates the need for laparotomy without any further tests.

• Negative FAST means source of bleed is from other than abdomen

FAST

ADVANTAGES:

.Rapid , Fast, Cheap.

.Non invasive, no radiation.

. Can be performed at bed side.

. No need to shift patient to radiology.

FAST:‐ Limitations

• Obesity

• Gas interposition

• Subcutaneous emphysema

• Operator dependent

Management

• Conservative

• Operative

Conservative management by observation

• Haemodynamically stable patients with blunt abdominal trauma with mild to moderate grade of solid organ injuries

• Hollow viscus injuries must have been ruled out

Operative Management

• Laparotomy indicated if

‐ signs of peritoneal irritation‐ unexplained shock‐ evisceration of viscus

‐ ‐ + ve DPL‐ ‐ Deterioration during observation‐ ‐ Gunshot wounds‐ ‐ Stab wound with penetration of peritoneum

LIVER INJURIES

• Liver injuries are uncommon because of the

‐ the liver’s position under diaphragm and

‐ its protection by the chest wall.

• Liver trauma can be divided into:

• BLUNT trauma

• PENETRATING trauma

ΩBLUNT TRAUMA:

contusions

Laceration and

avulsion injuries to liver

‐ Spleen and kidney often involved in blunt trauma.

Ω PENETRATING TRAUMA:

stab wound

gunshot wound

DIAGNOSIS OF LIVER INJURY

• The liver is an extremely well vascularised organ.

• Major early complication is blood loss where massive bleeding leads to rapid development of coagulopathy.

• In lower chest & upper abdomen wound, if large amount of blood tranfusion is required, then suspect liver injury.

• Severe crushing injury to lower chest & upper abdomen can result in Injury to

INVESTIGATION

Haemodynamically stable pts should have

Oral & intravenous contrast enhanced CT scan of chest & abdomen

‐ It will show parenchymal damage to liver or spleen as well to feeding vessels.

The chest scan ‐ excludes injuries to great vessels & lung parenchyma.

• Additional investigations that may be of value include:

‐ PERITONEAL LAVAGE which can confirm the

presence of haemoperitoneum

‐ LAPAROSCOPY which can demonstrate

associated diaphragmatic rupture.

CT criteria for staging liver trauma

• Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking

• Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick

• Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter

• Grade 4 - Parenchymal/subcapsular hematoma

COGBILL’S GRADING OF LIVER INJURIES

GRADE 1

GRADE 2

GRADE 3

GRADE 4

Present

< 10cm

> 10cm

Massive expanding hematoma with multiple lacerations

Both Lateral lobes present

• < 1cm

• < 3cm

• > 3cm

• Not present

• Not present

• Present

• Active Bleeding, IVC And hepatic vein injury

Radiological Findings

• Associated haemo or pneumothorax• A massive soft tissue shadow• Deformity of dome of diaphragm due to

blood clot• Associated fracture rib• Haemorrhage into the peritoneal cavity

along the greater curvature causes opacity

LIVER INJURY MANAGEMENT

• Unstable patients –laparotomy mandatory.

• Stable patients – Selective non‐operative approach.

MANAGEMENT OF LIVER TRAUMA

• Remember associated injuries.

• At risk groups

‐ stabbing/gun shot in lower chest or upper

abdomen.

‐ crush injury with multiple rib fractures.

• Resuscitate

‐ airway

‐ breathing

‐ circulation

• Assessement of injury

‐ Spiral CT with contrast

‐ laparotomy if haemodynamically unstable

• Treatment

‐ correct coagulopathy

‐ suture lacerations

‐ resect if major vascular injury

‐ packing if diffuse parenchymal injury.

Treatment

• Minor injuries– Hepatorraphy– Omentoplasty– Selective hepatic arterial ligation

• Major Injuries– Segmental resection– Perrihepatic packing\Shrock’s atrio caval sunting,

Romal tourniquet and Moore pilchers shunt for IVC injury.

THE SURGICAL APPROACH TO LIVER TRAUMA

A rooftop incision gives excellent visualisation of liver & spleen.

Stab incision – suture with fine absorbable monofilament suture.

Laceration of hepatic artery – identified by placing,

‐ an atraumatic bulldog clamp &

‐ repair with 5/0 or 6/0 prolene suture

‐ or hepatic artery ligated,athough

parenchymal necrosis & abscess may

Crush injuries results in large parenchymal hematoma & diffuse capsular laceration.Suturing usually ineffective.Packing is necessary – removed after48 hrs with antibiotic cover.Refer to specialist center if there is major liver vascular injury.Venovenous bypass for IVC & hepaticveinrepair.A RAPID INFUSER BLOOD TRANSFUSION MACHINE instant delivery of large volume

OTHER COMPLICATIONS OF LIVER TRAUMA

• Intrahepatic haematoma

• Liver abscess

• Bile collection

• Biliary fistula

• Hepatic artery aneurysm

• Arteriovenous fistula

• Arteriobiliary fistula

• Liver failure

LONG TERM OUTCOME OF LIVER TRAUMA

Capacity of liver to recover from extensive trauma is remarkable.Parenchymal regeneration is rapid.Biliary tract stricture – after many years‐ Segmental or lobar stricture:Atrophy of corresponding liver

parenchyma & compensatory hypertrophy of other

lobe.‐ Dominant extra‐hepatic bile duct

stricture:

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