2. Liver traumatic injury 92-7-7

3. Introduction The liver is the most commonly injured abdominal organ after penetrating and blunt trauma Blunt abdominal trauma-- most common cause of injuries, 95 % secondary to vehicle accident

4. Anatomy

5. Mechanism of injury(1) Deceleration injury --producing a laceration of its relatively thin capsule and parenchyma at the sites of attachment to the diaphragm --usually tears between the post. sector(segments VI, VII ) and the ant. sectors(segments V,VIII ) of the R ’ t lobe

6. Mechanism of injury(2) Crush injury --direct blow to the abdomen --damage to the central portion of the liver (segments IV, V, VIII)

7. Grading system(1) American Association for the surgery of trauma organ injury scale:liver *Advance one grade for multiple injuries, up to grade III.

8. Grading system(2) Grade I,II ---minor injuries, represent 80-90% of all injuries, require minimal or no operative treatment Grade III-V -- severe,require surgical intervention Grade IV --incompatible with survival

9. Assessment and initial investigation A conscious p ’ t, hemodynamically unstable with generalized peritonism →laparotomy without investigation Neurologically impaired or physical sign are equivocal →Diagnostic peritoneal lavage(DPL) and laparotomy performed if the test is positive Hemodynamically stable →further radiological assessment

10. Diagnosis of liver injury DPL --fast, sensitive, accurate and simple to perform --invasive, cannot diagnose retroperitoneal injury X-ray --nonspecific, but useful in showing the extent of associated skeletal trauma Ultrasonography --fast, accurate, noninvasive, a good initial screening test --sensitivity 88%, specificity 99%, accuracy 97%

11. Ultrosonography

12. Computed tomography(1) The standard evaluation method for stable p ’ t Performed with Dilute water soluble oral contrast agent and intravenous contrast

13. Computed tomography(2)

14. Computed tomography(3)

15. Non-operative management 86% of liver injuries stopped bleeding by the time of surgical exploration 67% of operations performed are nontherapeutic Standard method of pediatric p ’ t for the past 20 years, with a success rate of 90% For 50-82% of adult p ’ t more serious injuries (Grade III,IV) have been successfully managed without surgery

16. Non-operative management Criteria --hemodynamically stable --simple hepatic parenchyma laceration of inrahepatic hematoma --absence of active hemorrhage --hemoperitoneum of less than 500ml --limited need for liver related blood transfusions (12U) --absence of peritoneal sign --absence of other peritoneal injuries that would otherwise require an operation

17. Non-operative management Criteria --good quality CT scans --experienced radiologist --intensive care setting Currently believe that ultimate decisive factor should be the hemodynamic stability at presentation or after initial resuscitation, irrespective of the grade of injury on CT or the amount of hemoperitoneum

18. Non-operative management --Arteriography is useful in selected patients after operative perihepatic packing who have postoperative evidence of ongoing haemorrhage. --Biliary endoscopy may be helpful in the diagnosis and treatment of complications secondary to complex liver injury Complication --delayed hemorrhage, biliary fistula and liver abscess, hemobilia and bilhemia, extrahepatic bile duct stricture

19. Non-operative management Complication --Delayed hemorrhage ‧ most common, usual indication for a delayed operation ‧ under strict guidelines, the incidence ranges from 0-5%, and blood transfusions were required in fewer than 20% ‧ common errors:(1)assuming that the hemorrhage is not related to the liver (2)multiple(more than four)blood transfusions in the hope that it will stop (3)misreading CT and underestimating hemoperitoneum and active bleeding

20. Non-operative management

21. Complication --biliary fistula and liver abscess ‧ ranges from 0.5-20% ‧ success rate 70% with percutaneous technique ‧ more aggressive surgical treatment may be considered --Hemobilia ‧ 1%,iatrogenic causes most common ‧ injury causes communication between the biliary tract and blood vessels ‧ abdominal trauma, jaundice, RUQ colicky pain and blood in vomitus or stool point to this diagnosis ‧ managed by percutaneous selective hepatic a. embolization or surgical intervention

22. Non-operative management Complication --bilihemia ‧ rare complication of severe decelerationon injury, in which the hepatic venules and the intrahepatic bile ducts rupture ‧ excessive bilirubin level ‧ endoscopic sphincterotomy and biliary endostenting --Extrahepatic bile duct stricture ‧ the incidence is higher than the past ‧ no uniformity of treatment criteria

23. Non-operative management Mortality rate --7-13% with most resulting from associated injuries --0-0.4% resulting from liver itself

24. Non-operative management In haemodynamically stable patients with blunt hepatic injury, an expeditious abdominal CT scan and a proper classification using the AAST Organ Injury Scale will facilitate non-operative management and the development of protocols. haemodynamic stability rather than findings on CT determines which patients should be managed conservatively in haemodynamically stable patients less treatment is probably the best treatment most blunt hepatic injuries can be managed without operation with minimal morbidity and mortality rates

25. Non-operative management increasing transfusion requirements should be regarded with suspicion the interventional radiologist should be part of the treatment team when conservative management fails, abbreviated laparotomy and planned reoperation should be considered at an early point during surgery most complications should be managed in a non- operative fashion unless clear surgical indications are present.

26. Operative management Initial control of bleeding achieved with temporary tamponade using packs, portal triad occlusion(Pringle manoeuvre), bimanual compression of the liver or even manual compression abdominal aorta above celiac trunk If hemorrhage is unaffected by portal triad occlusion(Pringle manoeuvre) by digital compression or vascular clamp, major vena cava injury or atypical vascular anatomy should be expected

27. Operative management Hepatotomy with direct suture ligation --using the finger fracture technique, electrocautery or an ultrasonic dissector to expose damaged vessels and hepatic duct which ligated, clipped or repaired --low incidence of rebleeding, necrosis and sepsis --effectives following blunt liver trauma requires further evaluation

28. Operative management Resection debridement --removal devitalized tissue --rapid compared with standard anatomical resection, which are more time consuming and remove more normal liver parenchyma --reduced risk of post-op sepsis secondary hemorrhage and bile leakage

29. Operative management Anatomical resection --reserved for deep laceration involving major vessels or bile ducts, extensive devascularization and major hepatic venous bleeding Perihepatic packing --Indication:coagulopathy, irreversible shock from blood loss (10u), hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries

30. Perihepatic packing

31. Operative management Mesh rapping --new technique for grade III,IV laceration, tamponading large intrahepatic hematomas --not indicated where juxtacaval or hepatic vein injury is suspected

32. Mesh rapping

33. Operative management Omental packing Intrahepatic tamponade with penrose drains Fibrin glue Retrohepatic venous injuries --Total vascular exclusion --venovenous bypass --Atriocaval shunting Liver transplantation

34. Operative management Complication --Hemorrhage,sepsis --Biliary fistula --Respiratory problems --Liver failure --Hyperpyrexia --Acalculous cholecystitis --Pancreatic, duodenal of small bowel fistula --Drainage of intra-abdominal abscess or bilioma under ultrasonography or CT guidance and embolization of AV fistula and deep bleeding vessels

35. Conclusion Optium results need a specialist team -experienced liver surgeon, and anaesthetist used to dealing with the coagulopathyof liver disease -interventional hepatobiliary radiologist and endoscpoist to manage post-op complication -rapid infusers, cell savers and venovenous bypass to deal with massive blood loss -Appropriate intensive care facilities -perihepatic packs to control hemorrhage -hepatotomy with direct suture ligation or resection debridement was preferred

36. Reference --Management of liver trauma R.W. Parks, E. Chrysos and T. Diamond British Journal os Surgery 1999,86,112-1135 --Non-operative management of blunt hepatic trauma E. H. CARRILLO*, A. PLATZ†‡, F. B. MILLER*, J. D. RICHARDSON* and H. C. POLK JR British Journal of Surgery 1998, 85, 461–468 -- Liver, Trauma http://www.emedicine.com/radio/topic397.htm

37. INJURY TO THE BILIARY TRACT Injuries to the gallbladder are uncommon. Penetrating injuries are usually caused by gunshot wounds or stab wounds, and rarely by a needle biopsy procedure of the liver. Nonpenetrating trauma is extremely rare. These types of injury to the gallbladder include contusion, avulsion, laceration, rupture, andtraumatic cholecystitis. The treatment of choice is cholecystectomy, and the prognosis is directly related to the type and incidence of associated injury.

38. Extrahepatic Bile Ducts The great majority of injuries of the extrahepatic biliary duct system are iatrogenic, occurring in the course of laparoscopic or open cholecystectomies. 72 Less commonly, biliary injury is associated with common bile duct exploration, division or mobilization of the duodenum during gastrectomy, and dissection of the hepatic nhilum during liver resections. The exact incidence of bile duct injury during cholecystectomy is unknown, but data suggest that during open cholecystectomy, the incidence is relatively low (about 0.1% to 0.2%). However, the incidence during laparoscopic cholecystectomy, as derived from state and national databases, estimates the rate of major injury to range between 0.1% to 0.55%, and the incidence of minor injuries and bile leaks to be about 0.3%, a total of 0.85%. Limited view, difficult orientation and assessment of depth on a two- dimensional image, and the lack of tactile sensation and unusual manual skills that are needed have led to the rise in bile duct injury during laparoscopic cholecystectomy.

39. Extrahepatic Bile Ducts A number of different factors are associated with bile duct injury during laparoscopic cholecystectomy. These include acute or chronic inflammation, obesity, anatomic variations, and bleeding. Surgical technique with inadequate exposure and failure to identify structures before ligating or dividing them are themost common cause of significant biliary injury. The bile ducts may be narrow and can be mistaken for the cystic duct. The cystic duct may run along side the common bile duct before joining it, leading the surgeon to the wrong place. Additionally, the cystic duct may enter the right hepatic duct, and the right hepatic duct may run aberrantly, coursing through the triangle of Calot and entering the common hepatic duct.

40. Extrahepatic Bile Ducts A number of intraoperative technical factors have been implicated in biliary injuries. Excessive cephalad retraction of the gallbladder may align the cystic duct with the common bile duct, and the latter is then mistaken for the cystic duct and clipped and divided. The use of an angled laparoscope instead of an end-viewing one will help visualize the anatomic structures, in particular those around the triangle of Calot. An angled scope also will aid in the proper placement of clips. Careless use of electrocautery may lead to thermal injury. Dissection deep into the liver parenchyma may cause injury to intrahepatic ducts, and poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile duct.

41. Extrahepatic Bile Ducts The routine use of intraoperative fluoroscopic cholangiography to prevent bile duct injury is controversial. Routine use may limit the extent of injury but does not seem to prevent it entirely. Nonetheless, the frequency of bile duct injuries is cut by 50% when an intraoperative cholangiogram is performed. Critical to the successful use of cholangiography is accurate interpretation of the imaging. It is important to check that the whole biliary system fills with contrast, including both major ducts on the right and the left hepatic duct, and that there is no extravasation of contrast

42. Diagnosis. Only about 25% of major bile duct injuries (common bile duct or hepatic duct) are recognized at the time of operation. Most commonly, intraoperative bile leakage, recognition of the correct anatomy, and an abnormal cholangiogram lead to the diagnosis of a bile duct injury. More than half of patients with biliary injury will present within the first postoperative month. The remainder will present months or years later, with recurrent cholangitis or cirrhosis from a remote bile duct injury.

43. Diagnosis. In the early postoperative period, patients present either with progressive elevation of liver function tests due to an occluded or a stenosed bile duct, or with a bile leak from an injured duct. Bile leak, most commonly from the cystic duct stump, a transected aberrant right hepatic duct, or a lateral injury to the main bile duct, usually presents with pain, fever, and a mild elevation of liver function tests.

44. Diagnosis. CT scan or an ultrasound will show either a collection (biloma) in the gallbladder area or free fluid (bile) in the peritoneum (Fig. 32-24). Bilious drainage through operatively placed drains or through the wounds is abnormal. The site of the bile leak can be confirmed noninvasively with a HIDA scan. In patients with a surgical drain or a percutaneously placed catheter, injection of water-soluble contrast media through the drainage tract (sinogram) can often define the site of leakage and the anatomy of the biliary tree.

45. Diagnosis. CT scan and ultrasound also are important in the initial evaluation of the jaundiced patient, as they can demonstrate the dilated part of the biliary tree proximal to the stenosis or obstruction, and may identify the level of the extrahepatic bile duct obstruction. In the jaundiced patient with dilated intrahepatic ducts, a percutaneous cholangiogram will outline the anatomy and the proximal extent of the injury and allow decompression of the biliary tree with catheter or stent placements. An endoscopic cholangiogram demonstrates the anatomy distal to the injury and may allow the placement of stents across a stricture torelieve an obstruction (see Fig. 32-23). MRI cholangiography, if available, provides an excellent, noninvasive delineation of the biliary anatomy both proximal and distal to the injury.

46. Management. The management of bile duct injuries depends on the type, extent, and level of injury, and the time of its diagnosis. Initial proper treatment of bile duct injury diagnosed during the cholecystectomy can avoid the development of a bile duct stricture. If a major injury is discovered and an experienced biliary surgeon is not available, an external drain and, if necessary, transhepatic biliary catheters are placed, and the patient is transferred to a referral center.

47. Management. Transected bile ducts <3 mm or those draining a single hepatic segment can safely be ligated. If the injured duct is ≥4 mm, it is likely to drain multiple segments or an entire lobe, and thus needs to be reimplanted. Lateral injury to the common bile duct or the common hepatic duct, recognized at the time of surgery, is best managed with a T-tube placement. If the injury is a small incision in the duct, the T tube may be placed through it as if it were a formal choledochotomy. In more extensive lateral injuries, the T tube should be placed through a separate choledochotomy and the injury closed over the T-tube end to minimize the risk of subsequent stricture formation.

48. Management. Major bile duct injuries such as transection of the common hepatic or common bile duct are best managed at the time of injury. In many of these major injuries, the bile duct has not only been transected, but a variable length of the duct removed. This injury usually requires a biliary enteric anastomosis with a jejunal loop. Either an end-to-side Roux-en-Y choledochojejunostomy or, more commonly, a Roux-en-Y hepaticojejunostomy should be performed. Transhepatic biliary catheters are placed through the anastomosis to stent it and to provide access to the biliary tract for drainage and imaging. Although rare, when the injury is to the distal common bile duct, a choledochoduodenostomy can be performed. If there is no or minimal loss of ductal length, a duct-to-duct repair may be done over a T tube that is placed through a separate incision. It is critical to perform a tension-free anastomosis to minimize the high risk of postoperative stricture formation.66

49. Management. Cystic duct leaks can usually be managed with percutaneous drainage of intra-abdominal fluid collections followed by an endoscopic biliary stenting

50. Management. Major injuries diagnosed postoperatively require transhepatic biliary catheter placement for biliary decompression as well as percutaneous drainage of intra- abdominal bile collections, if any. When the acute inflammation has resolved 6 to 8 weeks later, operative repair is performed.

51. Management. Patients with bile duct stricture from an injury or as a sequela of previous repair usually present with either progressive elevation of liver function tests or cholangitis. The initial management usually includes transhepatic biliary drainage catheter placement for decompression as well as for defining the anatomy and the location and the extent of the damage. These catheters will also serve as useful technical aids during subsequent biliary enteric anastomosis. An anastomosis is performed between the duct proximal to the injury and a Roux loop of jejunum.

52. Management. Balloon dilatation of a stricture usually requires multiple attempts and rarely provides adequate long-term relief. Self-expanding metal or plastic stents, placed either percutaneously or endoscopically across the stricture, can provide temporary drainage and, in the high-risk patient, permanent drainage of the biliary tree.

53. Outcome. Good results can be expected in 70% to 90% of patients with bile duct injuries. The best results are obtained when the injury is recognized during the cholecystectomy and repaired by an experienced biliary tract surgeon. The operative mortality rate varies from 0% to almost 30% in various series, but commonly is about 5% to 8%.

54. Outcome. Common complications that are specific for bile duct repairs include cholangitis, external biliary fistula, bile leak, subhepatic and subphrenic abscesses, and hemobilia. Restenosis of a biliary enteric anastomosis occurs in about 10% of patients, and may manifest up to 20 years after the initial procedure. Approximately two thirds of recurrent strictures become symptomatic within 2 years after repair.

55. Outcome. The more proximal strictures are associated with a lower success rate than are distal ones. The worst results are in patients with many operative revisions and in those who have evidence of liver failure and portal hypertension. However, previous repair does not preclude successful outcome of repeated attempts, particularly in patients with good liver function. Patients with deteriorating liver function are candidates for liver transplants