LIVER TRAUMA

Dr. D.K.SharmaM.S., MCh. (GI Surgery)Prof. & Head, Deptt. Of SurgeryRNT Medical College, Udaipur, Raj.

Synopsis

Epidemiology Relevant Anatomy Pathophysiology

Mechanisms of Injury Grades of Liver Trauma

Clinical Features Investigations Treatment Important Concepts

DPL FAST / eFAST ALTS DCS Death Triangle Total Vascular Exclusion

Epidemiology

Associations

Isolated liver injury occurs in less than 50% of patients.

Blunt trauma 45% with spleen

Rib fracture 33% with Liver injury

Bowel injuries

Pancreatic Injuries

Gall Bladder & Bile Duct Injuries Rare

Contusions, avulsions, lacerations or perforations.

Relevant Anatomy

Pathophysiology

Why the liver…

Large organ

Friable parenchyma, thin capsule, fixed position in relation to spine prone to blunt injury

Wide bore, thin walled blood vessels with high blood flow Excessive blood loss

Right lobe larger, closer to ribs more injury

In children:

compliant ribs

transmitted force

Mild injuries heal in 3 months.

Moderate injuries heal in 6 months.

Severe injuries in 9-15 months.

Healing

Classification & Grading

Grade VI Hepatic Avulsion

Clinical Features

Blood Loss Peritonism Symptoms Abdominal Pain Radiation to shoulder Altered Sensoium

Signs Hypotension RUQ tenderness, and guarding Generalized Peritonism

Hemoperitoneum Biliary Peritonitis

Delayed – Intra-abdominal abscess

Investigations

Labs & Radiology

Hematologic

Elevated LFTs

DPL -- high sensitivity

CT scan is the diagnostic procedure of choice.

USG

MRI ??

Diagnostic Laparoscopy

USG

FAST

eFAST

Angiography

Active bleeding

Transcatheter embolization

Embolization & stenting for fistulas.

CT Scan

Localization.

Monitor healing.

Grades 1-6

Management

Management

In the Past vs Now treatment of blunt liver trauma Stopped bleeding at Laparotomy- 86% Non-therapeutic explorations- 67% Conservative Management-

Adults-80% Children-97%

Reasons MDCT TAE Liver regenerative capacity Improved Critical Care

Operative / Non-Operative CT scan diagnosis and follow up

Remember associated injuries Spleen

Pancreas

Bowel

Resuscitate

Consider Cryoprecipitate, FFP

Assessment of injury Spiral CT

Laparotomy

♦ Treatment♦ OM

♦ NOM

Management

Damage Control Surgery Perihepatic packing Hepatorrhaphy Mesh Wrapping

Enough Tension Anchoring

Hepatotomy & Selective Vascular Ligation Resection

Non-anatomical Anatomical

Intrahepatic Balloon Tamponade Total Vascular exclusion Liver Transplantation

Post-Operative Complications

Hemorrhage Correct coagulopathy

TAE

Operative Control

Remove perihepatic packing bet 36-72 h

Sepsis & Abscess Percutaneous drainage

Surgical Drainage

Biliary Complications Biloma

Biliary Ascites

Biliary Fistulae

ATLS

Advanced Trauma Life Support

Aggressive fluid resuscitation

CVP

UO Monitoring

Avoidance of “Death Triangle”

Hypothermia

Coagulopathy

Acidosis

Damage Control Surgery

Stone (1980); Univ. of Pennsylvania (1983)

To avoid or deal with Danger Triad

Early recognition

Already at physiologic limit

Concepts & Sequence

Control of Hemorrhage & Contamination

Temporary closure & Return to ICU

Deal with the Triad

Return to OT Definitive repair

Death Triangle

Danger Triad; Bloody Vicious Cycle

Components

Hypothermia

Decreasing Temp

<34 C

Coagulopathy

Non-surgical Oozing

PT > 50% of normal

Acidosis

<7.2 despite adequate volume resuscitation

surgeryclasses.blogspot.in

Thank you