HEGAZY SURGERY

2. • Because of its size and location in the abdominal cavity, the liver is
frequently injured in both blunt and penetrating trauma. Despite
progress in the management of trauma patients in the last 2
decades, mortality after hepatic trauma has remained stable.
• Spontaneous hemostasis is observed in more than 50% of small
hepatic lacerations at the time of laparotomy. In fact, most liver
injuries require only documentation and no drainage. Although
most liver injuries can be properly managed with simple
procedures, control of profuse bleeding from deep hepatic
lacerations remains a formidable challenge for trauma surgeons.
• The overall mortality rate ranges from 8% to 10%, and the overall
morbidity rate varies from 18% to 30%, depending on the number
of associated injuries and the severity of the injury.
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3. • The majority of liver injuries are due to blunt trauma, caused by
direct blow, crushing or fall from a height.
• The liver is a solid organ and compressive forces can easily burst
the liver substance, being compressed between the force and the
rib cage or vertebral column.
• Contusion, laceration and avulsion injuries may occur as a result of
blunt trauma.
• Most are relatively minor in severity and can be managed non
operatively. Many are not even suspected at the time. C.T scan
played a role in detection.
AETIOLOGY:
(1) Blunt Injury:
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4. • Stab wounds and gunshot wounds, are often associated with chest
or pericardial involvement.
• Bullets have a shock wave and when they pass through the liver
they cause significant damage some distance from the actual track
of the bullet.
(2) Penetrating Injury:
• Abdominal surgery, needle biopsy, laparoscopy, P.T.C.
(3) Iatrogenic Injury:
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5. • The liver is an extremely well vascularised organ, so blood loss is the major
early compilation of liver trauma.
• Clinical suspicion of a possible liver injury is essential, as a laporatomy by an
inexperienced surgeon with inadequate preparation preoperatively is
doomed to failure.
• All lower chest and upper abdominal stab wounds should be suspect,
especially if considerable blood volume replacement was required. Similarly,
sever crushing injuries to the lower chest or upper abdomen often combine
rib fractures, haemothorax and liver and/or splenic trauma.
• Patients with a penterating wound will require a laparotomy and/or
thoracatomy once active resuscitation is under way.
• Patients who are haemodynamically stable should have a C.T scan of the
chest and abdomen. Chest x-ray will be of value. Diagnostic peritoned
aspiration may be of value for detection of haemoperitoneum. Additional
investigations that may be of value include DPL and laparoscopy.
DIAGNOSIS OF LIVER INJURY:
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6. GRADING OF LIVER INJURY
By a system brought by:
AAST (American Association for the
Surgery of Trauma)
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7. * Advance one grade for multiple injuries, up to grade III.
Table (1): AAST liver injury scale (1994 revision):
Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver
(1994 rev). J Trauma. 1995; 38: 323-4.
Grade* Injury Description
I Haematoma
Laceration
Subcapsular, <10% surface
Capsular tear, <1 cm parenchymal depth
II Haematoma
Laceration
Subcapsular, 10-50% surface area; intra-parenchymal, <10 cm in diameter
1-3 cm parenchymal depth, <10 cm in length
III Haematoma
Laceration
Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal
haematoma
Intraparenchymal haematoma >10 cm or expanding
> 3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinaud’s segments
within a single lobe.
V Laceration
Vascular
Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments
within a single lobe.
Juxtavenous hepatic injuries, i.e. retrohepatic vena cava/central major hepatic veins
VI Vascular Hepatic avulsion
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8. • ABCDE of trauma resuscitation.
• Once initial resuscitation done Transfer to op. theatre
(Operative treatment)
INITIAL MANAGEMENT OF LIVER INJURIES:
* Penetrating:
• ABCDE of trauma resuscitation.
• Haemodynamically stable patients C.T scan abdomen & pelvis
(Severity of injury) Non operative management in most of cases
• Haemodynamically unstable patients
• Haemodynamically stable patients with
evidence of on-going blood loss despite Operative treatment
conservative treatment or development
of peritonitis
* Blunt Trauma:
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9. • Blunt hepatic injuries in hemodynamically stable patients without other
indications for exploration are best served by a conservative,
nonoperative approach. In the absence of contrast extravasation during
the arterial phase of the CT scan, most injuries can potentially be treated
nonoperatively.
• The classic criteria for nonoperative treatment of liver injuries include
hemodynamic stability, normal mental status, absence of a clear
indication for laparatomy such as peritoneal signs, lowgrade liver injuries
(grade I-III), and transufion requirements of less than 2 units of blood.
• These patients are monitored by serial hematocrit and vital signs rather
than by serial abdominal examinations, which is the reason why intact
mental status is not the sine qua non for nonoperative management.
Furthermore, if the hematocrit drops, most patients will undergo a
repeat CT scan to evaluate and quantify the hemoperitoneum.
NONOPERATIVE TREATMENT:
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10. • Patients are admitted to the intensive care unit for monitoring of vital signs
and hematocrit. Usually, after 48 hours patients are transferred to an
intermediate care unit, where they are started on an oral diet; however,
they remain on bed rest until postinjury day 5. A repeat CT scan before
discharge does not seem to be necessary. Normal physical activity resumes 3
months after injury.
• The overall reported success of nonoperative management of blunt hepatic
injuries is greater than 90% in most series. Angiographic embolization has
been added to the protocol for nonoperative management of liver injuries in
some institutions in an attempt to decrease the necessity for blood
transfusions and the number of operations.
- Complications for nonoperative treatment (5-20%):
• Biliary leak and peritonitis.
• Liver abscess.
• Abdominal compartment syndrome.
• Hepatic necrosis.
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11. - Failure of nonoperative treatment (11%):
• Usually attributed to reasons unrelated to liver injury. Other injuries can be
missed in a blunt trauma victims, such as: Bowel – Pancreas – Diaphragm –
Bladder.
• Management of patients with contrast extravasation during the arterial phase of
CT is still debatable. Fang and associates proposed a classification system based
on the location and character of extravasation and pooling of contrast material
from a liver laceration on CT. In type 1, there is contrast extravasation to the
peritoneal cavity. All patients in this category required operative intervention.
Type 2 consisted of hemoperitoneum and extravasation of contrast material
within the hepatic parenchyma. The authors recommend that patients in this
category undergo angiography with embolization, although some will require
operative intervention. Type 3 was characterized by no hemoperitoneum and
extravasation of contrast material within the hepatic parenchyma. Angiography
is required in this subgroup of patients, and the results are usually good.
• The most important concern of nonoperative management is the potential for
missed injuries, particularly hollow viscus perforations. Delay in diagnosing a
hollow viscus injury is associated with significant morbidity and increased
mortality.
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12. • The type of injury dictates the surgical management. The principles of
surgical management of liver injury are the same regardless of the
severity of injury. They involve control of bleeding, removal of
devitalized tissue, and establishment of adequate drainage.
• A roof top incision which can be extended upwards for a median
sternatomy gives excellent visualisation to the liver.
• Some small nondeep bleeding lacerations are easily controlled with
simple suture or the use of hemostatic agents. More severe liver injuries
require more complex procedures, including deep mattress sutures,
packing, débridement, resection, mesh hepatorrhaphy, and other
measures. The resurgence of packing and the emergence of damage
control, as an alternative for the treatment of severe hepatic injuries in
patients with shock, metabolic derangement, and coagulopathy, have
been incorporated in the armamentarium of trauma surgeons in recent
years. A 34% survival rate was reported when packing was used as an
adjunct to other measures to control bleeding.
THE SURGICAL APPROACH TO LIVER TRAUMA:
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13. • The liver is reconstituted as best as possible in its normal position and
bleeding is controlled by direct compression (push).
• Subcapsular hematomas can simply be observed or surgically evacuated if
there is no associated parenchymal injury.
• Simple lacerations that are not bleeding at the time of surgery do not
require drainage unless they are deep into the parenchyma with the
possibility of a postoperative biliary fistula.
• Lacerations that continue to bleed despite attempts at local control require a
more extensive approach, usually opening the liver wound and directly
approaching the bleeding vessels, a procedure known as tractotomy.
Bleeding vessels and biliary radicles should be individually ligated.
• In the event that bleeding continues despite directly ligating small vessels, a
vascular clamp or vessel loops can be placed around the porta hepatis
(Pringle’s maneuver). If the bleeding stops after clamping the portal triad, it
can be assumed to be from the portal veins or hepatic artery branches. If the
bleeding continues despite clamping the portal triad, an injury to the
hepatic veins or the retrohepatic vena cava is suspected. The portal triad can
also be intermittently clamped to allow visualization during the placement
of sutures as the parenchymal vessels are ligated. If a Pringle maneuver is
applied, caution regarding the duration of inflow occlusion is necessary.
Some authors have reported occlusion of inflow for up to 1 hour with the
use of adjuvant steroid therapy without major consequences. 13

14. • Packing the liver wound is performed when the techniques just described
fail to control hemorrhage. Perihepatic packing was once condemned
because of the high incidence of intra-abdominal abscesses. Temporary
packing has recently been used, particularly in patients with hypothermia,
coagulopathy, and severe acidosis with severe injuries in other intra-
abdominal organs.
• Usually, these patients are taken to the intensive care unit for rewarming
and resuscitation. Re-exploration for removal of the packing is performed
within 48 to 72 hours after the initial operation. After hemostasis is achieved
and the packs are removed, copious irrigation of the abdominal cavity is
performed and closed suction drains are placed. Arteriography is a useful
adjunct to locate the arterial bleeding, and embolization may be of benefit
before re-exploration for removal of the packing. The incidence of intra-
abdominal abscess in survivors of liver packing is generally less than 15%.
• Despite the use of any method to obtain hemostasis, all necrotic tissue
should be débrided before closure. If bleeding in the raw surface of the liver
after resectional débridement is not significant, an omental flap can be used
to cover or fill the defect in the liver parenchyma.
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15. • Deep liver lacerations should not be simply closed because of the risk for
abscess. Alternatively some propose extending the liver laceration to
expose and directly ligate the bleeding vessel. This is achieved by
performing a finger fracture hepatotomy along nonanatomic planes. The
technique should be performed only by experienced surgeons.
• Formal hepatic resection is unusual after liver injuries and has been
largely abandoned in the past decade because of high mortality and
morbidity rates after this procedure and because other more
conservative approaches have proved to be as effective in controlling
hemorrhage, with significantly lower complication rates and mortality.
• Another technique described recently encompasses the use of
absorbable mesh, with each lobe of the liver wrapped individually and
the mesh attached to the falciform ligament. This technique is useful for
multiple superficial lacerations of the liver with active bleeding;
however, it is not effective when major vascular injuries are present.
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16. • Ligation of the hepatic artery is also an alternative for continued
bleeding; however, with the use of modern cauterization devices
(electric or argon bean coagulators), topical hemostatic agents, and fibrin
glue, this is seldom required. It should be reserved for the occasional
stab wound or gunshot wound involving one lobe in which exposure of
the wound will require extensive incision of the liver. The proper hepatic
artery must never be ligated. Injudicious hepatic artery ligation may
result in liver infarction, particularly if associated with portal vein injury.
Packing the liver is a reasonable alternative to hepatic artery ligation.
• Lacerations to the hepatic artery should be identified by placing an
atraumatic bulldog clamp on the proximal vessel prior to repair with 5/0
or 6/0 Prolene suture. If unavoidable, the hepatic artery may be ligated,
although parenchymal necrosis and abscess formation will result in some
individuals. Portal vein injuries should be repaired with 5/0 Prolene,
again with exposure of the vessel being facilitated by the placement of
an atraumatic vascular clamp.
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17. • If a major liver vascular injury is suspected at the time of the initial
laparotomy, then referral to a specialist centre should be considered. A
common surgical approach in these circumstances would be to place the
patient on veno-venous bypass using cannulae in the femoral vein via a
long saphenous cut-down with the blood returned, using a roller pump,
to the superior vena cava (SVC) via an internal jugular line. Veno-venous
bypass allows the IVC to be safely clamped to facilitate caval or hepatic
vein repair. A rapid infuser blood transfusion machine facilitates the
delivery of large volumes of blood instantaneously. Once prepared, the
patient is re-laparotomised. The liver is mobilized by division of the
supporting ligaments, and complete vascular isolation of the liver is
achieved by occluding the hilar inflow and the IVC above the renal veins
and at the level of the diaphragm with atraumatic vascular clamps.
Venous return is provided by the veno-venous bypass. Warm ischaemia
of the liver is tolerated for up to 60 min, allowing sufficient time in a
blood-free field for repair of injuries to the IVC or hepatic veins.
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18. Fig. (1): The Pringle maneuver controls arterial and portal vein hemorrhage
from the liver. Any hemorrhage that continues must come from the
hepatic veins. 18

19. Fig. (2): Perihepatic packing is often effective in managing extensive
parenchymal injuries. It has also been successfully employed for
grade V juxtahepatic venous injuries. 19

20. • Significant complications after liver injury include pulmonary
complications, postoperative bleeding, coagulopathy, biliary fistulae,
hemobilia, hepatic artery aneurysm, arteriovenous fistula and
subdiaphragmatic and intraparenchymal abscess formation.
• Hepatic failure may occur following extensive liver trauma. This will
usually reverse with conservative supportive treatment if the blood
supply and biliary drainage of the liver are intact.
COMPLICATIONS OF LIVER TRAUMA:
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21. The capacity of the liver to recover from extensive trauma is remarkable,
and parenchymal regeneration occurs rapidly. Late complications are rare,
but the development of biliary tract strictures many years after recovery
from liver trauma has been reported. The treatment depends on the mode
of presentation and the extent and site of stricturing. A segmental or lobar
stricture, associated with atrophy of the corresponding area of liver
parenchyma and compensatory hypertrophy of the other liver lobe, may be
treated expectantly. A dominant extrahepatic bile duct stricture associated
with obstructive jaundice may be treated initially with endobiliary balloon
dilatation or stenting, but will usually require surgical correction using a
Roux-en-Y hepatodochojejunostomy.
LONG-TERM OUTCOME OF LIVER TRAUMA:
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22. Thank You …