Hapatobilliary trauma

1. Hapatobilliary trauma Dr awad al dumour Al basheer hospital

2. 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

3. Locate your liver Upper right quadrant deep to inferior ribs Dome of liver abuts aganst inferior diaphragm surface Left/right lobes Gall bladder is thin muscular sac on inferior surface where bile collects (1 above) 1. ANATOMY

4. Percuss your liver Easiest organ to percuss Dense tissue gives rock-solid sound/feel on percussion Mid-clavicular line moving inferiorly from mid-chest to lower right quadrant Measuring liver span by percussion: variation in liver span Variation in liver span according to the vertical plane of examination. Since there is variability in where clinicians determine the mid-clavicular line to be, the inevitable consequence is that liver span may also vary even if multiple observers are perfectly accurate in measuring it.

5. Portal Triad - Common Bile duct - Proper Hepatic Artery - Portal Vein

6. LIVER

7. 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.

8. 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.

9. 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.

10. Liver Segments

11. Liver Segments

12. 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.

13. 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.

14. CLASSIFICATION Penetrating wounds • Stabs wounds , gunshots…. • Level of injury • Frequency of organ injury : • Liver 37% • Small bowel 26% • Stomach 19% • Colon 17% • Major vessels & retroperitoneal structures

15. Penetrating wounds

16. CLASSIFICATION Blunt trauma • RTAs , direct blows , falls , ….. • Sudden application of pressure , seat belt syn • Frequency of organ injury • Spleen 25% • Kidney 12% • Intestine 15% • Liver 15% • Retro peritoneal haematoma 13%

17. CLASSIFICATION Iatrogenic injury Due to diagnostic & therapeutic procedures • Endoscopy • External cardiac massage • Peritoneal dialysis • Paracentesis • PTC • Liver biopsy

18. 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.

19. Classification • IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction, or devasularization. • V- Global destruction or devascularization of the liver. • VI-Hepatic avulsion

20. LIVER INJURIES • Incidence • Clinical picture • Management • Non operative • Drainage of deep lacerations Sump drain • Removal of devitalized tissue • Pringle maneuver , ? HA ligation where ? • Segmentectomy ? Lobectomy ? Packing • Repair CBD over T- tube

21. 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.

22. 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.

23. 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.

24. 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.

25. Physical examination • Ecchymosis or abrasions ,respiratory pattern • inspect urethra & perineum • Examine the back ,sprung the pelvis. • PR exam why ? • Bowel sounds • Palpation spasm & rigidity ? Rebound • Foley catheter Why ? when? • Re evaluations why ?

26. 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.

27. ADJUVANT STUDIES FOR ASSESSMENT • Laboratory studies Hct , UA , S amylase , other tests baseline • Radiological studies PFA , Erect CXR ,US , CT ? Contrast , IVU, Urethrogram , Cystogram and Angiography . • Four quadrant tap test

28. DIAGNOSTIC PERITONEAL LAVAGE • Indications of DPL • Contraindications • Technique , precautions Results are positive IF • RBCs > 100,000/cubic mm • WBCs > 5000/cubic mm • Amylase >200 units • Presence of bacteria ,bile, faeces • Rough index

29. 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.

30. 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.

31. Angiography

32. Grade I Liver Injury

33. Grade II Liver Injury

34. Grade III

35. Grade IV

36. Grade V

37. MANAGEMENT Pre hospital care Little can be done • ABC • Sterile dressing • Don't remove FB from trunk • Saline dressing over evisceration

38. MANAGEMENT cont… Hospital care • Detailed history specially in blunt trauma • Physical examination • Resuscitation • ABC • Basic blood tests, cross match, amylase • Closed monitoring • If patient is stable complete investigation

39. Biliary Injury & Laparoscopic Cholecystectomy

40. Causes of Biliary Injury in LC • Failure to properly occl. the cystic duct • Injury to the ducts in the liver bed caused by entering a plane too deep to the gallbladder • Cautery Misuse – thermal necrosisductal tissue loss • Pulling forcefully up on the gallbladder when clipping the cystic duct  tenting injury to the junction of the CBD & common hepatic duct

41. Biliary Injuries During Cholecystectomy (CCY) Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 180 (1) : 101-25. • Reviews revealed the incidence of biliary injury during open CCY to be 0.1-0.3% • 1995 – Strasberg’s study which incl. more than 124,000 laparoscopic cholecystectomies (LC) reported in the literature found the incidence of major bile duct injury to be 0.5%.

42. Diagnosis of Bile Leaks • Persistent fullness, anorexia, abdominal pain, fever & tenderness,jaundice, elev WBC • High level of suspicion following surgery • Bile draining from a drain left in the operative field

43. Radiographic Diagnosis of Biliary Injury • US/CT – detect bilomas (poss. perc drainage)

44. Radiographic Diagnosis of Biliary Injury • US/CT – detect bilomas (poss. perc drainage) • HIDA – presence of active bile leak (physiologic)

45. ERCP • Provides exact anatomical diagnosis of bile duct leak; while allowing treatment w/ decompression of the biliary tree. • Principal of treatment is to establish a pressure gradient that will favor flow into the duodenum not the leak site; may entail removal of retained stone or internal stenting +/- sphincterotomy

46. Internal stenting is currently the procedure of choice for treating bile duct leaks ( types A & D) • Cessation of bile extravasation in 70-95% of cases w/in 7 days

47. Percutaneous Transhepatic Cholangiography • Another method of non-surgical mgmt of bile leak • Usually reserved for when ERCP unsuccessful; since bile ducts of normal caliber increasing the difficulty of the procedure

48. Plastic surgery meets GI surgery • BOTOX injection to sphincter of Oddi

49. Intraoperative Injury • Strasberg D injury - (partial injury to a major duct) should be repaired at initial operation w/ T-tube drainage • Strasberg E injury - (complete transection of major duct) may be reconstructed at the initial operation w/ a R-Y hepaticojejunostomy. • *** No primary re-anastomosis secondary to ischemic factors***

50. Detection in post-op period • Abx, nutrition support, percutaneous drainage of bile collex (US or CT) • MRCP, PTC or ERCP to delineate location of injury. • Once sepsis and leaks are controlled, then may perform definitive reconstruction w/ R-Y hepaticojejunostomy Kaman et al. Management of Major Bile Duct Injuries following LC. Surg Endosc (2004)18:1196 –1199