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

2. Case SW Cheng, M/47 5.5 tones lorry driver Hit on road side and trapped within wreck

3. 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

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

5. 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?

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

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

9. 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

10. Management ATLS Haemodynamically stable: further assessment

11. 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

12. Non-operative Management

13. 50-80% of liver injuries stop bleeding spontaneously Increasing trend towards conservative management

14. 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

15. 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

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

17. 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

18. 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

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

20. Operative Management

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

22. 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

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

24. 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

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

26. 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

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

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

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

30. 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

31. Adjunctive Technique Fibrin glue: raw liver surfaces

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

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

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

35. Thank You

36. References Beal SL. Fatal hepatic haemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma 1990; 30: 163-9. Bynoe RP et al. Complications of nonoperative management of blunt hepatic injuries. J Trauma 1992; 32: 308-15. Farnell MB et al. Nonoperative management of blunt hepatic trauma in adults. Surgery 1988; 104: 748-56. Feliciano DV. Surgery for liver trauma. Surg Clin North Am 1989; 69: 273-84. Feliciano DV et al. Continuing evolution in the approach to sever liver trauma. Ann Surg 1992; 216: 521-3. Meyer AA et al. Selective nonoperative management of blunt liver injury using computed tomography. Arch Surg 1985; 120: 550-4. Moore EE et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995; 38: 323-4. Pachter HL et al. Significant trends in the treatment of hepatic trauma. Experience with 411 injuries. Ann Surg 1992; 215: 492-502. Pachter HL et al. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995; 169: 442-54. Parks RW et al. Management of liver trauma. BJS 1999; 86: 1121-35. Simon AW et al. Management of liver trauma with implications for the rural surgeon. ANZ J Surg 2002; 72: 400-4.