Management of Liver Trauma

Joint Hospital Surgical Grand Round19 June 2004United Christian Hospital

Case

SW Cheng, M/475.5 tones lorry driverHit on road side and trapped within wreck

Fully conscious on arrival to AEDEpigastric pain, right lower chest pain and right foot pain with wound over foot dorsumBP 100/60 P90Hb 7.8, AST > 1000, ALT > 200Fracture right 6th and 8th ribs with chest drain inserted

Urgent CT scan abdomen: Right lobe liver haematoma with rupture and subphrenic fluid

Question

What should we do now?Should we operate on him right the way or should we adopt conservative management?What should we do if we are going to perform laparotomy?

Liver Trauma

Most frequently injured intra-abdominal organ (Feliciano, 1989)

Blunt injuries Deceleration injuries Direct blow

Penetrating injuries

Grading System

Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (Moore, 1995) Hepatic Injury Scale Revised in 1994

Grade I and II Minor injuries 80-90% Require minimal or no operative

treatment

Grade III, IV and V Severe and require surgical intervention

Grade VI Incompatible with survival

Management

ATLSHaemodynamically stable: further assessment

Assessment

USG Sensitivity 82-88% and specificity 99% Operator dependent

CT scan Grading does not correlate precisely Sensitivity and specificity increase with

increased time between injury and CT

Laparoscopy

Non-operative Management

Non-operative Management

50-80% of liver injuries stop bleeding spontaneouslyIncreasing trend towards conservative management

Criteria for Non-operative Management

Meyer (1985) Haemodynamic stability Absence of peritoneal gas Good quality CT scan Experienced radiologist Ability to monitor patient in ICU Facility for immediate surgery Simple parenchymal laceration or

intrahepatic haematoma with less than 125 ml free intraperitoneal blood

No other significant intra-abdominal injuries

Farnell (1998) Haemoperitoneum 250 ml Specific CT requirements

Subcapsular or intraparenchymal haematoma

Unilobar fracture Absence of devitalized tissue Absence of other intra-abdominal injuries

Feliciano (1992) Haemodynamically stable Haemoperitoneum of less than 500 ml

Ultimate Decisive Factor

Haemodynamic stability at presentation or after initial resuscitationIrrespective of the grade of injury on CT or the amount of haemoperitoneum

Pachter 1995

Review of 495 patientsSuccess rate of non-operative management: 94%Mean transfusion rate: 1.9 unitsComplication rate 6% (bile leak 4, biloma 10, abscess 3, haemorrhage 14)Mean hospital stay 13 days

Potential complications

Discrepancy between CT and operative findingsRisk of missing other intra-abdominal injuries: reduce with use of DPLPotential for transmission of bloodborne viral illness from repeated blood transfusion: actually require fewer blood transfusionsRisk of continued haemorrhageHaemobilia, bile leak and spesis

Bynoe 1992

Complication rates no greater than those in patient treated surgically

Operative Management

Prerequisites

ResuscitationExperienced surgeonFamiliar with liver anatomyBlood, platelets, FFP, cryoprecipitateFully equipped ICUDiagnostic back-up to monitor and detect potential complications

Initial Control of Bleeding

Midline or bilateral subcostal incision

Temporary tamponade of RUQ using packsPringle maneuverBimanual compression of liverManual compression of abdominal aorta above celiac trunk

Pringle Maneuver

If haemorrhage is unaffected by portal triad occlusion, major vena cava injury or atypical vascular anatomy should be suspected

Hepatotomy With Direct Suture Ligation

Division of normal hepatic parenchymaTo expose damaged vessels and hepatic ducts which can be ligated, clipped or repaired under direct vision

Resectional debridement

Removal of all devitalized tissue down to normal hepatic parenchyma using line of injuryRapid compared to anatomical resection

Perihepatic Packing

Serious complications associated with gauze packing of hepatic injuries during WWII and Vietnam warLed to abandonment of this treatmentDuring past decade, re-established as an acceptable method of management of liver injuries

Perihepatic Packing

Indications When other surgical methods failed in

a hameodynamically unstable patient Uncontrollable coagulopathy Bilobar liver injury Large non-expanding haematoma Capsular avulsion

Minimal number of dry abdominal packs or single rolled gauze around liverNOT to force into deep fractures

Mesh Wrapping

Grade III-IV lacerationsTamponading large intrahepatic haematomas, minimize risk of delayed ruptureRelaparotomy not routinely required

Selective Hepatic Artery ligation

When source of bleeding cannot be identified in hepatotomy sitePerihepatic packing failsPringle maneuver seems to be effective

Contraindications: Bleeding from portal or posthepatic veins Cirrhosis

Adjunctive Technique

Fibrin glue: raw liver surfaces

Retrohepatic Venous Injuries

Suspected if: Portal triad occlusion fails to control

bleeding Injury extends to bare area on

palpation

Management of Retrohepatic Injuries

Total vascular exclusionVenovenous bypassAtriocaval shuntingBeal (1990): perihepatic packing

Conclusion

ResuscitationConservative treatment if haemodynamically stableOperation: perihepatic packing, then transfer to hepatobiliary centreHepatotomy with direct suture ligation or resectional debridement

Thank You

ReferencesBeal SL. Fatal hepatic haemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma 1990; 30: 163-9.Bynoe RP et al. Complications of nonoperative management of blunt hepatic injuries. J Trauma 1992; 32: 308-15.Farnell MB et al. Nonoperative management of blunt hepatic trauma in adults. Surgery 1988; 104: 748-56. Feliciano DV. Surgery for liver trauma. Surg Clin North Am 1989; 69: 273-84.Feliciano DV et al. Continuing evolution in the approach to sever liver trauma. Ann Surg 1992; 216: 521-3.Meyer AA et al. Selective nonoperative management of blunt liver injury using computed tomography. Arch Surg 1985; 120: 550-4.Moore EE et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995; 38: 323-4.Pachter HL et al. Significant trends in the treatment of hepatic trauma. Experience with 411 injuries. Ann Surg 1992; 215: 492-502.Pachter HL et al. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995; 169: 442-54.Parks RW et al. Management of liver trauma. BJS 1999; 86: 1121-35.Simon AW et al. Management of liver trauma with implications for the rural surgeon. ANZ J Surg 2002; 72: 400-4.