TRAUMA HEPAR

Arif Hidayat
PPDS Bedah FK UNDIP / RSUP Dr. Karyadi
Semarang
 2nd commonest organ injured in blunt
abdominal trauma and the commonest
injured in penetrating trauma
 1-8 % pt with multiple blunt trauma sustain a
liver injury
 Risk factor :
 Large size of liver
 Its freable parenchyma
 Its thin capsule
 Relatively fixed position in relation to the
spine and ribs
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

Yes
Peritonitis / Overt Hemoperitoneum ? Expl. Laparotomy

No

Hemodinamically Stable Hemodinamically UnStable

Alur Penanganan Penderita Trauma Tumpul Abdomen

 Hemodinamically Stable
Yes No
Reliable PE ?

Abdominal Tenderness Yes

USG / DPL DPL
Multiple Ribs Fracture
Abdominal Wall Contusion USG
Negv Postv
Equivocal Findings
Free Fluid ?
No Yes Repeat USG Hollow
No
Admid Serial PE CT Scan Observation Organ
Repeat DPL Injury ?
CT Scan
No Yes
CT Scan Expl lap
Yes
Solid Visceral injury ? Solid Visceral injury ?
No No
Consider Expl. Lap Consider Non Operative Consider Expl. Lap
 Hemodinamically Unstable

USG DPL

Free Fluid ? Aspiration of Gross Blood

RBC > 100 K/mm3
WBC > 500/mm3
Particulate matter
Bile

No Yes No

Expl lap
Continue Resuscitation Continue Resuscitation
Evaluate Other Potential Source Evaluate Other Potential Source
Repeate USG Repeate DPL
DPL
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
ALGORITHM FOR THE INTRAOPERATIVE MANAGEMENT OF COMPLEX HEPATIC INJURIES

HEMOPERITOEUM WITH INSTABILITY

BIMANUAL COMPRESSION RESUSCITATION

PRINGLE MANEUVER

BLEEDING CONTINUES (CONSIDER

BLEEDING ARRESTED RETROHEPATIC IVC OR
HEPATIC VENOUS INJURY
NO VASCULAR
ISOLATION
FINGER FRACTURES TECHNIQUE TO
PACK PATIENTT
SITE OF INJURY

BLEEDING NOT ARRESTED BLEEDING ARRESTED

REPAIR SEVERED BLOOD
VESELS AND BILE DUCTS VASCULAR ISOLATION
LEAVE PACK IN PALCE
INTRACAVAL SHUNT
(ATRICAVAL OR
COAGULOPATHY AND
SAPHENOCAVAL)
DEBRIDEMENT OF NONVIABLE OTHER INDICATIONS PACKING, RAPID ABDOMINAL
HEPATIC PARENCHYME FOR PACKING CLOSURE WITH TOWEL CLIPS,
PLANNED RE-EXPLORATION
RAPID REPAIR OF
OMENTAL PACK LACERATED VENOUS
RE-EXPLORE WHEN
STRUCTURESS
HYPOTHERMIA, ACIDOSIS
CORRECTED (18-36 H)
REMOVE PACK

BLEEDING RECURS
NO BLEEDING DEFINITIVE REPAIR, MAY
IRRRIGATE, DEBRIDE, CLOSED REQUIRE VASCULAR ISOLATION
SUCTION DRAINAGE, CLOSE
Liver
Rupture
Incision
 Liver Rupture

MANUAL COMPRESSION
 Liver
Rupture

Pringle
Maneuver
 Liver Rupture

Haemostasis
Liver Rupture

Liver Suture
 Liver Rupture

Omentum : A living pack

Liver Rupture

Atrio Caval Shunt

 Penetrating Liver Trauma

Gunshot
Stabwound through
peritoneum
>>Exp. Laparotomy

Intraparenchymal Ballon Tamponade

Terima Kasih