Lecture on Liver Trauma for UG, RNT Medical College, Udaipur

1. LIVER TRAUMA
Dr. D.K.Sharma
M.S., MCh. (GI Surgery)
Prof. & Head, Deptt. Of Surgery
RNT Medical College, Udaipur, Raj.

2. Synopsis

3.  Epidemiology
 Relevant Anatomy
 Pathophysiology
 Mechanisms of Injury
 Grades of Liver Trauma
 Clinical Features
 Investigations
 Treatment
 Important Concepts
 DPL
 FAST / eFAST
 ALTS
 DCS
 Death Triangle
 Total Vascular Exclusion

4. Epidemiology

5. Associations
 Isolated liver injury occurs in less than 50% of
patients.
 Blunt trauma 45% with spleen
 Rib fracture  33% with Liver injury
 Bowel injuries
 Pancreatic Injuries
 Gall Bladder & Bile Duct Injuries
 Rare
 Contusions, avulsions, lacerations or perforations.

6. Relevant Anatomy

8. Pathophysiology

9. Why the liver…
 Large organ
 Friable parenchyma, thin capsule, fixed position in
relation to spine  prone to blunt injury
 Wide bore, thin walled blood vessels with high
blood flow  Excessive blood loss
 Right lobe larger, closer to ribs  more injury
 In children:
 compliant ribs
 transmitted force

10.  Mild injuries heal in 3 months.
 Moderate injuries heal in 6 months.
 Severe injuries in 9-15 months.
Healing

11. Classification & Grading

12. Grade VI Hepatic Avulsion

14. Clinical Features

15.  Blood Loss
 Peritonism
 Symptoms
 Abdominal Pain
 Radiation to shoulder
 Altered Sensoium
 Signs
 Hypotension
 RUQ tenderness, and guarding
 Generalized Peritonism
 Hemoperitoneum
 Biliary Peritonitis
 Delayed – Intra-abdominal
abscess

16. Investigations

17. Labs & Radiology
 Hematologic
 Elevated LFTs
 DPL -- high sensitivity
 CT scan is the diagnostic procedure of choice.
 USG
 MRI ??
 Diagnostic Laparoscopy

18. USG
 FAST
 eFAST

19. Angiography
 Active bleeding
 Transcatheter embolization
 Embolization & stenting for fistulas.

20. CT Scan
 Localization.
 Monitor healing.
 Grades 1-6

21. Management

22. Management
 In the Past vs Now treatment of blunt liver trauma
 Stopped bleeding at Laparotomy- 86%
 Non-therapeutic explorations- 67%
 Conservative Management-
 Adults-80%
 Children-97%
 Reasons
 MDCT
 TAE
 Liver regenerative capacity
 Improved Critical Care
 Operative / Non-Operative
 CT scan diagnosis and follow up

23.  Remember associated injuries
 Spleen
 Pancreas
 Bowel
 Resuscitate
 Consider Cryoprecipitate, FFP
 Assessment of injury
 Spiral CT
 Laparotomy
♦ Treatment
♦ OM
♦ NOM
Management

24.  Damage Control Surgery
 Perihepatic packing
 Hepatorrhaphy
 Mesh Wrapping
 Enough Tension
 Anchoring
 Hepatotomy & Selective Vascular Ligation
 Resection
 Non-anatomical
 Anatomical
 Intrahepatic Balloon Tamponade
 Total Vascular exclusion
 Liver Transplantation

26. Post-Operative Complications
 Hemorrhage
 Correct coagulopathy
 TAE
 Operative Control
 Remove perihepatic packing bet 36-72 h
 Sepsis & Abscess
 Percutaneous drainage
 Surgical Drainage
 Biliary Complications
 Biloma
 Biliary Ascites
 Biliary Fistulae

27. ATLS
 Advanced Trauma Life Support
 Aggressive fluid resuscitation
 CVP
 UO Monitoring
 Avoidance of “Death Triangle”
 Hypothermia
 Coagulopathy
 Acidosis

28. Damage Control Surgery
 Stone (1980); Univ. of Pennsylvania (1983)
 To avoid or deal with Danger Triad
 Early recognition
 Already at physiologic limit
 Concepts & Sequence
 Control of Hemorrhage & Contamination
 Temporary closure & Return to ICU
 Deal with the Triad
 Return to OT Definitive repair

29. Death Triangle
 Danger Triad; Bloody Vicious Cycle
 Components
 Hypothermia
 Decreasing Temp
 <34 C
 Coagulopathy
 Non-surgical Oozing
 PT > 50% of normal
 Acidosis
 <7.2 despite adequate volume resuscitation

30.  surgeryclasses.blogspot.in

31. Thank you