Liver & Spleen Injuries (PDF)

LIVER TRAUMA Ò The liver is the 2nd commonly injured solid ab- dominal organ, despite its relative protected location. 1. In blunt trauma: the spleen is the most common organ to be injured. Liver is the 2nd (fixed under the ribs: so injured usually when they are severely...

LIVER TRAUMA Ò The liver is the 2nd commonly injured solid ab- dominal organ, despite its relative protected location. 1. In blunt trauma: the spleen is the most common organ to be injured. Liver is the 2nd (fixed under the ribs: so injured usually when they are severely affected + fixed with numerous ligaments). 2. In stab injuries: liver is the most common to be injured. Spleen is the less. Liver is like a female you must treat it gently. THE LIVER IS PRONE TO INJURY: 1. The large size of the liver, 2. its friable parenchyma, Spleen is more strong than the liver. 3. its thin capsule, and 4. Its relatively fixed position in relation to the spine and ribs. Shearing movement in high velocity injuries. Disturbance of movement occurs.  MECHANISM OF INJURY : Most common. Ò Road traffic accident, or fall from a height, may result in a deceleration injury. This leads to tears at sites of fixation to the diaphragm and abdominal wall. Ò antisocial violent behaviors, industrial and farmer accidents are the commonest mode of injury to the liver. Ò Penetrating injuries may be associated with a significant vascular injury. Gunshots may disrupt these major vessels Ò Iatrogenic injury Wipple, gallbladder, stomach surgeries. Ò Spontaneous rupture (very rare). TYPES OF TRAUMA Types of trauma 60 50 40 30 20 10 0 run over blow stab gun shot Cars.  GRADING OF LIVER INJURY BY AAST (AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA) Liver trauma may result: Subcapsular hematoma or intrahepatic hematoma Laceration Contusion Hepatic vascular disruption Bile duct injury GRADE OF LIVER INJURY: Ò I Hematoma (Subcapsular, 75% of hepatic lobe >3 C ouinaud segments within a single lobe Vascular (Juxtahepatic venous injuries). Ò VI Hepatic avulsion Shedding from the major vessels. IVC is open. ‫في الغالب مش بيتلحق‬ GRADE 1 A 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 2 A BLUNT ABDOMINAL TRAUMA CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick. GRADE 3 A 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 4 A 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 5 A 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 6 A MOTOR VEHICLE ACCIDENT CT demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam. PRESENTATION Polytrauma. stable biliary peritonitis hemodynamic instability Major stages: 4-6 37% 55% 8% Or associated with other organ injures.  SYMPTOMS: Ò Pain and rigidity in the abdomen, especially on the Rt side. Ò Other symptoms, which are associated with a decrease in blood pressure due to internal bleeding, include: -Feeling light headed -Confusion -Fainting -Restlessness -Nausea -Blurred vision SIGNS Ò Dyspnea, pallor, rapid pulse and hypotension. Ò Abd tenderness and rigidity. Ò Fracture rib increase the suspecion of liver injury.  INVESTIGATIONS Ò An ultrasound scan is the most sensitive diagnostic method, although a normal scan may not rule out liver injury. Ò In people who are hemodynamically stable, a CT scan is typically used to help determine the grade of injury. Ò In the emergency trauma setting, an ultrasound scan is performed while other monitoring and management continue uninterrupted. This scan is done according to the focused assessment with sonography for trauma (FAST) protocol, which forms part of the advanced trauma life support (ATLS) protocol developed by the American College of Surgeons. Ò A FAST ultrasound enables clinicians to scan for fluid in four areas of the abdomen. Ò Diagnostic peritoneal aspiration (DPA) or lavage (DPL) is another diagnostic test that may be used. Ò CT scan in a stable individual with a suspected liver injury. CT is done if the patient is stable. Surgeons works on different If not stable don’t do it. ways in the same time? MANAGEMENT OF LIVER TRAUMA MANAGEMENT Operative vs Non-Operative  Penetrating: exploration. Blunt: NOM or operative according to the stability of TREATMENT the patient and facilities requires for intervention. Stable and no need for blood transfusion. Like in stage I or II. Ò Treatment of traumatic liver injuries is based on patient physiology, mechanism and degree of injury, associated abdominal and extra-abdominal injuries and local expertise. Ò Non-operative management (NOM) became the treatment of choice for most patients with blunt liver injuries who are hemodynamically stable. Important. Ò Success rates for NOM commonly are greater than 95%. Incidence of complications attributed to NOM increases in concert with the grade of injury.. Ò Some patients with a liver injury experience serious bleeding that requires immediate surgery on the abdomen. If you don’t have the facilities from the beginning refer the patient to a suitable center. EARLY MEASURES: Ò initial resuscitation and management is the same as for any patient with major trauma and should follow the Advanced Trauma Life Support (ATLS) principles. Ò Aggressive fluid resuscitation, guided by monitoring of central venous pressure and urinary output. Ò management should also be directed toward avoidance of any of the danger triad of hypothermia, coagulopathy, and acidosis, which are associated with significantly increased mortality. Hypothermia cause coagulopathy that deteriorates the patient. Metabolism is affected.  Unstable from the beginning? OPERATIVE MANAGEMENT:Midline is faster and less blood loss + accessible? Ò Incision; a long midline laparotomy, which can be extended to the right chest or to Rt subcostal in case of a posterior right lobe injury, major hepatic venous injury, or vena caval injury. Ò Pedicle occlusion(Pringle manoeuvre) should be done by atraumatic vascular clamp or noncrushing bowel clamp. If bleeding stops the bleeding is from branches of portal vein or hepatic artery. If bleeding continuous it is likely to be from hepatic vein or IVC. The time of Pringle manoeuvre is up to 1 hour. Ò The massive transfusion protocol should be activated so that the blood bank is always ahead of the patient’s needs for packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. Adequate vascular access and arterial blood pressure monitoring are essential. Ò It is important to have venous access above the diaphragm. Stop the problem ASAP and exit without doing the final treatment. DAMAGE CONTROL SURGERY (DCS) Ò Describes initial control of haemorrhage and contamination followed by packing and temporary abdo minal closure, ICU restoration of normal physiology, and delayed definitive repair of intra-abdominal injuries. Ò The decision for DCS should be made very early in the operation before the onset of severe coagulopathy, acidosis, and hypothermia. Ò Early start of packing as DCS to lessen mortality of major liver injuries. Ò Once the patient is stabilized, patient is returned to the operation theatre and definitive surgery is undertaken if needed. Draining and stopping the bleeding. Resuscitation DIC may occur from is done and acidosis is corrected. Then introduce the lost coagulation the patient again with expert surgeons. factors in the bleeding. NON-OPERATIVE MANAGEMENT  CRITERIA FOR NOMLI No peritonitis, no GIT injury. The patient is conscious to be able to assess clinically. Ò No indications for laparotomy (physical examination signs/symptoms or other injuries) Ò Hemodynamically normal after resuscitation with crystalloid Ò No injuries that preclude physical examination of the abdomen (e.g., CHI, spinal cord injury) Ò No transfusion requirements (PRBC) Ò Constant availability of surgical and critical care resources  FAILURE OF NOMLI Ò Usually attributed to reasons unrelated to liver injury Ò Other injuries can be missed in a blunt trauma victims, such as: É Bowel É Pancreas É Diaphragm Sepsis, bleeding, hepatic abscess? É Bladder Which can lead to failure of NOMLI  CRITERIA OF FAILURE OF NOMLI Ò Increasing fluid requirements to maintain normal hemodynamic status Ò Failed angio embolization of A-V fistulae/pseudoaneurysm Ò Transfusion requirements to maintain Hct/Hgb and normal hemodynamic status Ò Increasing hemoperitoneum associated with hemodynamic liability Increasing in sonar. Ò Peritoneal signs/rebound tenderness COMPLICATIONS OF NOMLI Ò Biliary (bile peritonitis, bile leak, biloma, hemobelia..) Ò Infection (liver abscess, necrosis, abdominal sepsis, SIRs) Ò Abdominal compartment syndrome Ò Hemorrhage Ò Hepatic necrosis &/or Acalculous Cholecystitis OPERATIVE MANAGEMENT  INDICATIONS IN BLUNT TRAUMA IN PENETRATING TRAUMA MCQ. Exploration from the start. Ò Hemodynamic instability Ò Exploratory lapratomy is Ò Transfusion> 2 blood volume or indicated in any penetrating > 40 ml/kg trauma in with peritoneal penetration Ò Devitalized parenchyma Ò Sepsis / biloma ‫أصل أنت مش عارف‬ ‫هو عور ايه كمان‬  OPERATIVE TECHNIQUE/OPTIONS Ò Initial à à Explore Laparotomy Ò Temporary control of hemorrhage: É Why temporary? Ð Ongoing hemorrhage, life threatening, no time to restore circulatory volume. Ð Liver injuries not highest priority  Methods of controlling hepatic bleeding § Pressure on the edges of liver wound § Occluding hepatico-duodenal ligament (Pringle maneuver) § Ligation of the bleeding vessel in the liver substance. § Perihepatic packing. § Diathermy/argon. § Suturing of the liver (figure of 8, deep liver suture) § Use of Omentum as a pack in the liver fracture § Vascular isolation. (see Grade V and VI injuries) § Fibrin Glue to the bleeding surface § Selective angiography. Methods of controlling hepatic bleeding Ò Therapeutic packing should be performed early and not as a last resort when all else has failed. Ò Peri hepatic packing the most significant therapeutic modality in the reduction of mortality after a sever liver injury. Ò Non-anatomical resection has a place, whereas anatomic resection, when required , needs an experienced liver surgeon.  OPERATIVE MANAGEMENT ÒMesh rapping --new technique for grade III,IV laceration, tamponading large intrahepatic hematomas --not indicated where juxtacaval or hepatic vein injury is suspected  OPERATIVE MANAGEMENT Ò Omental packing Ò Intrahepatic tamponade with penrose drains Ò Fibrin glue Ò Retrohepatic venous injuries --Total vascular exclusion --venovenous bypass --Atriocaval shunting Liver transplantation Packing. Packing around the liver not in the tear or it will widen. Count the packs.  Gastroduodenal ligament. Less sac is opened. Portal vein, hepatic duct and hepatic artery. Repair under running? ‫أو أحرقه‬ ‫م ش مهم‬  MESH RAPPING If the liver is largely injured? Not sure. Rupture of spleen — A ruptured spleen occurs when the surface of this organ is injured, which can lead to internal bleeding. — A ruptured spleen can potentially be life- threatening if it is not treated quickly. — The spleen is an organ about the size of a fist, located in the left upper abdomen, hidden by ribs and muscles. causes Thalassemia, SCA, lymphoma and leukemia. Bilharziasis and lichmania. Predisposing factors: EBV and autoimmune diseases. — splenomegaly (an enlarged spleen). — Friable spleen such as mononucleosis or malaria Types of trauma: — Blunt trauma can be caused by Car, motorcycle or bicycle accidents, Contact sports such as football — Penetrating trauma. — Iatrogenic trauma. — Spontaneous rupture is rare. More common than the spleen. ‫بتحصل وشفتها السنة اللي فاتت‬ Very very very rare in the liver.  Stages Taking into account the level of laceration, injury to the veins and arteries, and clotting. The American Association for the Surgery of Trauma grading system : — Grade 1: This stage involves a tear in the capsule that goes less than 1 Similar centimeter (cm) deep into the spleen, or hematoma covers less than 10 to liver? percent of the surface area of the spleen. — Grade 2: At this stage, a 1-to-3-cm tear occurs that does not involve the arterial branches of the spleen. Alternatively, a hematoma may occur under the capsule that covers between 10 and 50 percent of the surface area. This stage can also involve a hematoma less than 5 cm in diameter in the tissue of the organ. — Grade 3: This mid-stage rupture is a tear more than 3 cm deep. It can also involve the splenic artery or a hematoma that covers over half of the surface area. A grade 3 rupture can also mean that a hematoma is present in the organ tissue that is greater than 5 cm or expanding. — Grade 4: This is a tear that lacerates the segmental or hilar blood vessels and causes the loss of more than 25 percent of the organ’s blood supply. — Grade 5: This is an extremely severe tear that lacerates certain blood = 6 in vessels and causes a total loss of blood supply to the organ. This stage can liver. also mean that a hematoma has completely shattered the spleen. — The grading of a ruptured spleen helps doctors determine whether surgical or non-operative management is indicated for treatment.  Complications — The main complication is bleeding. — Spleenic cysts. for 1 week up to 10 days. Sudden shock. Must be admitted — Delayed bleeding and death may also result from a ruptured spleen. — The decrease in immune activity following a splenectomy. — Associated injuries.  Clinical picture — There are 3 clinical presentations : 1-fatal type: 2- classic rupture: Like any bleeding. 3-delayed rupture: After conservative management? Symptoms: — The main symptom of a ruptured spleen is severe pain in the abdomen, especially on the left side. Left — The pain may also be referred to (felt in) the left shoulder, and can make breathing painful (kehr’s sign). — Other symptoms, which are associated with a decrease in blood pressure due to internal bleeding, include: -Feeling light headed -Confusion -Fainting -Restlessness -Nausea -Blurred vision  Signs — Dyspnea, pallor, rapid pulse and hypotension. — Abd tenderness and rigidity. — Special signs: Fixed dullness in the left - balance’s sign. hypochondrium due to hematoma? - Kehr’s sign. flat or in Trendlenberg position. As the collection compresses Tenderness or pain in the left hypochondrium if the patient lies the diaphragm. Sever pain referred to the left shoulder. - Cullen’s sign. Also occurs in pancreatitis. Extravasation of blood extending to the parietal layer causing discoloration. Ecchymosis around the umbilicus.  Investigations — An ultrasound scan is the most sensitive diagnostic method for injuries to the abdomen, although a normal scan may not rule out splenic rupture. — In people who are hemodynamically stable, a CT scan is typically used to help determine the grade of injury. — In the emergency trauma setting, an ultrasound scan is performed while other monitoring and management continue uninterrupted. This scan is done according to the focused assessment with sonography for trauma (FAST) protocol, which forms part of the advanced trauma life support (ATLS) protocol developed by the American College of Surgeons. — A FAST ultrasound enables clinicians to scan for fluid in four areas of the abdomen, including the space around the spleen. — Diagnostic peritoneal aspiration (DPA) or lavage (DPL) is another diagnostic test that may be used. — In some cases, such as where a patient has allergy to the contrast Vaccination substance used in a CT scan, a stable individual with a suspected is required. ruptured spleen may undergo an MRI scan. Conservative in children as you can. Responsible for the immunity. Spleen is a reservoir or Capsular infection: H. Influenza B, meningococcal, and pneumococci. blood and antibodies?  Treatment — There are two main types of treatment for a ruptured spleen: Surgical intervention and observation. — Many people with a ruptured spleen experience serious bleeding that requires immediate surgery on the abdomen. — less severe splenic rupture need close monitoring and observation instead of surgery. However, these individuals still require active treatment and usually need a blood transfusion. — People that have a low-grade splenic rupture and no signs of other injuries in the abdomen hemodynamically stable need conservative treatment. The girl with: Torsion of spenule in the pelvis. Misdiagnosed as ovarian cyst. A non-operative approach — is a modern development in adult trauma surgery and was adopted following its success in treating children without surgery. — Surgery is now avoided in 95 percent of children and 60 percent of adults that have a splenic rupture. — People who remain stable under observation will often undergo further scans for monitoring purposes, including CT scans. Splenic embolization — Those in a stable condition may also undergo a procedure called splenic embolization. — The procedure aims to stop any bleeding from the spleen. This procedure usually needs to be performed quickly and can help avoid the need to remove the spleen. — Splenic embolization requires specialized facilities and staff. operative approach — When surgery is performed, it is still common practice to remove the entire spleen. — Although less severe cases may allow a surgeon to repair a tear and put pressure on the spleen until the bleeding stops, then do splenorraphy or partial spleenectomy. Most common sites of spenules: 1. splenic hilium. Most common. 2. Greater omentum. 3. Stomach bed. 4. Any place else. Thank you