Management of Liver Trauma Joint Hospital Surgical Grand Round 19 June 2004 United Christian Hospital

Case SW Cheng, M/ tones lorry driver Hit on road side and trapped within wreck

Fully conscious on arrival to AED Epigastric pain, right lower chest pain and right foot pain with wound over foot dorsum BP 100/60 P90 Hb 7.8, AST > 1000, ALT > 200 Fracture right 6 th and 8 th ribs with chest drain inserted

Urgent CT scan abdomen: Right lobe liver haematoma with rupture and subphrenic fluid

Question What should we do now? Should we operate on him right the way or should we adopt conservative management? What should we do if we are going to perform laparotomy?

Liver Trauma Most frequently injured intra-abdominal organ (Feliciano, 1989) Blunt injuries Deceleration injuries Direct blow Penetrating injuries

Grading System Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (Moore, 1995) Hepatic Injury Scale Revised in 1994

Grade I and II Minor injuries 80-90% Require minimal or no operative treatment Grade III, IV and V Severe and require surgical intervention Grade VI Incompatible with survival

Management ATLS Haemodynamically stable: further assessment

Assessment USG Sensitivity 82-88% and specificity 99% Operator dependent CT scan Grading does not correlate precisely Sensitivity and specificity increase with increased time between injury and CT Laparoscopy

Non-operative Management

50-80% of liver injuries stop bleeding spontaneously Increasing trend towards conservative management

Criteria for Non-operative Management Meyer (1985) Haemodynamic stability Absence of peritoneal gas Good quality CT scan Experienced radiologist Ability to monitor patient in ICU Facility for immediate surgery Simple parenchymal laceration or intrahepatic haematoma with less than 125 ml free intraperitoneal blood No other significant intra-abdominal injuries

Farnell (1998) Haemoperitoneum 250 ml Specific CT requirements  Subcapsular or intraparenchymal haematoma  Unilobar fracture  Absence of devitalized tissue  Absence of other intra-abdominal injuries Feliciano (1992) Haemodynamically stable Haemoperitoneum of less than 500 ml

Ultimate Decisive Factor Haemodynamic stability at presentation or after initial resuscitation Irrespective of the grade of injury on CT or the amount of haemoperitoneum

Pachter 1995 Review of 495 patients Success rate of non-operative management: 94% Mean transfusion rate: 1.9 units Complication rate 6% (bile leak 4, biloma 10, abscess 3, haemorrhage 14) Mean hospital stay 13 days

Potential complications Discrepancy between CT and operative findings Risk of missing other intra-abdominal injuries: reduce with use of DPL Potential for transmission of bloodborne viral illness from repeated blood transfusion: actually require fewer blood transfusions Risk of continued haemorrhage Haemobilia, bile leak and spesis

Bynoe 1992 Complication rates no greater than those in patient treated surgically

Operative Management

Prerequisites Resuscitation Experienced surgeon Familiar with liver anatomy Blood, platelets, FFP, cryoprecipitate Fully equipped ICU Diagnostic back-up to monitor and detect potential complications

Initial Control of Bleeding Midline or bilateral subcostal incision Temporary tamponade of RUQ using packs Pringle maneuver Bimanual compression of liver Manual compression of abdominal aorta above celiac trunk

Pringle Maneuver If haemorrhage is unaffected by portal triad occlusion, major vena cava injury or atypical vascular anatomy should be suspected

Hepatotomy With Direct Suture Ligation Division of normal hepatic parenchyma To expose damaged vessels and hepatic ducts which can be ligated, clipped or repaired under direct vision

Resectional debridement Removal of all devitalized tissue down to normal hepatic parenchyma using line of injury Rapid compared to anatomical resection

Perihepatic Packing Serious complications associated with gauze packing of hepatic injuries during WWII and Vietnam war Led to abandonment of this treatment During past decade, re-established as an acceptable method of management of liver injuries

Perihepatic Packing Indications When other surgical methods failed in a hameodynamically unstable patient Uncontrollable coagulopathy Bilobar liver injury Large non-expanding haematoma Capsular avulsion

Minimal number of dry abdominal packs or single rolled gauze around liver NOT to force into deep fractures

Mesh Wrapping Grade III-IV lacerations Tamponading large intrahepatic haematomas, minimize risk of delayed rupture Relaparotomy not routinely required

Selective Hepatic Artery ligation When source of bleeding cannot be identified in hepatotomy site Perihepatic packing fails Pringle maneuver seems to be effective Contraindications: Bleeding from portal or posthepatic veins Cirrhosis

Adjunctive Technique Fibrin glue: raw liver surfaces

Retrohepatic Venous Injuries Suspected if: Portal triad occlusion fails to control bleeding Injury extends to bare area on palpation

Management of Retrohepatic Injuries Total vascular exclusion Venovenous bypass Atriocaval shunting Beal (1990): perihepatic packing

Conclusion Resuscitation Conservative treatment if haemodynamically stable Operation: perihepatic packing, then transfer to hepatobiliary centre Hepatotomy with direct suture ligation or resectional debridement

Thank You

References Beal SL. Fatal hepatic haemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma 1990; 30: Bynoe RP et al. Complications of nonoperative management of blunt hepatic injuries. J Trauma 1992; 32: Farnell MB et al. Nonoperative management of blunt hepatic trauma in adults. Surgery 1988; 104: Feliciano DV. Surgery for liver trauma. Surg Clin North Am 1989; 69: Feliciano DV et al. Continuing evolution in the approach to sever liver trauma. Ann Surg 1992; 216: Meyer AA et al. Selective nonoperative management of blunt liver injury using computed tomography. Arch Surg 1985; 120: Moore EE et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995; 38: Pachter HL et al. Significant trends in the treatment of hepatic trauma. Experience with 411 injuries. Ann Surg 1992; 215: Pachter HL et al. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995; 169: Parks RW et al. Management of liver trauma. BJS 1999; 86: Simon AW et al. Management of liver trauma with implications for the rural surgeon. ANZ J Surg 2002; 72: