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Hepatic Trauma

Hepatic Trauma. Adegbesan Adeniyi. Case 1: Blunt trauma. 29 year old female Driver of a car, wearing seatbelt Collision heavy vehicle Airbags activated Managed as per ATLS protocols GCS 15 /15, haemodynamically stable RUQ pain, left wrist fracture-dislocation. Radiology.

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Hepatic Trauma

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  1. Hepatic Trauma Adegbesan Adeniyi

  2. Case 1: Blunt trauma • 29 year old female • Driver of a car, wearing seatbelt • Collision heavy vehicle • Airbags activated • Managed as per ATLS protocols • GCS 15 /15, haemodynamically stable • RUQ pain, left wrist fracture-dislocation

  3. Radiology • Bi-malleolar left ankle fracture • Ultrasound abdomen: free fluid, splenic contusion • CT abdomen • oblique tear through right lobe of the liver • right adrenal gland contusion • blood in peritoneum

  4. Management • Transferred to ICU with IV fluids & blood • Ankle dislocation reduced, back slab applied • Laparotomy: full assessment performed • Large volume of intraperitoneal blood • 2 liver lacerations • Small haematoma at splenic hilum • Small contusion of tail of pancreas • No active bleeding • Surgicel to splenic hilum and liver lacerations • Washout performed and drains placed

  5. Post-operative course • Remained haemodynamically stable • MRI brain: confirmed small contusion near internal capsule

  6. Case 2: Penetrating trauma • 24 year old male • Stab wounds • Three in upper abdomen • Left side of neck

  7. Clinical findings • GCS 13/15, haemodynamically stable • 3cm wound over the right zygoma • 1.5cm wound zone 2 left side of the neck • Abdomen: 1.5cm wound over the right and left upper quadrants breaching rectus sheath and muscles • Managed as per ATLS protocol • IV Fluids, Catheterized • Hb = 13.5

  8. Management • Chest x-ray normal • Ultrasound abdomen: No free fluid • Admitted to ICU pre laparotomy • Became haemodynamically unstable with increasing abdo pain • Responded to IV fluids and blood transfusion

  9. Emergency laparotomy findings • Haemoperitoneum • Wound in the right upper quadrant obliquely traversed both lobes of liver, through the 1st part of duodenum into pancreas • Bleeding from D1 and pancreas • Haemostasis achieved • Duodenum repaired with interrupted PDS • Wash out performed, drain placed

  10. Anatomy of the injury

  11. Management • Neck wound: fascia breached but no vascular injuries, closed in layers • Managed with NG tube, antibiotics and parenteral nutrition • Developed bile leak, conservatively managed • Small pelvic collections were managed with antibiotics • Discharged on 31st post-operative day

  12. Background • Largest solid abdominal organ, fixed position • Liver injury is the most common cause of death after abdominal trauma • Blunt injury due to road traffic accidents most common • 80% adults, 97% children have successful conservative management • Liver injured more easily in children

  13. Liver anatomy • Cantile described main divisions along axis from gallbladder fossa to the IVC • This divides the liver into equal halves • Couinaud divided the liver into 8 segments.

  14. Liver segments • Divided vertically by the 3 main hepatic veins and transversely by the right and left portal branches.

  15. Types of liver injuries • Haematoma: subcapsular or intrahepatic • Laceration • Contusion • Hepatic vascular disruption • Bile duct injury • 86% of injuries have stopped bleeding at time of surgical exploration • Transfusion requirements are reduced with conservative management

  16. Management • Initial resuscitation as per ATLS protocol • It is important to note the mechanism of injury • Clinical picture may vary from mild RUQ pain through to peritonism to haemorrhagic shock • Stable patients undergo CT imaging • Unstable patients require resuscitation and laparotomy

  17. CT Scans • Accurate in localizing the site of liver injury and any associated injuries • Used to monitor healing • CT criteria for staging liver trauma uses AAST liver injury scale • Grades 1-6

  18. Classification • I- Subcapsular hematoma<1cm or superficial laceration<1cm deep • II- Parenchymal laceration 1-3cm deep or subcapsular hematoma1-3 cm thick • III- Parenchymal laceration >3cm deep and subcapsular hematoma >3cm diameter • IV- Parenchymal/supcapsular hematoma >10cm in diameter, lobar destruction or devasularization • V- Global destruction or devascularization of the liver • VI- Hepatic avulsion

  19. Example of a grade 3 injury Subcapsular hematoma Parenchymal hematoma and laceration

  20. Angiography • May be useful in localizing the site of haemorrhage in stable patients • Transcatheter embolization of bleeding sites

  21. Treatment • Conservative • Blunt liver trauma, • Haemodynamically stable • No other injuries requiring surgery • Surgical • Penetrating injuries • Haemodynamically unstable • Other injuries requiring surgery Pachter et al, Annals of Surgery 1994 Pietro padalino, European Journal of Trauma and Emergency Surgery July 2009

  22. Surgical management • Full laparotomy • Pringles manoeuvre to occlude the portal triad • Packing of the liver • Treat other intra-abdominal injuries as appropriate

  23. Learning points! • Liver injuries frequently are associated with multiple other injuries • Most liver injuries can be managed conservatively • Essential Skills: Laparotomy, Pringles, Ligament mobilisation and liver packing • As with all trauma, the ATLS protocol is the foundation of treatment

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