Liver trauma

Definition

Major liver injury

· Associated CV compromise

· In pt with significant liver co-morbidity

— Tx

— Tumours

— Cirrhosis

· Grade I-III : 95% success for non-operative Mx

Grading

· AAST OIS

 and grade 6 = hepatic avulsion.

Mx

Non-operative

· up to 2/3 of laparotomies done for positive DPL are non-therapeutic

· somewhere b/t 50-80% of blunt hepatic injuries can be managed non-operatively

· Non-operative management of blunt liver trauma is successful in 95% (series of 1000 patients)

· 5% complication rate

· grade IV and V and VI injuries

— require follow up CT scanning

— require operative intervention in 70%

Criteria

· Haemodynamic stability

· CT scan

— delineating the extent of injury

— lack of associated enteric or retroperitoneal injuries requiring no intervention

— no evidence of ongoing bleeding (pooling of contrast at the site of injury)

· Absence of peritoneal signs

· Ltd transfusion requirement < 4unit over 24 hrs

Missed associated injuries

· there is a 5% incidence of associated enteric injury with “isolated” hepatic injury in blunt trauma

· CT is 97% accurate but not 100%

· in most series missing these injuries in the initial assessment is not associated with poorer outcome

· no substitute for repeated examination by the same examiner

Complications

· Bile leak

—   » 0.5% require intervention

—   Biloma: collection of bile – frequently become infected. Treated by percutaneous drainage.

—   Biliary-pleural fistula: cause empyema

—   Bilhemia: Intra-hepatic fistula between hepatic vein and bile duct producing jaundice

—   Haemobilia: rupture of an arterial pseudoaneurysm into biliary tree causing upper Gi haemorrhage.

—   Diagnosis with HIDA scan or ERCP and treat with biliary stenting/sphincterotomy/percutaneous drain

· Infected hameatoma

· Liver necrosis

· Haemobilia

· Haemorrhage

v Pachter 1996 J Trauma 404 patients - Western multicentre trial group

— 90% of conservatively treated blunt liver trauma does not require transfusion

— Hepatic related mortality as a result of failed conservative management is 0.5%

Resumption of normal activities

· HDU monitoring 48-72h, then 2-5d further of bed rest, depending on clinical judgement
- remember thromboprophylaxis.
- 12 weeks to normal activity

· based on experimental studies of healed liver bursting strengths

Angio-embolization

Candidiates are those who are haemodynamically stable with continuing transfusion requirement and with contrast extravasation.

Blush --> urgent angio

Angio is effective at controlling arterial bleeding, but venous bleeding better managed by tamponade

- may need a combination in effective therapy.

Predictors of failed conservative management:

- positive FAST
- injury to other solid organs (spleen and kidney)
- blood in multiple intraperitoneal areas on imaging
- need for transfusion
--> absence of all 4 = 96% chance of success

Surgery

Approach
Must be organised and systematic, well planned before beginning surgery

- blood produces, rapid infusre, warmer, multiple suctions, cell saver considered
- experienced team, wide prep to knees, self retaining retractor eg omni, many sponges, hemostatic agents.

Indications

· Cardiovascular compromise

· Peritoneal signs

· Ongoing transfusion requirement (and not amenable or failed rad. therapy

· Large subcapsular haematoma

— Needs deroofing otherwise get ­ subcapsular stripping

Technique

· Long midline ± RUQ transverse

· 4 quadrant pack

· ? RUQ blood

— Evacuate blood

— Briefly assess injury

— Pack, manual / bimanual pressure on liver, place retractor, catch up on resuscitation, get everything ready

Medium abdo's in 1/2 with radio-opaque stripes
- release pressure slowly to gauge degree of injury, then management will depend on severity

Mobilise within limits of incision as necessary falciform,
Don't forget to control other major sources quickly if easily to keep on top of bleeding
Enteric content control follows haemorrhage control.

Minor Injuries
Simple hemostatic techniques

Superficial lacerations:

- 5-10m of direct compression
- topical agents
- electrocautery or argon beam coagulation
Diffuse surface bleeding from capsule disruption
- topical agents, e.g. fibrin flue
- hemostat fabric
- topical collagen
Then compress for another 5-10 minutes by clock and reassess
Continued bleeding:
- consider direct sutures
- transcapsular sutures of 0-chromic with blunt-nose needles
- avoid tight sutures that will tear liver capsule
- pledgets may be helpul, or surgicel

- place sutures quite close to liver edge to avoid large areas of necrosis.

Moderate to Severe Injuries
Slightly larger lacerations

- pack with tongue of omentum and use transcapsular liver sutures to hold it in place
- enter defect first and ligate any bile duct or vascular injuries with figure-8 sutures
--> may not work if larger branches of hepatic artery or portal system deep in liver parenchyma
--> then use finger fracture technique; pinch parenchyma to enlarge injury, until larger bleeders identified, then clip / ligate / repair
Major bleeding when compression released

Reapply compression.

Rapidly control inflow and mobilize liver

- Pringle maneuver; left index finger through foramen and use thumb to compress the hepatic artery and vein.

- gastrohepatic ligament opened bluntly or cautery bein aware of possible replaced or accessory L hepatic artery
--> vascular clamp here; usually stated 20m on 5m off but no good evidence that longer is bad.
--> will control ~85% of injuries

Then mobilize liver to identify and manage the injury.

- ligamentum teres and falciform divided and followed back to the suprahepatic vena cava
- right and left triangular and coronary ligaments then mobilized
- take care to evaluate haematomas in triangular ligaments; may represent a stable major vessel injury and would result in rapid exsanguination.

Delineate extent of injury

- can bleeding intrahepatic vessels and ducts be identified and controlled?

- venous bleeding is generally controlled by packing to tamponade

--> ongoing bright red bleeding is arterial.

--> consider packing and angioembolization of bleeding arteries / arterioles as a damage control procedure.
Formal hepatectomy?
- hazardous. only experience hands; most injuries are not in anatomical lines.
Liver may be devascularized - then hepatectomy, in experienced hands.
ICU for aggressive resuscitation and warming.

Optimal Packing
Fully mobilize
L lateral segment - rotate to right, place packs posteriorly.

Superiorly - packs to diaphragm and liver
Right lobe - rotate medially, pack along vena cava between liver and diaphragm.
--> compression of liver between anterior chest, diaphragm and retroperitoneum
--> tamponade

Penetrating Injuries
Long narrow wounds that bleed from deep within the tract = challenging
Foley catheter and 1 inch penrose drain and silk ties to create a tamponade balloon
- cut balloon so fills penrose

Can drain bile leaks and sort out electively later.

- minor injuries can be treated with repair over a T-tube

Complications

1. Early haemorrhage
- bleeding can occur at any time
- CT angiography; most can be managed non-operatively
- nb liver injury contraindicates chemical thromboprophylaxis

2. Bile leak
- CT guided drainage
- high output (>50ml/day) and not resplving, need ERCP
- if required may be able to stent the injury, rare operative intervention required.

3. Abscess.
- esp. if associated enteric injuries, extensive parenchymal injury, inadequate debridement, and massive transfusions
- treat as per hepatic abscess; rarely will require operative drainage and debridement

4. Necrosis
- devascularization problem. 
- abdo pain, tenderness, feeding intolerance, coagulopathy, LFT elevation, sepsis, liver failure.
- CT scan for devascularized segments; resect major devascularized segments

5. Hemobilia
- problem mainly historic when surgery created iatrogenic connections between arteries and ducts
- triad of RUQ pain, jaundice and GI bleeding.

Rest of Jeromes notes

Majority will stop with compressive packing and haemostatic agents
- surgicel, fibrillar, flowseal

· Assess rest of abdo

· Reassess

— Stopped® close

· Continued bleeding ® Dnostic Pringle

— +ve in flow problem

—   -ve retrohepatic problem (rare)

—   Or replaced left or right hepatic artery

Trauma

· Optimise conditions

— Incision

— Lighting

— Retraction

— Instruments

— Personnel (call for help from most experienced available liver surgeon)

— CVP/ resuscitation

· Mobilise liver

— For R lobe

Retract R lobe medially

Divide with scissors

R D

Superior & inferior coronaries

Mobilise bare area; careful of adrenal

Falciform

— L lobe

Divide falciform & L triangular

· Remove packs, reassess ± release pringle

— Nature & extent

— ? devitalised liver

— ? inflow, ? outflow

· Repringle & definitive packing

— Pack to restore anatomical shape

above and below; in front and behind

— Care not to compress IVC

— Majority of remainder will stop with packing and second look laparotomy
+/- interventional radiology if ongoing bleeding suspected in ICU

· Release pringle

· Works ® close

· Doesn’t work

— Wrong packing technique

— Significant inflow bleeding

— Outflow obstruction

Intrahepatic haematoma

2° to packs (wrong technique)

Over resuscitated

Cardio respiratory problems

Pneumothorax, temponade

Lacerated hepatic veins

— Retrohepatic bleed

· Consider

— Selective hepatic artery ligation

Hepatic venous injury ± inflow problem

When pringle works well & can’t control with packing

Mass ligate the affected side with knowledge that hemi hepatectomy will be required later

— Hepatic isolation

Retrohepatic bleed

Dissect up duodenum and clamp IVC

Manoeuveure clamp over dome of liver and clamp IVC above

1° repair of caval /hepatic outflow injury

· Rebleed

— Angio ± embolisation

for inflow bleeding

angioportography for outflow

— CT to assess injury & packing

Other techniques

· 1° suture to appose

— packing generally better

· Mesh pita pocket

— 2 pieces of mesh sutured together with slit for IVC & portal structures

— packing probably better

· Finger fracture & 1° suture of vessels

— if heavily contused or lacerated

anatomical resection by specialist surgeons  someimtes required for definitive control of major bleeding.

finger fracture technique to expose underlying major bleeders which can then be ligated

93% success with grade III or IV (Pachter J trauma 1996)

· Atriovenous shunting

— Rarely used, takes too long, need experience ++

— with a no. 8 endotracheal tube chest tube

— median sternotomy

— Satinsky on the R atrial appendage with a prolene pursestring