For review of liver trauma

1. Liver Trauma

2. Objectives
• To outline evaluation and management of
Liver trauma in children

3. Back ground
• To create a document for rapid review of this
commonly encountered injury

5. Why the liver…
• Friable parenchyma, thin capsule, fixed
position in relation to spine
 prone to blunt injury .
• Right lobe larger, closer to ribs.
more injury
• In children compliant ribs,
transmitted force

6. Mechanism of injury
• Deceleration injury
--producing a laceration of its relatively
thin capsule and parenchyma at the sites
of attachment to the diaphragm
• Crush injury
--direct blow to the abdomen
--damage to the central portion of the
liver

7. Blunt trauma

8. Penetrating injuries

9. Pearl
• posterior segment of the right liver lobe is the
most frequently injured part.
This part also involves the bare area and this
can lead to retroperitoneal bleeding rather
than bleeding into the peritoneal cavity.

10. Associations
• Isolated liver injury occurs in less than 50% of
patients.
• Blunt trauma 45% with spleen
• Rib fracture  33% with Liver injury

11. Injuries
• Contusion
• Laceration
• Subcapsular hematoma
• Parenchymal damage
• Hepatic vascular disruption
• Bile duct injury

12. Grading

13. Grading outcomes
• Grade I,II
---minor injuries, represent 80-90% of all
injuries, require minimal or no operative
treatment
• Grade III-V
-- severe, most managed conservatively but
surgical intervention is occasionally needed
• Grade IV
--incompatible with survival

14. Diagnosis of liver injury
• Ultrasonography
--fast, accurate, noninvasive, a good initial
screening test
--sensitivity 88%, specificity 99
• DPL
--fast, sensitive, accurate and simple to
perform
--invasive, cannot diagnose retroperitoneal
injury

15. Computed tomography
• The standard evaluation method for stable
patient
• Performed with Dilute water soluble oral
contrast agent and intravenous contrast

16. Classification
(AAST)
• I-Subcapsular hematoma<1cm, superficial
laceration<1cm deep.

17. • II-Parenchymal laceration 1-3cm deep,
subcapsular hematoma1-3 cm thick.

18. • III-Parenchymal laceration> 3cm deep and
subcapsular hematoma> 3cm diameter.

19. • IV-Parenchymal/supcapsular hematoma>
10cm in diameter, lobar destruction

20. • V- Global destruction or devascularization of
the liver.

21. • VI-Hepatic avulsion

22. Management

23. Conservative treatment
• 86% of liver injuries have stopped
bleeding by the time of surgical
exploration
• 67% of operations performed are
nontherapeutic
• Standard method of pediatric patient
for the past 20 years, with a success
rate of 90%

24. Criteria for conservative treatment
 hemodynamically stable
 simple hepatic parenchyma laceration of
inrahepatic hematoma
 absence of active hemorrhage
 limited need for liver related blood
transfusions
 absence of peritoneal sign
 absence of other peritoneal injuries that
would otherwise require an operation

25. Complications of conservative
treatment
Conservative
treatment
Delayed
hemorrhage
Stable
CT scan
Liver injury
worse
Angiogram
Embolization
Unstable
Liver injury
unchanged
Exploration
Search for
other causes
Hemobilia Bili Hemia
Liver
abscess

26. Operative treatment
• Initial hemostasis
 Packing
 Pringle maneoevre
 Bimanual liver compression
 Cross clamping aorta above celiac trunk

27. Blood supply
• Portal vein
• Hepatic artery
• Hepatic vein

28. Liver segments

29. Technique
• Hepatotomy with direct suture ligation
 using the finger fracture technique,
electrocautery or an ultrasonic dissector to
expose damaged vessels and hepatic duct
 low incidence of rebleeding, necrosis and
sepsis
Resection and debridement

30. Surgical options
Anatomical resection
--reserved for deep laceration involving major
vessels or bile ducts, extensive devascularization
and major hepatic venous bleeding
Perihepatic packing
--Indication:coagulopathy, irreversible shock from
blood loss , hypothermia(32C), acidosis(PH7.2),
bilobar injury,large nonexpanding hematoma,
capsular avulsion, vena cava or hepatic vein
injuries

31. Perihepatic packing

33. Mesh Wrapping

34. Ultrasonic dissector

35. Harmonic scalpel

36. Argon Coagulation

37. Tissue link

38. Outcome
Liver regeneration post
resection of the right liver
The mortality rate from
liver trauma has fallen
from 66 per cent in
World War I, to 27 per
cent in World War II, to
current levels of 10-15
per cent

39. Summary
• Liver 2nd most commonly injured solid organ.
• Hemodynamic stability is the principle guide
to management.
• Resuscitation is of primary importance rather
than wasting time and blood on grading either
outside or inside the theatre.

40. •Thank you