SOLID ABDOMINAL ORGAN

INJURY /LIVER & SPLEEN/

By: Yamral (GSR-1)

Moderators:
Dr. Henok Seife (MD, consultant General and
Hepatobiliary surgeon)
Dr. Alliya Qazi (MD, Consultant trauma surgeon)
18-06-2020 G.C

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 Outline
• Overview on anatomy of liver and spleen
• Epidemiology of liver and splenic injury
• Causes and grading of liver and splenic injury
• Clinical presentation
• Investigations
• Management
• Complications
• Summary
• References
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Liver Injury

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ANATOMY

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• Blood supply: Portal vein
– Superior mesenteric and splenic veins
– Supply 75% of liver
– Posterior to hepatic artery and bile duct at
hepatoduodenal junction
• Hepatic artery
– From celiac trunk and 25% of liver supply
– LHA- segment 1,2,3 and MHA-segment 4
– RHA- Rt. Lobe and cystic artery
• Hepatic vein…. Drain respective segments to IVC
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 Epidemiology
• The 1st abdominal organ injured by penetrating and 2nd by
blunt abdominal trauma
• 1-8% of patients with multiple blunt trauma have liver
injury
• It represents 5% of trauma admissions
• Majority of liver injuries are not severe & do not require
surgical intervention
• Associated hollow viscus injury occurs in 5-20% of liver
injury.
• Large size, friable parenchyma, thin capsule & its fixed
position makes liver prone to injury
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 Clinical features
• Mechanisms could be blunt(RTA,fall down,
fighting…), penetrating(gunshot,stab…)
• Patients present with
– Rt. Sided rib fracture
– Abd. distention (hemo-peritonium)
– Abd. Pain, tenderness
– Shock, change in mentation
– Stable with only history of abdominal trauma

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• Grade 1 & 2 injuries account 60-70% of
injuries and do not usually require operation
• Grade 3--25%, grade 4--7% & grade 5-- 3%

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 Diagnosis
• FAST: the primary modality to detect
hemoperitonium in unstable patient
• 73-88% sensitive & 98-100% specific
• The sensitivity increase with grade,
• >98% sensitive in grade 3 and above
• In penetrating 43% sensitive and 98% specific
• Negative fast can’t preclude liver injury
• At least >200 ml fluid needed for detection
• DPL: replaced by FAST and CT.
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 Diagnosis
• CT-SCAN: 99.6% negative predictive value
• 95% sensitive and 99% specific
• It tells us grade, hemoperitonium, contrast
extravasation, pseudo-aneurysm
• Usually in stable patients
• Laparoscopy: sometimes used in penetrating
injury
• Basic Ix: CBC, coagulation profile, cxr, pelvic x-
ray
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 Treatment
• ABCDE…1ry, 2ry survey.

Non Operative Management

• If stable, NOM irrespective of grade
• low grade or high grade; follow with serial hct, physical
examination
• There should be a setting to intensively follow and monitor
patients
• In stable patient with contrast extravasation and blush, angio-
embolization can be done
• Penetrating injuries can be managed by NOM
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• 73% G-4 & 63% G-5 can be managed by NOM.
• If abdominal pain, jaundice, fever,
leukocytosis; (CT SCAN) percutanous drainage,
OR

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 Switch to OM
• Increasing fluid requirement to maintain
normal hemodynamic status
• Transfusion requirement to maintain normal
hemodynamic status (usually>4units)
• Failed angio-embolization
• Increasing hemoperitonium with
hemodynamic unstability
• Peritoneal signs

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 Operative Management
• Hemodynamic unstability
• Evisceration, impalement
• Concomitant internal organ injury requiring surgery
• Unstable and if the grade is low, find other cause
but still go to OR
• If unstable and high grade, OR
• There is no correlation between AAST grade and
patient stability. So, AAST grade should be
supplemented by patient stability
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 Cont…
• Most blunt lacerations occur around
segmental fissure
• If blunt injuries involves vessels; Hepatic veins
• Major hepatic resection should be done later
• Aim should be to control hemorrhage & bile
leak plus resuscitation.

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 Operative techniques
• Mannual compression
• Perihepatic packing
• Pringle maneuver
• Hepatotomy (sharp or finger fracture with distal vein
isolation)
• Resectional debridement
• Omental buttress and hepatorrhaphy
• Intrahepatic balloon tamponade
• Hepatic artery ligation
• Atrial-caval shunt (or to the superior vena cava bypass)
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• Liver packing is the most successful technique
for venous injuries
• Liver packing and a second look operation is
preferable
• Portal vein injuries should be repaired primarily
• Blood salvage system and venous access
• In complete hepatic avulsion,hepatic
transplantation could be an option(last resort)

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• For lacerations G-3 and above suturing is necessary,
because they don’t stop by topical procedures
• Juxta-hepatic injuries are difficult to manage (direct
vv repair, anatomic resection or caval stent).
• Extra hepatic biliary tract injury can be repaired
primarily if partial circumference injury.
• And bypass if complete injury and an alternative is
biliary stent or external drainage.
• If there is GB injury… cholecystectomy

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• Coagulation abnormality, hypothermia and
acidosis should be corrected for successful
operative management
• Liver injuries operative management is
difficult
• Damage control surgery is convenient
• Pack removal is usually done with in 48-72 hrs.

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 Complications

• 12-14% of patients with NOM develop complications

(Grade 3-5)
• Bleeding
• Abdominal compartment syndrome
• Infection, abscess,
• Bile leak, Hemobilia
• DVT
• Hepatic necrosis
• Biliary fistula
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Splenic Injury

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 Physiology
• Immune function and removal of senescent
red blood cells
• White pulp(removal of senescent red blood
cells)
• Red pulp(lymphocyte…Ig, opsonin,
complement activation)
• 30-50 % of spleen is needed for normal
function

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 Anatomy
• Thick capsule in children, has important role
for conservative Rx
• During malaria, leukemia, lymphoma,
leshmania, mononucleosis and portal htn…
spleen will be enlarged and has less
consistency……….. prone to injury
• Splenic and short gastric arteries and veins
• Attached to different ligaments(sr,sc,sp,gs)

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 Epidemiology
• The commonest organ to be injured by blunt trauma
• The most commonly injured solid viscus requiring laparotomy
• 33% of isolated blunt splenic injuries require immediate
operation,
• Further 23% treated with initial non-operative management
required operation
• Penetrating injuries often need operative mgt, doesn’t mean
splenectomy
• 14 % of pts. With lower rib tenderness have splenic injury
• Causes could be blunt vs penetrating & also could be
iatrogenic

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 Clinical features
• Abdominal pain, distension
• External signs of trauma… bleeding
• Shock… deranged v.s
• Abdominal tenderness
• LUQ tenderness
• Lt. lower rib #
• Change in mentation
• Kehr’s sign

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 Investigations
• CBC, Coagulation
• CXR, pelvic x-ray
• DPL
• Laparoscopy (limited role)
• FAST
• CT SCAN

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Grading of splenic injury(AAST)
CT/ Intra-op…

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WSES Classification

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 Management
• ABCDE…1ry, 2ry survey.
Non Operative Management
• Success 95% pedi….. 80-94% adult
• Stable
• No other indication for laparotomy
• If close follow up feasible
• Age <55
• No loss of consciousness
• Blood transfusion < 4 units
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 CONT…
• ICU if possible
• Serial hct(6-8hr)
• Serial abd. Exam(by pt. condition…Q4 hr )
• V.s (frequently)
• Vaccination
• DVT prophylaxis?
• Routine follow up CT scan is not
recommended
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 Embolization
• Grade >=3
• CT contrast blush
• Ongoing bleeding
• Hemoperitonium/moderate
Complication
Abscess
Infarction(>25%)
Re-hemorrhage
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 NOM Cont..
• Unsuccessful NOM occurs in
– Patients with hemodynamic unstabiity(SBP<90)
– Age>55
– Persistent leukocytosis
– Requiring >4 unit transfusion
– Worsening of imaging signs of splenic injury
– Abd. Compartment syndrome… intra-vesical pressure
>20 cmH2O
– The onset or aggravating signs of peritoneal irritation

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 Operative Management
• Pre op antibiotics
• NGT decompression
• Midline incision
• Four quadrant pack
• Inspection of adjacent organs(pancrease,lt.
lobe of liver, diaphragm, kidney, bowel)
• Splenic mobilization

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 Cont…
• If grade 1 + minor bleeding….hemostatic agents like
microfibrillar collagen, gelatin sponge, and fibrin
glue.
• If grade 2 and 3-splenorrhaphy; less used due to
NOM + suture with catgut or monofilament
• Mattress or mesh wrapping can be done if pt.
is stable & in selected patients

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Splenorrhaphy

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 Cont…
• Splenectomy (partial or total)
Unstable
Grade 4 & 5 injury
Serious associated Injury
Majority of patients with failed NOM
• Partial splenectomy(if <50% injured) can be
done due to segmental blood supply.
• Autotransplantation?

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• Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia
•
•
.
Kirubel Abebe, 1 Mahteme Bekele,1 Ayelign Tsehaye,1 Befekadu Lemmu,1 and Engida Abebe1
Author information Article notes Copyright and License information Disclaimer
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• Abstract
• Background
• Abdominal injury is among the major causes of trauma admissions. The aim was to determine etiology, commonly
injured organs, indication and outcome of patients with abdominal injuries requiring laparotomy.
• Methods
• A retrospective study of all adult patients who underwent laparotomy for abdominal injury at St. Paul's Hospital
Millennium Medical College was conducted from January 2014 to December 2016. The factors associated with
outcome were identified with bivariate and multivariate logistic regressions.
• Results
• Laparotomy for abdominal injury was performed for 145 patients. Of these, 129 (89%) case records were
retrieved. The male to female ratio was 6.2:1. The mean age was 29 years, and most of them were unemployed.
Penetrating trauma was the commonest injury, stab (46, 35.7%) and Road Traffic Accidents (RTA) (27, 20.9%) being
the leading causes. Extra-abdominal injuries were seen in 33.3% (46) of the cases. Hollow organs were commonly
injured than solid organs. Small intestine (35, 43.8%) and Spleen (17, 34.7%) were the leading injured organs in
penetrating and blunt respectively. The main procedure performed was repair of hollow and solid organ
laceration/perforation (70,54.3%). The negative laparotomy rate was 4.6% (6). Complications were seen in
23(17.8%) patients, the commonest being irreversible shock (7,30.4%). The mortality rate was 8.5 % (11), and it
was significantly associated with blunt abdominal injury (AOR=7.25; 95% CI 1.09–48.37; p=0.041) and systolic
blood pressure<90mmHg (AOR=8.66; 95% CI 1.1–68.41; p=0.041).
• Conclusion
• Stab and RTA were the commonest indications of laparotomy. The mortality was significantly associated
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with blunt abdominal injury and hypotension (SBP<90mmHg).
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 Complications
NOM
• Bleeding(delayed rupture vs delayed bleeding)
• Other abdominal injury requiring surgery will
be missed (5-10%)
• DVT(rare)

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 Cont…
Operative Management complications
• Bleeding
• Gastric leak
• Pancreatic injury
• A-V fistula
• Thrombotic event
• OPSI

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 OPSI
• Rapidly fatal infection following removal of
spleen
• Most occur in the 1st 2 years after splenectomy
• Life time risk is 1-5%
• S. pneum(commonest), H.infl, N.meningitis
• Prevention by immunoprophylaxis and
antibiotics prophylaxis for <5 yrs age.

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 Summary
• Liver is commonest organ injured by penetrating trauma
and spleen is commonest to be injured by blunt trauma.
• FAST is the primary modality in unstable pt. and CT
scan with contrast is gold standard imaging.
• The most important indication for OM is unstability.
• NOM is the preferred and the first mgt of choice in
stable patients irrespective of grade of injury.
• Management should be based on combination of clinical
status of the patient, imaging and associated injuries

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 References
• Mattox 8th edition
• Maingot’s abdominal operations 13th edition
• ATLS
• Uptodate 2018
• Researches(internet)
• SRB mannual of surgery

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THANK YOU

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