LIVER INJURIES PROFF. S.FLORET

Transcription

1 LIVER INJURIES PROFF. S.FLORET

2 Abdominal injuries For anatomical consideration: Abdomen can be divided in four areas Intra thoracic abdomen True abdomen Pelvic abdomen Retroperitoneal abdomen

3 ETIOLOGY Penetrating Trauma Blunt trauma Iatrogenic injuries

4 PENETRATING INJURY Stab Wound Gun Shot Injury Blast Injuries

5 BLUNT INJURY Road Traffic Accidents Fall From Height Crush Injuries Sport Injuries Violence

6 IATROGENIC INJURY Endoscopic External Cardiac Message Peritoneal Dialysis Paracentesis Liver Biopsy Barium Enema

7 Primary survey A Air way management B Breathing C Circulation D Disability E Exposure

8 Abdominal Trauma: Examination Inspection: Abdominal distension Movement of Abdominal wall Discoloration of skin Record all external marks of injury Record entry & exit site of bullet injury.

9 PALPATION Look for tenderness/rigidity/guarding Spine tenderness Pelvic compression test &compression of lower chest wall Per rectal examination

10 Examination (cont) PERCUSSION: Look for free fluid AUSCULTATION: Bowel sounds.

11 Investigations Lab investigations: Haematocrit estimation Urine analysis Serum Amylase estimation Other routine lab test for base line

12 Radiological Investigations X ray chest erect for fracture ribs & free gas under diaphragm X ray Abdomen supine for bowel gas pattern & psoas shadow

13 Peritoneal Lavage INDICATIONS: Unconscious patient Patients with high energy transfer with equivocal physical signs Multiple injury with unexplained shock Pts. With spinal cord injury Intoxicated Pts. Pts. with suspected abdominal injury undergoing surgery for other condition

14 DPL CONTRAINDICATIONS Previous abdominal surgery Pregnancy obesity Patient with obvious surgical abdomen

15 DPL Positive DPL Aspiration of gross blood RBC count > /cumm(for stab wound >1000RBC/cumm) WBC count >500/cumm Amylase>200 units Presence of bile, faces or bacteria

16 DPL Limitations False + ve in 20% of cases mainly in pelvic fractures Does not differentiate between solid organ & hallow viscus injuries

17 CT abdomen Indicated in haemodynamically stable patients, To identify & grade solid organ injuries To diagnose retroperitoneal injuries To follow patients of solid organ injuries treated conservatively

18 CT abdomen draw backs Expensive Requires to Radiology Department Low sensitivity to diagnose bowel or diaphragmatic injuries

19 DIAGNOSTIC LAPAROSCOPY ( gas less laparoscopy ) To identify peritoneal violation in anterior or flank stab wounds To identify diaphragmatic injuries

20 Ultra sonography (FAST) To evaluate presence of haemoperitoneum in blunt abdominal trauma FAST means focused abdominal sono tomography

21 FAST Positive FAST in unstable trauma patients indicates the need for laparotomy without any further tests. Negative FAST means source of bleed is from other than abdomen

22 FAST ADVANTAGES:.Rapid, Fast, Cheap..Non invasive, no radiation.. Can be performed at bed side.. No need to shift patient to radiology.

23 FAST: Limitations Obesity Gas interposition Subcutaneous emphysema Operator dependent

24 Management Conservative Operative

25 Conservative management by observation Haemodynamically stable patients with blunt abdominal trauma with mild to moderate grade of solid organ injuries Hollow viscus injuries must have been ruled out

26 Operative Management Laparotomy indicated if signs of peritoneal irritation unexplained shock evisceration of viscus + ve DPL Deterioration during observation Gunshot wounds Stab wound with penetration of peritoneum

27 LIVER INJURIES Liver injuries are uncommon because of the the liver s position under diaphragm and its protection by the chest wall.

28 Liver trauma can be divided into: BLUNT trauma PENETRATING trauma

29 ΩBLUNT TRAUMA: contusions Laceration and avulsion injuries to liver Spleen and kidney often involved in blunt trauma. Ω PENETRATING TRAUMA: stab wound gunshot wound

30 DIAGNOSIS OF LIVER INJURY The liver is an extremely well vascularised organ. Major early complication is blood loss where massive bleeding leads to rapid development of coagulopathy. In lower chest & upper abdomen wound, if large amount of blood tranfusion is required, then suspect liver injury. Severe crushing injury to lower chest & upper abdomen can result in Injury to

31 INVESTIGATION Haemodynamically stable pts should have Oral & intravenous contrast enhanced CT scan of chest & abdomen It will show parenchymal damage to liver or spleen as well to feeding vessels. The chest scan excludes injuries to great vessels & lung parenchyma.

32 Additional investigations that may be of value include: PERITONEAL LAVAGE which can confirm the presence of haemoperitoneum LAPAROSCOPY which can demonstrate associated diaphragmatic rupture.

33 CT criteria for staging liver trauma Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter Grade 4 - Parenchymal/subcapsular hematoma

34 COGBILL S GRADING OF LIVER INJURIES GRADE 1 Present < 10cm < 1cm Not present GRADE 2 GRADE 3 > 10cm Massive expanding hematoma with multiple lacerations Both Lateral lobes present < 3cm > 3cm Not present Present GRADE 4 Active Bleeding, IVC And hepatic vein injury

35 Radiological Findings Associated haemo or pneumothorax A massive soft tissue shadow Deformity of dome of diaphragm due to blood clot Associated fracture rib Haemorrhage into the peritoneal cavity along the greater curvature causes opacity

36 LIVER INJURY MANAGEMENT Unstable patients laparotomy mandatory. Stable patients Selective non operative approach.

37 MANAGEMENT OF LIVER TRAUMA Remember associated injuries. At risk groups stabbing/gun shot in lower chest or upper abdomen. crush injury with multiple rib fractures. Resuscitate airway breathing circulation Assessement of injury Spiral CT with contrast laparotomy if haemodynamically unstable Treatment correct coagulopathy suture lacerations resect if major vascular injury packing if diffuse parenchymal injury.

38 Treatment Minor injuries Hepatorraphy Omentoplasty Selective hepatic arterial ligation Major Injuries Segmental resection Perrihepatic packing\shrock s atrio caval sunting, Romal tourniquet and Moore pilchers shunt for IVC injury.

39 THE SURGICAL APPROACH TO LIVER TRAUMA A rooftop incision gives excellent visualisation of liver & spleen. Stab incision suture with fine absorbable monofilament suture. Laceration of hepatic artery identified by placing, an atraumatic bulldog clamp & repair with 5/0 or 6/0 prolene suture or hepatic artery ligated,athough parenchymal necrosis & abscess may

40 Crush injuries results in large parenchymal hematoma & diffuse capsular laceration. Suturing usually ineffective. Packing is necessary removed after48 hrs with antibiotic cover. Refer to specialist center if there is major liver vascular injury. Venovenous bypass for IVC & hepaticvein repair. A RAPID INFUSER BLOOD TRANSFUSION

41 OTHER COMPLICATIONS OF LIVER TRAUMA Intrahepatic haematoma Liver abscess Bile collection Biliary fistula Hepatic artery aneurysm Arteriovenous fistula Arteriobiliary fistula Liver failure

42 LONG TERM OUTCOME OF LIVER TRAUMA Capacity of liver to recover from extensive trauma is remarkable. Parenchymal regeneration is rapid. Biliary tract stricture after many years Segmental or lobar stricture: Atrophy of corresponding liver parenchyma & compensatory hypertrophy of other lobe. Dominant extra hepatic bile duct stricture:

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