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LIVER TRAUMA

LIVER TRAUMA. Dr.Ramdas Rai Prof. & Unit Chief Dept. Of Surgery YMCH. Anatomy. Wedge shaped organ Largest organ in the body after skin. Weight is 1500 gm. 1500 ml of blood flow per min. (30% of cardiac output) Lies : Right – 6-10 ribs /costal cartilages

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LIVER TRAUMA

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  1. LIVER TRAUMA Dr.Ramdas Rai Prof. & Unit Chief Dept. Of Surgery YMCH

  2. Anatomy • Wedge shaped organ • Largest organ in the body after skin. • Weight is 1500 gm. • 1500 ml of blood flow per min. (30% of cardiac output) • Lies : Right – 6-10 ribs /costal cartilages Left- 6-7 costal cartilages • Nerve supply:- right vagus via coeliac ganglia, left directly to porta hepatis. Sympathetics on vessels.

  3. Liver has four lobes—right lobe, left lobe, quadrate lobe and caudate lobe. • Supporting structures are right triangular ligament, left triangular ligament and falciform ligament

  4. Blood Supply:- • It is a unique organ with dual blood supply. • Hepatic blood flow is around 1500 ml/minute of which portal vein contributes 80% and hepatic artery 20%. • Superior mesenteric vein and splenic vein join dorsal to the neck of pancreas to form portal vein. • Hepatic artery, portal vein and bile duct are located in the free edge of the lesser omentum until it enters the liver.

  5. Venous drainage is usually through the three major hepatic veins, right, left, and middle which drain into the IVC. • Often inferior hepatic vein may be present. • The liver parenchyma is entirely covered by a thin capsule called ‘Glissons capsule’ and by visceral peritoneum in all but the posterior surface of liver termed ‘bare area’.

  6. The liver is the second most common organ injured in abdominal trauma. • Liver trauma can be divided into blunt and penetrating injuries. • Blunt injury produces contusion, laceration and avulsion injuries to the liver, often in association with splenic, mesenteric or renal injury.

  7. Penetrating injuries, such as stab and gunshot wounds, are often associated with chest or pericardial involvement • Blunt injuries are more common and have a higher mortality than penetrating injuries

  8. Diagnosis of liver injury:- • The liver is an extremely well-vascularised organ, and blood loss is therefore the major early complication of liver injuries. • Clinical suspicion of a possible liver injury is essential. • All lower chest and upper abdominal stab wounds should be suspect, especially if considerable blood volume replacement has been required.

  9. Similarly, severe crushing injuries to the lower chest or upper abdomen often combine rib fractures, haemothorax and damage to the spleen and or liver. • Focused assessment sonography in trauma (FAST) performed in the emergency room by an experienced operator can reliably diagnose free intraperitoneal fluid.

  10. Patients with free intraperitoneal fluid on FAST and haemodynamicinstability, and patients with a penetrating wound will require a laparotomy and or thoracotomy once active resuscitation is under way. • Owing to the opportunity for massive ongoing blood loss and the rapid development of a coagulopathy, the patient should be directly transferred to the operating theatre while blood products are obtained and volume replacement is taking place.

  11. Patients who are haemodynamically stable should have a contrast-enhanced CT scan of the chest and abdomen as the next step. • This will demonstrate evidence of parenchymal damage to the liver or spleen, as well as associated traumatic injuries to their feeding vessels. Free fluid can also be clearly established. • The chest scan will help to exclude injuries to the great vessels and demonstrate damage to the lung parenchyma.

  12. Additional investigations that may be of value include diagnostic peritoneal lavage, which can confirm the presence of haemoperitoneum, but this is rarely performed nowadays due to inceased use of FAST and CT.

  13. Initial management of liver injuries :- • Penetrating injuries:- • The initial management is maintenance of airway patency, breathing and circulation (ABC) following the principles of advanced trauma life support (ATLS). • Peripheral venous access is gained with two large-bore cannulae and blood sent for crossmatch of ten units of blood, full blood count, urea and electrolytes, liver function tests, clotting screen, glucose and amylase.

  14. Initial volume replacement should be with colloid or O-negativebloodif necessary. • Arterial blood gases should be obtained and the patient intubated and ventilated if the gas exchange is inadequate. Intercostal chest drains should be inserted if associated pneumothorax or haemothorax is suspected. • Once initial resuscitation has commenced, the patient should be transferred to the operating theatre, with further resuscitation performed on the operating table.

  15. These patients rapidly develop irreversible coagulopathies due to a lack of fibrinogen and clotting factors. • Hence fresh frozen plasma & cryoprecipitate have to be kept ready. • Standard coagulation profiles are inadequate to evaluate this acute loss of clotting factors and factors should be given empirically, aided by the results of thromboelastography(TEG), if available.

  16. A contrast CT prior to laparotomy should be considered if the patient is haemodynamically stable.

  17. Blunt trauma:- • Patients who are haemodynamically unstable will require an immediate laparotomy. • For the patient who is haemodynamicallystable, imaging by CT should be performed to further evaluate the nature of the injury. • Most patients with blunt liver injury who are haemodynamically stable can be managed conservatively.

  18. The indication for discontinuing conservative treatment for blunt liver trauma would be development of haemodynamic instability, evidence of ongoing blood loss despite correction of any underlying coagulopathy and the development of signs of generalisedperitonitis. • Interventional radiology has an important role in management of liver trauma and embolisation to control hepatic artery bleeding is safe and effective in a stable patient with no evidence of hollow viscus perforation.

  19. The surgical approach to liver trauma :- • Compression of the liver with packs and correction of coagulopathy, if present, will control most of the active bleeding. • If bleeding persists, further control can be achieved by vascular inflow occlusion by placing an atraumatic clamp across the foramen of Winslow (the Pringle manoeuvre).

  20. A stab incision in the liver can be sutured with a fine absorbable monofilament suture. • Lacerations to the hepatic artery should be identified and repaired. • 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.

  21. Inflow occlusion facilitates suturing of lacerations and vessels. • If bleeding persists despite inflow occlusion, consider major hepatic vein or IVC injuries, and also look for abberantarteries to the liver. • Deceleration injuries often produce lacerations of the liver parenchyma adjacent to the anchoring ligaments of the liver. These may be amenable to suture with an absorbable monofilament suture.

  22. Diffuse parenchymal injuries should be treated by packing the liver to produce haemostasis. • This is effective for the majority of liver injuries if the liver is packed against the natural contour of the diaphragm by packing from below.

  23. Large abdominal packs should be used to ease their removal, and the abdomen closed to facilitate compression of the parenchyma. • Care should be taken to avoid overzealous packing, as this may produce pressure necrosis of the liver parenchyma or abdominal compartment syndrome.

  24. Crush injuries to the liver often result in large parenchymal haematomasand diffuse capsular lacerations. • Suturing is usually ineffective, and perihepatic packing which involves placing packs above, behind and below the liver, is the most useful method of providing haemostasis. • If packing is necessary, the patient should have the packs removed after 48 hours.

  25. Antibiotic cover is advisable, and full reversal of any coagulopathy is essential. • If a major liver vascular injury is suspected at the time of the initial laparotomy, a common surgical approach in these circumstances would be to place the patient on venovenous 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.

  26. Venovenous 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 relaparotomised. • The liver is mobilised by division of the supporting ligaments, and complete vascular isolation of the liver is achieved by occluding the hilarinflow and the IVC above the renal veins and at the level of the diaphragm with atraumatic vascular clamps.

  27. Venous return is provided by the venovenous bypass. • Warm ischaemia of the liver is tolerated for up to 45 minutes, allowing sufficient time in a blood-free field for repair of injuries to the IVC or hepatic veins.

  28. Other complications of liver trauma:- • Intrahepatic haematoma • Liver abscess • Bile collection • Biliary fistula • Hepatic artery aneurysm • Arteriovenous fistula • Arteriobiliaryfistula • Liver failure

  29. Hepatic aneurysm following liver trauma. An aneurysm arising from the right hepatic artery (arrow), which can be optimally treated by the interventional radiologist using transarterialembolisation.

  30. Long-term outcome of liver trauma:- • 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. .

  31. 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.

  32. LIVER ABSCESS Dr. Ramdas Rai Prof. & Unit Chief Dept. Of Surgery YMCH

  33. AMOEBIC LIVER ABSCESS:- • It is common in India and other tropical countries and it is caused by a parasite entamoebahistolytica. • It is more common in alcoholics and cirrhotic patients. • It is the commonest extra intestinal presentation of amoebiasis. • It is often called as tropical abscess.

  34. Infection commonly occurs from the caecum after an attack of amebic typhlitis (inflammation of the caecum) through the superior mesenteric vein and portal vein. • Infection from sigmoid (rectosigmoid) colon spreads through the inferior mesenteric vein and portal vein to liver. • Right lobe is commonly involved over postero-superior surface (because of streamline effect and larger size of the right lobe).

  35. Trophozoites destroy the hepatocytes by releasing histiolysin, a cytolytic agent. It causes amoebic hepatitis with multiple micro abscess formation. It leads into liquefaction necrosis, thrombosis of blood vessels, release and breaking of red cells. • It causes formation of “Anchovy sauce’ pus which is chocolate brown coloured and odourless (Anchovy sauce is sauce prepared from a type of fish). • Pus may be green coloured if mixed with bile. Secondary infection is common (30%).

  36. In western countries pyogenic abscess is much more common. Amebic abscess is much more common than pyogenic abscess in endemic areas like Indian subcontinent and Africa. • Amebic abscess is usually sterile unless infected. • Trophozoitesare found in the wall of the abscess not in the content

  37. Pathology:- • Initially from infected recto-sigmoid or ileocaecal region, amoebic trophozoites reach the liver through portal veins causing amoebic hepatitis, may be in the form of micro-abscesses all over the liver. • This might resolve on its own or with antiamoebicdrugs, but often leads to a localized amoebic liver abscess

  38. Spread of trophozoites occurs from ileocaecal region and sigmoid through mesenteric vessels.

  39. In 70% of cases it is single large abscess, in 30% it is multiple, may involve both lobes. • Problems and difficulties in treating, in addition to poor prognosis are more common in multiple abscesses. • Amoebic liver abscess is more common in right posterior-superior region (80%) because of streamline effect i.ethe portal vein is in direct continuation with the right branch. It can be multiloculated also.

  40. Pus is chocolate coloured, classically called as anchovy—sauce, contains dead liver cells, RBC’s, necrotic material. • Pus may be green due to bile admixture. • Often secondary infection by E. coli, staph, strepto may occur (30%) and so may present with features of pyogenic liver abscess. • Because of perihepatitis, liver is fixed to diaphragm or abdominal wall, hyperaemiain the diaphragm causes sympathetic pleural effusion on right side.

  41. Anchovy sauce pus seen in amoebic liver abscess

  42. Commonly amoebic abscess presents as an acute entity, but it can also be present as chronic type where it is covered by a capsule, that remains dormant for a long period. • Sometimes it can get calcified also.

  43. Course and Sequelae of Amoebic Liver Abscess:- • It can rupture into lungs leading to expectoration of chocolate-colouredsputum resulting in natural regression of abscess—commonest site of rupture. • It can rupture into the peritoneum causing peritonitis which requires emergency laparotomy.

  44. It can rupture into pleural cavity leading to empyema. • Rupture into bronchus can cause bronchopleural fistula leading into coughing out of Anchovy sauce pus. • Rupture into bare-area of liver causing retro-peritoneal abscess. • Rupture into the intestines, or to the skin (Amoebiasis cutis).

  45. Most dangerous complication is rupture into pericardial cavity (cardiac tamponade) which has very high mortality requiring emergency thoracotomy and pericardial decompression. • Septicaemiaand liver failure can occur in a patient with amoebic liver abscess with cirrhosis.

  46. Clinical Features:- • It is common in males (20:1), may be after an attack of amoebic dysentery or many months after the attack or history of dysentery may not be there at all. • They present with fever, loss of weight, chills and rigors, non productive cough, shoulder pain. • Pain in the right hypochondrium.

  47. Soft, tender, smooth, liver with increased liver span. • Intercostal tenderness is elicited which is a useful clinical sign. • Right sided pleural effusion may be evident. • Mild jaundice is not uncommon especially in cirrhoticsand multiple abscesses which may signify poor prognosis. • Tenderness, rigidity and skin oedema in right hypochondriummay be present in acute cases. • In chronic amoebic liver abscess, smooth, firm/hard, nontenderliver may be palpable.

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