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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
Recommended