Contemporary

Management of Liver
Injuries


Stephen L. Barnes MD FACS

Professor of Surgery & Anesthesia
Chief, Division of Acute Care Surgery, Trauma & Burn
Program Director, Surgical Critical Care
University of Missouri School of Medicine
Mechanism
Are all liver injuries
created equal?
AAST Classification
Liver Injuries
Grade Type Description
I

Hematoma

Subcapsular, non-expanding, <10cm



Laceration

Subcapsular, non-bleeding, < 1cm

II

Hematoma

Subcapsular, non-expanding, 10-50% of surface area;
intraparenchymal < 10cm



Laceration

Capsular tear, bleeding, 1-3cm deep and < 10cm long

III

Hematoma

Subcapsular > 50% or bleeding, or ruptured; hematoma > 10cm or
growing



Laceration

>3cm

IV

Hematoma

Ruptured intraparenchymal hematoma



Laceration

Destruction of 25-75% or 1-3 Couinaud segments in 1 lobe

V

Laceration

Destruction > 75% or 1-3 Couinauds segments in 1 lobe



Vascular

Juxtahepatic venous injury (cava/major hepatic vein)

VI

Vascular

Hepatic avulsion

Non-operative Management
(What? Is he crazy?)




Management of
Major Liver Injuries
Croce M, Fabian T, et al. Non-operative management of blunt hepatic trauma is the
treatment of choice for hemodynamically stable patients: Results of a prospective
trial. Ann Surg 1995;221:744-55.
Longstanding Change in
Practice
85% of all blunt
hepatic trauma are
stable
Non operative
management
Improves outcomes
Fewer Infections
Fewer Transfusion
Decreased LOS
Non-operative Management of
Major Liver Injuries
Hemodynamic stability
CT documentation
No evidence of extra-hepatic abdominal injury
that requires surgery (eg. bowel injury)
No peritonitis
Limited liver-related transfusions
Criteria
Non-operative Management of
Major Liver Injuries
Is done routinely
Can be done successfully
With improved outcomes
Liberal use of angio-embolization,
especially if iv contrast blushes on CT
Watch these people closely !!!!
If no acute surgery required, beware of
delayed complications
Successful Non-operative Management
of Grade IV Blunt Liver Injury
Stable patient
No blood transfusions

CT scan two weeks
later showing healing
of lacerations
Hepatic Angioembolization in
Non-operative Management
Vascular blush
Vascular blush = extravasation of iv contrast
Hepatic Arteriography and
Embolization
Widely used/over-used
Effective in hemorrhage control
When?
as a component of non-operative
management, particularly if vascular
blush seen on CT
following urgent laparotomy and
packing



Case #1
Too Much Punch at the Party
University student after 3 feet fall from
stepladder in dorm room
No peritonitis
Hct 28
HR 100
BP 130/80
No other
injuries
IV contrast
extravasation
University student after 3 feet fall from
stepladder in dorm room
Hepatic Arteriography -
extravasation and traumatic
arterial-portal venous fistula
Early filling of portal
venous system
Operative Management
Acute surgery for Hemorrhage

Surgery for persistent hepatic bleeding during
non-operative management

Delayed surgery for sequelae of a
massive liver injury




Operative Management of
Massive Liver Injury
Generous midline incision
Four quadrant packing
Extreme hypotension - clamp supraceliac aorta
Divide falciform ligament
Put in retractor system
Look quickly for splenic and mesenteric bleeding
If brisk bleeding from liver, apply Pringle

I ncision and
I nitial Exploration
Pringles Maneuver =
Portal Triad Occlusion

Pringle JH. Notes of the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg
1908; 48:541

A Key Maneuver
for the Massively
Bleeding Liver
Pringles Maneuver =
Portal Triad Occlusion
Reduces blood loss while you operate
Diagnostic maneuver
Clamp and look behind the liver
If there is brisk venous bleeding OR a
large retroperitoneal hematoma behind
the liver, you have a major problem on
your hands !!!!!
If you are leaving the clamp on a long time you
may be trying to do too much !!!


Mobilize the liver up into the wound so you can
examine and work on it




BUT consider early whether the liver should be
definitively packed and left alone before you spend a
lot of time and effort

Exposure is Everything
Damage Control Laparotomy
Surgery is resuscitative, not definitive
Expeditious control of hemorrhage,
primarily peri-hepatic packing
Key is knowing when to stop operating and
get out
Blood pressure, temperature, acidosis, and
coagulopathy are the key markers
Packing
Has improved survival in massive liver injury
Should always be asking yourself
Is it time to pack ?
Try to evaluate whether there is a portal
vascular injury or a retrohepatic vascular
injury prior to packing it in
Lap sponges
Avoid IVC compression
When is it time to pack?
Massive liver injury with limited
institutional resources
Massive liver injury with limited experience
Massive liver bleeding and patient in extremis
Active bleeding after control of identified
bleeding vessels and application of topical
hemostatic agents
Active retrohepatic hemorrhage
When is it time to unpack?
Normal coagulation parameters
Normothermic
Resolution of acidosis
Following hepatic
angiography/embolization
24 - 48 hours after packing
Prepare for the worst, hope for the best
Control of bleeding points, debridement,
drainage
Resectional Debridement
Massive Liver Injury
In the presence of active bleeding from a
massive liver injury try and avoid large
anatomical liver resections
You may need to resect liver to get at a
source of active bleeding (eg. approach to
left hepatic vein thru liver)
If a piece is dangling...remove it !


Resectional Debridement
Massive Liver Injury
MVC, failed
non-operative
management
Debridement of
devitalized liver,
hemostasis and drainage
Retrohepatic IVC
and Hepatic Vein Injuries
Quick recognition
Dont pack and peek, pack and peek
Two main strategies:
Pack and fight another day
Fix it now
Key Points:
Retrohepatic IVC &
Hepatic vein injuries
Reports of unpacking these injuries with no
rebleeding
Angiography and embolization prior to pack
removal
Consider cavagram prior to pack removal
Endovascular venous stenting
Prepare for:
Atriocaval shunt/Venovenous bypass
Pack and fight another day:
Retrohepatic IVC/hepatic vein injuries
Fix it now approach
Direct attack
Hepatic Vascular Isolation
Pringle, clamp IVC above and
below liver poorly tolerated
Atriocaval shunt
Venovenous bypass

The Approaches:
Retrohepatic IVC/hepatic vein injuries
Direct attack approach
Advocated by some due to poor
results with vascular isolation
Need to know what you are
doing and be quick about it
Pringle, mobilize liver as required
One look behind liver to see if you can get it
Finger fracture thru whatever liver is needed to
get directly at venous injury





Case #2
Be Careful around Ambulance
Drivers
Recent Case
Direct attack approach
Runner struck by ambulance during road
race
Talking, hypotensive, FAST +
Laparotomy
Bleeding from liver
Spleen/mesentery normal
Pringle applied, continued bleeding
Bleeding from right hepatic vein/IVC junction






Recent Case
Direct attack approach







Venous repair performed
Expanding right renal hematoma, renal lac and
transection of renal artery.nephrectomy
Liver and right renal bed packed
Temporary abdominal wall closure
OR>>Hepatic angiography >>ICU
Bleeding, coagulopathy, acidosis and hypothermia
resolved
Return to OR, pack removal, closure
Atriocaval Shunt
Generally done too late
Small experience
Results are generally poor
Trend is away from shunting

Not easy
Pack liver
Median sternotomy
You need a shunt!
Chest tube
Endotracheal tube
32Fr open heart bypass catheter
Control of intrapericardial IVC and
suprarenal infrahepatic IVC
How ?
Atriocaval Shunt
Venovenous Bypass

Makes you look like you know
what you are doing !!!
Almost bloodless view of retrohepatic
IVC and hepatic veins
Maintains venous return to heart from
below diaphragm
Can avoid sternotomy


What does it do for you?
Venovenous Bypass
Need to plan for it
Need help
Need time
Need catheters
Need pump (eg Biomedicus)
Need perfusionist
Need some luck
Do not need heparin


Drains
Generally, drain grade IV/V
liver injuries
Place drains after packs
removed
Closed suction drains
You are draining for bile
If the drains dont drain bile
in 3-4 days, take them out
Delayed Complications
of Massive Liver Injury
Complications of open abdomen
fistula, hernia
Biliary fistula
Biliary peritonitis
Biloma
Hemobilia
Hepatic or peri-hepatic abscess
Hepatic failure
Case#3
Beware when Shoveling Snow
EMS Report
38 year old male
Struck by falling tree limb ~18 inch
diameter, from height of 30 feet after snow
storm while shoveling driveway.
Struck on right side and pinned
Brief loss of consciousness
Hemodynamically stable throughout
ground transport
Imaging
AP Chest
Multiple right rib fractures
AP Pelvis
Left superior rami fracture
Spine
T10-12 right transverse
process fractures
F.A.S.T.
Intra-peritoneal free fluid
Radiographic Evaluation
CT Abdomen /
Pelvis
Grade V* Liver
Laceration with
extravasation of iv
contrast
Moderate
hemoperitoneum
Labs stable
Not acidotic
*AAST Organ Injury Scale J Trauma 1989
Angiography
Extravasation, branch
of right hepatic artery
Embolized with 3 mm
coils
Extravasation, branch
of left hepatic artery
Embolized with gelfoam
pellets
No extravasation on
completion angiogram
Hospital Course
Hospital day #3
Hct drop to 24% (36%)
PT/PTT normal
HR increased to 125
Complained of
increasing RUQ pain
2 U PRBC
Repeat CT Scan
Hospital Course
CT scan revealed
intra-hepatic
extravasation of iv
contrast

Repeat angiogram
with successful
embolization of
pseudoaneurysm
Delayed Complications
Non-operative Management
Hospital day 5
Surgical Floor
Hct stable
Increasing abdominal
distention and pain
Jaundice
Total bilirubin 4 mg/dl

HIDA Scan
Endoscopic Retrograde
Cholangiography
Hospital Day # 8
Biliary leak visualized
Unable to stent leak
10 french ampullary
stent placed
Suspected biliary
peritonitis
Laparoscopy following
stent placement
Laparoscopy & Drainage
Hospital course
Discharged on POD
4
Hct stable ~ 30%
Afebrile, VSS
JP drains in place
with minimal output
Tolerating regular
diet
Case #4
Hunting with my Buddy
Complications of Massive
Liver Injury
Transferred to Mizzou for clinical deterioration
Hunting Accident
GSW-RUQ/liver
Sick
Packed/unpacked/
drained &closed at
outside hospital
Lots of drain output

Complications of Massive
Liver Injury
Draining infected
biloma
Bile drainage of
1 liter/day
Complications of Massive
Liver Injury
ERC proximal common
hepatic duct injury
Contemporary Management of
Liver Injuries Keys to Success
Hemodynamically unstable patients need to
be in the operating room
No patient should die as a result of non
operative management
Beware of delayed complications of non
operative management strategies
Role of angio\embolization
Both Pre and/or Post Operative
Utilize minimally invasive technology where
appropriate in a multidisciplinary approach
Thank you