1 B.A - Liver Injury - Case presentation.pptx

Injury hepatic

1. LIVER INJURY Presenter :- Dr. Bukenya Ali. Moderator(s) :- Dr Ssenyonjo Peter. Dr. Kiweewa Ronald Department of Surgery - Nsambya Hospital CASE PRESENTATION

2. LIVER

3. Surface anatomy In RUQ 5 th ICS in midclavicular line to the Rt costal margin. Weighs 1400 g n women and 1800g n men . Span 10 cm +/-2 Superior, anterior, and right lateral surfaces  fit diaphragm. Falciform ligament Posterior surface  Rt lobe: colon, right kidney, and duodenum Lt lobe: stomach

4. ANATOMY

5. Introduction Liver Trauma Most commonly injured organ in Blunt abdominal trauma 2 nd most commonly injured organ in Penetrating abdominal trauma after Bowel. Motor vehicle collision is the most common injury mechanism The posterior portion of the right lobe is the most common site of hepatic injury in blunt trauma 

6. Why the Liver is Prone to Injury 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 Associations: Isolated liver injury occurs in less than 50% of patients. Blunt trauma 45% with spleen Rib fracture 33% with Liver injury

7. Parenchymal damage Subcapsular hematoma Laceration Contusion Hepatic vascular disruption Bile duct injury Liver Injury

8. MECHANISMS Blunt Penetrating injury Blast

9. MECHANISM Blunt trauma the organs most frequently injured are the spleen (40% to 55%), liver (35% to 45%), and small bowel (5% to 10%). There is a 15% incidence of retroperitoneal hematoma in patients who undergo laparotomy for blunt trauma Stab wounds traverse adjacent abdominal structures Most commonly involve the liver (40%), small bowel (30%), diaphragm (20%), and colon (15%) GSW most commonly injure the small bowel (50%), colon (40%), liver (30%), and abdominal vascular structures (25%).

10. HISTORY Goal is to rapidly identify injury and establish injury requiring hemorrhage control MVCs look for vehicle speed, type of collision, restraints used, status of other occupants Falls from a height – Distance Penetrating injuries– Look for type of instrument used, distance from assailant, external bleeding from scene Blast --- Proximity from blast 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

11. Rare Predisposing factors. contusions, avulsions, lacerations or perforations. Gallbladder injuries…

12. Labs Hematologic Elevated LFTs DPL -- high sensitivity Radiology CT scan is the diagnostic procedure of choice. USG ( FAST, and/or eFAST ) MRI ?? Diagnostic Laparoscopy Angiography (In case of active bleeding) Transcatheter embolization Embolization & stenting for fistulas. Investigations Required

13. CT Scans – Most preferred because . . . 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

14. Classification & Grading

15. ALGORITHM

16. Remember associated injuries Spleen Pancreas Bowel Resuscitate Consider Cryoprecipitate, FFP Assessment of injury Spiral CT Laparotomy Management Treatment Operative Mgt Non-Operative Mgt Non-operative Mgt Considered in patients who are hemodynamically stable without peritoneal signs or evisceration. Operative Mgt Considered if the patient is hemodynamically unstable with Signs of peritoneal irritation

17. Non-operative management (NOM) Consists of close observation of the patient complemented with angioembolization, if necessary. Observational management involves admission to a unit and the monitoring of vital signs, strict bed rest, frequent monitoring of hemoglobin concentration serial abdominal examinations Operative management (OM) In hemodynamically unstable patient Grade IV, V and VI injuries Goal is to arrest Hemorrhage Initial control of hemorrhage is attained by Perihepatic packing Mannual compression

18. 4 Ps of operative management Operative management can be summarized as PUSH PRINGLE PLUG PACK

19. Hemorrhage control “Hepatorraphy” Ligation up to common hepatic artery is tolerated due to collaterals Common hepatic artery should be repaired If the right hepatic artery is ligated the cholecystectomy should be performed A running suture is used to approximate the edges of shallow lacerations, Deeper lacerations are approximated using interrupted horizontal mattress sutures placed parallel to the edge of the laceration. When the suture is tied, tension is adequate when visible hemorrhage ceases or liver blanches around the suture

20. Intrahepatic balloon tamponade Useful for transhepatic penetrating injury. A Foley catheter and Penrose drain or a Sengstaken-Blakemore tube can be used Passed into the length of the tract and then inflated. Radio-opaque contrast fluid is used so integrity and position can be later confirmed radiologically. Once the patient is stabilized it is removed through re-laparotomy

21. Other Procedures Mesh Wrapping Highly selective tight compression without increased intraabdominal pressure Key points - Apply mesh under enough tension to create a tamponade effect. Finger fracture technique (digitoclasy): Here, the liver parenchyma is crushed between the thumb and one finger isolating vessels and bile ducts, which can then be ligated and divided. Total vascular exclusion: Last resort limited to specialist centres Used for extensive retrohepatic venous injuries,

22. Take Home Non-operative management with interventional techniques is preferred Grade IV and V injuries in stable patients can also be managed conservatively In surgical management  damage control surgery is preferred over definite procedures

23. THANK YOU