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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. - PowerPoint PPT Presentation
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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
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
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
Post-operative course
Remained haemodynamically stable
MRI brain: confirmed small contusion near internal capsule
Case 2: Penetrating trauma
24 year old male
Stab wounds – Three in upper abdomen – Left side of neck
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
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
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
Anatomy of the injury
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
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
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.
Liver segments
• Divided vertically by the 3 main hepatic veins and transversely by the right and left portal branches.
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
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
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
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
Example of a grade 3 injury
Subcapsular hematoma
Parenchymal hematoma and laceration
Angiography
May be useful in localizing the site of haemorrhage in stable patients
Transcatheter embolization of bleeding sites
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 1994Pietro padalino, European Journal of Trauma and Emergency Surgery July 2009
Surgical management
Full laparotomy
Pringles manoeuvre to occlude the portal triad
Packing of the liver
Treat other intra-abdominal injuries as appropriate
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