LIVER INJURY- TRAUMA SURGERY.pptx

In this presentation, I discussed the mechanism of injury, grading, clinical features, diagnosis, and treatment of liver injuries.

1. LIVER INJURY DR.B.SELVARAJ MS;Mch;FICS ; ‘Surgical Educator’ MALAYSIA BLUNT ABDOMINAL TRAUMA

2. LIVER INJURY Etiology Pathology Clinical features Workup/Investigations Differential diagnosis Liver CT injury grading Treatment Complications Treatment algorithm for Liver injury LEARNING OBJECTIVES

3. LIVER INJURY The liver is the 2nd most frequently injured solid organ in blunt injury 0f the abdomen after spleen. Hepatic injury is more common in patients with penetrating injuries (30%) than in patients with blunt abdominal trauma (15% to 20%). The overall mortality of liver trauma is approximately 10%. Blunt injuries are usually more complex and result in mortality approaching 25%. Most deaths occur in the early postoperative period (< 48 hours) from shock and transfusion-related coagulopathies. OVERVIEW

4. LIVER INJURY H/O Blunt abdominal or lower thoracic trauma Penetrating trauma to Right Hypochondrium and epigastric areas Blunt injury produces contusion, laceration and avulsion injuries to the liver, often in association with splenic, mesenteric or renal injury. Penetrating injuries, such as stab and gunshot wounds, are often associated with chest or pericardial involvement. Blunt injuries are more common and have a higher mortality than penetrating injuries. ETIOLOGY Injury types Subcapsular hematoma Lacerations (± disruption of hepatic lobes/ segments) Deeper injuries + vascular (IVC/ hepatic vein) injuries Mechanism of injury Crushing Deceleration Sudden increase in intra abdominal pressure because of seat belt

5. LIVER INJURY The main immediate consequence is hemorrhage. The amount of hemorrhage may be small or large, depending on the nature and degree of injury. Many small lacerations, particularly in children, cease bleeding spontaneously. Larger injuries hemorrhage extensively, often causing hemorrhagic shock. Mortality is significant in high-grade liver injuries. PATHOLOGY

6. LIVER INJURY CLINICAL FEATURES

7. LIVER INJURY Other causes for hemoperitoneum Splenic injury Ruptured ectopic pregnancy Ruptured abdominal aortic aneurysm Acute hemorrhagic pancreatitis DIFFERENTIAL DIAGNOSIS

8. LIVER INJURY INVESTIGATIONS

9. LIVER INJURY INVESTIGATIONS- CECT CT is the procedure of choice for diagnosis and estimation of the degree of liver injury in the hemodynamically normal patient. Contrast blush (intraparenchymal hyperdense contrast collection)suggests active hemorrhage and is associated with failure of nonoperative management in all solid organ injuries.

10. LIVER INJURY INVESTIGATIONS SELECTIVE CELIAC ARTERIOGRAPHY Angiography may be used in patients demonstrating a contrast blush on CT scan to identify and treat a vascular abnormality with angioembolisation

11. LIVER INJURY INVESTIGATIONS DPA/DPL

12. LIVER INJURY AAST – CT GRADING

13. LIVER INJURY TREATMENT Nonoperative management Requires ICU monitoring in a dedicated trauma center and immediate ability to convert to operative management should that become necessary Isolated blunt hepatic injury is increasingly managed nonoperatively. Indications Hemodynamic stability Minimal evidence of blood loss, < 2 units packed red blood cells as transfusion requirement Absence of active contrast extravasation on CT scan Absence of other indication for laparotomy Length of intensive care unit (ICU) monitoring is generally 24 to 48 hours initially, with serial hematocrit evaluation and continuous hemodynamic monitoring Blood transfusion is limited to 2 units of packed red blood cells. If the patient has an ongoing transfusion requirement of more than 2 units, operative management should be performed The majority of pediatric hepatic trauma is successfully managed nonoperatively. Recovery recommendations include restricted activity in terms of contact sports, running, or similar stresses for 3 months following injury. Angiography is performed in patients who are hemodynamically normal and have a blush on initial CT scan.

14. LIVER INJURY TREATMENT Operative management Initial management to combat hypothermia - Have a warmed operating room available - Give warm IV fluids - Heating pad on the operating room table - Convection heater prepared for use Prepare and drape from the neck to the mid thigh to allow access to the chest via a sternotomy or thoracotomy and to allow access to the upper leg for harvesting a saphenous vein for a vascular injury. Prophylactic antibiotics are given and a midline incision from the xiphoid to the pubis is used All intraperitoneal blood should be quickly evacuated and bleeding sources controlled with packs Simple injuries (grades I and II) - The majority of hepatic injuries (blunt 60% and penetrating 90%) are minor and will have stopped bleeding or, if not, can be managed by simple techniques. These include suture ligatures, electrocautery or argon beam coagulation, and application of topical agents. - For 1- to 3-cm deep bleeding lacerations, suture hepatorrhaphy using horizontal mattress sutures of 0 chromic on a large blunt needle are used to loosely approximate liver parenchyma. - Topical agents (i.e., Surgicel or Avitene ) are useful once major hemorrhage is controlled. - Fibrin glue is also used as a topical hemostatic agent

15. LIVER INJURY TREATMENT Operative management Complex hepatic injuries (grade III or greater) in 10% of penetrating and 40% of blunt trauma Initial management should be the control of the hemorrhage with manual compression of the injury using laparotomy pads. Prior to definitive hemostatic control of the liver injury, the portal triad is occluded with manual compression, a Rummel tourniquet , or an atraumatic vascular clamp (the Pringle maneuver ) Liver can tolerate up to 90 minutes of warm ischemia Hepatotomy with selective vascular ligation is the most widely used method to control extensive bleeding After hemorrhage is controlled and necrotic parenchyma debrided, the resulting hepatotomy site can be filled with a pedicle of omentum based on the right gastroepiploic vessel The liver edges are then loosely approximated with 0 chromic liver sutures. Omentum will tamponade minor oozing, decrease dead space, and increase absorption of small amounts of blood and bile.

16. LIVER INJURY TREATMENT Operative management Resectional debridement (do not confuse this with anatomic resection) is indicated when there is partially devascularized tissue Hepatic resection refers to anatomic removal of a segment (or lobe) and is reserved for patients with total destruction of a segment (or lobe) Selective hepatic artery ligation can be used to control arterial hemorrhage from the liver parenchyma. This maneuver is usually tolerated because of the high oxygen saturation of the portal blood and can be performed without subsequent hepatic necrosis. Perihepatic packing is indicated in patients with extensive uncontrolled lacerations, expanding subcapsular hematomas. This is typically referred to as damage control , where hemorrhage and contamination are controlled. Packing should be removed after the patient has stabilized hemodynamically after 24 to 72 hours

17. LIVER INJURY TREATMENT Operative management Internal tamponade for penetrating injuries using red rubber catheter and a Penrose drain tied at each end. Injuries to the retrohepatic IVC or hepatic veins are frequently lethal. Total vascular isolation of the liver (clamping the hepatoduodenal ligament, suprarenal IVC and suprahepatic IVC sequentially; Heaney technique ) After the shunt is in place, the hepatic ligaments are taken down and the repair can be accomplished

18. LIVER INJURY COMPLICATIONS Recurrent bleeding in 3% of cases which can be managed by therapeutic embolisation Intra-abdominal abscesses occur in 2% to 10% of all hepatic trauma which can be treated by CT guided drainage Biliary fistula: drainage of >50ml bile for > 2 weeks in 1 to 10% of cases which can be managed conservatively or ERCP stenting Hemobilia : Rare. Classic triad of right upper quadrant pain, gastrointestinal tract hemorrhage , and jaundice. “Quincke’s triad” Can be treated by therapeutic embolisation

19. LIVER INJURY Treatment Algorithm