liver trauma its etiology and management

Trauma

1. LIVER TRAUMA Dr.purushotham.G Associate professor Department of general Surgery Ggh,gmc ongole

2. INTRODUCTION Liver is the most commonly injured organ in blunt abdominal trauma. It is the second most injured organ in penetrating abdominal injury after bowel. The posterior portion of the right lobe is the most common site of hepatic injury in blunt trauma. Blunt injury is often associated with splenic,mysentric and renal injuries. Penetrating injuries are often associated with chest or pericardial injuies .

3. MECHANISM: Blunt hepatic trauma includes compression with direct parenchymal damage and shearing forces,which tear hepatic tissue and disrupt vascular and ligamentous attachmentds . Penetrating mechanisms directly laceratethe hepatic parenchyma while also causing adjacent tissue contusion.

4. Why the liver?? The liver is more susceptible to injuries because The liver is a large organ with friable parenchyma thin capsule fixed position in relation to spine ->prone to blunt injury. Wide bore thin walled vessels with high blood flow->Excessive blood loss Right lobe larger,closer to the ribs -> more injury.

5. INJURIES: Parenchymal damage Subcapsular hematoma Laceration Contusion hepatic vascular disruption Bile duct injury

6. CLINICAL FEATURES: Blood loss Symptoms of shock including a rapid heart rate,rapid breathing,cold and clammy skin. Abdominal pain and altered sensorium. SIGNS : Hypotension,RUQ tenderness Generalised peritonitis Delayed -> intra abdominal abscess.

7. MANAGEMENT: Modern approaches to liver trauma are based on conservative management where possible. Initial resuscitation as per the ATLS protocol. It is important to note the history of the injury. Clinical picture may vary from mild RUQ pain to peritonitis to haemorrhagic shock. In the physiologically-non compromised patient CT is the investigation of choice. Unstable patients require resuscitation and laparotomy.

8. EVALUATION: Standard set of laboratory tests such as a complete blood picture,liver function tests,urea and electrolytes,coagulation panel and lactate levels. Radiological : It can begin in the trauma bay with a focused assessment with sonography for trauma( FAST ).It can help clinicians decide if patients with liver injuries should proceed directly to the operating room. In stable patients CECT abdomen and pelvis is the investigation of choice.

9. CLASSIFICATION AND GRADING: The characteristics of the liver injury on the CT can be useful to categorise the injury with the AAST liver injury scale ,which accounts for parenchymal injury and the presence of vascular injury. It consists of Grade 1-5 The injury scale was revised in 2018 to incorporate vascular injury such as pseudoaneurysms and arteriovenous fistula.

10. MANAGEMENT: Remember associated injuries such as spleen,bowel,pancreas etc. Resuscitate Consider cryoprecipitate and FFP as these patients rapidly develop irreversible caogulopathies due to alack of clotting factors and fibrinogen. Assessment of injury: -spiral ct -laparotomy TREATMENT : 1.Non operative management 2.Operative management.

11. NON-OPERATIVE MANAGEMENT: It consists of close observation of the patient complemented with angio-embolization if necessary. Observational management involves: Admission to the icu and monitoring of the vitals. Strict bed rest Frequent monitoring of hemoglobin levels. Serial abdominal examinations.

12. OPERATIVE MANAGEMENT: In hemodynamically unstable patient. Grade IV,V injuries. Primary goal is to arrest the ongoing hemorrhage. Initial control of hemorrhage is attained by ->Perihepatic packing ->Manual compression

13. 4 P’s of operative management: Operative management can be summarized as -PRESSURE -PRINGLE -PLUG -PACK

14. PRESSURE: At laparotomy the liver is reconstituted and bleeding is controlled by direct bimanual compression to achieve iss normal architecture as best as possible. The edges of the liver laceration should be opposed for local pressure.

15. PERIHEPATIC PACKING: Lobes of liver must be compressed back to normal position. Packs should never be inserted into the hepatic wound as it will tear the vessels and increase the bleeding. Care must be taken to prevent abdomibnal compartment syndrome from aggressive packing. The right costal margin is elevated,and the packs are strategically placed over and around the bleeding site.

16. Additional pads should be placed between the liver,diaphragm,and the anterior chest wall until the bleeding has been controlled. Packing is not as effective for the injuries of left hemiliver . With the abdomen open,there is insufficient abdominal and thoracic wall anterior to the left hemiliver to provide adequate compression. Fortunately,hemorrhage from the left hemiliver can be controlled by mobilizing the lobe and compressing it between the surgeon’s hands.

17. Packs are removed after 36 to 48 hours provided the patient is stable. Packs should not be removed before 24 hours as there is chance of rebleed. Perihepatic packing will control profuse hemorrhage in up to 80% of patients.

18. PRINGLE MANEUVER: With extensive injuries and major hemorrhage,a pringle maneuver should be done immediately. If the patient has persistent bleeding despite packing,injury to the hepatic artery,portal vein and retro hepatic vasculature should be considered. A pringle maneuver will help delineate the source of hemorrhage. In fact hemorrhage from hepatic artery and portal vein injuries will halt with the application of a vascular clamp across the portal triad. Whereas bleeding from the hepatic veins and retrohepatic vena cava will continue.

19. HEMORRHAGE CONTROL: Ligation upto the common hepatic artery is well tolerated due to extensive collaterals. Common hepatic artery should be repaired. If right hepatic artery is ligated then cholecystectomy should also be performed. If the vascular injury is a stab wound with clean transection of the vessels,primary end to end repair can be done.

20. HEPATORRAPHY : A running suture is used to approximate edges of shallow lacerations,deeper lacerations with interrupted horizontal mattress placed parallel to edge of the laceration. MESH WRAPPING : Highly selective tight compression without increased intraabdominal pressure. Applied with enough tension to create a tamponade effect.

21. Non-anatomical resection of liver: Removal of devitalized parenchyma using the line of injury as the boundary of the resection rather than standard anatomica planes. Used in conjunction with hepatotomy . Anatomical resection of liver: Mortality exceeds 50% so perfomed rarely.

22. Intrahepatic balloon tamponade: Useful for transhepatic penetrating injury . Foley’s catheter,penrose drain or a Sengstaken -Blakemore tube can be used. Passed into the length of the tract and inflated. Radio-opaque contrast fluid is used so integrity and position can be later confirmed radiologically. Once patient is stabilized it is removed through re lapratomy .

23. Total hepatic vascular isolation: Last resort limited to specialist centres Used for extensive retrohepatic venous injuries, venovenous bypass is done Involves clamping of the of the portal triad and infra and supra hepatic IVC. Used to manage grade V penetrating injuries.

24. Complications of liver trauma: Intrahepatic hematoma Liver abscess Biliary fistula Hemobilia Ascites Biliary strictures Intra abdominal collections Hepatic artery aneurysm Arteriovenous fistula Liver failure

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