Management of Liver Trauma

Joint Hospital Surgical Grand

Round
19 June 2004
United Christian Hospital
Case
SW Cheng, M/47
5.5 tones lorry driver
Hit on road side and trapped within
wreck
Fully conscious on arrival to AED
Epigastric pain, right lower chest pain
and right foot pain with wound over
foot dorsum
BP 100/60 P90
Hb 7.8, AST > 1000, ALT > 200
Fracture 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
ATLS
Haemodynamically 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
spontaneously
Increasing 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 resuscitation
Irrespective of the grade of injury on CT
or the amount of haemoperitoneum
Pachter 1995
Review of 495 patients
Success rate of non-operative
management: 94%
Mean transfusion rate: 1.9 units
Complication rate 6% (bile leak 4,
biloma 10, abscess 3, haemorrhage 14)
Mean hospital stay 13 days
Potential complications
Discrepancy between CT and operative
findings
Risk of missing other intra-abdominal injuries:
reduce with use of DPL
Potential for transmission of bloodborne viral
illness from repeated blood transfusion:
actually require fewer blood transfusions
Risk of continued haemorrhage
Haemobilia, bile leak and spesis
Bynoe 1992
Complication rates no greater than
those in patient treated surgically
Operative Management
Prerequisites
Resuscitation
Experienced surgeon
Familiar with liver anatomy
Blood, platelets, FFP, cryoprecipitate
Fully equipped ICU
Diagnostic back-up to monitor and
detect potential complications
Initial Control of Bleeding
Midline or bilateral subcostal incision

Temporary tamponade of RUQ using

packs
Pringle maneuver
Bimanual compression of liver
Manual 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 parenchyma
To 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 injury
Rapid compared to anatomical resection
Perihepatic Packing
Serious complications associated with
gauze packing of hepatic injuries during
WWII and Vietnam war
Led to abandonment of this treatment
During 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 liver
NOT to force into
deep fractures
Mesh Wrapping
Grade III-IV lacerations
Tamponading large intrahepatic
haematomas, minimize risk of delayed
rupture
Relaparotomy not routinely required
Selective Hepatic Artery
ligation
When source of bleeding cannot be
identified in hepatotomy site
Perihepatic packing fails
Pringle 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 exclusion
Venovenous bypass
Atriocaval shunting
Beal (1990): perihepatic packing
Conclusion
Resuscitation
Conservative treatment if
haemodynamically stable
Operation: perihepatic packing, then
transfer to hepatobiliary centre
Hepatotomy with direct suture ligation
or resectional debridement
Thank You
References
Beal 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.