LIVER TRAUMA MANAGEMENT EXPERIENCE AMONG A CLUSTER OF PATIENTS PRESENTING WITHIN A MONTH

Muhammad SaaiqSurgical Grand Round, Pakistan Institute of Medical

Sciences (PIMS), Islamabad.September 29, 2006.

What prompted this presentation ?What prompted this presentation ?

Case No. 1Case No. 1Male aged 18 , presented with H/O Male aged 18 , presented with H/O RTA and blunt trauma abdomen.RTA and blunt trauma abdomen.Exploratory Laparotomy revealed :Exploratory Laparotomy revealed :i) About 4 cm long and 1cm deep liver i) About 4 cm long and 1cm deep liver laceration just on the left side of the FL.laceration just on the left side of the FL.ii) Another 4cm long and 4 cm deep ii) Another 4cm long and 4 cm deep irregular laceration just lat. to L. Teres irregular laceration just lat. to L. Teres with a bleeder spurting blood. with a bleeder spurting blood. iii) 800cc bloodiii) 800cc blood

AAST grade III Liver trauma.AAST grade III Liver trauma.

Case No. 2Case No. 2Male aged 19 , Male aged 19 , presented with H/O FAI Rt. Lower presented with H/O FAI Rt. Lower rib cage / chest.rib cage / chest.

Exploratory Laparotomy revealed : Exploratory Laparotomy revealed : *Sealed firearm wound on the frontal *Sealed firearm wound on the frontal surface of Rt lobe ( B/w segments V surface of Rt lobe ( B/w segments V and VIII) corresponding to a similar and VIII) corresponding to a similar wound on posterior surface of liver.wound on posterior surface of liver.

* About 200 cc free blood.* About 200 cc free blood.AAST Grade III Liver trauma.AAST Grade III Liver trauma.

Case No. 3Case No. 3Male aged 15 presented with H/O FAI abdomen / Lt. Male aged 15 presented with H/O FAI abdomen / Lt. lower back.lower back.Exploratory Laparotomy revealed :Exploratory Laparotomy revealed :

i) Firearm exit wound epigastrium / Lt hypochondrium with i) Firearm exit wound epigastrium / Lt hypochondrium with omentum coming out through it .omentum coming out through it .

ii) Fragmented Spleen.ii) Fragmented Spleen.iii) Parenchymal disruption of Lt lobe of liver involving > 50 iii) Parenchymal disruption of Lt lobe of liver involving > 50 % %

of the lobe. iv) Two lacerations ( about 6 cm each) in the of the lobe. iv) Two lacerations ( about 6 cm each) in the stomach.stomach.

v) 3 cm rent in diaphragm leading to the Firearm entry v) 3 cm rent in diaphragm leading to the Firearm entry wound near inferior angle of Lt scapula.wound near inferior angle of Lt scapula.

vi) Irregular laceration of Lt costal margin with diaphragmvi) Irregular laceration of Lt costal margin with diaphragmseparate from costal margin over an area of 4 cm.separate from costal margin over an area of 4 cm.

vii) About 2000 cc free blood in the peritoneal cavity.vii) About 2000 cc free blood in the peritoneal cavity.AAST Grade IV Liver trauma.AAST Grade IV Liver trauma.

Case No. 4Case No. 4Male aged 20 presented with H/O Stab Rt Male aged 20 presented with H/O Stab Rt

flank.flank.Exploratory Laparotomy revealed :Exploratory Laparotomy revealed :

i) One Litre free blood in the peritoneal cavity.i) One Litre free blood in the peritoneal cavity.ii) Irregular laceration of the abdominal wall ii) Irregular laceration of the abdominal wall

communicating with the outside stab wound.communicating with the outside stab wound.iii) 3 cm long and 5 cm deep laceration on iii) 3 cm long and 5 cm deep laceration on

segment V communicating with a 1 cm segment V communicating with a 1 cm wound just lateral to the Gall bladder fossa.wound just lateral to the Gall bladder fossa.

iv) A small rent in the peritoneal reflections over iv) A small rent in the peritoneal reflections over the duodenum with bruising of the adjoining the duodenum with bruising of the adjoining area.area.

AAST Grade III Liver trauma.AAST Grade III Liver trauma.

Liver TraumaLiver TraumaAnatomical ConsiderationsAnatomical Considerations

FUNCTIONALLY LIVER HAS :FUNCTIONALLY LIVER HAS :2 Lobes2 Lobes4 Sectors4 Sectors

8 Segments8 Segments

Etiology / Mechanisms :Etiology / Mechanisms :

Blunt trauma :Blunt trauma :DecelerationDecelerationCompressionCompressionSecondary penetrating injury from spicules Secondary penetrating injury from spicules

of fractured ribs / bonesof fractured ribs / bones

Penetrating trauma :Penetrating trauma :Low energy traumaLow energy traumahigh energy traumahigh energy trauma

American Association for Surgery American Association for Surgery of Trauma (AAST )of Trauma (AAST )

Grading systemGrading system

Grade I : Grade I : HematomaHematoma ; Subcapsular, non; Subcapsular, non--expanding < 10 % surface expanding < 10 % surface LacerationLaceration ; Capsular tear, Non; Capsular tear, Non--bleeding, < 1 cm bleeding, < 1 cm parenchymal depthparenchymal depth

Grade II :Grade II :Hematoma Hematoma ; Subcapsular, Non; Subcapsular, Non--expanding, 10expanding, 10--50 % surface 50 % surface area Or intraparenchymal, Nonarea Or intraparenchymal, Non--expanding, < 2 cm in expanding, < 2 cm in diameter.diameter.Laceration Laceration ; Capsular tear, active bleeding, 1; Capsular tear, active bleeding, 1--3 cm deep, 3 cm deep, < 10 cm in length.< 10 cm in length.

Grade III:Grade III:HematomaHematoma ; Sucapsular, > 50 % surface area Or; Sucapsular, > 50 % surface area Or

Ruptured subcapsular hematomea with active bleeding Ruptured subcapsular hematomea with active bleeding Or Intraparenchymal hematoma > 2 cm or expanding.Or Intraparenchymal hematoma > 2 cm or expanding.

Laceration Laceration ; > 3 cm parenchymal depth.; > 3 cm parenchymal depth.

Grade IV:Grade IV:Hematoma Hematoma ; ruptured intrparenchymal hematoma with ; ruptured intrparenchymal hematoma with active bleeding.active bleeding.LacerationLaceration; Parenchymal disruption involving 25; Parenchymal disruption involving 25--50 % of 50 % of hepatic lobehepatic lobe

Grade V :Grade V :LacerationLaceration; Parenchymal disruption involving over 50 % of ; Parenchymal disruption involving over 50 % of hepatic lobehepatic lobeVascularVascular; Juxtahepatic venous injuries(major hepatic veins, ; Juxtahepatic venous injuries(major hepatic veins, retrohepatic vena cava)retrohepatic vena cava)

Grade VI :Grade VI : VascularVascular; Hepatic Avulsion; Hepatic Avulsion

Diagnostic IssuesDiagnostic IssuesActive Management and Diagnostic investigationsActive Management and Diagnostic investigations if any should proceed simultaneously.if any should proceed simultaneously.

No investigation should delay the proper treatmentNo investigation should delay the proper treatment

Penetrating Vs blunt and whether the patient is Penetrating Vs blunt and whether the patient is hemodynamically stable or not will rationalize the hemodynamically stable or not will rationalize the route of investigations as well as management.route of investigations as well as management.

Confirmation of hemoperitoneum may be done Confirmation of hemoperitoneum may be done with DPL or fourwith DPL or four--quadrant aspiration or FAST U/S. quadrant aspiration or FAST U/S. Ct scan abdomen and chest helps to determine Ct scan abdomen and chest helps to determine the Nature and Extent of liver injury plus any other the Nature and Extent of liver injury plus any other associated injuries.associated injuries.

MANAGEMENT :MANAGEMENT :

Initial Resuscitation.Initial Resuscitation.

Definitive measures for Liver trauma.Definitive measures for Liver trauma.

Initial ResuscitationInitial ResuscitationAABBCCDDEEF ?F ?

Definitive Definitive ManagementManagement

Surgical Options :Surgical Options :

Suture HepatorrhaphySuture Hepatorrhaphy

Suture Hepatorrhaphy with Suture Hepatorrhaphy with .. Omental ButtressingOmental Buttressing

Perihepatic PackingPerihepatic Packing

Perihepatic PackingPerihepatic Packing

Hepatic Artery LigationHepatic Artery Ligation

PRINGLE MANOEUVREPRINGLE MANOEUVRE

Application of BioadhesivesApplication of Bioadhesives

Mesh HepatorrhaphyMesh Hepatorrhaphy

Major Vascular InjuriesMajor Vascular Injuries

Arterial EmbolizationArterial Embolization

Liver ResectionLiver ResectionLiver transplantationLiver transplantation

Interventional radiologyInterventional radiology

ReRe--emergence of Perihepatic emergence of Perihepatic packing with packing with Temporary abdominal closureTemporary abdominal closure

Recent AdvancesRecent Advances

IntraIntra--hepatic Packinghepatic Packing

Immediate Postoperative Immediate Postoperative ConcernsConcerns

Common ProblemsCommon Problems

HemorrhageHemorrhageSepsisSepsisBile leakBile leakCoagulopathyCoagulopathy

Lethal Triangle ( a.k.a Bloody Lethal Triangle ( a.k.a Bloody vicious cycle of trauma)vicious cycle of trauma)

Core HypothermiaCore Hypothermia

Metabolic AcidosisMetabolic Acidosis

CoagulopathyCoagulopathy

Other Complications of Liver TraumaOther Complications of Liver Trauma

Bile collectionBile collectionLiver abscessLiver abscessBiliary fistulaBiliary fistulaHepatic artery aneurysmHepatic artery aneurysmArteriovenous FistulationArteriovenous FistulationArterioArterio--biliary Fistulationbiliary FistulationBiliary tract stricturesBiliary tract strictures

LIVER TRAUMA

Muhammad SaaiqUnit-I , Department of

Surgery.

LIVER TRAUMA