TRAUMA HEPAR

Soetamto Wibowo
Bagian Bedah FK UNAIR / RSUD Dr Soetomo
Surabaya

DIAGNOSIS
Riwayat Penyakit :
> Mekanisme Trauma : Trauma Tumpul

Trauma Tembus : Tusuk , Tembak

> Kejadian (waktu)
> Nyeri Febris

Pemeriksaan Fisik : Manajemen ATLS

Pemeriksaan Penunjang : FAST
DPL
CT Scan + Kontras

BLUNT ABDOMINAL TRAUMA

Peritonitis / Overt Hemoperitoneum ?

Yes

Expl. Laparotomy

No
Hemodinamically Stable

Hemodinamically UnStable

Alur Penanganan Penderita Trauma Tumpul Abdomen

Hemodinamically Stable
Yes

No

Reliable PE ?

Abdominal Tenderness

Yes

Multiple Ribs Fracture

Abdominal Wall Contusion

USG

Equivocal Findings
No
Admid Serial PE

DPL

USG / DPL

Negv

Free Fluid ?
Yes
CT Scan

No

Repeat USG

Hollow

Observation

Organ

Repeat DPL

Injury ?

CT Scan

No
CT Scan

No

Solid Visceral injury ?

Consider Expl. Lap

Postv

Yes

Consider Non Operative

Yes
Expl lap

Solid Visceral injury ?

Consider Expl. Lap

No

Hemodinamically Unstable
USG

DPL

Free Fluid ?

Aspiration of Gross Blood

RBC > 100 K/mm3

WBC > 500/mm3
Particulate matter
Bile
No

No

Yes
Expl lap

Continue Resuscitation

Continue Resuscitation

Evaluate Other Potential Source

Evaluate Other Potential Source

Repeate USG

Repeate DPL

DPL

Liver Injury Scale : AAST (Revised 1994)

Grade
I. Hematoma
Laceration

Injury Description

ICD - 9

AIS 90

Subcapsular Non expanding, <10 cm surface area

864.01
864.11

Capsular tear, Non bleeding,< 1 cm parenchymal depth

864.02

864.12
II. Hematoma

Laceration
III. Hematoma

Subcapsular Non expanding, 10-50% surface area

864.01

Intraparenchymal non expanding < 10 cm in diameter

864.11

Capsular tear, Active bleeding,1-3 cm parenchymal

depth

864.03

<10 cm length

864.13

Subcapsular,>50% surface area or expanding

2
3

Ruptured subcapsular hematoma with active bleeding

intraparenchymal hematoma > 10 cm or expanding
Laceration
IV. Hematoma
Laceration

> 3 cm parenchymal depth

864.04

Ruptured intraparenchymal hematoma with active

bleeding

864.04

Parenchymal disruption involving 25-75% hepatic lobe

or 1-3 Coinaud's segment within single lobe

V. Laceration

Parenchymal disruption involving >75% hepatic lobe

4
864.14

or 1-3 Coinaud's segment within single lobe

Vascular

Juxtahepatic venous injuries (ie retroheaptic vena cava /

central major veins

VI. Vascular

Hepatic avulsion

Manajemen Non Operative

I. Dasar Keputusan
1. Hemodinamik Stabil : Saat Datang atau Rapid Response

Stabil bila : MAP > 80 mmHg, Nadi < 120 x/mt

Transfusi tidak lebih dari 2 unit Whole Blood

Tidak ada tanda-tanda klinis Shock

Produksi urine > 50 cc/jam
2. Hasil CT Scan Abdomen : Grading, Pooling (AAST)

3. Tidak ada gejala Peritonitis secara klinis

4. Tidak ada tanda-tanda Perforasi Organ Berongga,
Pancreas, Kandung seni atau Diafragma (CT Scan,
Plain Foto Abdomen, DPL)

Manajemen Non Operative

II. Perawatan di RS
1. Bed Rest dengan NGT, sebaiknya di Ruang Intensif
2. Pemeriksaan Fisik Hb (Hct) @ 6 jam (hari I), @ 12
jam (hari II)
3. Hct < 25% : Transfusi PRC, bila transfusi > 4 unit
dalam 72 jam : Laparotomi
4. Realimentasi bila fungsi saluran cerna baik
5. CT Scan dapat diulang : 3-5 hari Pasca Trauma
lalu 6 minggu pasca trauma
6. Keluar RS setelah 12 hari
7. Tidak melakukan aktivitas fisik berlebihan & olah
raga kontak selama 4-6 bulan.

PEMBEDAHAN
Indikasi Laparotomi :
1. Hemodinamik tidak stabil
2. Peritonitis Generalisata
3. Perlu Transfusi > 4 unit WB
4. Pada CT Scan abdomen :
> Cairan Bebas dalam abdomen
tanpa perlukaan organ padat
> Pooling kontrast dalam
parenchym hepar,lien atau intra
abdomen

Liver
Rupture

Incision

ALGORITHM FOR THE INTRAOPERATIVE MANAGEMENT OF COMPLEX HEPATIC INJURIES

HEMOPERITOEUM WITH INSTABILITY
BIMANUAL COMPRESSION RESUSCITATION
PRINGLE MANEUVER
BLEEDING CONTINUES (CONSIDER
RETROHEPATIC IVC OR
HEPATIC VENOUS INJURY

BLEEDING ARRESTED

FINGER FRACTURES TECHNIQUE TO

SITE OF INJURY

NO VASCULAR
ISOLATION

PACK PATIENTT
BLEEDING NOT ARRESTED

REPAIR SEVERED BLOOD

VESELS AND BILE DUCTS

DEBRIDEMENT OF NONVIABLE
HEPATIC PARENCHYME

OMENTAL PACK

BLEEDING ARRESTED

VASCULAR ISOLATION

INTRACAVAL SHUNT
(ATRICAVAL OR
SAPHENOCAVAL)

LEAVE PACK IN PALCE

COAGULOPATHY AND
OTHER INDICATIONS
FOR PACKING

RAPID REPAIR OF
LACERATED VENOUS
STRUCTURESS

PACKING, RAPID ABDOMINAL

CLOSURE WITH TOWEL CLIPS,
PLANNED RE-EXPLORATION
RE-EXPLORE WHEN
HYPOTHERMIA, ACIDOSIS
CORRECTED (18-36 H)
REMOVE PACK

NO BLEEDING
IRRRIGATE, DEBRIDE, CLOSED
SUCTION DRAINAGE, CLOSE

BLEEDING RECURS
DEFINITIVE REPAIR, MAY
REQUIRE VASCULAR ISOLATION

Liver Rupture

MANUAL COMPRESSION

Liver
Rupture
Pringle
Maneuver

Liver Rupture

Haemostasis

Liver Rupture

Liver Suture

Liver Rupture

Perihepatic packing for left & right lobes rupture

Liver Rupture

Dividing The Liver Ligament

Segmental Anatomy of the Liver : Described by Couinaud

Liver Rupture

Omentum : A living pack

Liver Rupture

Atrio Caval Shunt

Penetrating Liver Trauma

Gunshot
Stabwound through
peritoneum
>>Exp. Laparotomy

Intraparenchymal Ballon Tamponade

Sukses (8) : Mortalitas = 0

MNO (9)
Gagal (1) : Laparotomi
Ruptur
Hepar (27)
Laparotomi (18)

Trauma
Tumpul
Abdomen

MNO (9)

(46)

Ruptur
Lien (19)

Mortalitas = 2

Sukses (8)
Gagal (1) : Laparotomi

Laparotomi (10)

Mortalitas = 0

Trauma Tumpul di Surabaya (2003 2005)

Comparison of patients with succesful vs failed NOM

(Velmahos. Arch Surg 2003 ; 56 : 537-541)
NOM
Success

NOM
Failure

n=116 (%)

n=33 (%)

1. FAST Positive Result

26 (22)

20 (61)

< 0,01

2. Liver

60 (52)

12 (36)

0,11

3. Spleen

44 (38)

23 (70)

< 0,01

4. Renal

27 (23)

6 (18)

0,64

5. Associated Intra Abd

1 (1)

6 (18)

<0,01

6. Associated Extra Abd

79 (68)

18 (55)

0,13

7. Amount of fluid on CT
(mean+SD)

92 + 154

308 + 396

<0,01

Factors

p
value

Comparison of Immediate Operative & NOM Failure : Surabaya & LA

Soetamto (n=46)

Velmahos (n=206)

2003 - 2005

1999 - 2001

Surabaya

Los Angeles USA

Liver

18 (66,7)

17 (24)

Spleen

10 (52,6)

27 (33)

Renal

2 (10)

Liver

1 (11,1)

12 (16,7)

Spleen

1 (11,1)

23 (34,3)

Renal

6 (18,2)

2 (4,3)

15 (7)

Compare
1. Immediate Operative

2. NOM Failure

3. Mortality

CASE I
MRS. NS 49 YRS
21.03.2003 : CAR TRAFFIC ACCIDENT
HISTORY OF AUTOIMMUNE DISEASE
AND CORTICOSTEROID THERAPY
PE
: ABDOMINAL PAIN AND RIGIDITY
BP
:100/70
P 120/MIN TEMP. 37C
RONTGENT : FRACTURE LEFT RIBS # 4,5,6,7,8
PELVIC FRACTURE
FAST
: FREE FLUID +

MRS. NS 49 YRS
HB

LIVER RUPTURE

HEMODYNAMIC

TRANSFUSSION

(g/dl)
24.03.03
22.03.03
23.03.03
24.03.03
25-03.03
18.03.03
07-04.03

8.5
6.2
9.2
7.7
10.3
12.0

STABLE
STABLE
STABLE
STABLE
STABLE
STABLE

3
3
1
2
-

PRC
PRC
PRC
PRC

CT SCAN I

CT SCAN II

Mrs.NS, 49 yrs

22 Maret 2003

7 April 2003

Mr. KLT, 45 yrs

Spleen Rupture Grd IV

Mr. YY 49 yrs

Spleen Rupture Grd III

JT, Male, 29 yo
4 May 2005 : Traffic accident, car accident
5 May 2005 : 6:00 AM > BP 120/80 mmHg; Hb 11,7 g/dl
FAST : Fluid +
Abdomen CT Scan : Spleen Rupture grade IV
Th/ : Non Operative Management
6:00 PM > Hb 10,0 g/dl

perivesical

paracolica

splenorenal

FAST

Morison pouch

Mr JT,Abdomen CT Scan ( II )

Spleen Rupture Grade IV

Abdomen CT Scan ( III )

Spleen Rupture Grade IV - NOM

Mr H, 13 yrs

Perihepatic Packing

Mr S, 18 yrs

Liver Rupture Grd III - NOM

Ms R, 25 yrs

Liver Rupture Grd IV - NOM

Terima Kasih