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Liver trauma
- 2. • Because ofits size and location in the abdominal cavity, the liver is frequently injured in both blunt and penetrating trauma. Despite progress in the management of trauma patients in the last 2 decades, mortality after hepatic trauma has remained stable. • Spontaneous hemostasis is observed in more than 50% of small hepatic lacerations at the time of laparotomy. In fact, most liver injuries require only documentation and no drainage. Although most liver injuries can be properly managed with simple procedures, control of profuse bleeding from deep hepatic lacerations remains a formidable challenge for trauma surgeons. • The overall mortality rate ranges from 8% to 10%, and the overall morbidity rate varies from 18% to 30%, depending on the number of associated injuries and the severity of the injury. 2
- 3. • The majorityof liver injuries are due to blunt trauma, caused by direct blow, crushing or fall from a height. • The liver is a solid organ and compressive forces can easily burst the liver substance, being compressed between the force and the rib cage or vertebral column. • Contusion, laceration and avulsion injuries may occur as a result of blunt trauma. • Most are relatively minor in severity and can be managed non operatively. Many are not even suspected at the time. C.T scan played a role in detection. AETIOLOGY: (1) Blunt Injury: 3
- 4. • Stab woundsand gunshot wounds, are often associated with chest or pericardial involvement. • Bullets have a shock wave and when they pass through the liver they cause significant damage some distance from the actual track of the bullet. (2) Penetrating Injury: • Abdominal surgery, needle biopsy, laparoscopy, P.T.C. (3) Iatrogenic Injury: 4
- 5. • The liveris an extremely well vascularised organ, so blood loss is the major early compilation of liver trauma. • Clinical suspicion of a possible liver injury is essential, as a laporatomy by an inexperienced surgeon with inadequate preparation preoperatively is doomed to failure. • All lower chest and upper abdominal stab wounds should be suspect, especially if considerable blood volume replacement was required. Similarly, sever crushing injuries to the lower chest or upper abdomen often combine rib fractures, haemothorax and liver and/or splenic trauma. • Patients with a penterating wound will require a laparotomy and/or thoracatomy once active resuscitation is under way. • Patients who are haemodynamically stable should have a C.T scan of the chest and abdomen. Chest x-ray will be of value. Diagnostic peritoned aspiration may be of value for detection of haemoperitoneum. Additional investigations that may be of value include DPL and laparoscopy. DIAGNOSIS OF LIVER INJURY: 5
- 6. GRADING OF LIVERINJURY By a system brought by: AAST (American Association for the Surgery of Trauma) 6
- 7. * Advance onegrade for multiple injuries, up to grade III. Table (1): AAST liver injury scale (1994 revision): Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38: 323-4. Grade* Injury Description I Haematoma Laceration Subcapsular, <10% surface Capsular tear, <1 cm parenchymal depth II Haematoma Laceration Subcapsular, 10-50% surface area; intra-parenchymal, <10 cm in diameter 1-3 cm parenchymal depth, <10 cm in length III Haematoma Laceration Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal haematoma Intraparenchymal haematoma >10 cm or expanding > 3 cm parenchymal depth IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinaud’s segments within a single lobe. V Laceration Vascular Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments within a single lobe. Juxtavenous hepatic injuries, i.e. retrohepatic vena cava/central major hepatic veins VI Vascular Hepatic avulsion 7
- 8. • ABCDE oftrauma resuscitation. • Once initial resuscitation done Transfer to op. theatre (Operative treatment) INITIAL MANAGEMENT OF LIVER INJURIES: * Penetrating: • ABCDE of trauma resuscitation. • Haemodynamically stable patients C.T scan abdomen & pelvis (Severity of injury) Non operative management in most of cases • Haemodynamically unstable patients • Haemodynamically stable patients with evidence of on-going blood loss despite Operative treatment conservative treatment or development of peritonitis * Blunt Trauma: 8
- 9. • Blunt hepaticinjuries in hemodynamically stable patients without other indications for exploration are best served by a conservative, nonoperative approach. In the absence of contrast extravasation during the arterial phase of the CT scan, most injuries can potentially be treated nonoperatively. • The classic criteria for nonoperative treatment of liver injuries include hemodynamic stability, normal mental status, absence of a clear indication for laparatomy such as peritoneal signs, lowgrade liver injuries (grade I-III), and transufion requirements of less than 2 units of blood. • These patients are monitored by serial hematocrit and vital signs rather than by serial abdominal examinations, which is the reason why intact mental status is not the sine qua non for nonoperative management. Furthermore, if the hematocrit drops, most patients will undergo a repeat CT scan to evaluate and quantify the hemoperitoneum. NONOPERATIVE TREATMENT: 9
- 10. • Patients areadmitted to the intensive care unit for monitoring of vital signs and hematocrit. Usually, after 48 hours patients are transferred to an intermediate care unit, where they are started on an oral diet; however, they remain on bed rest until postinjury day 5. A repeat CT scan before discharge does not seem to be necessary. Normal physical activity resumes 3 months after injury. • The overall reported success of nonoperative management of blunt hepatic injuries is greater than 90% in most series. Angiographic embolization has been added to the protocol for nonoperative management of liver injuries in some institutions in an attempt to decrease the necessity for blood transfusions and the number of operations. - Complications for nonoperative treatment (5-20%): • Biliary leak and peritonitis. • Liver abscess. • Abdominal compartment syndrome. • Hepatic necrosis. 10
- 11. - Failure ofnonoperative treatment (11%): • Usually attributed to reasons unrelated to liver injury. Other injuries can be missed in a blunt trauma victims, such as: Bowel – Pancreas – Diaphragm – Bladder. • Management of patients with contrast extravasation during the arterial phase of CT is still debatable. Fang and associates proposed a classification system based on the location and character of extravasation and pooling of contrast material from a liver laceration on CT. In type 1, there is contrast extravasation to the peritoneal cavity. All patients in this category required operative intervention. Type 2 consisted of hemoperitoneum and extravasation of contrast material within the hepatic parenchyma. The authors recommend that patients in this category undergo angiography with embolization, although some will require operative intervention. Type 3 was characterized by no hemoperitoneum and extravasation of contrast material within the hepatic parenchyma. Angiography is required in this subgroup of patients, and the results are usually good. • The most important concern of nonoperative management is the potential for missed injuries, particularly hollow viscus perforations. Delay in diagnosing a hollow viscus injury is associated with significant morbidity and increased mortality. 11
- 12. • The typeof injury dictates the surgical management. The principles of surgical management of liver injury are the same regardless of the severity of injury. They involve control of bleeding, removal of devitalized tissue, and establishment of adequate drainage. • A roof top incision which can be extended upwards for a median sternatomy gives excellent visualisation to the liver. • Some small nondeep bleeding lacerations are easily controlled with simple suture or the use of hemostatic agents. More severe liver injuries require more complex procedures, including deep mattress sutures, packing, débridement, resection, mesh hepatorrhaphy, and other measures. The resurgence of packing and the emergence of damage control, as an alternative for the treatment of severe hepatic injuries in patients with shock, metabolic derangement, and coagulopathy, have been incorporated in the armamentarium of trauma surgeons in recent years. A 34% survival rate was reported when packing was used as an adjunct to other measures to control bleeding. THE SURGICAL APPROACH TO LIVER TRAUMA: 12
- 13. • The liveris reconstituted as best as possible in its normal position and bleeding is controlled by direct compression (push). • Subcapsular hematomas can simply be observed or surgically evacuated if there is no associated parenchymal injury. • Simple lacerations that are not bleeding at the time of surgery do not require drainage unless they are deep into the parenchyma with the possibility of a postoperative biliary fistula. • Lacerations that continue to bleed despite attempts at local control require a more extensive approach, usually opening the liver wound and directly approaching the bleeding vessels, a procedure known as tractotomy. Bleeding vessels and biliary radicles should be individually ligated. • In the event that bleeding continues despite directly ligating small vessels, a vascular clamp or vessel loops can be placed around the porta hepatis (Pringle’s maneuver). If the bleeding stops after clamping the portal triad, it can be assumed to be from the portal veins or hepatic artery branches. If the bleeding continues despite clamping the portal triad, an injury to the hepatic veins or the retrohepatic vena cava is suspected. The portal triad can also be intermittently clamped to allow visualization during the placement of sutures as the parenchymal vessels are ligated. If a Pringle maneuver is applied, caution regarding the duration of inflow occlusion is necessary. Some authors have reported occlusion of inflow for up to 1 hour with the use of adjuvant steroid therapy without major consequences. 13
- 14. • Packing theliver wound is performed when the techniques just described fail to control hemorrhage. Perihepatic packing was once condemned because of the high incidence of intra-abdominal abscesses. Temporary packing has recently been used, particularly in patients with hypothermia, coagulopathy, and severe acidosis with severe injuries in other intra- abdominal organs. • Usually, these patients are taken to the intensive care unit for rewarming and resuscitation. Re-exploration for removal of the packing is performed within 48 to 72 hours after the initial operation. After hemostasis is achieved and the packs are removed, copious irrigation of the abdominal cavity is performed and closed suction drains are placed. Arteriography is a useful adjunct to locate the arterial bleeding, and embolization may be of benefit before re-exploration for removal of the packing. The incidence of intra- abdominal abscess in survivors of liver packing is generally less than 15%. • Despite the use of any method to obtain hemostasis, all necrotic tissue should be débrided before closure. If bleeding in the raw surface of the liver after resectional débridement is not significant, an omental flap can be used to cover or fill the defect in the liver parenchyma. 14
- 15. • Deep liverlacerations should not be simply closed because of the risk for abscess. Alternatively some propose extending the liver laceration to expose and directly ligate the bleeding vessel. This is achieved by performing a finger fracture hepatotomy along nonanatomic planes. The technique should be performed only by experienced surgeons. • Formal hepatic resection is unusual after liver injuries and has been largely abandoned in the past decade because of high mortality and morbidity rates after this procedure and because other more conservative approaches have proved to be as effective in controlling hemorrhage, with significantly lower complication rates and mortality. • Another technique described recently encompasses the use of absorbable mesh, with each lobe of the liver wrapped individually and the mesh attached to the falciform ligament. This technique is useful for multiple superficial lacerations of the liver with active bleeding; however, it is not effective when major vascular injuries are present. 15
- 16. • Ligation ofthe hepatic artery is also an alternative for continued bleeding; however, with the use of modern cauterization devices (electric or argon bean coagulators), topical hemostatic agents, and fibrin glue, this is seldom required. It should be reserved for the occasional stab wound or gunshot wound involving one lobe in which exposure of the wound will require extensive incision of the liver. The proper hepatic artery must never be ligated. Injudicious hepatic artery ligation may result in liver infarction, particularly if associated with portal vein injury. Packing the liver is a reasonable alternative to hepatic artery ligation. • Lacerations to the hepatic artery should be identified by placing an atraumatic bulldog clamp on the proximal vessel prior to repair with 5/0 or 6/0 Prolene suture. If unavoidable, the hepatic artery may be ligated, although parenchymal necrosis and abscess formation will result in some individuals. Portal vein injuries should be repaired with 5/0 Prolene, again with exposure of the vessel being facilitated by the placement of an atraumatic vascular clamp. 16
- 17. • If amajor liver vascular injury is suspected at the time of the initial laparotomy, then referral to a specialist centre should be considered. A common surgical approach in these circumstances would be to place the patient on veno-venous bypass using cannulae in the femoral vein via a long saphenous cut-down with the blood returned, using a roller pump, to the superior vena cava (SVC) via an internal jugular line. Veno-venous bypass allows the IVC to be safely clamped to facilitate caval or hepatic vein repair. A rapid infuser blood transfusion machine facilitates the delivery of large volumes of blood instantaneously. Once prepared, the patient is re-laparotomised. The liver is mobilized by division of the supporting ligaments, and complete vascular isolation of the liver is achieved by occluding the hilar inflow and the IVC above the renal veins and at the level of the diaphragm with atraumatic vascular clamps. Venous return is provided by the veno-venous bypass. Warm ischaemia of the liver is tolerated for up to 60 min, allowing sufficient time in a blood-free field for repair of injuries to the IVC or hepatic veins. 17
- 18. Fig. (1): ThePringle maneuver controls arterial and portal vein hemorrhage from the liver. Any hemorrhage that continues must come from the hepatic veins. 18
- 19. Fig. (2): Perihepaticpacking is often effective in managing extensive parenchymal injuries. It has also been successfully employed for grade V juxtahepatic venous injuries. 19
- 20. • Significant complicationsafter liver injury include pulmonary complications, postoperative bleeding, coagulopathy, biliary fistulae, hemobilia, hepatic artery aneurysm, arteriovenous fistula and subdiaphragmatic and intraparenchymal abscess formation. • Hepatic failure may occur following extensive liver trauma. This will usually reverse with conservative supportive treatment if the blood supply and biliary drainage of the liver are intact. COMPLICATIONS OF LIVER TRAUMA: 20
- 21. The capacity ofthe liver to recover from extensive trauma is remarkable, and parenchymal regeneration occurs rapidly. Late complications are rare, but the development of biliary tract strictures many years after recovery from liver trauma has been reported. The treatment depends on the mode of presentation and the extent and site of stricturing. A segmental or lobar stricture, associated with atrophy of the corresponding area of liver parenchyma and compensatory hypertrophy of the other liver lobe, may be treated expectantly. A dominant extrahepatic bile duct stricture associated with obstructive jaundice may be treated initially with endobiliary balloon dilatation or stenting, but will usually require surgical correction using a Roux-en-Y hepatodochojejunostomy. LONG-TERM OUTCOME OF LIVER TRAUMA: 21
- 22.