Lésions Abdominales et Mécanismes

Introduction and Objectives

• The presentation is on traumatic liver injuries.
• The presenters are OUEDRAOGO Judion and TRAORE Lionel, both of whom are in the DES II Chirurgie Générale program.
• The supervisor is Pr Adama SANOU.
• The objectives are to define hepatic traumas, classify liver traumas, cite criteria for non-operative treatment, describe operative treatment modalities, and cite operative indications for a hepatic trauma.

Plan

• Introduction and General Information: Definitions and interests, Epidemiology, Reminders, Circumstances and mechanisms of lesions, Classifications
• Clinical Study: Type of description: Hepatic trauma grade II of MOORE, Clinical forms
• Explorations Paraclinics: Biological and morphological examinations
• Treatment: Pre-hospital and in-hospital phases, Non-operative and Operative treatments
• Conclusion

Introduction

• Major issue in abdominal surgery
• High-velocity or penetrating trauma
• Ranges from simple hematoma to severe hemorrhage
• Management has evolved in the last 30 years
• Can present difficult treatment challenges
• Severe prognosis, 1st cause of mortality in abdominal contusion (20-25%)

General Information

• Definition: Any hepatic trauma, with or without parietal discontinuity.
• Frequency: Hepatic trauma observed in 11.8% to 14.2% of abdominal trauma cases and 3.03% of abdominal emergencies in BF.
• Interests: AVP: first cause (44.1%), CBV(26.4%).

General Information - 2.

• Diagnostic approaches (DC): History-taking and clinical examination.
• Imaging: CT scan is the preferred modality
• Evaluation of injury severity through classification
• Treatment: Dependent on hemodynamic stability and peritoneal signs.
• Prognosis: Remains serious, mortality rate: 23.5% (2011) to 4.3% (2016)

General Information - 3.

• Epidemiology: Young adult males (average age of 27 years)
• Common cause: AVP (motor vehicle accidents), often 2-wheeled
• Common injury types: Moore Type II and Type I
• Treatment pattern differences: 80% treated without intervention in Europe, versus 10% in BF.
• High mortality rates: 80% in severe cases
• Associated hemorrhage and other organ damage is critical.

Anatomical Reminders

• Liver: largest gland in the body, weighing 1500g (approximately).
• Location: Extending from the right upper quadrant (RUQ) to the left upper quadrant (LUQ), below the diaphragm.
• Anatomy details: 3 surfaces, 3 edges and 2 extremities.
• Structure: Right extremity is voluminous and rounded, left extremity is flattened and tapered..

Anatomical reminders - 2

• Liver fixation: details on the right and left diaphragmatic recesses, the falciform ligament, the coronary ligament, the round ligament, and the ligaments related to the inferior vena cava,
• Liver relationships: details on the relationships between the liver and surrounding structures, such as the diaphragm, lungs, heart, pericardium, and the various abdominal organs and tissues.

Anatomical details- 3

• Relevant anatomical segments details:
• Right lateral segment: divided into segments VI and VII
• Right medial segment: composed of segments V and VIII
• Left lateral segment: single segment II
• Left medial segment: divided into segments III and IV
• Overall, eight segments in total

Physiological Reminders

• Liver functions: Glycogen storage, protein synthesis (albumin), lipid synthesis and breakdown, detoxification, hormone metabolism, biliary, ureogenic and hematologic functions.

Fatal Triad of Polytrauma

• Hypothermia, acidosis, coagulopathy.

Circumstances and Mechanisms

• Contusions (70%): Vehicle accidents (AVP 72%), falls from height (12.09%), occupational accidents, sports injuries, others.
• Injuries (30%): Gunshot wounds, knife wounds, others types.

Mechanism of Contusions

• Crushing: Anterior-posterior or lateral force on the abdominal wall, injuring organs tightly anchored by peritoneal attachments
• Shearing: Sudden deceleration causing tearing at liver attachment sites
• Rupturing: Rapid and significant increase in intra-abdominal pressure (blast effect)
• Piercing: direct penetration from sharp objects, injuries are usually concentrated.

Mechanism of Injuries

• Penetrating Injuries (e.g., stab wounds): Usually localized damage; less associated visceral injury.
• Gunshot Wounds: Vary depending on caliber; small caliber injuries can mimic stab wounds, high caliber injuries can cause extensive damage and rupture.

Classification of Liver Injuries

• Moore classification (detailed breakdown of grades).
• Mirvis Classification (breakdown of grades).

Clinical Study

• Patient history/interrogatory, General symptoms, specific symptoms, detailed physical examination .

Clinical Examination

• Inspection: Ecchymoses, abrasions, entrance wounds. • Palpation: Abdominal guarding, rigidity, tenderness, umbilicus tenderness, cutaneous hyperesthesia. • Percussion: normal sounds. • Auscultation: normal or auscultatory silence. • Pelvic examinations

Clinical Forms

• Subcapsular hematoma: Sharp pain, respiratory distress, fever, jaundice, pallor, enlarged liver dullness, intolerable pain
• Intrahepatic hematoma: Primary or secondary (unsatisfactory hemostasis), small or dissecting (severe VX injury extending to parenchyma with signs of substantial liver distress)
• Post-traumatic hemobilia: Blood in the bile ducts, often a pathological communication between blood vessels and bile ducts that leads to a triad of Sandbloom (pain, jaundice, hemorrhage).
• Biliary and VBP injuries: Commonly found with liver injuries; often along with damage to other organs.
• Polytrauma patient cases, pediatric, pregnant patients

Biological and Morphological examinations

• Lab tests (blood tests): Complete blood count (including hemoglobin and hematocrit), coagulation tests, liver function tests (enzymes), blood chemistry.
• Imaging studies (e.g. ultrasound, CT scan and MRI): Evaluation of the severity and extent of internal injury (liver parenchyma, blood vessel, other abdominal organs), to detect the presence of hemoperitoneum, and for the assessment of the appropriateness of surgical approach, in cases where surgical intervention is necessary.

Treatment - Pre-hospital Phase

• Rapid and effective (ABCDE)
• Establishing adequate respiration
• Volume replacement (if necessary)
• Initial stabilization of fractures

Treatment - Pre-hospital

• Criteria to consider
• Kinetic elements:Vehicle ejection or passenger fatalities, entrapment time length exceeding twenty minutes, falls from heights over six meters, and a high degree motor vehicle accident speed (>80 km/h for cars and >40 km/h for motorbikes).
• Physiological elements:The Glasgow Coma Scale score below 13; systolic blood pressure less than 90 mm Hg, oxygen saturation under 90%, heart rate below 10 or above 29; burns over more than 15% body surface area; and neurological deficit or paralysis.

Initial Management and Resuscitation

• Assessment of airway, breathing, and circulation in a stepwise manner
• Peripheral vasoactive or intravenous fluids replacement
• Supplemental oxygen and ongoing assessment of ventilation and perfusion are essential
• Monitoring of vital signs in a stepwise manner
• Group blood for the patient as well as obtaining blood tests:Complete Blood Count (CBC), liver function tests, and coagulation tests.

Initial Management and Resuscitation-2

• For polytrauma: a fully multidisciplinary care approach.

Treatment - In-hospital phases- Medical (non-operative)

• Stable hemodynamic profile
• Blood supply availability and sufficient blood volume.
• Absence of injury to hollow organs and the brain.
• Close observation and monitoring capability.
• Access to ultrasonography, computed tomography (CT) imaging, and angiography with embolization capabilities.
• Availability of immediate laparotomy capabilities if required
• Hemoperitoneum volume less than 500 mL.

Treatment - In-hospital phase- Medical (non-operative)-2

• In-hospital monitoring, care, and assessments.

Treatment - Specific (nonoperative)

• Arterial angiography with embolization: Use of interventional radiology to control bleeding in critical medical conditions

Treatment – In-hospital phase - Medical (non-operative)-3

• Complications: Compartment syndrome, abdominal hypertension, organ failures (respiratory, cardiovascular, kidney, or neurological)

Treatment- In-hospital phases: Operative Treatment

• Urgent laparotomy: for unstable patients despite initial resuscitation.
• Wide surgical field, access to the thorax and abdomen (e.g., via Scarpa's fascia).
• Approach to the liver through a midline incision, possibly extending to a sternotomy or transverse incision (RUQ/RUQ).

Treatment -Operative -2.

• Damage Control Laparotomy: a shortened surgical procedure focusing on initial stabilization, rather than complete repair. It features a technique known as "packing." Materials such as wound protectors and temporary hemostasis are used to create a form of "packing."
• Hemostatic Techniques: temporary hemostasis techniques used before definitive closure; these techniques may include ligation or compression techniques.

Treatment- Operative -3

• Primary Hemostasis: Opening the peritoneum, draining the hemoperitoneum, thoroughly examining the entire abdomen for associated injuries, without directly accessing the liver, and cautiously removing any clotting around the liver, while avoiding the damaged area.

• Definitive repair/fixation of lesions and hemostasis: sutures in the liver using large stitches to secure the bleeding areas. It is important to avoid damaging surrounding tissue and blood vessels during the surgical procedure.
• If necessary, larger fragments of omentum may be used as dressings which are usually sutured to the liver to enhance hemostasis • Resections and other operations: If necessary, some sections of the liver may have to be surgically removed (resected)

Treatment- Operative -4

• Pringle maneuver: A method of controlling liver blood flow by clamping blood vessels related to the liver Techniques such as compression and clamping are used during the procedure for the most effective hemostasis, but the surgeon must pay attention to time constraints, and the preservation of the liver vessels and surrounding organs during the surgical procedure
• Further operations: techniques for clamping vessels in the quadrupla clamping technique are used

Treatment- Operative -5

• Packing procedure: Employing large pads to compress the bleeding region; using the correct placement of such pads to minimize the risk of further injuries
• Definitive repair/fixation of lesions and hemostasis: stitches/ sutures to hold the bleeding areas together (to stop the bleeding)

Treatment - Operative -6

• Suturing Techniques.
• Resections: Procedures used to remove injured tissue sections (e.g., in a partial liver resection).
• High-major liver resections: carry a significant mortality risk (up to 50%).

Indications for Operative Treatment - Moderate Liver Injury

• Type I MIRVIS: No edge approximation; avoid sutures; early non-operative treatment favored.
• Type II MIRVIS: Hematoma that is not ruptured; if no rupture detected, further observation such as CT scan and ultrasound are required; if a laceration/rupture is detected, surgical intervention will involve selective edge trimming and tissue removal. A more permanent method of stopping the oozing/bleeding is the ligature procedure.

Indications for Operative Treatment - Severe Liver Injury

• Type III MIRVIS: Deep laceration/rupture; surgical repair necessary
• Type III MIRVIS - fractures, complete surgical tissue removal as well as stopping blood bleeding.
• Type III MIRVIS - if a complete injury to the liver is observed; this requires more extensive surgical intervention (e.g., major hepatectomy) for long gaps to ensure the liver tissue is adequately repaired; however, due to the damage, a higher fatality rate must be anticipated.
• Type IV MIRVIS: large-sized lesions in two lobes; stabilization and further repair.

Indications for Operative Treatment- Severe Liver Injury - 2

• Central Hematoma : Small size, no surgery; large size and/or dissecting, surgical intervention required, with ligation of vessels after a diagnostic imaging approach such a CT scan or angiography
• Postoperative Complications: Potential complications that demand surgical intervention based on patient response, as well as the condition of the patient.

Closure and Drainage

• Stopping bleeding in a simple way (no clamping; no severe collapse):
• Closing the wound in steps + large drainage of the affected liver region to remove any residual fluid or blood.
• Additional drainage if needed.
• Complication Avoidance: preventing significant problems, including abdominal compartment syndrome, is a critical aspect of management.

Special Considerations (TOF, penetrating wounds)

• Need for early recognition; often misdiagnosed because of lack of shock or other signs of widespread injury; early recognition of the need for further surgery
• Laparotomy as a strategy may not always be successful in these cases, and alternative procedures such as the "Pringle's maneuver" may be required.
• Utilization of a Blake Moore tube: It is important to note that this particular method is frequently employed in the management of penetrating abdominal wounds.
• Further interventions may be needed.

Complications Postoperative

• Common complications: Abdominal issues (opening up, blockage, peritonitis, subphrenic abscesses, parietal suppurations), decubitus issues (breathing and urination infections, skin breakdown, blood clots), pulmonary embolism, acute kidney failure, and sepsis.
• Specific liver complications: Continued bleeding, new hematomas forming at the site of injury (secondary to initial injury or due to complications), liver necrosis (if blood vessels were clamped), bile leaks (fistula).
• Other possible complications :abdominal compartment syndrome, visceral failure (lung, heart, kidneys, brain), sepsis.

Conclusion

• Traumatic hepatic injuries (TH) primarily associated with acute vascular accidents (AVP).
• Diagnosis depends on clinical exam and CT, particularly with stable patients.
• Management is often conservative(80% nonoperative), but mortality remains high.