classification and management of liver injury

1. Liver injury
‫طـارق‬‫المنيـزل‬
‫الكبــد‬ ‫وزراعــة‬ ‫جراحــة‬ ‫أول‬ ‫إخصائـي‬
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:
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:
1. Bile leak.
2. Abscess.
3. Hemorrhage.
4. Devascularization of liver segment.
5. Hemobilia.
6. 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 :
1. Hemodynamic instability.
2. Presence of concomitant internal injury.
3. 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 24 -48 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 :
a) Packing of the tract with omentum .
b) Packing the tract with gelatin sponge covered with rolled cellulose.
c) 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:
1. Isolated liver injury.
2. No neurological compromise.
3. Hemodynamic stability.
4. Corrected coagulopathy.
5. 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 :
1. Bleeding.
2. Abdominal compartment.
3. Hemobilia.
4. Bilhemia.
5. Biliary fistula(external , internal, thoracobiliary).
6. 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
Stable
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 if pain or
jaundice
Grade 4,5,6
Repeat CT Scan 1 month
Not healed
Light duty -Repeat
CT Scan 1 month
until healed
healed
Ad lib activity

57. Thank you