Liver Trauma

Anatomy & Etiology - Liver's Weak Spots

• Relevant Anatomy:
  • Lobes (Right/Left), 8 Couinaud segments.
  • Ligaments: Falciform, coronary, triangular.
  • Dual Blood Supply: Portal Vein (75%), Hepatic Artery (25%).
  • Glisson's capsule: Fibrous, pain-sensitive covering.
• Mechanisms of Injury:
  • Blunt Trauma: Most common (e.g., MVCs, falls, direct blows).
  • Penetrating Trauma: (e.g., GSW, stab wounds).
• Common Injury Sites: Posterior segments of the right lobe (especially VI, VII, VIII).

⭐ The right lobe of the liver is injured in approximately 75-80% of cases of hepatic trauma, with segments VI, VII, and VIII being most commonly affected.

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Classification & Diagnosis - Grading the Hurt

AAST (American Association for the Surgery of Trauma) Liver Injury Scale:

Diagnostic Approach:

• Initial: ATLS principles (ABCDE).
• Hemodynamically Stable:
  • CT scan with IV contrast (gold standard).
  • Findings: Laceration, hematoma (subcapsular, intraparenchymal), active contrast extravasation, pseudoaneurysm.
• Hemodynamically Unstable:
  • FAST scan (Focused Assessment with Sonography for Trauma) for free fluid.
  • If FAST equivocal/unavailable: DPL (Diagnostic Peritoneal Lavage).
  • Or direct laparotomy.

⭐ The AAST liver injury scale is crucial for guiding management decisions, particularly for non-operative management (NOM) candidacy.

Management Principles - Stop the Bleed!

• Non-Operative Management (NOM): Standard for stable blunt liver trauma.
  • Criteria: Hemodynamic stability, no peritonitis/laparotomy indications.
  • CT: Grade; contrast blush → consider angioembolization.
  • Monitoring: ICU (high-grade); serial Hct, vitals, abdominal exams.
  • Failure: Instability, peritonitis, transfusion >4 units PRBC.
• Operative Management (OM):
  • Indications: Hemodynamic instability (post-resuscitation), peritonitis, evisceration, other surgical injuries.
• Damage Control Surgery (DCS): For exsanguination.
  • Principles: Abbreviated laparotomy → control hemorrhage (packing, Pringle) & contamination → temporary closure → ICU → re-laparotomy.
• Pringle Maneuver: Clamps hepatoduodenal ligament. 📌 'Pinch the Pedicle'.
  • Controls most hepatic bleeding. Intermittent: 15-20 min on, 5 min off.

⭐ Non-operative management is standard for hemodynamically stable blunt liver trauma, regardless of injury grade, with appropriate resources (ICU, IR, surgery).

Operative Techniques & Complications - Surgical Fixes & Woes

• Surgical Fixes (when NOM fails/contraindicated):
  • Hepatorrhaphy: Suture for superficial lacerations.
  • Perihepatic packing: For diffuse bleeding (Damage Control Surgery).
  • Resectional debridement: Devitalized tissue removal.
  • Omental packing/patch: Deep lacerations.
  • Hepatic artery ligation: Selective, for persistent arterial bleed.
  • Balloon tamponade: For tract injuries.
  • Anatomic resection: Rarely indicated in trauma.
• Angioembolization:

  ⭐ Angioembolization is a critical adjunct in both non-operative and operative management of liver trauma, particularly for controlling arterial hemorrhage identified by contrast extravasation on CT.

  • Role in NOM (arterial blush on CT) & post-op.
• Complications (Woes): 📌 'BILE HAPpens': Bleeding, Infection/abscess, Leak (bile), Edema (compartment syndrome), Hematoma, AV fistula, Pseudoaneurysm.
  • Early: Re-bleeding (↑NOM failure/death), abdominal compartment syndrome.
  • Delayed: Bile leak/biloma (most common; percutaneous Rx), intra-abdominal abscess, pseudoaneurysm, AV fistula, post-traumatic biliary stricture.
• Key Mortality Factors: Associated injuries, admission shock, high AAST grade, coagulopathy, massive transfusion.

High‑Yield Points - ⚡ Biggest Takeaways

• Liver is the most common solid organ injured in blunt abdominal trauma.
• Right lobe is more frequently affected than the left.
• Non-Operative Management (NOM) is standard for hemodynamically stable patients.
• Contrast-Enhanced CT (CECT) is gold standard for diagnosis and grading.
• AAST liver injury scale (Grades I-VI) is crucial for guiding management.
• Perihepatic packing is a key damage control surgery technique for unstable patients.
• Common complications include bile leak, abscess, and delayed hemorrhage (biloma).