Liver trauma

Portal triad

Blood supply

Liver trauma is divided into:

• Blunt and
• Penetrating injuries

• Blunt injury produces contusion, laceration and avulsion injury.
• Penetrating injuries (like stab and gunshot wounds are often associated with chest or pericardial involvement.

Blunt force-liver injury

Penetrating injuries

Clinical features

• Features of shock due to severe bleeding.(pallor, hypotension, tachycardia, sweating)
• Distension of abdomen with dull flank, guarding, tenderness and rigidity.
• Oliguria
• Tachypnoea, respiratory distress and often cyanosis.
• Rupture of right lobe is more common than the left lobe leading to haemoperitoneum.
• Occasionally can cause localised hematoma which may form an abscess.
• Bile leak from the injured site can lead to biliary peritonitis.

Investigations

• Chest X-ray to look for the rib fracture.
• USG abdomen
• CT scan of chest and abdomen
• Diagnostic peritoneal lavage
• Hb%, PCV, blood groouping and cross matching.
• Arterial blood gas analysis (ABG)
• Coagulation profile.

Treatment :

General measures

Maintain airway
Breathing
Circulation-

• I.V fluids, blood transfusion (massive), FFP
• Have both central and peripheral venous access.
• Bladder catheterization to measure the urine output

Specific treatment

• Laparotomy is done through a large abdominal incision or thoracoabdominal incision, and extent of liver injury and also other associated injuries are looked for.
• Small liver tear is sutured with absorbable sutures with placing of gel foam to control bleeding.
• To control intraoperative bleeding, from hepatic artery and portal vein, both are temporarily occluded using fingers, compressing at foramen of Winslow. Often bull-dog clamp or vascular clamps can be used.
• In deep severe injuries, following methods are used:

1. Hepatic artery ligation
2. Segmental resection
3. Hemihepatectomy
4. Packing the liver temporarily with mops.

• Cholecystectomy and placement of “T” tube in CBD
• In associated IVC injuries , it is very difficult to manage. A veno-venous bypass between femoral vein  and SVC is done and then repair of IVC is carried out.
• ICT placement to thorax and repair of diaphragmatic injury.

Post operatively patients require:

• Ventilator support
• Blood transfusion
• Electrolyte management
• Antibiotics
• FFP, cryoprecipitate

Complications and Sequelae of liver injury

• Shock and haemorrhage
• Intrahepatic haematoma
• Liver abscess and septicaemia
• Bile leak, biliary peritonitis, biliary fistulas
• Disseminated intravascular coagulation
• Hepatic artery aneurysm
• Arterio-venous fistula
• Arterio-biliary fistula
• Electrolyte imbalance
• Liver failure
• Late sequelae
• CBD stricture