Trauma: Liver Trauma

Liver Trauma

General

  • The Most Commonly Injured Intraabdominal Organ Overall
  • Most Common Injured Intraabdominal Organ in Blunt Trauma

AAST Liver Injury Scale (2018 Revision) Mn

Liver Trauma 1

Grade I 2

Grade II 2

Grade III 3

Grade IV 4

Grade V 5

Initial Management

  • Unstable: Laparotomy
    • Diffuse Peritonitis Indicates Bowel Injury & Warrants Laparotomy – Diffuse Peritonitis Should Never be Attributed to Solid Organ Injury as Isolated Hemoperitoneum Should Not Cause Diffuse Peritoneal Irritation
  • Transient Responder: Angioembolization
  • Stable: CT
    • Active Extravasation or Pseudoaneurysm: Angioembolization (93% Success Rate)
    • Nonoperative Management Otherwise (< 10% Failure Rates)
  • If Angioembolization Fails: Laparotomy

Nonoperative Management Complications

  • Early: Hemorrhage & Abdominal Compartment Syndrome
  • Late: Biliary (Biloma/Fistula) & Infection (Perihepatic Sepsis/Abscess)

Liver Trauma – Surgical Management

Exposure

  • Divide Falciform Ligament – Visualize Superior or Lateral Aspects
  • Divide Triangular Ligaments – Further Mobilize the Right/Left Lobes
    • If Stable Hematoma Noted Within Triangular Ligament: Do Not Enter
      • Concern for Hepatic Vein or IVC Injury

Achieving Initial Surgical Hemostasis

  • Initial: Manual Compression Until Resuscitated
    • *Most Liver Bleeding is Venous
  • If Significant Hemorrhage After Release: Pringle Maneuver
    • 85% Success in Complex Injuries
    • Up to 75 Minutes Without Adverse Sequelae
    • Failure Raises Concern for Hepatic Vein/IVC Injury
  • Options if Still Bleeding After Pringle Maneuver:
    • Total Hepatic Isolation – Involves Pringle Maneuver, Infrahepatic IVC Occlusion & Suprahepatic IVC Occlusion
      • Also Consider Supraceliac Aortic Occlusion – Abdominal Blood Flow Will Be Lost from Circulation Above the Diaphragm
    • Atriocaval (Schrock) Shunt

Atriocaval (Schrock) Shunt

  • Consider for Retrohepatic Venous Injury
  • Shunt from IVC to Right Atrium
  • Technique:
    • Pringle Maneuver
    • Median Sternotomy
    • Prepare Shunt
      • Chest Tube – Cut a Hole 20 cm from the Nearest Drainage Hole
      • Endotracheal Tube – Cut a Hole 17-18 cm from the Nearest Hole Past the Balloon
    • Control Perihepatic IVC with Rumel Tourniquets:
      • Control Suprarenal IVC (Omit Step if Using an ETT)
      • Control Intrapericardial IVC
    • Insert the Shunt Through a Right Atrial Incision
      • Apply a Partially Occluding Clamp on the Right Atrial Appendage
      • Place a Purse-String Suture
      • Create an Incision Between the Purse-String
      • Remove the Clamp
      • Insert the Shunt Through the Incision
    • Palpate the Tube terminating in the Correct Infrarenal Position
      • All Shunt Holes Should Be Outside the Area of Vascular Isolation
    • Secure all Purse-Strings, Tourniquets or Inflated Balloons

Pringle Maneuver 6

Total Hepatic Isolation 7

Surgical Treatment

  • Subcapsular Hematoma: Leave
  • Minor Injuries (Grade I-II)
    • Initial: Simple Techniques
      • Techniques:
        • Manual Compression (5-10 Minutes)
        • Topical Agents (Fibrin Glue/Surgicel)
        • Electrocautery/Argon Beam Electrocoagulation
      • If Successful – No Further Intervention
      • No Drain Needed if No Obvious Bile Leakage
    • Superficial Laceration: Suture Hepatorrhaphy
      • Liver Suture – Absorbable & Blunt Tipped Needle
        • 0 Chromic Commonly Used
        • Small Suture Can Tear Glisson’s Capsule & Worsen Bleeding
        • Tapered/Cutting Needles Can Cause Damage to Vascular or Biliary Structures
    • Deep Laceration: Omental Packing & Loosely Approximate Edges
  • Complex Injuries (Grade III-V): Hepatectomy
    • Finger Fracture Technique
      • Glisson’s Capsule Incised Towards Injury
      • Parenchyma Fractured Between Thumb and Forefinger
      • Rapidly Exposes Lacerated Vessels and Bile Ducts for Direct Ligation/Repair
    • Debride Devascularized Tissue Once Hemostasis Achieved
    • Consider Omental Pedicle Packing
    • Leave Closed-Suction Drains
  • Juxtahepatic Venous Injury (Grade V): Perihepatic Packing
    • If Controlled – No Further Intervention Indicated
    • Consider Endovascular Stent When Stable Before Packing Removal
    • Other Options:
      • Direct Hepatectomy (Finger Fracture Through Cantlie’s Line) to Reach Injury
      • Venovenous Bypass with Vascular Exclusion & Primary Repair
    • Last Resort: Total Hepatectomy & Delayed Liver TXP
  • Damage Control: Perihepatic Packing & Planned Reexploration

Portal Triad Injury

  • CBD Injury
    • < 50% Circumference: Primary Repair (Over T-Tube)
    • > 50% Circumference: Roux-en-Y Hepaticojejunostomy
    • Delayed Biloma: Percutaneous Drain
  • Portal Vein Injury: Lateral Venorrhaphy
    • If Emergent: Portal Vein Ligation
    • May Require Pancreas Neck Division to Access
  • Hepatic Artery Injury: Ligation
    • Concurrent Cholecystectomy Mandatory
    • Increased Risk for Hepatic Abscess

Mnemonics

Liver Injury Grading

  • I/II/III: 1/2/3 cm Depth

References

  1. Latifi R, Khalaf H. Selective vascular isolation of the liver as part of initial damage control for grade 5 liver injuries: Shouldn’t we use it more frequently? Int J Surg Case Rep. 2015;6C:292-5. (License: CC BY-NC-SA-3.0)
  2. Parray FQ, Wani ML, Malik AA, Thakur N, Wani RA, Naqash SH, Chowdri NA, Wani KA, Bijli AH, Irshad I, Nayeem-Ul-Hassan. Evaluating a conservative approach to managing liver injuries in Kashmir, India. J Emerg Trauma Shock. 2011 Oct;4(4):483-7.(License: CC BY-NC-SA-3.0)
  3. Ghnnam WM, Almasry HN, Ghanem MA. Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia. Int J Crit Illn Inj Sci. 2013 Apr;3(2):118-23. (License: CC BY-NC-SA-3.0)
  4. Zago TM, Tavares Pereira BM, Araujo Calderan TR, Godinho M, Nascimento B, Fraga GP. Nonoperative management for patients with grade IV blunt hepatic trauma. World J Emerg Surg. 2012 Aug 22;7 Suppl 1(Suppl 1):S8. (License: CC BY-2.0)
  5. Tugnoli G, Cinquantini F, Coniglio C, Biscardi A, Piccinini A, Gordini G, Di Saverio S. “The best is nothing”: Non-operative management of hemodynamically stable grade V liver trauma. J Emerg Trauma Shock. 2015 Oct-Dec;8(4):239-40.(License: CC BY-NC-SA-3.0)
  6. Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, Peitzman AB, Rizoli S, Tugnoli G, Sartelli M, Manfredi R, Ansaloni L. Liver trauma: WSES position paper. World J Emerg Surg. 2015 Aug 25;10:39. (License: CC BY-4.0)
  7. Ho MH, Chen TW, Ou KW, Yu JC, Hsieh CB. Rescue strategy for advanced liver malignancy with retrohepatic inferior vena cava thrombi: experience to promote surgical oncological benefit. World J Surg Oncol. 2017 Apr 12;15(1):83. (License: CC BY-4.0)