Dr. Aisha Al-ZuhairGeneral Surgery

KFHU – Khobar – Saudi ArabiaDec 16, 2009

Surface anatomyIn RUQ 5th ICS in midclavicular

line to the Rt costal margin.

Weighs 1400 g n women and 1800g n men .

Span 10 cm +/-2

Surface anatomySuperior, anterior, and right lateral surfaces

fit diaphragm.Falciform ligament

Posterior surface Rt lobe: colon, right kidney, and duodenum Lt lobe: stomach

The liver covered by fibrous capsule that reflects on the diaphragm and post abdominal wall

Leaving a bear area that connects the liver to the retroperitoneum directly

Ligaments Liver supported

by: Coronary ligRt & Lt

Triangular lig Falciform lig

Fissures

Segmental anatomyClassically; liver divided to 4 lobes:

Right lobe Left lobeCaudate lobe Quadrate lobe

Segmental anatomyFunctionally; on the basis of the distribution of

vessels and ducts within the liver segments. Cantlie’s line.

Blood Supply

Portal veinHepatic arteryHepatic vein

Blood Supply – Portal Vein Superior Mesentric and Splenic veins Posterior to hepatic artery and bile duct at the

hepatodudenal junction. Valveless 75% of total blood supply the liver Pressure 3-5 mmHg

Blood supply – Hepatic artery

Intrahepatic anatomy; part of portal tried follows segmental anatomy.

Extrahepatic anatomy; highly variable:Commonest ( in 60%) anatomy: abdominal aorta

celiac trunk CHA proper hepatic art Rt and Lt hepatic artery

LHA seg 1,2,3 and middle hepatic artery seg 4.RHA cystic art , Rt liver

Blood supply – Hepatic vein

Rt hepatic vein Drain seg 5,6,7,8 vena cava.Middle hepatic vein Drain seg 4,5,8 Lt hepatic vein Drain seg 2,3 [ seg 1 drain by short hepatic vena cava]

Radiological anatomy

Radiological anatomy

Introduction It is the 2nd commonest organ injured in

blunt abdominal trauma and the commonest injured in penetrating trauma.

1%-8% of pt with multiple blunt trauma sustain a liver injury.

During last 3 decades, liver injury increased. This inc could be actual or artificial d/t better diagnostic modalities.

Richardson JD. Ann Surg. 2000;232:324-330. Lucas CE. Am Surg. 2000;66:337-341.

While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference:

If lacerations be extensive and vessels of any magnitude are torn, hemorrhage will, owing to the structural arrangement of the liver, go on continously.

JH Pringle, 1908

History of Liver Trauma

WW1WW2Vietnam

Mortality 66% -- 28% -- 15%

Factors making the liver prone to injury:

1. The large size of the liver, 2. its friable parenchyma, 3. its thin capsule, and 4. Its relatively fixed position in relation to the

spine and ribs.

1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4

Grade 1A stabbing injury to the RUQ of the abdomen

Contrast CT demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.

Grade 2A blunt abdominal trauma

CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.

Grade 3A blunt abdominal trauma

Contrast CT shows a 4-cm-thick subcapsular hematoma associated with parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver..

Grade 4A blunt abdominal trauma

CT scan of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-attenuating areas within the lesion represent clotted blood

Grade 4A blunt abdominal trauma

Contrast CT shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the capsular laceration and large hemoperitoneum.

Grade 5A motor vehicle accident

CT demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam.

Management

Operative vs

Non-Operative

Non-Operative Management of Liver Injury

An absolute increase in the incidence of nonoperatively managed liver injuries (NOMLI) is unequivocal.

Multiple studies have shown that NOMLI is effective

Knudson MM. Surg Clin North Am. 1999;79:1357-1371. Malhotra AK. Ann Surg. 2000;231:804-813. Maull KI. World J Surg. 2001;25:1403-1404. Pachter HL. Am J Surg. 1995;169:442-454. Sherman HF J Trauma. 1994;37:616-621. Schweizer W. Br J Surg. 1993;80:86-88. . Miller PR. J Trauma. 2002;53:238-242. Goan YG. J Trauma. 1998;45:360-364. Brasel KJ. Am J Surg. 1997;174:674-677. . Ochsner MG.. World J Surg. 2001;25:1393-1396.

Criteria for NOMLI

No indications for laparotomy (physical examination signs/symptoms or other injuries)

Hemodynamically normal after resuscitation with crystalloid

No injuries that preclude physical examination of the abdomen (e.g., CHI, spinal cord injury)

No transfusion requirements (PRBC) Constant availability of surgical and critical care

resources

Liver injury score of patients is not as important as the hemodynamic status for determining conservative management

High Success With Non-operative Management of Blunt Hepatic Trauma

Arch Surg. 2003;138:475-481

Hypothesis Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events.

Setting High-volume academic level I trauma center

Cont.Results 78 patients23 (29%) were operated on immediately, but only 12

(15%) for bleeding from the liver. NOMLI failed in 8 for reasons unrelated to the liver injury.

The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%.

No adverse events were attributed to NOMLI.

Cont.Conclusions NOMLI is safe and effective regardless of the grade

of liver injury. Failure of NOMLI is caused by associated abdominal

injuries and not the liver. Fluid and blood requirements, the degree of injury

severity, and the presence of other abdominal organ injuries may help predict failure.

Complications of NOMLIBiliary (bile peritonitis, bile leak, biloma, hemobelia..) Infection (liver abscess, necrosis, abdominal sepsis,

SIRs)Abdominal compartment syndrome Hemorrhage Hepatic necrosis &/or Acalculous Cholecystitis

Failure of NOMLI Usually attributed to reasons unrelated to liver

injuryOther injuries can be missed in a blunt trauma

victims, such as:Bowel PancreasDiaphragmBladder Which can lead to failure of NOMLI

Criteria of failure of NOMLIIncreasing fluid requirements to maintain normal

hemodynamic status Failed angio embolization of A-V

fistulae/pseudoaneurysm Transfusion requirements to maintain Hct/Hgb and

normal hemodynamic status Increasing hemoperitoneum associated with

hemodynamic liability Peritoneal signs/rebound tenderness

How to manage conservatively

Grade I II III IV

ICU 0 0 0 1

Hospital stay (d)

2 3 4 5

Activity Restriction (w)

3 4 5 6

Follow up There is no evidence supporting routine imaging (CT or

US) of the hospitalized, clinically improving, hemodynamically stable patient.

Nor is there evidence to support the practice of keeping the clinically stable patient at bed rest.

2003 Eastern Association For The Surgery of Trauma

Indications In Blunt Trauma In Penetrating TraumaHemodynamic

instabilityTransfusion> 2 blood

volume or > 40 ml/kgDevitalized parenchymaSepsis / biloma

Exploratory lapratomy is indicated in any penetrating trauma in with peritoneal penetration

Operative technique/optionsInitial Explore Laparotomy Temporary control of hemorrhage:

Why temp? Ongoing hemorrhage, life threatening, no time to

restore circulatory volume. Liver injuries not highest priority

Operative technique/options

How? Manual compression Perihepatic packing. Pringle maneuver. Tourniquet Hepatic vascular isolation Placement of atriocaval shunt Moore-Pilcher balloon

commonest

Juxtahepatic venous injury

Operative technique/optionsDefinitive management of the injuries:

1. Moore EE, Cogbill TH, Jurkovitch GJ, Shackford SR, Malangoni MA, Champion. Organ injury scaling-spleen, liver (1994 rev). J Trauma. 1995; 38:323-4

Hepatic segments ResectionsRight hemihepatectomy (segments 5 to 8);

AKA as Right hepatectomy or right hepatic lobectomyRight trisectionectomy (segments 4 to 8);

AKA as Right lobectomy or Rrisegmentectomy of StarzlLeft hemihepatectomy (segments 1 to 4);

AKA as Left hepatectomy or Left hepatic lobectomyLeft lateral sectionectomy (segments 1 to 3);

AKA as Left lobectomy or Left lateral segmentectomy

References Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.Sabiston Textbook of Surgery, 18th ed.Khatri: Operative Surgery Manual, 1st ed.ACS Surgery principles and Practice 2006.Cameron; current surgical therapy, 8th ed.

http://www.netterimages.com/http://www.adhb.govt.nz http://emedicine.medscape.com/article/370508-overviewhttp://www.east.org