This document provides tips and instructions for using a PowerPoint presentation on liver trauma. Some key points: - Slides can be freely edited and modified. Blank slides are included to facilitate active learning sessions. - The presentation follows the AAST classification system for liver injuries and also discusses the WSES classification. - Imaging studies like CT, ultrasound, and angiography play an important role in diagnosis. Conservative management is preferred for stable patients. - Indications for surgery include signs of peritonitis, uncontrolled bleeding, or clinical deterioration. Surgical techniques aim to control bleeding and remove devitalized tissue.

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. Introduction & History.

3. Introduction & History.
• The liver is the largest solid abdominal
organ with a relatively fixed position, which
makes it prone to injury.
• The liver is the second most commonly
injured organ in abdominal trauma.
• Damage to the liver is the most common
cause of death after abdominal trauma.
• The most common cause of liver injury is
blunt abdominal trauma, which is secondary
to motor vehicle accidents in most
instances.

4. Introduction & History.
• In the past, most of these injuries were
treated surgically.
• However, surgical literature confirms that
as many as 86% of liver injuries have
stopped bleeding by the time surgical
exploration is performed, and 67% of
operations performed for blunt abdominal
trauma are nontherapeutic.

5. Etiology

6. Etiology
• Blunt
– RTA
– Assaults
– falls and industrial or recreational
accidents.
– iatrogenic trauma during
cardiopulmonary resuscitation, manual
thrusts to clear an airway, and the
Heimlich maneuver.
• Penetrating

7. Pathophysiology

8. Pathophysiology
• Blunt force injuries to the abdomen can
generally be explained by 3 mechanisms-
1. Deceleration. Rapid deceleration causes
differential movement among adjacent structures.
2. Crushing. Intra-abdominal contents are crushed
between the anterior abdominal wall and the
vertebral column or posterior thoracic cage.
3. Eexternal compression, whether from direct
blows or from external compression against a
fixed object (eg,seat belt).

9. AAST Liver Trauma
Classification

10. AAST Liver Trauma
Classification
• American Association for the Surgery
(AAST)
• Grade I: hematoma: subcapsular <10%
surface area; laceration: capsular tear <1 cm
parenchymal depth.
• Grade II: hematoma: subcapsular 10-50%
surface area; intraparenchymal <10 cm
diameter; laceration: capsular tear 1-3 cm
parenchymal depth, <10 cm in length.

11. AAST Liver Trauma
Classification
• Grade III: hematoma: subcapsular >50%
surface area of ruptured subcapsular or
parenchymal hematoma; intraparenchymal
hematoma >10 cm or expanding; laceration:
>3 cm parenchymal depth.
• Grade IV: laceration: parenchymal
disruption involving 25-75% hepatic lobe or
1-3 Couinaud segments.

12. AAST Liver Trauma
Classification
• Grade III: hematoma: subcapsular >50%
surface area of ruptured subcapsular or
parenchymal hematoma; intraparenchymal
hematoma >10 cm or expanding; laceration:
>3 cm parenchymal depth.
• Grade IV: laceration: parenchymal
disruption involving 25-75% hepatic lobe or
1-3 Couinaud segments.

13. AAST Liver Trauma
Classification
• Grade V: laceration: parenchymal
disruption involving >75% of hepatic lobe
or >3 Couinaud segments within a single
lobe; vascular: juxtahepatic venous injuries
(ie, retrohepatic vena cava/central major
hepatic veins).
• Grade VI: hepatic avulsion.

14. WSES Classification

15. WSES Classification
• The World Society of Emergency Surgery
(WSES) has presented the following
classifications utilizing the AAST grading
system-
• Grade I (minor hepatic injury): AAST grade
I-II hemodynamically stable either blunt or
penetrating lesions.
• Grade II (moderate hepatic injury): AAST
grade III hemodynamically stable either
blunt or penetrating lesions.

16. WSES Classification
• Grade III (severe hepatic injury): AAST
grade IV-VI hemodynamically stable either
blunt or penetrating lesions.
• Grade IV (severe hepatic injury): AAST
grade I-VI hemodynamically unstable either
blunt or penetrating lesions.

17. Symptoms

18. Symptoms
• The initial clinical assessment of patients
with blunt abdominal trauma is often
difficult and notably inaccurate. The most
reliable signs and symptoms in alert patients
are as follows:
– Asymptomatic
– Pain
– Tenderness
– Hypovolemia
– Evidence of peritoneal irritation

19. Signs

20. Signs
• Abrasions or ecchymosis on abd. wall
• Abdominal distention
• Local or generalized tenderness, guarding,
rigidity, or rebound tenderness:
• Fullness and doughy consistency on
palpation: May indicate intra-abdominal
hemorrhage

21. Complications

22. Complications
• Missed injuries
• Delays in diagnosis
• Delays in treatment
• Iatrogenic injuries
• Intra-abdominal sepsis and abscess
• Inadequate resuscitation

23. Diagnostic peritoneal lavage

24. Diagnostic peritoneal lavage
• Patients with a spinal cord injury
• Those with multiple injuries and
unexplained shock
• Obtunded patients with a possible
abdominal injury
• Intoxicated patients in whom abdominal
injury is suggested
• Patients with potential intra-abdominal
injury who will undergo prolonged
anesthesia for another procedure

25. Investigations

26. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

27. Diagnostic Studies

28. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

29. Imaging Studies
•

30. Imaging Studies
• Contrast-enhanced CT scanning is the
examination of choice in stable patients
with blunt abdominal trauma.
•

31. FAST:Focused Abdominal Sonography for
Trauma
• Emergency ultrasonographic findings
based on the demonstration of free fluid
and/or parenchymal injury demonstrate the
overall sensitivity of ultrasonography for
detection of blunt abdominal trauma to be
72%. However, the sensitivity is higher
(98%) for injuries of grade 3 or higher.
However, negative ultrasonographic
findings do not exclude hepatic injury.

32. Imaging Studies
• Radionuclide study with technetium-99m
(99mTc) iminodiacetic acid (IDA) is the
examination of choice in patients in whom
bile leaks are suspected.
• Magnetic resonance
cholangiopancreatography (MRCP) may be
used for the diagnosis and follow-up
observation of bile duct injuries.

33. Imaging Studies
• Angiography is useful in localizing the site
of hemorrhage and in providing an
opportunity for the interventional
radiologist to proceed to transcatheter
embolization of bleeding sites.

34. Management

35. Management
• Assessment of hemodynamic stability is the
most important initial concern in the
evaluation of a patient with blunt abdominal
trauma.
• In the hemodynamically unstable patient, a
rapid evaluation for hemoperitoneum can be
accomplished by means of
– Abdominal and Thoracic Paracentesis
– Diagnostic peritoneal lavage (DPL)
– Focused assessment with sonography for
trauma (FAST).

36. Management
• Radiographic studies of the abdomen are
indicated in stable patients when the
physical examination findings are
inconclusive. CECT

37. Non Operative Therapy

38. Non Operative Therapy
• Conservative, nonoperative management
has become the treatment of choice for
blunt hepatic trauma in hemodynamically
stable patients.
• Almost 80% of adults and 97% of children
are treated conservatively by using careful
follow-up imaging studies.
• When reliable monitoring, serial clinical
evaluations, and an operating room
available for urgent laparotomy are readily
available.

39. Non Operative Therapy
• The increased use of nonoperative
management has been facilitated by
advancements such as higher-resolution CT,
increased availability of interventional
procedures such as angiography and
embolization, image-guided percutaneous
drainage, and endoscopy.
• Such advancements have also helped to
quickly identify the need for urgent
laparotomy and attention to visceral and
vascular injuries.

40. Operative Therapy

41. Operative Therapy
• Indications for laparotomy in a patient with
blunt abdominal injury include the
following:
– Signs of peritonitis
– Uncontrolled shock or hemorrhage
– Clinical deterioration during observation
– Hemoperitoneum findings on FAST or DPL
– Perforating liver wounds,
– multiple organ damage, exploratory laparotomy
can locate and repair occult trauma.

42. Operative Therapy
• The aim of operation-
1. To ascertain the traumatic condition,
2. Stop any bleeding,
3. Prevent bile leakage,
4. Remove the devitalized tissues and give
adequate drainage.

43. Operative Therapy
• Operation methods-
1. Single pure suture,
2. Deep mattress suture,
3. Debridement,
4. Anatomical hepatectomy,
5. Hepatic arterial ligation,
6. Gauze packing,
7. Liver coated mesh method.
8. Pringle 's maneuver.

44. Operative Therapy
• Minor liver wounds can be treated by single
pure suture.
• Deep mattress suture is appropriate for
contusion and laceration including the
placement of hemostatic gauze and
omentum into the liver tissue defect.
• This is suitable for level III injury, and even
some cases of level IV injury.

45. Operative Therapy
• Debridement should be performed based on
the anatomical structure of the liver, in
order to completely remove any necrotic
tissues, ligature the damaged vessels and
bile ducts, and retain the normal liver tissue
to the greatest extent.
• The anatomical hepatectomy requires
excellent technical skill and a prolonged
operation time, and is thus rarely used
clinically.

46. Operative Therapy
• The peripheral hepatic gauze is effective to
control bleeding for level III liver trauma,
even for levels IV and V liver trauma.
• This technique is practical for primary
hospitals.
• The secondary operation should be
performed 48 h after the condition becomes
stable and the hypotension, hypothermia,
acidosis and blood coagulation disorders
should be corrected

47. Operative Therapy
• Many surgeons usually use mesh wrapping
for hepatic trauma. Mesh wrapping is to use
absorbable synthetic mesh to pack the
damaged area of the liver or the entire
organ, to achieve hemostasis by
compression. This method is suitable for
extensive damage to the liver parenchyma
or star-shaped liver laceration, which has
vitality and is connected with hepatic
pedicle.

48. New surgical methods

49. New surgical methods
• Laparoscopic exploration
• Hepatic artery embolization
• Liver transplantation.

50. Damage control of hepatic
trauma

51. Damage control of hepatic
trauma
strict indications:
• Act according to the traumatic condition of
patients
• Patients with serious combined injuries are
preferred.
• Present with hemodynamic instability,
clotting disorders and low temperature.

52. Damage control of hepatic
trauma
Purpose of damage control surgery-
• To rapidly control the hemorrhage
• Shorten operation time
• Avoid complex surgery.

53. Damage control of hepatic
trauma
High risk of complications
• wound infection
• Abdominal abscess,
• wound dehiscence
• Abdominal compartment syndrome.

54. Postoperative complications of
hepatic trauma
• Bleeding
• Biliary fistula
• Abdominal abscess
• Cyst formation.
• Postoperative cholestasis
• hepatic artery pseudoaneurysm,

55. Prevention

56. Prevention
• Wear lap belts in conjunction with shoulder
restraints.
• Adjust lap belts so that they fit snugly, and place
them across the lower abdomen and below the
iliac crests.
• Wear restraints even in vehicles equipped with
supplemental vehicle restraints (eg, airbags).
• Adjust seats and steering wheels so that the
distance between the abdominal wall and the
steering wheel is as wide as possible while still
allowing proper control of the vehicle.

57. Prevention
• Practice defensive driving by observing speed
limits and keeping a safe distance between them
and other automobiles on the road.

59. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
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3. Open Google lens.
4. Scan qr code from
next slide.

60. Get this ppt in mobile

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