Liver Trauma

Mechanism of injury
Deceleration injury
--producing a laceration of its
relatively thin capsule and
parenchyma at the sites of
attachment to the diaphragm
Crush injury
--direct blow to the abdomen
--damage to the central portion
of the liver
Blunt trauma
Penetrating injuries
 Pearl
posterior segment of the right liver
lobe is the most frequently injured
part.
This part also involves the bare area
and this can lead to retroperitoneal
bleeding rather than bleeding into
the peritoneal cavity.
 Associations
Isolated liver injury occurs in less
than 50% of patients.
Blunt trauma 45% with spleen
Rib fracture 33% with Liver injury
 Injuries
Contusion
Laceration
Subcapsular hematoma
Parenchymal damage
Hepatic vascular disruption
Bile duct injury
Grading
 Grading outcomes
Grade I,II
---minor injuries, represent 80-90% of all
injuries, require minimal or no operative
treatment
Grade III-V
-- severe, most managed conservatively
but surgical intervention is occasionally
needed
Grade VI
--incompatible with survival
 Diagnosis of liver injury
Ultrasonography
--fast, accurate, noninvasive, a good
initial screening test
--sensitivity 88%, specificity 99
DPL
--fast, sensitive, accurate and simple
to perform
--invasive, cannot diagnose
retroperitoneal injury
 Computed tomography
The standard evaluation method for
stable patient
Performed with Dilute water soluble
oral contrast agent and intravenous
contrast
MANAGEMENT OF LIVER
TRAUMA
Management
Operative
vs
Non-Operative
 Non-Operative Management of Liver Injury

An absolute increase in the

incidence of nonoperatively
managed liver injuries (NOMLI) is
unequivocal.
Multiple studies have shown that
NOMLI is effective
Knudson MM. Surg Clin North Am. 1999;79:1357-1371. Malhotra AK. Ann Surg. 2000;231:804-813. Maull KI. World J Surg. 2001;25:1403-1404.
Pachter HL. Am J Surg. 1995;169:442-454. Sherman HF J Trauma. 1994;37:616-621. Schweizer W. Br J Surg. 1993;80:86-88.
. Miller PR. J Trauma. 2002;53:238-242. Goan YG. J Trauma. 1998;45:360-364. Brasel KJ. Am J Surg. 1997;174:674-677.
. Ochsner MG.. World J Surg. 2001;25:1393-1396.
Criteria for NOMLI
No indications for laparotomy (physical
examination signs/symptoms or other injuries)
Hemodynamically normal after resuscitation
with crystalloid
No injuries that preclude physical examination
of the abdomen (e.g., CHI, spinal cord injury)
No transfusion requirements (PRBC)
Constant availability of surgical and critical
care resources
Liverinjuryscoreofpatients is not as
important as the hemodynamic status
for determining conservative
management
High Success With Non-operative
Management of Blunt Hepatic Trauma
Arch Surg.2003;138:475-481

HypothesisNonoperative
management of liver injuries
(NOMLI)is highly successful and
rarely leads to adverse events.
SettingHigh-volume academic
level I trauma center
 Complications of conservative
treatment
Conservat
ive
treatment
Delayed
Liver
hemorrha Hemobilia Bili Hemia
abscess
ge

Stable Unstable

Exploratio
CT scan
n
Liver
Liver
injury
injury
unchange
worse
d
Angiogra
Search for
m
other
Embolizati
causes
Complications of NOMLI
Biliary (bile peritonitis, bile leak,
biloma, hemobilia..)
Infection (liver abscess, necrosis,
abdominal sepsis, SIRs)
Abdominalcompartment syndrome
Hemorrhage
Hepatic necrosis &/or Acalculous
Cholecystitis
Failure of NOMLI
Usually attributed to reasons
unrelated to liver injury
Other injuries can be missed in a
blunt trauma victims, such as:
Bowel
Pancreas
Diaphragm
Bladder
Which can lead to failure of NOMLI
Criteria of failure of NOMLI
Increasing fluid requirements to maintain
normal hemodynamic status
Failed angio embolization of A-V
fistulae/pseudoaneurysm
Transfusion requirements to maintain
Hct/Hgb and normal hemodynamic status
Increasing hemoperitoneum associated
with hemodynamic liability
Peritoneal signs/rebound tenderness
How to manage
conservatively
Grade I II III IV

ICU 0 0 0 1
Hospital 2 3 4 5
stay (d)
Activity 3 4 5 6
Restriction
(w)
Follow up
There is no evidence supporting
routine imaging (CT or US) of the
hospitalized, clinically improving,
hemodynamically stable patient.
Nor is there evidence to support the
practice of keeping the clinically
stable patient at bed rest.

2003 Eastern Association For The Surgery of Trauma

Indications
In Penetrating
In Blunt Trauma Trauma
Hemodynamic
instability
Transfusion> 2 Exploratory
blood volume or > lapratomy is
40 ml/kg indicated in any
penetrating trauma
Devitalized
in with peritoneal
parenchyma
penetration
Sepsis / biloma
Operative
technique/options
Initial Explore Laparotomy

Temporary control of hemorrhage:

Why temp?
Ongoing hemorrhage, life threatening, no time to
restore circulatory volume.
Liver injuries not highest priority
Operative
technique/options
How?
Manual compression
Perihepatic packing. commonest
Pringle maneuver.
Tourniquet
Hepatic vascular isolation
Placement of atriocaval shunt Juxtahepatic
Moore-Pilcher balloon venous injury
 Blood supply
Portal vein
Hepatic
artery
Hepatic vein
Liver segments
 Technique
Hepatotomy with direct suture
ligation
using the finger fracture technique,
electrocautery or an ultrasonic
dissector to expose damaged vessels
and hepatic duct
low incidence of rebleeding, necrosis
and sepsis
Resection and debridement
 Surgical options
Anatomical resection
--reserved for deep laceration involving
major vessels or bile ducts, extensive
devascularization and major hepatic venous
bleeding
Perihepatic packing
--Indication:coagulopathy, irreversible shock
from blood loss , hypothermia(32C),
acidosis(PH7.2), bilobar injury,large
nonexpanding hematoma, capsular
avulsion, vena cava or hepatic vein injuries
Perihepatic packing
Mesh Wrapping
Ultrasonic dissector
Harmonic scalpel
Argon Coagulation
Tissue link
 Outcome
The mortality rate
from liver trauma
has fallen from 66
per cent in World
War I, to 27 per
cent in World War II,
to current levels of
10-15 per cent

Liver regeneration
post resection of the
 Summary
Liver 2nd most commonly injured
solid organ.
Hemodynamic stability is the
principle guide to management.
Resuscitation is of primary
importance rather than wasting time
and blood on grading either outside
or inside the theatre.
 Thank you