1. Complex liver injury (CLI) Hassan Bukhari Trauma Fellow Dec 7 th, 2010

2. Objectives You should be familiar with the following –Definition, incidence and outcome –Approach to liver injury –Role of conservative therapy and angiogram –Intraoperative approach to complex liver injury Laceration Bleeding from a missile tract Damage control strategy for CLI Juxtahepatic caval injury

3. Content Liver anatomy and mechanism of injury Mechanism, Definition, incidence and outcome Algorithms Nonoperative management: is it safe? Angiogram Intraoperative strategy –General principles –Simple/ complex laceration –Bleeding from missile tract –Damage control –Grade V liver injury (juxtahepatic caval injury)

4. Anatomy

5. Juxtahepatic cava

6. Mechanism of injury Blunt –MVC 80% –Thoracic trauma is most common associated injury –Head injury is the most significant determinant in overall mortality. Penetrating –Thoracoabdominal penetrating injury is associated with liver injury in 40%

7. Definition of CLI

9. Incidence and outcome It is infrequent –15% of all liver injuries Mortality rate –40-80% –Higher in blunt injury than penetrating injury –Exsanguination is the most immediate cause of death in CLI. –Concomitant head injury increases the mortality

10. *Current Therapy of Trauma and SCC.

11. Nonoperative management of CLI Blunt –Successful in <20% of patients with CLI. –You have to be very selective. Penetrating –Not indicated. –Some authors suggest conservative therapy for stable low grades and absence of peritonitis.

12. *Current Therapy of Trauma and SCC.

13. CLI with a blush on CTA

14. Angiogram

16. 3 scenarios where angiogram is indicated Stable patient with a blush on CT Patient was treated (operatively or non) and now is dropping H and H or having hemobilia Immediate post op following packing / damage control procedure

17. Conclusion Early angiogram (as an adjunct) decreases mortality especially in patients with grade V liver injury

18. Major hepatic necrosis

19. *Current Therapy of Trauma and SCC.

20. Operative principles Massive transfusion protocol Decide whether you are dealing with a tiny problem or a big one. Avoid hypothermia Avoid excessive crystalloid resuscitation Good exposure Consider damage control early on before it is too late (Quick In and Out) Good hemostasis and drainage. Do the minimal that fails the best.

21. Is it a damage control procedure? Decide whether you are dealing with a small vs. a big bleeder. Damage control early on before it is to late Damage control strategy –Bi-manual compression –Pringle maneuver –Perihepatic packing –Angioembolization –Atriocaval shunt

22. Important critical approaches Hepatotomy –Finger fracture, large Kelly’s clamp Hepatorrhaphy –Suture, hemostatic agents, omental patch Packing Balloon tamponade. Resection

24. GSW to Lt lobe

25. Bi-manual compression

26. Pringle maneuver

27. Bleeding stopped

29. Mobilization

30. Finger fracture

31. Exposure

32. Ligation / clip

33. Argon beam / hemostatic agent

34. Hepatorrhaphy +/- Omental flap

35. GSW to liver

36. Liver resection Usually performed when the trauma itself did the resection for you. Anatomic vs. nonanatomic resection –Anatomic resection is associated with better control of the bleeding Resection is associated with higher mobidity

37. Liver resection

38. Conclusion Liver resection should be considered as an option when dealing with CLI with no increase in mortality

39. Bleeding from through-and- through missile tract

40. Surgiflo (porcine gelatin)

41. Evicel (human fibrin)

43. Damage Control

45. Perihepatic packing

46. Bleeding controlled TO ICU –Resuscitation –Correction of the triad of death Early angioembolization

47. Bleeding did not stop Call for HB/tranplant surgeon

48. Vascular exclusion + Repair

49. Access the inaccessible Extend your incision –Thoracoabdominal –Sternotomy –Porta hepatis control (Pringle maneuver) –IVC control Suprahepatic cava control –Space of Gibben’s –Supradiaphragmatic approach Infrahepatic control –Rt medial visceral rotation

50. Schrock shunt

51. References Asensio J, Trunkey D (2008). Current Therapy of Trauma and Surgical Critical Care. Hirshberg A, Mattox K (2005).Top Knife. Trauma.org