LIVER TRAUMA MANAGEMENT EXPERIENCE AMONG A

CLUSTER OF PATIENTS PRESENTING WITHIN A MONTH

Muhammad Saaiq
Surgical Grand Round, Pakistan Institute of Medical
Sciences (PIMS), Islamabad.
September 29, 2006.
What prompted this presentation ?
 Case No. 1
„ Male aged 18 , presented with H/O
RTA and blunt trauma abdomen.
„ Exploratory Laparotomy revealed :
i) About 4 cm long and 1cm deep liver
laceration just on the left side of the FL.
ii) Another 4cm long and 4 cm deep
irregular laceration just lat. to L. Teres
with a bleeder spurting blood.
iii) 800cc blood
AAST grade III Liver trauma.
 Case No. 2
Male aged 19 ,
presented with H/O FAI Rt. Lower
rib cage / chest.
Exploratory Laparotomy revealed :
*Sealed firearm wound on the frontal
surface of Rt lobe ( B/w segments V
and VIII) corresponding to a similar
wound on posterior surface of liver.
* About 200 cc free blood.
AAST Grade III Liver trauma.
 Case No. 3
„ Male aged 15 presented with H/O FAI abdomen / Lt.
lower back.
„ Exploratory Laparotomy revealed :

i) Firearm exit wound epigastrium / Lt hypochondrium with

omentum coming out through it .
ii) Fragmented Spleen.
iii) Parenchymal disruption of Lt lobe of liver involving > 50 %
of the lobe. iv) Two lacerations ( about 6 cm each) in the
stomach.
v) 3 cm rent in diaphragm leading to the Firearm entry
wound near inferior angle of Lt scapula.
vi) Irregular laceration of Lt costal margin with diaphragm
separate from costal margin over an area of 4 cm.
vii) About 2000 cc free blood in the peritoneal cavity.
AAST Grade IV Liver trauma.
 Case No. 4
Male aged 20 presented with H/O Stab Rt
flank.
„ Exploratory Laparotomy revealed :
i) One Litre free blood in the peritoneal cavity.
ii) Irregular laceration of the abdominal wall
communicating with the outside stab wound.
iii) 3 cm long and 5 cm deep laceration on
segment V communicating with a 1 cm
wound just lateral to the Gall bladder fossa.
iv) A small rent in the peritoneal reflections over
the duodenum with bruising of the adjoining
area.
AAST Grade III Liver trauma.
 Liver Trauma
Anatomical Considerations
FUNCTIONALLY LIVER HAS :
2 Lobes
4 Sectors
8 Segments
 Etiology / Mechanisms :

Blunt trauma :
Deceleration
Compression
Secondary penetrating injury from spicules
of fractured ribs / bones
Penetrating trauma :
Low energy trauma
high energy trauma
American Association for Surgery
of Trauma (AAST )
Grading system
Grade I :
Hematoma ; Subcapsular, non-expanding < 10 % surface
Laceration ; Capsular tear, Non-bleeding, < 1 cm
parenchymal depth
Grade II :
Hematoma ; Subcapsular, Non-expanding, 10-50 % surface
area Or intraparenchymal, Non-expanding, < 2 cm in
diameter.
Laceration ; Capsular tear, active bleeding, 1-3 cm deep,
< 10 cm in length.
Grade III:
Hematoma ; Sucapsular, > 50 % surface area Or
Ruptured subcapsular hematomea with active bleeding
Or Intraparenchymal hematoma > 2 cm or expanding.
 Laceration ; > 3 cm parenchymal depth.

Grade IV:
Hematoma ; ruptured intrparenchymal hematoma with
active bleeding.
Laceration; Parenchymal disruption involving 25-50 % of
hepatic lobe

Grade V :
Laceration; Parenchymal disruption involving over 50 % of
hepatic lobe
Vascular; Juxtahepatic venous injuries(major hepatic veins,
retrohepatic vena cava)

Grade VI : Vascular; Hepatic Avulsion

 Diagnostic Issues
„ Active Management and Diagnostic investigations
if any should proceed simultaneously.

„ No investigation should delay the proper treatment

„ Penetrating Vs blunt and whether the patient is

hemodynamically stable or not will rationalize the
route of investigations as well as management.

„ Confirmation of hemoperitoneum may be done

with DPL or four-quadrant aspiration or FAST U/S.
„ Ct scan abdomen and chest helps to determine
the Nature and Extent of liver injury plus any other
associated injuries.
 MANAGEMENT :

Initial Resuscitation.

Definitive measures for Liver trauma.

Initial Resuscitation
A
B
C
D
E
F?
 Definitive
Management
Surgical Options :
Suture Hepatorrhaphy
 Suture Hepatorrhaphy with
. Omental Buttressing
Perihepatic Packing
Perihepatic Packing
Hepatic Artery Ligation
PRINGLE MANOEUVRE
Application of Bioadhesives
Mesh Hepatorrhaphy
Major Vascular Injuries
Arterial Embolization
 Liver Resection
Liver transplantation
 Recent Advances

Re-emergence of Perihepatic
packing with
Interventional radiology Temporary abdominal closure
Intra-hepatic Packing
Immediate Postoperative
Concerns
Common Problems

Hemorrhage
Sepsis
Bile leak
Coagulopathy
Lethal Triangle ( a.k.a Bloody
vicious cycle of trauma)

Core Hypothermia

Metabolic Acidosis

Coagulopathy
Other Complications of Liver Trauma
Bile collection
Liver abscess
Biliary fistula
Hepatic artery aneurysm
Arteriovenous Fistulation
Arterio-biliary Fistulation
Biliary tract strictures
LIVER TRAUMA
LIVER TRAUMA

„ Muhammad Saaiq
„ Unit-I , Department of
Surgery.