Management of Liver Trauma

1. Management of Liver Trauma Joint Hospital Surgical Grand Round 19 June 2004 United Christian Hospital

2. Case • SW Cheng, M/47 • 5.5 tones lorry driver • Hit on road side and trapped within wreck

3. 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

4. Urgent CT scan abdomen: Right lobe liver haematoma with rupture and subphrenic fluid

5. 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?

6. Liver Trauma • Most frequently injured intra-abdominal organ (Feliciano, 1989) • Blunt injuries • Deceleration injuries • Direct blow • Penetrating injuries

7. Grading System • Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (Moore, 1995) • Hepatic Injury Scale • Revised in 1994

9. 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

10. Management • ATLS • Haemodynamically stable: further assessment

11. 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

12. Non-operative Management

13. Non-operative Management • 50-80% of liver injuries stop bleeding spontaneously • Increasing trend towards conservative management

14. 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

15. 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

16. Ultimate Decisive Factor • Haemodynamic stability at presentation or after initial resuscitation • Irrespective of the grade of injury on CT or the amount of haemoperitoneum

17. 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

18. 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

19. Bynoe 1992 • Complication rates no greater than those in patient treated surgically

20. Operative Management

21. Prerequisites • Resuscitation • Experienced surgeon • Familiar with liver anatomy • Blood, platelets, FFP, cryoprecipitate • Fully equipped ICU • Diagnostic back-up to monitor and detect potential complications

22. 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

23. Pringle Maneuver • If haemorrhage is unaffected by portal triad occlusion, major vena cava injury or atypical vascular anatomy should be suspected

24. 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

25. Resectional debridement • Removal of all devitalized tissue down to normal hepatic parenchyma using line of injury • Rapid compared to anatomical resection

26. 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

27. Perihepatic Packing • Indications • When other surgical methods failed in a hameodynamically unstable patient • Uncontrollable coagulopathy • Bilobar liver injury • Large non-expanding haematoma • Capsular avulsion

28. Minimal number of dry abdominal packs or single rolled gauze around liver • NOT to force into deep fractures

29. Mesh Wrapping • Grade III-IV lacerations • Tamponading large intrahepatic haematomas, minimize risk of delayed rupture • Relaparotomy not routinely required

30. 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

31. Adjunctive Technique • Fibrin glue: raw liver surfaces

32. Retrohepatic Venous Injuries • Suspected if: • Portal triad occlusion fails to control bleeding • Injury extends to bare area on palpation

33. Management of Retrohepatic Injuries • Total vascular exclusion • Venovenous bypass • Atriocaval shunting • Beal (1990): perihepatic packing

34. Conclusion • Resuscitation • Conservative treatment if haemodynamically stable • Operation: perihepatic packing, then transfer to hepatobiliary centre • Hepatotomy with direct suture ligation or resectional debridement

35. Thank You

36. 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.