1. إخصائـي أول جراحــة وزراعــة الكبــد HPB and liver transplant surgeon
Liver injury
طـارق المنيـزل
إخصائـي أول جراحــة وزراعــة الكبــد
Tariq Almunaizel
HPB and liver transplant surgeon

2. Liver injury INTRODUCTION
Liver injury occurs in approximately 5% of all trauma admissions.
The liver is the most common susceptible organ for injury in blunt trauma and a frequently involved organ in penetrating trauma, due to its size and anatomic location, directly under the right costal margin.
Mortality from liver injury was as high as 62.5% in the early 20th century.
During World War II early laparotomy, drainage procedures, advances in anesthetic and aseptic care, as well as transfusion technology improve mortality to 27.7%.

3. ANATOMY
Comprehensive knowledge of hepatic anatomy is essential to the proper management of traumatic liver injuries.  
Lobes
The liver is divided into 2 lobes by Cantlie’s line, which is a line with a 75° angle traversing from the gallbladder fossa posteriorly to the left side of the inferior vena cava. 
So the right lobe formed of S5,6,7 and 8 , while left lobe form of S2,3 and S4a-4b.
Functional Anatomy
Couinaud divid the liver based on the distribution of the hepatic veins and glissonian pedicles into 8 segments.
The right hepatic vein traverses between the right posterolateral (VI and VII) and right anteromedial (V and VIII) segments. On the left, the left hepatic vein delineates the anterior (III and IV) and posterior (II) segments. The caudate lobe (I) drains directly into the inferior vena cava.

4. Hepatic Artery
The common hepatic artery branches from the celiac artery. This provides about 25% of the hepatic blood flow and 50% of hepatic oxygenation.
The artery then branches into the gastroduodenal, right gastric, and proper hepatic. The proper hepatic is found in the porta hepatis usually to the left of the common bile duct and anterior to the portal vein. Close to the hilum of the liver, the artery bifurcates into a right (the longer branch) and a left hepatic artery.
There are a number of anatomic variances such as :
The aberrant superior mesenteric origin of the right hepatic artery traversing behind the duodenum.
The left hepatic artery origin from the left gastric artery.
The left and right hepatic arteries arising from a superior mesenteric artery origin.

5. Hepatic Veins:
The hepatic veins develop from within the hepatocytes’ central lobar veins.
The right posterior sector veins (S6 & 7) form the right hepatic vein (RHV).
Veins from S4,5 & 8 form the middle hepatic vein (MHV).
Viens from S2 &3 from the left hepatic vein (LHV)
In 90% of patients the MHV joins the LHV just before draining into the IVC.

6. Inferior vena cava:
The retrohepatic vena cava is about 8–10 cm in length. It receives the blood of the hepatic veins and also multiple small direct hepatic vessels.
In 60% of cases right inferior hepatic vein present and usually drain segment 6 .

7. Portal Vein:
The portal vein is formed from the confluence of the splenic and superior mesenteric veins directly behind the pancreatic head. It provides about 75% of hepatic blood flow and 50% of hepatic oxygen. The portal vein lies posteriorly to the hepatic artery and bile ducts as it ascends toward the liver. At the parenchyma, the portal vein divides into a short right and a longer left extrahepatic branch.

8. Ligaments:
The coronary ligaments attach the diaphragm to the parietal surface of the liver.
The triangular ligaments are at the lateral extensions of the right and left coronary ligaments.
The falciform ligament with the underlying ligamentum teres attaches to the anterior peritoneal cavity.

10. LIVER INJURY INCIDENCE AND CLASSIFICATION
Liver injury occurs in approximately 5% of all trauma admissions. Since the liver is the largest intra-abdominal organ, it is the most commonly injured solid organ in blunt and penetrating injury.

11. INITIAL MANAGEMENT
Care for the patient with possible liver injury should proceed by the tenants of Advanced Trauma Life Support (ATLS) , airway, breathing, and circulation.
Physical exam may reveal hypotension, tachycardia, peritoneal signs, penetrating injury, or increasing distention.

12. Diagnosis DIAGNOSIS OF LIVER INJURY Include evaluation of:
Include evaluation of:
1- Hemodynamically Unstable Patient
2- Hemodynamically Stable Patient

13. Diagnosis 1- Hemodynamically Unstable Patient
After primary survey and resuscitation have been initiated and the patient still be hemodynamically unstable, search for the possible causes of the continued hypovolemic shock.
The two most important modalities is:
A- diagnostic peritoneal lavage (DPL).
B- Focused abdominal sonography for trauma (FAST).

14. Diagnosis A- Diagnostic Peritoneal Lavage
DPL is a very accurate method for determining the presence of intraperitoneal blood (98% accuracy).
A positive DPL is defined as:
a gross aspiration of 10 mL of blood
or greater than 100,000 RBC/mm in at least 300 mL of irrigant.
A finding of gross blood in an unstable patient leads to immediate operative intervention.
DPL does have limitations:
It is not useful in determining the origin of the bloody aspirate and can actually be too sensitive since it is positive with minimal hemoperitoneum. Therefore, DPL has been replaced in most trauma centers by ultrasound and in more stable patients by computed tomography (CT) scanning.

15. Diagnosis B- Focused Abdominal Sonography for Trauma (FAST)
The FAST exam has replaced DPL in many institutions for the determination of hemoperitoneum in the unstable bluntly injured patient (98% sensitivity of ultrasound for hemoperitoneum in grade III and higher liver injury).
“two most common patterns of fluid accumulation after hepatic injuries were the RUQ only and the RUQ and lower recesses.”
If the initial exam of the RUQ is negative, it is recommended that the pericardial, LUQ, and pelvic areas also be examined.
Limitation: FAST are unable to distinguish between different grades of hepatic injury by ultrasound.

16. Diagnosis 2- Hemodynamically Stable Patient
Ultrasound and CT scanning are the mainstays of diagnosing hepatic injury in the hemodynamically stable but bluntly injured patient.
A- CT Scanning
Trauma surgeons now use CT scans for diagnosis and for management decisions in liver injuries. Being able to grade the extent of injury and to follow an existing injury , also can determine if nonoperative management is possible and successful .

17. Diagnosis B- Laparoscopy
Laparoscopy has been successfully used to diagnose peritoneal penetration of penetrating trauma, thus saving the patient from a nontherapeutic exploratory laparotomy.

18. Diagnosis
CT scan Grading of liver injury, depends on the presence 4 factors: 1- Liver laceration ( depth, length, presence of active bleeding and heptic parenchymal disruption). 2- Subcapsular hematoma ( size, Expansion, ruptured and the presence of active bleeding). 3- Intraparenchymal hematoma ( size, Expansion, ruptured and the presence of active bleeding). 4- Major Vascular Injury (retrohepatic IVC, Hepatic veins, and Hilar vessels). *(Advance one grade for multiple injuries, up to grade III)

19. Grade-I Liver injury

20. Grade-II Liver injury

21. Grade-III Liver injury

22. Grade-IV Liver injury

23. Grade-V Liver injury

24. Grade-VI Liver injury

25. Management of liver trauma :
Blunt trauma: Due to the presence of fibrous covering around the portal triad , artries ,portal vein and bile duct are usually protected , and the hepatic veins are the primary structures injured in blunt trauma due to the lack of these fibrous structures . Penetrating trauma: Involve both hepatic veins and portal triad structures with transection of any structure in the trajectory.

26. Hemodynamically stable patients with blunt injury :
85-89% of the patients with blunt liver injury are stable and are candidate for nonoperative management .
This due to the fact that most blunt injuries result in hepatic venous injury that are low pressure (3-5 cm H2O), and the hemorrhage stops once a clot forms on the area of disruption.

27. High grade injury , large hemoperitoneum (3-5 U of blood), presence of contrast extravasation and pseudoaneurysm are not a contraindication for non operative management .
However these patient are at higher risk for failure of nonoperative management and may need a multimodality approach.
Failure rate increases with increase in the grade of injury .
Presnce of contrast extravasation (blush) for example was considered a contraindication for nonoperative management , however with the aid of interventional radiology , some patients are candidate for angioembolisation and nonoperative management.

28. Complications of nonoperative blunt hepatic injury :
Most patients with nonoperative blunt hepatic injury heal without complications and show complete resolution within 4 months.
15% show complete resolution at hospital discharge.
Complications include:
Bile leak.
Abscess.
Hemorrhage.
Devascularization of liver segment.
Hemobilia.
Compartment syndrome of the liver.

29. 1- Bile leak:
One of the most common complication , occur in 3-20 % of patients , especially with higher grades ( < or = III).
management usally require :
Percatanous biloma drainage .
ERCP with endobiliary stenting or sphincterotomy to decrease biliary pressure and allow healing.
Occasionaly surgical intervention.

30. 2- Abscess :
Management usally by percatneous drainage .
Surgical drainage and hepatic debridment if the patients fail to improve with percatneous drainage and antibiotis.

31. 3- hemorrhage :
Delayed hemorrhage from ruptured hematoma may occur in up to 14% of patients , however most of these cases can be managed nonoperatively if the patient remain stable and undergo angiographic embolization and observation.

32. 4- devascularization of liver segment :
This may occur due to vascular inflow disruption or post-angioembolization leading to hepatic segment necrosis .
Hepatic necrosis may result in elevation of liver transaminases , coagulopathy , bile leak , abdominal pain , food intolerance , respiratory and renal failure , and sepsis.
Diagnosis is usally made by follow up Ct scan which may show devascularized segment or the presence of air at the devascularized segment .
Many surgeon advice early hepatic resection for patients with significant necrosis before complications arises.

33. 5- Hemobilia :
Hemobilia with nonoperative management is rare , however hemobilia is more often iatrogenic and occur with operative management due to large parenchymal suturing and vascular ligation result in communication between vessels and bile ducts .
Management :
Angioembolization in patints without sepsis and small cavities .
Formal hepatic resection fo septic patients and those with large cavities.

34. 6- compartment syndrome of the liver :
Large subcapsular hematoma may result in high intraparenchymal pressure causing segmental portal hypertension and hepatofugal flow.
Budd-chiari syndrome may occur when hemmatomas result in compression of the retrohepatic IVC or HV.
Management is usually successful with percutaneous or operative drainage of the hematoma.

35. Hemodynamically stable patient penetrating hepatic injury
Criteria for nonoperative management of penetrating injury includes:
Hemodynamic stability .
No peritoneal signs.
No mental impairment.
Serial abdominal examination , close monitoring and contrast enahanced CT scan is mandatory for nonoperative management.

36. Operative management of liver injury :
Indicated in :
Hemodynamic instability.
Presence of concomitant internal injury.
Failure of nonoperative management.

37. Operative liver injury management :
A- Initial approach:
Through a midline incision .
Focus on stopping any uncontrollable bleeding by packing of the hemorrhagic area .
Clearing of the peritoneal cavity clots with laparotomy pads.
Thorough examination of the peritoneal cavity for bowel and other solid organ injury .

38. B- Minor liver injury:
Nonbleeding wounds should not be manipulated or probed.
Small wonds with minor bleeding can be controlled by electrocautery or Argon beam coagulation.
Small or moderate cavities is inspected for any bleeding vessels that can be ligated followed by omental packing or by Wrapping a column of absorbable gelatin sponge with oxidized regenerated cellulose, This is then inserted like a plug into deeper bleeding cavities.

39. C- major liver injury:
Patient with major liver injury may present with hemodynamic instability and require immediate oeperative intervention.
Once the abdomen is opened , large amount of blood may be evacuated result in the loss of the natural tamponade effect.
Immediate manual compression and adequate resuscitation is mandatory at this point .

40. Correction of fluid loss and coagulopathy is carried on before any intervention .
Thorough examination of the peritoneal cavity is followed .
After adequate resuscitation and if bleeding is localized to the liver , compression is released .
If bleeding continued , Pringle maneuver performed to decrease the bleeding .

41. Any bleeding continues after Pringle maneuver must come from the hepatic viens .

42. Hemostatic maneuvers for major parenchymal injury:
1- Packing : Perihepatick packing is a successful method to control sever liver injury . However its often usfull in control of venous bleeding but not arterial as in the case of penetrating liver injury. Packing done by placing laparotomy pads between the anterior chest wall , diaphragm and retropertoneum to compress the liver wound. It require mobilization of the liver by taking down the right and left triangular ligaments, coronary ligaments and falciform ligament.

43. Hematoma at these ligaments indicate IVC or HV injury , and the ligmaents should not be opened.
Perihepatic packing is indicated for damage control and to give time for optimization of the patient condition at the ICU.
Pack removal is done hours post packing and usually before 3 days to decrease the risk of sepsis.
Early removal may result in rebleeding and require repacking .
One of the complication of pack removal is bleeding due to adherence of the pack to the liver surface , to overcome this complication , wetting the pads with saline or the more innovative technique which suggest palcing a nonadherent plastic drape at the surface of the liver followed by the laparotomy pads .
Skin only then closed or a temporary closure device placed over the open abdomen.

44. 2- Direct suture:
Used for lacerations less then 3 cm in depth , using a large blunt tip needle with 0-chromic suture.
3- Finger fracture technique:
Used for lacerations involve larger branches of the hepatic aretery and portal vien.
In this technique the laceration is extended by finger fracture untile the bleeding vessel is identified and controlled by ligattion clipping or direct repair.
This technique may result in further bleeding while searching for the bleeding vessels.

45. Finger fracture technique:

46. 4- Omental packing :
The omentum in this technique is mobilized from the transverse colon , and from the greater curvature of the stomach preserving the the right gastroepiploic vascular pedicle and the tongue of the omentum placed at the injury defect .
This technique provide hemostasis and also a source of macrophage activity .

47. Omental packing:

48. 5- control of bleeding from a penetrating tract :
Visualization of the entire Penetrating tract is usually impossible , and the management of these injusry includes :
Packing of the tract with omentum .
Packing the tract with gelatin sponge covered with rolled cellulose.
Balloon tampnade of the tract ( a penrose drain is palceced over a hollow perforated tube and tied on both ends , the balloon inserted I n the tract and inflated with contrast agent).

49. Poggetti technique of balloon tamponade

50. d) Tamponade using foley’s catheter ( a size 16 folye’s catheter inserted in the tract and inflated, if bleeding continued its moved back or forward and inflated again until bleeding stopped , its then brought through the skin and removed 3-4 days after deflation). 6- resection: Liver resection for major liver injury is associated with high morbidity and mortality rate , and indicated in less then 10 % of the cases . Hwever with perihepatic packing and adequet resuscitation the morbididty and mortality rate decreased significantly .

51. 7- liver transplantation:
Indicated in sever liver injury .
Criteria fro transplantation in these patients include:
Isolated liver injury.
No neurological compromise.
Hemodynamic stability.
Corrected coagulopathy.
The ability of obtaining a donor organ within 36 hours of anhepatic state.

52. 8- Retrohepatic VC and HV injury : Management plane include : Direct Venous repair(associated with high mortality rate). Anatomic resection (associated with high mortality rate).. Tamponade with containment(best approach).

53. Complications of operative management :
Bleeding.
Abdominal compartment.
Hemobilia.
Bilhemia.
Biliary fistula(external , internal, thoracobiliary).
Hepatic necrosis.

54. Summary of nonoperative management
CT scan
Grade 1,2,3
Stable
Admit to the floor, observe, serial PCV
Become unstable OR
Grade 4,5,6
ICU

55. At the ICU
developed abdominal pain, jaundice, unexplained signs of infection
CT Scan
Pseudoaneurysm
angiembolization
Improved / unchanged
Search for other sources
Abdominal fluid collection
drainage

56. Outpatient managment Grade 1,2,3
Repeat CT Scan 1 month
Not healed
Light duty -Repeat CT Scan 1 month until healed
healed
Ad lib activity
Grade 1,2,3
Repeat CT Scan 1 month if pain or jaundice

57. Thank you