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Surface anatomyIn RUQ 5th ICS in midclavicular
line to the Rt costal margin.
Weighs 1400 g n women and 1800g n men .
Span 10 cm +/-2
Surface anatomySuperior, anterior, and right lateral surfaces
fit diaphragm.Falciform ligament
Posterior surface Rt lobe: colon, right kidney, and duodenum Lt lobe: stomach
The liver covered by fibrous capsule that reflects on the diaphragm and post abdominal wall
Leaving a bear area that connects the liver to the retroperitoneum directly
Segmental anatomyClassically; liver divided to 4 lobes:
Right lobe Left lobeCaudate lobe Quadrate lobe
Segmental anatomyFunctionally; on the basis of the distribution of
vessels and ducts within the liver segments. Cantlie’s line.
Blood Supply – Portal Vein Superior Mesentric and Splenic veins Posterior to hepatic artery and bile duct at the
hepatodudenal junction. Valveless 75% of total blood supply the liver Pressure 3-5 mmHg
Blood supply – Hepatic artery
Intrahepatic anatomy; part of portal tried follows segmental anatomy.
Extrahepatic anatomy; highly variable:Commonest ( in 60%) anatomy: abdominal aorta
celiac trunk CHA proper hepatic art Rt and Lt hepatic artery
LHA seg 1,2,3 and middle hepatic artery seg 4.RHA cystic art , Rt liver
Blood supply – Hepatic vein
Rt hepatic vein Drain seg 5,6,7,8 vena cava.Middle hepatic vein Drain seg 4,5,8 Lt hepatic vein Drain seg 2,3 [ seg 1 drain by short hepatic vena cava]
Introduction It is the 2nd commonest organ injured in
blunt abdominal trauma and the commonest injured in penetrating trauma.
1%-8% of pt with multiple blunt trauma sustain a liver injury.
During last 3 decades, liver injury increased. This inc could be actual or artificial d/t better diagnostic modalities.
Richardson JD. Ann Surg. 2000;232:324-330. Lucas CE. Am Surg. 2000;66:337-341.
While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference:
If lacerations be extensive and vessels of any magnitude are torn, hemorrhage will, owing to the structural arrangement of the liver, go on continously.
JH Pringle, 1908
Factors making the liver prone to injury:
1. The large size of the liver, 2. its friable parenchyma, 3. its thin capsule, and 4. Its relatively fixed position in relation to the
spine and ribs.
1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4
Grade 1A stabbing injury to the RUQ of the abdomen
Contrast CT demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.
Grade 2A blunt abdominal trauma
CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.
Grade 3A blunt abdominal trauma
Contrast CT shows a 4-cm-thick subcapsular hematoma associated with parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver..
Grade 4A blunt abdominal trauma
CT scan of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-attenuating areas within the lesion represent clotted blood
Grade 4A blunt abdominal trauma
Contrast CT shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the capsular laceration and large hemoperitoneum.
Grade 5A motor vehicle accident
CT demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam.
Non-Operative Management of Liver Injury
An absolute increase in the incidence of nonoperatively managed liver injuries (NOMLI) is unequivocal.
Multiple studies have shown that NOMLI is effective
Knudson MM. Surg Clin North Am. 1999;79:1357-1371. Malhotra AK. Ann Surg. 2000;231:804-813. Maull KI. World J Surg. 2001;25:1403-1404. Pachter HL. Am J Surg. 1995;169:442-454. Sherman HF J Trauma. 1994;37:616-621. Schweizer W. Br J Surg. 1993;80:86-88. . Miller PR. J Trauma. 2002;53:238-242. Goan YG. J Trauma. 1998;45:360-364. Brasel KJ. Am J Surg. 1997;174:674-677. . Ochsner MG.. World J Surg. 2001;25:1393-1396.
Criteria for NOMLI
No indications for laparotomy (physical examination signs/symptoms or other injuries)
Hemodynamically normal after resuscitation with crystalloid
No injuries that preclude physical examination of the abdomen (e.g., CHI, spinal cord injury)
No transfusion requirements (PRBC) Constant availability of surgical and critical care
resources
Liver injury score of patients is not as important as the hemodynamic status for determining conservative management
High Success With Non-operative Management of Blunt Hepatic Trauma
Arch Surg. 2003;138:475-481
Hypothesis Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events.
Setting High-volume academic level I trauma center
Cont.Results 78 patients23 (29%) were operated on immediately, but only 12
(15%) for bleeding from the liver. NOMLI failed in 8 for reasons unrelated to the liver injury.
The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%.
No adverse events were attributed to NOMLI.
Cont.Conclusions NOMLI is safe and effective regardless of the grade
of liver injury. Failure of NOMLI is caused by associated abdominal
injuries and not the liver. Fluid and blood requirements, the degree of injury
severity, and the presence of other abdominal organ injuries may help predict failure.
Complications of NOMLIBiliary (bile peritonitis, bile leak, biloma, hemobelia..) Infection (liver abscess, necrosis, abdominal sepsis,
SIRs)Abdominal compartment syndrome Hemorrhage Hepatic necrosis &/or Acalculous Cholecystitis
Failure of NOMLI Usually attributed to reasons unrelated to liver
injuryOther injuries can be missed in a blunt trauma
victims, such as:Bowel PancreasDiaphragmBladder Which can lead to failure of NOMLI
Criteria of failure of NOMLIIncreasing fluid requirements to maintain normal
hemodynamic status Failed angio embolization of A-V
fistulae/pseudoaneurysm Transfusion requirements to maintain Hct/Hgb and
normal hemodynamic status Increasing hemoperitoneum associated with
hemodynamic liability Peritoneal signs/rebound tenderness
How to manage conservatively
Grade I II III IV
ICU 0 0 0 1
Hospital stay (d)
2 3 4 5
Activity Restriction (w)
3 4 5 6
Follow up There is no evidence supporting routine imaging (CT or
US) of the hospitalized, clinically improving, hemodynamically stable patient.
Nor is there evidence to support the practice of keeping the clinically stable patient at bed rest.
2003 Eastern Association For The Surgery of Trauma
Indications In Blunt Trauma In Penetrating TraumaHemodynamic
instabilityTransfusion> 2 blood
volume or > 40 ml/kgDevitalized parenchymaSepsis / biloma
Exploratory lapratomy is indicated in any penetrating trauma in with peritoneal penetration
Operative technique/optionsInitial Explore Laparotomy Temporary control of hemorrhage:
Why temp? Ongoing hemorrhage, life threatening, no time to
restore circulatory volume. Liver injuries not highest priority
Operative technique/options
How? Manual compression Perihepatic packing. Pringle maneuver. Tourniquet Hepatic vascular isolation Placement of atriocaval shunt Moore-Pilcher balloon
commonest
Juxtahepatic venous injury
1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4
Hepatic segments ResectionsRight hemihepatectomy (segments 5 to 8);
AKA as Right hepatectomy or right hepatic lobectomyRight trisectionectomy (segments 4 to 8);
AKA as Right lobectomy or Rrisegmentectomy of StarzlLeft hemihepatectomy (segments 1 to 4);
AKA as Left hepatectomy or Left hepatic lobectomyLeft lateral sectionectomy (segments 1 to 3);
AKA as Left lobectomy or Left lateral segmentectomy
References Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.Sabiston Textbook of Surgery, 18th ed.Khatri: Operative Surgery Manual, 1st ed.ACS Surgery principles and Practice 2006.Cameron; current surgical therapy, 8th ed.
http://www.netterimages.com/http://www.adhb.govt.nz http://emedicine.medscape.com/article/370508-overviewhttp://www.east.org