Mohamed. Hashim Milhim 4th year medstudent An-najah national univ. Liver Trauma Mohamed. Hashim Milhim 4th year medstudent An-najah national univ.

Background Largest organ, 2nd most common injured, Blunt trauma most common

(>85%) in segments 6, 7, 8.

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

Mechanisms of injury:- simple compression against ribs, spine, ligamentous attachment to diaphragm and the posterior abdominal wall ,shear forces during deceleration injury.

Mechanisms of injury:- High-velocity bullet injuries burst injuries with distant contusions and parenchymal disruption. Associations High-velocity bullet injuries High-velocity bullets tend to cause burst injuries with distant contusions and parenchymal disruption. Occasionally, these injuries are associated with aortic and renal injuries. All of the angiographic findings of blunt liver trauma can be seen in this group of patients.

Mechanisms of injury:- Low-velocity penetrating injury Stab wounds percutaneous biopsy cholangiography biliary drainage, (TIPS), capsular tears, hematoma, bile leaks, arteriobiliary fistulas, and hemoperitoneum, arterial aneurysms.

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

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

Injuries Mild injuries heal in 3 months. Moderate injuries heal in 6 months. Sever injuries in 9-15 months.

Clinically Symptoms & signs of injury are blood loss, peritoneal irritation, RUQ tenderness, and guarding. delayed abscess . Signs of blood loss may dominate the picture. Biliary peritonitis.

Labs & Radiology Elevated LFTs DPL -- high sensitivity CT scan is the diagnostic procedure of choice. US. MRI ?? Ultrasonography is the initial examination of choice in the pediatric age group who are ill and in whom the clinical condition is too unstable to allow transport to a CT facility. In a neonate with a decreasing hematocrit level and increasing abdominal distension, ultrasonography may rapidly help in confirming a diagnosis of liver trauma. Because most children with hepatic trauma are treated conservatively, most children can be monitored by using sonography.

Angiography active bleeding Transcatheter embolization Embolization & stenting for fistulas.

CT Scan Localization. monitor healing. Grades 1-6

Classification (AAST) I-Subcapsular hematoma<1cm, superficial laceration<1cm deep. American Association for the Surgery of Trauma (AAST)

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

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

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

V- Global destruction or devascularization of the liver.

VI-Hepatic avulsion

Gallbladder injuries… Rare Predisposing factors. contusions, avulsions, lacerations or perforations. Gallbladder injuries are classified as contusions, lacerations or perforations, and avulsions; contusions are most common. Avulsion injuries are the second most common; the gallbladder is torn partially or completely from the gallbladder fossa. Healing takes 1-15 months, and the rate of healing correlates with the severity of trauma.

Management In the past VS now treatment of blunt liver injury trauma 86% , 67% CT scan diagnosis and follow up 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. Imaging techniques, particularly CT scanning, have made a great impact on the treatment of patients with liver trauma, and use of these techniques has resulted in marked reduction in the number of patients requiring surgery and nontherapeutic operations. Almost 80% of adults and 97% of children are treated conservatively by using careful follow-up imaging studies. Ct

Management… Remember associated injuries Resuscitate Assessment of injury Spiral CT Laparotomy Treatment

Management… consider Cryoprecipitate, FFP Rooftop incision Control blood Loss The "rooftop" incision extends along the patient's right side (under the rib cage) to the left side at the level of the left nipple.

Suturing of Lacerations Resection Packing Recurrent parenchymal bleeding transcatheter embolization

Thank you