Dr.

Aisha Al-Zuhair General Surgery KFHU Khobar Saudi Arabia Dec 16, 2009

Surface anatomy
In RUQ 5th ICS in midclavicular

line to the Rt costal margin. Weighs 1400 g n women and 1800g n men . Span 10 cm +/-2

Surface anatomy
Superior, anterior, and right lateral surfaces fit diaphragm. Falciform ligament
Posterior surface Rt lobe: colon, right kidney, and duodenum Lt lobe: stomach

 The liver covered by

fibrous capsule that reflects on the diaphragm and post abdominal wall Leaving a bear area that connects the liver to the retroperitoneum directly

Ligaments
Liver supported by: Coronary lig Rt & Lt Triangular lig Falciform lig

Fissures

Segmental anatomy
Classically; liver divided to 4 lobes: Right lobe Left lobe Caudate lobe Quadrate lobe

Segmental anatomy
Functionally; on the basis of the distribution of vessels

and ducts within the liver segments. Cantlies line.

Blood Supply
Portal vein Hepatic artery Hepatic vein

Blood Supply Portal Vein

Superior Mesentric and Splenic veins
Posterior to hepatic artery and bile duct at the

hepatodudenal junction. Valveless 75% of total blood supply the liver Pressure 3-5 mmHg

Blood supply Hepatic artery

Intrahepatic anatomy; part of portal tried follows

segmental anatomy. Extrahepatic anatomy; highly variable:

Commonest ( in 60%) anatomy: abdominal aorta

celiac trunk CHA proper hepatic art Rt and Lt hepatic artery LHA seg 1,2,3 and middle hepatic artery seg 4. RHA cystic art , Rt liver

Blood supply Hepatic vein

Rt hepatic vein Drain seg 5,6,7,8 vena cava. Middle hepatic vein Drain seg 4,5,8 Lt hepatic vein Drain seg 2,3

[ seg 1 drain by short hepatic vena cava]

Radiological anatomy

Radiological anatomy

Introduction
It is the 2nd commonest organ injured in

blunt abdominal trauma and the commonest injured in penetrating trauma. 1%-8% of pt with multiple blunt trauma sustain a liver injury. During last 3 decades, liver injury increased. This inc could be actual or artificial d/t better diagnostic modalities.
Richardson JD. Ann Surg. 2000;232:324-330. Lucas CE. Am Surg. 2000;66:337-341.

While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference: If lacerations be extensive and vessels of any magnitude are torn, hemorrhage will, owing to the structural arrangement of the liver, go on continously.
JH Pringle, 1908

History of Liver Trauma

WW1 WW2 Vietnam Mortality 66% -- 28% -- 15%

Factors making the liver prone to injury:

The large size of the liver, 2. its friable parenchyma, 3. its thin capsule, and 4. Its relatively fixed position in relation to the spine and ribs.
1.

Grading of liver injury by a system brought by: AAST (American Association for the Surgery of Trauma)

1. 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 1
A stabbing injury to the RUQ of the abdomen

Contrast CT demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.

Grade 2
A blunt abdominal trauma

CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.

Grade 3
A blunt abdominal trauma

Contrast CT shows a 4-cm-thick subcapsular hematoma associated with parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver..

Grade 4
A blunt abdominal trauma

CT scan of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-attenuating areas within the lesion represent clotted blood

Grade 4
A blunt abdominal trauma

Contrast CT shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the capsular laceration and large hemoperitoneum.

Grade 5
A motor vehicle accident

CT demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam.

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. Pachter HL. Am J Surg. 1995;169:442-454. Sherman HF J Trauma. 1994;37:616-621. . Miller PR. J Trauma. 2002;53:238-242. Goan YG. J Trauma. 1998;45:360-364. . Ochsner MG.. World J Surg. 2001;25:1393-1396. Maull KI. World J Surg. 2001;25:1403-1404. Schweizer W. Br J Surg. 1993;80:86-88. Brasel KJ. Am J Surg. 1997;174:674-677.

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

Liver injury score of patients is not as important as the hemodynamic status for determining conservative management

High Success With Nonoperative Management of Blunt Hepatic Trauma

Arch Surg. 2003;138:475-481

Hypothesis Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events. Setting High-volume academic level I trauma center

Cont.
Results
78 patients 23 (29%) were operated on immediately, but only 12 (15%) for bleeding from the liver. NOMLI failed in 8 for reasons unrelated to the liver injury. The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%. No adverse events were attributed to NOMLI.

Cont.
Conclusions
NOMLI is safe and effective regardless of the grade of liver injury. Failure of NOMLI is caused by associated abdominal injuries and not the liver. Fluid and blood requirements, the degree of injury severity, and the presence of other abdominal organ injuries may help predict failure.

Complications of NOMLI
Biliary (bile peritonitis, bile leak, biloma, hemobelia..)
Infection (liver abscess, necrosis, abdominal sepsis,

SIRs) Abdominal compartment 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
ICU
Hospital stay (d)

II

III

IV

0 2

0 3

0 4

1 5

Activity 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 Blunt Trauma
Hemodynamic

In Penetrating Trauma
Exploratory lapratomy is

instability Transfusion> 2 blood volume or > 40 ml/kg Devitalized parenchyma Sepsis / biloma

indicated in any penetrating trauma in with peritoneal penetration

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 commonest Perihepatic packing. Pringle maneuver. Tourniquet Hepatic vascular isolation Juxtahepatic Placement of atriocaval shunt venous injury Moore-Pilcher balloon

Operative technique/options
Definitive management of the injuries:

1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4

Hepatic segments Resections

Right hemihepatectomy (segments 5 to 8); AKA as Right hepatectomy or right hepatic lobectomy Right trisectionectomy (segments 4 to 8); AKA as Right lobectomy or Rrisegmentectomy of Starzl Left hemihepatectomy (segments 1 to 4); AKA as Left hepatectomy or Left hepatic lobectomy Left lateral sectionectomy (segments 1 to 3); AKA as Left lobectomy or Left lateral segmentectomy

References
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Sabiston Textbook of Surgery, 18th ed. Khatri: Operative Surgery Manual, 1st ed. ACS Surgery principles and Practice 2006. Cameron; current surgical therapy, 8th ed.

http://www.netterimages.com/ http://www.adhb.govt.nz http://emedicine.medscape.com/article/370508-overview http://www.east.org