Liver & Extra-Hepatic Biliary Injury Hashmi Anatomy Liver

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Liver Extra-Hepatic Biliary Injury

• Hashmi

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Anatomy

• Liver anatomy can be described using two
  different aspects
• The traditional morphological anatomy is based on
  the external appearance of the liver and does not
  show the internal features of vessels and biliary
  ducts branching
• The functionally indepedent liver segments C.
  Couinaud (1957) divided the liver into eight

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Segments
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Segments
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Gross View
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Gross View
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Liver

• The liver is the largest solid abdominal organ
  with a relatively fixed position
• It normally weighs about 1.5-2kg with blood flow
  of 1.5L/min
• The liver is the second most commonly injured
  organ in abdominal trauma, but damage to the
  liver is the most common cause of death after
  abdominal injury
• The most common cause of liver injury is blunt
  abdominal trauma, which is secondary to motor
  vehicle crashes in most instances
• In the past, most of these injuries were treated
  surgically
• However as many as 86 of liver injuries have
  stopped bleeding by the time surgical exploration
  is performed
• Almost 80 of adults and 97 of children are
  treated conservatively by using careful follow-up
  imaging studies

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Liver Injury

• Initial patient management
• -resuscitation
• -injury assessment
• -operate or not
• -hemodynamic stability

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Operative Principles

• - Massive Hemorrhage -
• Control inflow
• Evacuate blood
• Determine major injuries
• Consider gauze packing
• Damage control

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Operative Management

• Options
• Mass sutures
• Resection
• Caval shunting
• SHAL
• Gauze pack
• Omental pack

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Surgical Management

• - Mass Sutures -
• Ineffective
• Leaves intrahepatic hematoma
• May lead to hemobilia
• Liver necrosis
• - Resection -
• Debridement
• Completion resection - Segmentectomy

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Parenchymal Division
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Regeneration

• Admission Pod 5
  Pod 20

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Surgical Management

• - SHAL Selective Hepatic Artery Ligation -
• Arteriolar hemorrhage
• Penetrating wounds
• - Caval Shunting -
• Retrohepatic caval injury
• Avulsion of the hepatic veins and a lacerated
  retrohepatic inferior vena cava

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Retrohepatic Caval Injuries
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Surgical Management

• - Gauze Packing -
• Damage control operations
• Coagulopathic
• Hypothermic
• Acidotic
• - Omental Packing -
• Tamponades low pressure bleeding
• Low infection rates
• Preferred method for lacerations

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Omental Packing
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Non-Operative Treatment

• 1970s Non-operative management in children
• 1980s Non-operative management in adults
• Non-operative management
• Less blood transfusions
• Less abdominal infection
• Less length of stay
• Less mortality
• Emergent operation is the treatment of choice for
  unstable patients

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Mechanism of Hepatic Injury

• Blunt ? Rapid Deceleration
• Falls
• Rupture of Glissons capsule
• Parenchymal fractures
• Venous/Arterial bleeding, bile duct disruption,
  devitalized liver
• Penetrating ? Direct trauma
• Gunshot or stab
• Minimal parenchymal disruption, venous/arterial
  bleeding, bile duct division. Devitalized liver
  rare.

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(No Transcript)
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Grade I

• Hematoma Subcapsular, non-exanding, lt10 surface
  area
• Laceration Capsular tear, non-bleeding, lt1cm
  parenchymal depth

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Grade II

• Hematoma Subcapsular, non-expanding, 10-50
  surface area
• Laceration Capsular tear, active bleeding 1-3cm
  parenchymal depth, lt10cm in length

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Grade III

• Hematoma Subcapsular, gt50 surface area or
  expanding ruptured subcapsular hematoma with
  active bleeding intraparenchymal hematoma gt2cm
  or expanding
• Laceration gt3cm parenchymal depth

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Grade IV

• Hematoma Ruptured intraparenchymal hematoma with
  active bleeding
• Laceration Parenchymal disruption involving
  25-50 of hepatic lobe

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Grade V

• Laceration Parenchymal disruption involving gt50
  of hepatic lobe
• Vascular Juxtahepatic venous injuries ie
  retrohepatic vena cava/major hepatic veins

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Indications to Operate

• Blunt
• Hemodynamic instability
• Transfusion gt 1blood volume
• Devitalised parenchyma
• Sepsis / Biloma

• Penetrating
• Penetrating beneath peritoneum
• Evisceration
• Selective exploration
• Instability
• Gaurding

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Incision - Exposure
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Hepatic Mobilization
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Lobar Mobilization
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Hilum
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Pringle
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Hilar Plate
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Parenchymal Tears

• Mobilize the liver
• Direct compression
• Inflow control
• Explore fracture
• Suture bleeding site
• Mattress sutures
• Packing

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Parenchymal Tears
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Packing
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Operative Prognosis

• Overall mortality is 10 for operatively managed
  trauma
• Grade III/IV injury is 10
• Grade V/VI injury is gt75
• Blunt trauma mortality is 27
• Penetrating trauma mortality is 11

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Extra Hepatic Biliary Tree
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Extra Hepatic Biliary Injury

• A mechanism of crushing or shear injury to the
  right upper quadrant
• The average delay until diagnosis is reportedly 9
  days and ranges from hours to 9 months
• A perforation or an avulsion of the GB from a
  blunt thoracoabdominal trauma is extremely rare
• Penetrating abdominal trauma is a more frequent
  cause of GB injuries
• The exact incidence of nonoperative biliary
  trauma is unknown
• Isolated biliary injury without trauma to
  associated intra-abdominal structures is
  extremely rare
• Fewer than 40 cases of common bile duct avulsion
  following blunt trauma are reported
• Patients with lesions that are promptly
  discovered and appropriately treated within hours
  of injury have a mortality rate of less than 10
• Patients with extensive injuries and delayed
  treatment may have a mortality rate nearing 40

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Signs of Injury

• Early signs of biliary leakage may be difficult
  to appreciate
• Hypovolemic shock can occur from intense chemical
  peritonitis
• This can be followed by septic shock from
  bacterial overgrowth within a period of hours to
  days
• Jaundice is usually observed 3-5 days after
  injury
• Passage of clay-colored stools and dark-colored
  urine
• Increasing abdominal girth
• Direct observation with laparoscopy or laparotomy
  
• The hepatoduodenal ligament may show
• Contusion
• Edema
• Fresh clot formation
• Active bleeding

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Imaging Studies

• Abdominal CT
• Transabdominal sonography
• Endoscopic retrograde cholangiopancreatography
  (ERCP)
• Percutaneous transhepatic cholangiography
• Intraoperative ultrasonography
• Magnetic resonance cholangiopancreatography
  (MRCP)

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Extra Hepatic Biliary Injury

• Blunt EBT injury
• Perform complete medial reflection of the
  duodenum to explore the retroperitoneal biliary
  system and to identify the injury
• Choledochoduodenostomy or choledochojejunostomy
  are the methods of treatment
• Penetrating EBT injury
• Perform exploratory surgery on patients with
  significant penetrating abdominal trauma
• Acutely control hepatoduodenal hemorrhage by
  compression of the hepatoduodenal ligament
  (Pringle maneuver)
• After proximal and distal control of the
  hepatoduodenal ligament is obtained, dissect
  apart the triad to identify injury to each
  structure
• If the bile duct is completely transected,
  perform a biliary-enteric anastomosis (eg,
  Roux-en-Y choledochojejunostomy). If the duct is
  partially transected, then primary repair may be
  possible a T-tube may be required in such
  instances
• If the patient cannot tolerate a lengthy
  operative procedure, a T-tube bridge between the
  ends of the defect may be possible

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Extra Hepatic Biliary Injury

• Laparoscopic EBT injury (2 categories)
• Minor ductal injuries are those that have intact
  ductal anatomy without associated strictures
• Sphincterotomy and stenting are helpful
• Major ductal injuries to the common bile duct
  occur when large segments of the duct are
  excised, severely destroyed, or occluded by clips
• Practically all of these injuries require formal
  operative repair
• Gallbladder injury
• Cholecystectomy is the best treatment for most
  injuries of the gallbladder regardless of the
  mechanism of injury
• When injury of other organs or hemodynamic
  instability precludes cholecystectomy, perform
  cholecystostomy
• Primary suture repair of the GB is not
  recommended because of the high likelihood of
  bile leakage