Hepatic Trauma

1.2.1. Hepatic veins

There are three large hepatic veins, which drain the hepatic parenchyma of the liver lobes into the inferior vena cava.

1.2.2. Nerve supply

Parasympathetic nerve from the right vagus via coelic plexus, left vagus to porta hepatis, and sympathetic nerve along the blood vessels.

Function of the liver:

1. Bile production and secretion.

2. Detoxification of toxins.

3. Protein synthesis.

4. Production of heparin, bile pigments.

5. Storage of glycogen.

6. Erythropoiesis in infants.

Epidemiology of liver trauma:

Liver is the second most common abdominal organ that can get injured by blunt trauma [1, 26] and is the most common cause of death in abdominal trauma—100% mortality if untreated or missed from examination. Blunt abdominal trauma is more fatal than penetrating trauma. Before 1993, all liver injuries were treated through surgery. From 1998 onwards, non-operative treatment was introduced as the standard method of treatment for liver trauma with 80% of adult liver trauma treated conservatively and 97% of children also treated non-operatively [25].

Liver injury can be mild when the trauma affects less than 25% of one lobe, moderate when the trauma affects between 25 and 50% of the lobe, and severe when the trauma affects more than 50% of the lobe.

Why liver is prone to trauma?

The liver is prone to trauma for the following reasons:

1. Fixed position of the liver: The liver is an organ which is huge and fixed at the right upper quadrant of the abdomen.

2. Liver is an organ with friable parenchyma.

3. Liver has a thin capsule.

Liver trauma can be the following:

Subcapsular haematoma, laceration, contusion, liver avulsion, bile duct injury, and gall bladder injury. Eighty percent of liver trauma involves segments 6, 7 and 8.

2.1.1. A: Clinical picture of liver trauma

1. Liver injury can be obvious.

2. Liver injury can be easily predicted.

3. Liver injury can be difficult to predict.

Obvious liver trauma:

Liver injury can be positively diagnosed where the following points are clearly established:

1. The patient is in a state of shock where he or she was involved in a road traffic accident or hit by a bullet at the right upper quadrant of the abdomen.

2. The patient is with hypotension and pain at the right upper quadrant of the abdomen after a road traffic accident.

3. Hypotensive patient shows tenderness over the right side of chest with fractured ribs after the trauma.

4. Hypotensive patient with bruises at the right upper quadrant.

Liver trauma can be easily predicted with the following points borne in mind:

1. Drop in blood pressure in a patient with road traffic accident and with guarding and tenderness at the right side of the upper abdomen.

2. Penetrating wound at the right upper quadrant of the abdomen.

Liver trauma is difficult to predict:

1. Normal blood pressure with right upper abdominal pain with guarding and tenderness at the right upper quadrant

Clinical presentation of liver trauma:

1. Pain at the right upper quadrant.

2. Fracture of right lower ribs.

3. Shock

Grading of liver trauma: American association of trauma

1. Grade I: Subcapsular haematoma less than 10% of the surface area. Laceration less than 1 cm.

2. Grade II: Haematoma more than 10–50% surface area. Laceration from 1 to 3 cm.

3. Grade III: Haematoma more than 50%. Laceration more than 3 cm.

4. Grade IV: Ruptured haematoma and bleeding. Laceration of the liver from 25 to 75% of the lobe.

5. Grade V: More than 75% of liver laceration, retrohepatic vena cava injury or hepatic vein injuries.

6. Grade VI: Hepatic avulsion.

2.1.2. B: Investigations

2.1.2.2. Imaging investigations

Ultrasound scan for liver trauma has 99% of specificity and 88% of sensitivity [19, 20, 21]. Fast ultrasound replaced peritoneal lavage. Looking to Morrison space if there is fluid in the space indicating bleeding. The use of contrast with ultrasound scan is more beneficial in liver trauma.

CT scan: This is done on a stable patient with oral and intravenous contrast. CT scan for liver injury has more than 90% of sensitivity and specificity (Figure 1). Useful for diagnosis of liver injury and follow-up of liver trauma, for any hemorrhage, bile accumulation or sepsis.

X-ray: X-ray chest may show fractured ribs at the site of the liver from 7th to 9th rib but is not specific and not done to look for liver injury.

DPL Diagnostic peritoneal lavage: This is an invasive procedure done on patients with trauma when there is intraperitoneal bleeding. It is useful and produces good results when performed by expert, but nowadays, it is replaced by ultrasound scan.

2.2.1. Conservative treatment of liver trauma

Blunt liver trauma can be mild, moderate or severe. Mild and moderate liver trauma can be managed conservatively without surgery [3, 11, 15, 18].

Conservative treatment includes the following:

1. Full assessment of patients.

2. Full assessment of the grade of liver injury by ultrasound and CT scan.

3. Correction of blood loss by giving blood.

4. Daily monitoring of patient.

5. Discharge of patient once he is fully stable and active.

6. Post-discharge follow-up by clinical assessment and imaging.

2.2.2. Non-operative treatment of liver injury

Non operative management was firstly conducted in children than started in adult, it is not indicated in elderly patients, choosing of the patients for non-operative management (NOM) depends on clinical condition of the patients and associated injury, less on grade of the liver of injury [2, 16].

2.2.3. Advantages of NOM

1. Less hospital stay.

2. Avoidance of unnecessary laparotomy.

An unstable patient can be defined as follows:

1. Systolic blood pressure less than 90 mmhg.

2. Pulse rate more than 120 beats per minute.

3. Altered consciousness level.

4. Altered breathing.

5. Cold clammy skin.

About 80% of blunt liver trauma can be treated conservatively, provided the patient is haemodynamically stable. It can be utilized even in grade IV.

Non-operative treatment can be performed for the following reasons:

1. Patients who are haemodynamically stable with no signs of peritonism.

2. Operative management should be available when needed.

3. Imaging facilities should be available to follow the treatments, which can lead to 100% success rate.

Liver trauma at Zliten University Hospital over a period of 9 years from 2009 to 2017—Patients: 231, deaths: 31, patients who underwent conservative treatment: 48 (Table 1).

Most of our patients with liver trauma during war, the time where the weapon is scattered in many regions of the country; none of our patients with hepatic trauma having had gun shot wounds left for conservative treatment, and all patients underwent surgery. This number affected our conservative management in hepatic trauma. Our rate of conservative treatment for patients with hepatic trauma was approximately 50%.

2.2.4. Complications of NOM

Complications of NOM can be diagnosed by clinical examination including blood tests, ultrasound scan and CT scan. Complications may reach up to 7% in grade III and V.

1. Bile collection may reach up to 20%—biliary peritonitis. Haemobilia: Bile leak is treated with endoscopic retrograde cholangiopancreatography most of our patients with liver trauma were during war. If fluid collection is significant, it can be drained percutaneously, laparoscopically or open surgery. Figure 2 shows the CT of a child with hepatic trauma managed conservatively with the development of bilioma). Figure 3 shows bilioma collection that was treated by laparotomy.

   Nagano-classified bile leak:

   1. Type A: Minor bile leak, small radicle from the liver surface—resolved spontaneously.

   2. Type B: Bile leak from a major duct on the liver surface not tied.

   3. Type C: Injury of duct branch from the main duct at the hilum.

   4. Type D: Main bile duct transected.

2. Infection and abscess formation may reach 7% and can be treated conservatively when clinical manifestation is significant.

3. Liver necrosis can be diagnosed clinically with raised liver enzymes, coagulation abnormalities or bile leak.

4. Bleeding: Hepatic artery pseudo-aneurysm accounts to about 1–2% and can be either extrahepatic or intrahepatic—more cases of extrahepatic nature. Liver compartment syndrome due to compression of the liver by huge subcapsular haematoma may result in liver failure.

2.2.5. Surgical treatment of liver injury

1. Surgery is indicated in a patient who is unstable.

2. Surgical treatment is indicated if the patient was on conservative treatment and showed signs of deterioration, [8, 27, 28, 29].

Surgical procedures (Figure 4 shows different repair of liver trauma).

1. Simple suturing of liver tear.

2. Debridment of unhealthy liver tissue and suturing.

3. Resection of severely damaged segment.

4. Liver lobectomy or hepatectomy for severely damaged lobe.

5. Perihepatic packing for uncontrolled bleeding in unstable patients.

6. Arterial embolization which can be performed as the first option in patients who are planned for non-operative treatment or for those patient who developed bleeding after surgery [17].

Damage control in liver trauma:

Damage control is of three phases:

1. Phase I: Control of bleeding, closure of the abdomen.

2. Phase II: Intensive care unit resuscitation and overcome on acidosis, hypothermia, hyper-coagulability.

3. Phase III: Re-exploration of the abdomen.

In 1983, Stone et al. proposed damage control for trauma patient [6, 14, 22, 23, 24]. Once patient had severe liver trauma, where the condition of the patient is deteriorating during surgery and the bleeding is continuous from the damaged liver, either the damage at the posterior aspect or whole of the liver, damage control is utilized in the form of packing the liver with abdominal gauze pack which are wrapped around the liver [4, 5, 6]. This technique is useful in the management of controlling the bleeding that occurs during surgery and liver resection. Packing is also useful to avoid the three killers of the patient during surgery which includes acidosis, hypercoagulability and hypothermia, which can cause cardiac arrest. To avoid the occurrence of these bad incidents, we should change to damage control. Usually six packs are placed around the liver to stop the bleeding. The abdomen left either open or closed depending on the patient’s condition with the use of Bogota bag. Packing the liver with gauze packs can be complicated when patients need to go through full resuscitation in the ICU. For the correction of the three killers including acidosis, hyperthermia, hypercoagulability, usually it needs time for our patients 48–72 h to control sepsis with the use of antibiotics.

Complication of perihepatic packing:

The complication of perihepatic packing includes the following:

1. Compartment syndrome.

2. Respiratory embarrassment due to compression on the right dome of the diaphragm.

3. Abdominal sepsis if the packs were left longer than 3 days.

Other surgical procedure for liver trauma include

1. Laparoscopic assessment of liver trauma and suturing of liver tear [12].

2. Liver transplantation for severely damaged liver is difficult to perform because of availability of the liver and the experienced team.

3. Liver exclusion and extracorporeal circulation is seldom done for severe liver trauma.

Controlling of liver bleeding: Bleeding from the liver is controlled by the following procedures

1. Simple suturing.

2. Hepatorrhaphy and control of the arterial bleeding.

3. Use of omental pack and mattress sutures.

4. Selective hepatic artery ligation may control the bleeding.

5. Non-anatomical resection, anatomical resection, venovenous shunt, atriocaval shunts.

Mortality of blunt trauma is 27% and of penetrating trauma is 11%.

Overall, mortality of liver trauma is 10%, Grade III and IV mortality is 10% and V and VI are 75%.

There are many haemostatic materials used for liver trauma are very helpful for controlling the bleeding, which includes the following:

1. Surgical.

2. Spongostan.

3. Tacoceil.

4. Fibrin glue.