Hapatobilliary trauma

Dr awad al dumour

Al basheer hospital

Background

Largest solid abdominal organ,fixed

position

Second most common injured, but most

common cause of death after abdominal

trauma

Blunt MVA most common

80% adults, 97% children-conservative rx

Locate your liver

Upper right quadrant deep to inferior ribs

Dome of liver abuts aganst inferior diaphragm surface

Left/right lobes

Gall bladder is thin muscular sac on inferior surface where bile collects (1 above)

1. ANATOMY

Measuring liver span by percussion: variation in liver span

Variation in liver span according to the vertical plane of examination. Since there is variability in where clinicians determine the mid-clavicular line to be, the inevitable consequence is that liver span may also vary even if multiple observers are perfectly accurate in measuring it.

Percuss your liver

Easiest organ to percuss

Dense tissue gives rock-solid sound/feel on percussion

Mid-clavicular line moving inferiorly from mid-chest to lower right quadrant

Portal Triad

- Common Bile duct

- Proper Hepatic Artery

- Portal Vein

LIVER

Anatomy

Cantile described main divisions along a

main plane from GB fossa to IVC. Divides

liver into equal halves.

Couinaud developed 4 sectors and 8

segments, divided into vertical and oblique

planes, defined by the 3 main hepatic veins

and transverse plane thru right and left

portal branches.

Anatomy

Hepatic veins lie between segments.

Left hepatc vein divides left lobe into

medial and lateral segments.

Middle hepatic vein divides liver into left

and right lobes.

Anatomy

Right hepatic vein divides right lobe into

anterior and posterior segments.

A horizontal line thru left and right main

portal veins is used to divide lobes into

inferior and superior segments.

The 8 liver segments are numbers

clockwise on the frontal view.

Liver Segments

Liver Segments

Injuries

Subcapsular hematoma or intrahepatic hematoma.

Laceration

Contusion

Hepatic vascular disruption

Bile duct injury

86% of injuries have stopped bleeding at time of exploration.

Decreased transfusion req.With conservative.

CLASSIFICATION

Penetrating wounds

Stabs wounds , gunshots….

Level of injury

Frequency of organ injury :

1. Liver 37%

2. Small bowel 26%

3. Stomach 19%

4. Colon 17%

5. Major vessels & retroperitoneal structures

Penetrating wounds

CLASSIFICATION

Blunt trauma

RTAs , direct blows , falls , …..

Sudden application of pressure , seat belt syn

Frequency of organ injury

1. Spleen 25%

2. Kidney 12%

3. Intestine 15%

4. Liver 15%

5. Retro peritoneal haematoma 13%

CLASSIFICATION

Iatrogenic injury

Due to diagnostic & therapeutic procedures

1. Endoscopy

2. External cardiac massage

3. Peritoneal dialysis

4. Paracentesis

5. PTC

6. Liver biopsy

Classification

I-Subcapsular hematoma 3cm diameter.

Classification

IV-Parenchymal/supcapsular hematoma>

10cm in diameter, lobar destruction, or

devasularization.

V- Global destruction or devascularization

of the liver.

VI-Hepatic avulsion

LIVER INJURIES

Incidence

Clinical picture

Management

1. Non operative

2. Drainage of deep lacerations Sump drain

3. Removal of devitalized tissue

4. Pringle maneuver , ? HA ligation where ?

5. Segmentectomy ? Lobectomy ? Packing

6. Repair CBD over T- tube

Pathophysiology

Friable parenchyma, thin capsule, fixed position in relation to spine.

Right lobe gets hit more since its larger, and closer to ribs.

85% injuries involve segments 6,7,8 from compressioin against ribs, spine, abd wall.

Shear forces at attachments to diaphragm

Transmission thru right hemithorax.

Pathophysiology

Liver injured easily in children since ribs

are compliant, force transmitted.

Liver not as developed in children, with

weaker connective tissue framework.

Iatrogenic injuries by biopsies, biliary

drainage, TIPS, can cause capsular tears

and bile leaks, fistulas, hemoperitoneum.

Clinical Details

Symptoms of injury are related to blood

loss, peritoneal irritation, RUQ tenderness,

and guarding.

Unrecognized delayed abcess

Bilomas

Signs of blood loss may dominate the

picture.

Clinical Details

Elevated liver tests

Biliary peritonitis (nausea, vomiting, abd pain).

DPL has high sensitivity, 1-2% complication rate.

Plain x-rays non-specific.

CT scan diagnostic procedure of choice.

Hida for leaks, angio for hemorrhage.

Physical examination

Ecchymosis or abrasions ,respiratory pattern

inspect urethra & perineum

Examine the back ,sprung the pelvis.

PR exam why ?

Bowel sounds

Palpation spasm & rigidity ? Rebound

Foley catheter Why ? when?

Re evaluations why ?

Limitations

FAST sensitivity highest (98%) for grade 3

injuries or greater. Negative findings do not

exclude hepatic injury.

Emergency sono findings demonstrating free

fluid, parenchymal injury, or both demonstrate

overall sensitivity for detection of blunt

abdominal trauma of 72%.

Angiogram may fail to detect active bleeding.

ADJUVANT STUDIES FOR

ASSESSMENT

Laboratory studies

Hct , UA , S amylase , other tests baseline

Radiological studies

PFA , Erect CXR ,US , CT ? Contrast , IVU,

Urethrogram , Cystogram and Angiography .

Four quadrant tap test

DIAGNOSTIC PERITONEAL

LAVAGE

Indications of DPL

Contraindications

Technique , precautions

Results are positive IF

1. RBCs > 100,000/cubic mm

2. WBCs > 5000/cubic mm

3. Amylase >200 units

4. Presence of bacteria ,bile, faeces

5. Rough index

CT Scans

Accurate in localizing the site of liver injury, associated injuries.

Used to monitor healing.

CT criteria for staging liver trauma uses AAST liver injury scale

Grades 1-6

Hematoma,laceration,vascular,acute bleeding,gallbladder injury,biloma.

Angiography

Demonstrates active bleeding

Transcatheter embolization may be the

only treatment required.

Findings include contusion, laceration,

hematoma, pseudoaneurysms, fistulas.

Embolization can reduce transfusion

requirements, stenting for fistulas.

Angiography

Grade I Liver Injury

Grade II Liver Injury

Grade III

Grade IV

Grade V

MANAGEMENT

Pre hospital care

Little can be done

ABC

Sterile dressing

Don't remove FB from trunk

Saline dressing over evisceration

MANAGEMENT cont…

Hospital care

Detailed history specially in blunt trauma

Physical examination

Resuscitation

1. ABC

2. Basic blood tests, cross match, amylase

3. Closed monitoring

4. If patient is stable complete investigation

Causes of Biliary Injury in LC

Failure to properly occl. the cystic duct

Injury to the ducts in the liver bed caused

by entering a plane too deep to the

gallbladder

Cautery Misuse – thermal necrosisductal

tissue loss

Pulling forcefully up on the gallbladder

when clipping the cystic duct tenting

injury to the junction of the CBD &

common hepatic duct

Biliary Injury &

Laparoscopic

Cholecystectomy

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury

during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 180 (1) :

101-25.

Reviews revealed the incidence of biliary

injury during open CCY to be 0.1-0.3%

1995 – Strasberg’s study which incl. more

than 124,000 laparoscopic

cholecystectomies (LC) reported in the

literature found the incidence of major bile

duct injury to be 0.5%.

Biliary Injuries During Cholecystectomy (CCY)

Diagnosis of Bile Leaks

Persistent fullness, anorexia, abdominal

pain, fever & tenderness,jaundice, elev

WBC

High level of suspicion following surgery

Bile draining from a drain left in the

operative field

Radiographic Diagnosis of Biliary

Injury

US/CT – detect bilomas (poss. perc drainage)

Radiographic Diagnosis of Biliary

Injury

US/CT – detect bilomas (poss. perc drainage)

HIDA – presence of active bile leak

(physiologic)

ERCP

Provides exact anatomical diagnosis of bile

duct leak; while allowing treatment w/

decompression of the biliary tree.

Principal of treatment is to establish a

pressure gradient that will favor flow into

the duodenum not the leak site; may entail

removal of retained stone or internal

stenting +/- sphincterotomy

Internal stenting is currently the procedure

of choice for treating bile duct leaks ( types

A & D)

Cessation of bile extravasation in 70-95%

of cases w/in 7 days

Percutaneous Transhepatic

Cholangiography

Another method of non-surgical mgmt of

bile leak

Usually reserved for when ERCP

unsuccessful; since bile ducts of normal

caliber increasing the difficulty of the

procedure

Plastic surgery meets GI surgery

BOTOX injection to sphincter of Oddi

Intraoperative Injury

Strasberg D injury - (partial injury to a major duct) should be repaired at initial operation w/ T-tube drainage

Strasberg E injury - (complete transection of major duct) may be reconstructed at the initial operation w/ a R-Y hepaticojejunostomy.

*** No primary re-anastomosis secondary to ischemic factors***

Detection in post-op period

Abx, nutrition support, percutaneous

drainage of bile collex (US or CT)

MRCP, PTC or ERCP to delineate location

of injury.

Once sepsis and leaks are controlled, then

may perform definitive reconstruction w/

R-Y hepaticojejunostomy Kaman et al. Management of Major Bile Duct Injuries following LC. Surg Endosc (2004)18:1196 –1199

Gallblader injury

Blunt trauma

Penetrating injury

Investigation

Ultrasound

CT SCAN

PANCREATIC INJURIES

Blunt or penetrating injury

Associated with other injuries

Persistent elevation of S. amylase

Laparotomy usually for other injuries

Select the surgical procedure ,

Debridment

Good drainage , Sump drain