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LIVER TRAUMA MANAGEMENT EXPERIENCE AMONG A CLUSTER OF PATIENTS PRESENTING WITHIN A MONTH Muhammad Saaiq Surgical Grand Round,

Pakistan Institute of Medical Sciences (PIMS), Islamabad. September 29, 2006.

What prompted this presentation ?

Case No. 1
aged 18 , presented with H/O RTA and blunt trauma abdomen. Exploratory Laparotomy revealed : i) About 4 cm long and 1cm deep liver laceration just on the left side of the FL. ii) Another 4cm long and 4 cm deep irregular laceration just lat. to L. Teres with a bleeder spurting blood. iii) 800cc blood AAST grade III Liver trauma.
Male

Case No. 2
Male aged 19 , presented with H/O FAI Rt. Lower rib cage / chest. Exploratory Laparotomy revealed : *Sealed firearm wound on the frontal surface of Rt lobe ( B/w segments V and VIII) corresponding to a similar wound on posterior surface of liver. * About 200 cc free blood. AAST Grade III Liver trauma.

Case No. 3
Male aged 15 presented with H/O FAI abdomen / Lt. lower back. Exploratory Laparotomy revealed : i) Firearm exit wound epigastrium / Lt hypochondrium with omentum coming out through it . ii) Fragmented Spleen. iii) Parenchymal disruption of Lt lobe of liver involving > 50 % of the lobe. iv) Two lacerations ( about 6 cm each) in the stomach. v) 3 cm rent in diaphragm leading to the Firearm entry wound near inferior angle of Lt scapula. vi) Irregular laceration of Lt costal margin with diaphragm separate from costal margin over an area of 4 cm. vii) About 2000 cc free blood in the peritoneal cavity. AAST Grade IV Liver trauma.

Male aged 20 presented with H/O Stab Rt flank. Exploratory Laparotomy revealed : i) One Litre free blood in the peritoneal cavity. ii) Irregular laceration of the abdominal wall communicating with the outside stab wound. iii) 3 cm long and 5 cm deep laceration on segment V communicating with a 1 cm wound just lateral to the Gall bladder fossa. iv) A small rent in the peritoneal reflections over the duodenum with bruising of the adjoining area. AAST Grade III Liver trauma.

Case No. 4

Liver Trauma Anatomical Considerations

FUNCTIONALLY LIVER HAS : 2 Lobes 4 Sectors 8 Segments

Etiology / Mechanisms :
Blunt trauma :
Deceleration Compression Secondary penetrating injury from spicules of fractured ribs / bones

Penetrating trauma :
Low energy trauma high energy trauma

American Association for Surgery of Trauma (AAST ) Grading system

Grade I : Hematoma ; Subcapsular, non-expanding < 10 % surface Laceration ; Capsular tear, Non-bleeding, < 1 cm parenchymal depth Grade II : Hematoma ; Subcapsular, Non-expanding, 10-50 % surface area Or intraparenchymal, Non-expanding, < 2 cm in diameter. Laceration ; Capsular tear, active bleeding, 1-3 cm deep, < 10 cm in length. Grade III: Hematoma ; Sucapsular, > 50 % surface area Or Ruptured subcapsular hematomea with active bleeding Or Intraparenchymal hematoma > 2 cm or expanding.

Laceration ; > 3 cm parenchymal depth. Grade IV: Hematoma ; ruptured intrparenchymal hematoma with active bleeding. Laceration; Parenchymal disruption involving 25-50 % of hepatic lobe Grade V : Laceration; Parenchymal disruption involving over 50 % of hepatic lobe Vascular; Juxtahepatic venous injuries(major hepatic veins, retrohepatic vena cava) Grade VI : Vascular; Hepatic Avulsion

Active Management and Diagnostic investigations if any should proceed simultaneously. No investigation should delay the proper treatment Penetrating Vs blunt and whether the patient is hemodynamically stable or not will rationalize the route of investigations as well as management. Confirmation of hemoperitoneum may be done with DPL or four-quadrant aspiration or FAST U/S. Ct scan abdomen and chest helps to determine the Nature and Extent of liver injury plus any other associated injuries.

Diagnostic Issues

MANAGEMENT :
Initial Resuscitation. Definitive measures for Liver trauma.

Initial Resuscitation
A B C D E

F?

Definitive Management

Surgical Options :

Suture Hepatorrhaphy

Suture Hepatorrhaphy with Omental Buttressing

Perihepatic Packing

Perihepatic Packing

Hepatic Artery Ligation

PRINGLE MANOEUVRE

Application of Bioadhesives

Mesh Hepatorrhaphy

Major Vascular Injuries

Arterial Embolization

Liver Resection Liver transplantation

Recent Advances

Interventional radiology

Re-emergence of Perihepatic packing with Temporary abdominal closure

Intra-hepatic Packing

Immediate Postoperative Concerns

Common Problems

Hemorrhage Sepsis Bile leak Coagulopathy

Lethal Triangle ( a.k.a Bloody vicious cycle of trauma)

Core Hypothermia Metabolic Acidosis Coagulopathy

Other Complications of Liver Trauma


Bile collection Liver abscess Biliary fistula Hepatic artery aneurysm Arteriovenous Fistulation Arterio-biliary Fistulation Biliary tract strictures

LIVER TRAUMA
LIVER TRAUMA

Muhammad Saaiq
Unit-I , Department of Surgery.