Liver Trauma - Surgery - Lecture Slides, Slides for General Surgery. Ambedkar University, Delhi
sachinii
sachinii20 December 2012

Liver Trauma - Surgery - Lecture Slides, Slides for General Surgery. Ambedkar University, Delhi

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This lecture covers a topic in Surgery. Keywords are given below: Liver Trauma, Friable Parenchyma, Subcapsular Hematoma, Intrahepatic Hematoma, Hepatic Vascular Disruption, Bile Duct Injury, Mild Hepatic Injuries, Gallb...
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Liver Trauma

Liver Trauma

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Background

• Largest solid abdominal organ,fixed position • Second most common injured, but most

common cause of death after abdominal trauma

• Blunt MVA most common • 80% adults, 97% children-conservative rx

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Pathophysiology

• Friable parenchyma, thin capsule, fixed position in relation to spine.

• Right lobe gets hit more since its larger, and closer to ribs.

• 85% injuries involve segments 6,7,8 from compressioin against ribs, spine, abd wall.

• Shear forces at attachments to diaphragm • Transmission thru right hemithorax.

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Pathophysiology

• Liver injured easily in children since ribs are compliant, force transmitted.

• Liver not as developed in children, with weaker connective tissue framework.

• Iatrogenic injuries by biopsies, biliary drainage, TIPS, can cause capsular tears and bile leaks, fistulas, hemoperitoneum.

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Injuries

• Subcapsular hematoma or intrahepatic hematoma. • Laceration • Contusion • Hepatic vascular disruption • Bile duct injury • 86% of injuries have stopped bleeding at time of

exploration. • Decreased transfusion req.With conservative.

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Injuries

• Mild hepatic injuries involving < 25% of one lobe heal in 3 mos.

• Moderate injuries involving 25-50% of one lobe heal in 6 mos.

• Sever injuries require 9-15 mos to heal. • Gallbladder injuries rare, with contusons being

most common, avulsions next most.

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Anatomy

• Cantile described main divisions along a main plane from GB fossa to IVC. Divides liver into equal halves.

• Couinaud developed 4 sectors and 8 segments, divided into vertical and oblique planes, defined by the 3 main hepatic veins and transverse plane thru right and left portal branches.

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Anatomy

• Hepatic veins lie between segments. • Left hepatc vein divides left lobe into medial

and lateral segments. • Middle hepatic vein divides liver into left and

right lobes.

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Anatomy

• Right hepatic vein divides right lobe into anterior and posterior segments.

• A horizontal line thru left and right main portal veins is used to divide lobes into inferior and superior segments.

• The 8 liver segments are numbers clockwise on the frontal view.

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Clinical Details

• Symptoms of injury are related to blood loss, peritoneal irritation, RUQ tenderness, and guarding.

• Unrecognized delayed abcess • Bilomas • Signs of blood loss may dominate the picture.

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Clinical Details

• Elevated liver tests • Biliary peritonitis (nausea, vomiting, abd

pain). • DPL has high sensitivity, 1-2% complication

rate. • Plain x-rays non-specific. • CT scan diagnostic procedure of choice. • Hida for leaks, angio for hemorrhage.

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Limitations

• FAST sensitivity highest (98%) for grade 3 injuries or greater. Negative findings do not exclude hepatic injury.

• Emergency sono findings demonstrating free fluid, parenchymal injury, or both demonstrate overall sensitivity for detection of blunt abdominal trauma of 72%.

• Angiogram may fail to detect active bleeding.

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CT Scans

• Accurate in localizing the site of liver injury, associated injuries.

• Used to monitor healing. • CT criteria for staging liver trauma uses AAST

liver injury scale • Grades 1-6 • Hematoma,laceration,vascular,acute

bleeding,gallbladder injury,biloma.

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Classification

• I-Subcapsular hematoma<1cm, superficial laceration<1cm deep.

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

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

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Classification

• IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction, or devasularization.

• V- Global destruction or devascularization of the liver.

• VI-Hepatic avulsion

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Angiography

• Demonstrates active bleeding • Transcatheter embolization may be the only

treatment required. • Findings include contusion, laceration,

hematoma, pseudoaneurysms, fistulas. • Embolization can reduce transfusion

requirements, stenting for fistulas.

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