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Chapter 18
trauma reported sensitivity rates ranging from 28% to
97% and specificity rates close to 100%.
18
Rozycki etal. demonstrated a significant correlation
between haemoperitoneum in the right upper quadrant
and injury to the liver, and suggested that adherence
to a pre-agreed protocol increased the reliability of
ultrasound assessment of abdominal trauma.
19
Other
centres have also reported that ultrasound is a reliable
‘first’ test for the assessment of a patient with suspected
liver trauma.
note comes from a study by Richards et al.
20
However, an important cautionary
21
In a
series of 1686 abdominal ultrasound scans for trauma,
71 patients had bowel or mesenteric injury and 30
patients had a negative ultrasound scan (43% falsenegative rate). Limitations of FAST include operator
dependence, poor assessment of the retroperitoneum,
unreliable detection of pneumoperitoneum and
difficulty in scanning obese patients or those with
overlying wounds.
Computed tomography (CT) is the ‘gold standard’
investigation for the evaluation of a patient
with suspected liver trauma (
Fig. 18.1). Modern
CT protocols provide simultaneous arterial and
portovenous images. CT has high sensitivity and
specificity for detecting liver injuries. Specific
CT features of liver trauma have been reported
by a number of authors. Fang et al. described
intraparenchymal ‘pooling’ of intravenous contrast
that correlated strongly to the presence of ongoing
haemorrhage.
‘periportal tracking’ to consist of a circumferential
area of low attenuation around the portal triad.
22
Yokota and Sugimoto documented
23
Periportal tracking is thought to represent blood
or fluid within the condensation of the Glissonian
sheath around the portal structures and indicates
the presence of injury to structures in the portal
triad. If the sign is present in the periphery of the
liver it may alert the clinician to the presence of a
peripheral bile duct injury that in turn may present
as a bile leak. Addition of oral contrast does not
add to the diagnostic yield of CT in the assessment
of liver injury and simply delays the acquisition of
24
images.
In order to maintain a balanced perspective, it
is worthwhile considering some of the limitations
of CT in the assessment of liver trauma. The
CT-defined grade of injury may differ from the
grade of liver injury found at operation, with the
predominant tendency being to overdiagnose the
grade of injury on CT as compared with subsequent
operative findings. Croce etal. concluded that CT
should not be used in isolation to estimate blood
loss and that CT may not provide an accurate
assessment of the extent of a liver laceration in some
areas of the liver – specifically in the vicinity of the
falciform ligament.
25
Bearing the above limitations in mind, CT will
define the extent of the liver injury and will be
of value in the detection of injury to other intraabdominal viscera, in particular pancreatic injury.
CT allows the liver injury to be graded and thus
will provide objective information if non-operative
treatment is to be contemplated. Further refinements
now permit accurate three-dimensional image
reconstruction, and demonstration of vascular
anatomy (CT angiography).
Figure18.1 • CT image of a 25-year-old male who sustained a blunt injury to the right chest wall but was admitted
to hospital haemodynamically stable. The scan shows a substantial subcapsular haematoma associated with an
intraparenchymal laceration. This patient was managed successfully without operation.
302
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Hepatobiliary and pancreatic trauma
Some authors recommend performing a wholebody CT (head, C-spine, chest, abdomen, pelvis)
as the standard diagnostic tool during the early
phase for patients with polytrauma, advocating that
this will alter treatment in up to 34% of patients
with blunt trauma.
using this approach has also been reported.
26
A 30% reduction in mortality
27
Other
arguments in favour of an imaging survey are the
reduction in time from admission to intervention
and consistency in managing haemodynamically
unstable patients.
28
In the UK, with the advent of the Major Trauma
Network, most patients with significant HPB
trauma will be managed in a Major Trauma Centre
(MTC). The protocols described above mean that
such patients will either proceed rapidly to theatre
for laparotomy, or to CT for full ‘head, neck, spine,
thorax, abdomen, and pelvis’ assessment. In this
way early and highly detailed visceral imaging can
be used to inform management decisions.
Other diagnostic/therapeutic modalities
for the assessment and treatment
of liver injury
Non-invasive imaging techniques such as magnetic
resonance imaging (MRI) have the advantage of
being free of ionising radiation, but increased cost
aside, the time taken to produce a scan means that
this technique is not yet widely used in the trauma
setting.
Angiography plays a vital role in the non-operative
management of liver injuries. Extravasation of
contrast seen on CT requires emergency angiography
and therapeutic angiographic embolisation for
ongoing blood loss.
reported following damage control surgery prior to
removal of packs if re-bleeding is suspected.
29
Angioembolisation is also
30,31
CT is the gold standard to define the extent of
injury in a stable patient and can be applied rapidly
in the context of UK Major Trauma Centres.
Management of liver injury:
selection of patients
for non-operative management
The feasibility of non-operative management of patients
with intra-abdominal solid organ injury was first
established in paediatric surgery but was subsequently
extended to adult practice. Richie and Fonkalsrud
described successful conservative management of
four patients with liver injury in an era before the
availability of CT.
feasibility of a non-operative approach came from
a report published by White and Cleveland
same year. They reported a consecutive series of 126
32
Further indirect evidence for the
33
in the
patients with liver trauma, all of whom underwent
laparotomy. Interestingly, 67 patients in this series
(53%) had placement of a drain to the subhepatic
space as their only liver-related surgical intervention at
laparotomy. Subsequent studies have recognised that
50–80% of liver injuries stop bleeding spontaneously
and this has led to a non-operative approach for blunt
liver trauma in selected patients.
Non-operative management of liver trauma is
now a well-established treatment option. Trunkey's
group in Portland, Oregon, first defined in 1985 the
following criteria for the selection of patients for
non-operative management:
• haemodynamic stability;
• absence of peritoneal signs;
• availability of good-quality CT;
• an experienced radiologist;
• ability to monitor patients in an intensive care
setting;
• facility for immediate surgery (and by
implication, availability of an experienced liver
surgeon);
• simple liver injury with <125 mL of free
intraperitoneal blood;
• absence of other significant intra-abdominal
injuries.
34
Farnell et al. extended the threshold of
haemoperitoneum to 250 mL and described
specific liver injuries suitable for non-operative
management.
35
Feliciano suggested subsequently
that any blunt hepatic injury, regardless of its
magnitude, should be managed without operation
if the patient was haemodynamically stable and had
a haemoperitoneum of <
500 mL.36 The degree of
liver injury amenable to successful non-operative
management has gradually extended over recent
years, and most authors now believe that the
ultimate decisive factor in favour of non-operative
management is haemodynamic stability of the
patient at presentation or after initial resuscitation,
irrespective of the grade of liver injury on CT or the
amount of haemoperitoneum.
37,38
A 22-month prospective study from Memphis
of the initial non-operative treatment of
haemodynamically stable blunt hepatic trauma
patients compared outcome to a matched cohort of
blunt hepatic trauma patients treated operatively.
39
The study reported that of 136 patients with blunt
trauma, 24 (18%) underwent emergency surgery.
Of the remaining 112 patients, 12 (11%) failed
conservative management (for causes not related
to the liver injury in seven) and the remaining 100
patients were treated successfully without operation.
Of these, 30% had minor injuries (grades I and II) but
70% had major injuries (grades III–V). This study
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303
Chapter 18
concluded that non-operative management was
safe for haemodynamically stable patients and that
this was independent of the CT-delineated grade of
the liver injury. The blood transfusion requirement
and the incidence of abdominal complications were
lower in the non-operatively treated group.
Reporting a single institutional experience, Boone
et al. stated that 46 (36%) of 128 consecutive
patients with blunt liver trauma were successfully
treated non-operatively, including 23 patients with
grade III and IV injuries.
from the published literature noted a success rate
for non-operative treatment of 94%.
37
A review of 495 patients
40
This was
accomplished with a mean transfusion rate of 1.9
units, a complication rate of 6% and a mean hospital
stay of 13days. There were no liver-related deaths,
nor were there any missed enteric injuries.
The current consensus view is that successful
selection of patients for conservative treatment after
blunt abdominal trauma cannot be carried out by CT
alone, but that an overall assessment of suitability
for such an approach must take into account the
findings of careful repeated clinical examination and
the results of close monitoring of haemodynamic
and haematological parameters. If non-operative
management is selected, haemodynamic instability
is the predominant indication for intervention early
in the clinical course whilst intervention (often
radiological or endoscopic) may be required later for
management of bile leak or intrahepatic collections.
If a non-operative strategy is selected, it should
be borne in mind that the risk of hollow organ
injury increases in proportion to the number of
solid organs injured
41
and that there is a small but
significant risk of delayed haemorrhage. However,
it appears that the natural course of liver injuries is
more analogous to that of lung or kidney injuries,
rather than splenic injuries, in that any deterioration
is usually gradual, with a fall in haemoglobin level
or an increase in fluid requirement, rather than
acute haemodynamic decompensation. Therefore,
with close supervision, patients who fail with an
initial non-operative approach can be detected early
and treated appropriately.
Although non-operative management of haemodynamically stable patients with liver trauma has become
the standard of care over the past decade, the role
of in-hospital follow-up CT to monitor the injury
remains controversial. Demetriades et al. reported
that follow-up CT at a mean of 10days after surgical
intervention showed a 49% incidence of liver-related
complications, most of which required subsequent
intervention.
little evidence that follow-up CT provides additional
information and rarely changes management.
42
However, other authors suggest there is
43
The management policy for abdominal gunshot
injuries in most centres continues to be a mandatory
laparotomy, regardless of the clinical presentation;
44
however, several studies have reported successful
non-operative management of selected liver gunshot
injuries.
45,46
In the study by Omoshoro-Jones etal.,
26.6% of patients who presented with liver gunshot
injuries were managed non-operatively, with an
overall success rate of 94% and a morbidity rate
of 36%, of which 3% were liver-related.
approach is associated with the risk of failure to
detect concomitant intra-abdominal visceral injury
and therefore should only be considered in specialist
centres with experience in management of liver
trauma and appropriate facilities to deal with any
Non-operative management is safe for
haemodynamically stable patients with CT evidence
of liver injury.
Operative management of liver
injury
General strategy
Primary operative intervention is indicated for liver
injury if the patient is haemodynamically unstable.
Important prerequisites for a successful outcome
are: adequate blood, platelets, fresh-frozen plasma
and cryoprecipitate; an intensive care unit; the
necessary diagnostic facilities to monitor and detect
potential complications; and an experienced trauma
and hepatobiliary surgeon. Although this is the
ideal, in the recent past patients with liver trauma
would routinely present to surgeons without
specialist hepatobiliary experience and without the
facilities available in liver surgery units. With the
introduction of MTCs, this situation is now much
less likely. However every operating general surgeon
should have a basic understanding of the principles
of HPB haemorrhage control. Once haemostatic
control is achieved, specialist advice may be
sought. Unfortunately the nature of HPB trauma
has repeatedly demonstrated that anatomically
misjudged initial surgical manoeuvres can lead to
irretrievable situations. Therefore, the non-specialist
should seek early assistance from an HPB surgeon.
Theatre set-up, patient positioning and
choice of incision
The patient should be positioned in the crucifix
position (both arms out on boards) with skin
preparation applied from knees to neck. Following
draping, access for both laparotomy and
thoracotomy should be possible. The patient should
be warmed. The theatre team should open general
45
This
304
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Hepatobiliary and pancreatic trauma
and liver instrument trays with additional vascular
clamps. An autotransfusion (cell salvage) device
should be available.
A long midline incision is the only appropriate
incision for an emergency laparotomy. It has
the advantages that it can be made rapidly, and
extended proximally (to enter the chest after median
sternotomy) or distally as required. Access to the
liver can be improved by converting the incision into
a ‘T’ by adding a right transverse component or to a
‘Y’ by adding a right lateral thoracotomy, although
extension of the incision into the chest is exceptional.
In situations where a delayed operation is being
carried out after initial conservative management,
for example to treat bile leakage or perform delayed
resectional debridement, a subcostal incision with
fixed costal margin retraction affords excellent
access to the liver.
The authors advocate routine early use of a tablemounted retractor. Access is vitally important in
high-grade injury and many HPB trauma scenarios
will definitely require this level of access for a
successful outcome.
Surgeons operating on HPB trauma patients
should be intimately familiar with their local
table-mounted retractor.
Initial manoeuvres and intraoperative
assessment
The operation should begin in the same manner as
employed for non-differentiated trauma. Once the
abdomen has been entered, blood and clots should
be removed and packs inserted into each quadrant
of the abdomen. In high-grade liver injury it will
be clear at this point that a great deal of blood is
flowing from the right upper quadrant. In stressful
situations such as these it can be helpful to keep
some simple sequential steps in mind. In the case of
a significant liver injury the author uses:
• PUSH – Gently compress the liver closing any
significant wounds and restore the anatomical
shape. If bleeding stops, continue with
PACKING the liver as definitive management.
• PACK – Bleeding stops = portovenous injury
(packing only sufficient).
Bleeding continues …
• PRINGLE – Bleeding stops = arterial injury
(definitive procedure required).
Bleeding continues …
Perihepatic packing
In many surgical texts ‘four quadrant packing’
constitutes the sum total of the instruction offered.
However, in the case of the right upper quadrant
and HPB trauma, pack insertion requires a little
more thought and technique. Perihepatic packing
of the liver is aimed at restoring the anatomical
conformation of the organ. As mentioned above,
the most common injuries associated with major
haemorrhage are distracted lacerations occurring
near fixed ligamentous attachments. In order to
‘reduce’ the liver, these ligaments must be mobilised
sufficiently to allow packs to compress lacerations
within the liver parenchyma. Consider the example
of a right/left laceration; blind direct packing over
the dome of the liver results in the right lobe of
the liver being pushed away from the left (which is
fixed by the falciform ligament). The distraction is
aggravated and the injury extended, potentially into
major intra-parenchymal vessels. Such manoeuvres
worsen hepatic injury and cause harm.
Such issues are easily avoided by dividing the
falciform and right triangular ligaments prior to
pack insertion. It is the authors’ practice to rapidly
divide the falciform ligament (using hand-held
diathermy) until air is seen to rush into the coronary
ligament. The left hand is then moved smoothly
over the dome of the liver until the apex of the right
triangular ligament is located. This can be isolated
between fingers and divided, thus allowing medial
rotation of the right lobe until the exposed raw
surface of the right lobe contacts the corresponding
left lobe surface (much like closing a book). The
pressure achieved by packing should not be too
aggressive – no degree of packing will overcome
hepatic arterial bleeding; the aim is to overcome
portovenous pressures. If this is greatly exceeded,
necrosis will occur. Ongoing haemorrhage despite
correct packing should lead to a Pringle manoeuvre
(see below) and further assessment/intervention. It
is not an indication for more aggressive and tighter
packing.
A typical example of a well-reduced liver will have
packs placed ‘under’ the right lobe between the
posterior abdominal wall and the capsule, as well as
over the anterior laceration (
Fig.18.2).
In most cases simple packing will induce
haemostasis. At this point, further evaluation of
the extent of liver injury should be delayed until
the anaesthetist has replenished adequately the
intravascular volume and stabilised the blood
pressure. Attempts to evaluate the liver injury before
adequate resuscitation may result in further blood
loss, with worsening hypotension and acidosis.
The packs can subsequently be gently removed to
allow a detailed evaluation of the type and extent
of the liver injury. It should be borne in mind that
a subcapsular haematoma may cover an area of
ischaemic tissue and that parenchymal lacerations
may be associated with damage to segmental bile
ducts. If bleeding is arrested satisfactorily with
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305
Chapter 18
Figure18.2 • Placement of gauze packs around the liver to compress the fracture.
Reproduced from Berne TV, Donovan AJ. Section10. Injury and haemorrhage. In: Blumgart LH, Fong Y, editors. Surgery
of the liver and biliary tract, 3rd edition. Vol. 2. Edinburgh: Churchill Livingstone; 1994. With permission from Elsevier.
low pressure packing, the appropriate decision
is to reapply and plan to relook in 48 hours. In
the vast majority of cases, haemostasis will occur
and on delayed removal no further bleeding is
seen. Occasionally the specialist HPB surgeon
may directly repair a venous injury. The benefit of
achieving immediate definitive repair is balanced
against the increased risk of a packing strategy and
should not be routinely undertaken.
In other situations where it is thought that
definitive control of haemorrhage cannot be
obtained, or patients are deemed critically
unstable, coagulopathic or acidotic, perihepatic
packing should be employed. Such an approach
follows the principles of damage control surgery –
rapid perihepatic packing, temporary closure
of the abdomen with a negative-pressure device
(Abthera™) and transfer to the intensive care unit
(ICU) as soon as possible for continued resuscitation
and rewarming. When the metabolic derangements
have been corrected or improved, the patient can be
taken back to theatre or transferred to a specialist
centre for re-exploration and definitive treatment.
47
The principal complications and limitations of
perihepatic packing can be considered as ‘early’
or ‘late’. Early complications include failure to
control haemorrhage. However, this is relatively
uncommon. Excessive packing will compromise
caval blood flow, although this can be avoided by
using an appropriate technique. The principal late
complications of packing are infection and multiple
organ dysfunction. The risk of septic complications
led to a recommendation that liver packs should
be removed as soon as possible. However, Nicol
et al. reported in a series of 93 patients requiring
liver packing that an early re-look laparotomy
at 24 hours rather than at 48 hours or later was
associated with a higher incidence of re-bleeding
necessitating re-packing, without any difference in
the incidence of liver-related complications or intraabdominal collections.
The first re-look laparotomy following packing for
a liver injury should ideally be performed after
36–48 hours, only when hypotension, hypothermia,
coagulopathy and acidosis have been corrected and
appropriate personnel and equipment are available.
48
The Pringle manoeuvre
This is defined as temporary digital compression
of the free edge of the lesser omentum (Pringle
manoeuvre;
despite packing, a Pringle manoeuvre can be used
diagnostically and compression can be maintained
with an atraumatic vascular clamp (
haemorrhage is arrested upon clamping, an arterial
injury is diagnosed. The options for definitive
management at this point are angiographic
embolisation or the surgical options detailed below.
If packing or a Pringle manoeuvre does not control
bleeding, a hepatic vein or retrohepatic caval
injury is suspected. Strategies to deal with these
are described below. The clamp should be occluded
only to the degree necessary to compress the blood
Fig. 18.3). If there is active bleeding
Fig. 18.4). If
306
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Hepatobiliary and pancreatic trauma
Figure18.3 • Manual occlusion of the structures of the portal triad – the Pringle manoeuvre.
vessels and not to injure the common bile duct. A
normal liver can tolerate inflow occlusion for up
to 1 hour; however, the ability of a damaged liver
to tolerate ischaemia may be impaired. Where a
Pringle manoeuvre is concerned, the adage ‘as long
as is required, as short as possible’ is best applied.
If there is significant hepatic venous bleeding,
hepatic outflow control may also be required.
Access to the suprahepatic cava is difficult even
for the experienced liver surgeon, and in patients
with an injured liver, such attempts can prove
fatal. Consideration should be made of accessing
and clamping the inferior vena cava within the
pericardium either through opening the chest or
splitting the diaphragm. Total vascular occlusion of
the liver requires control of the inferior vena cava
below the liver in addition to the suprahepatic cava
but is poorly tolerated by an injured liver.
Liver sutures are absorbable sutures on a large
curved blunt-tipped needle, often used in conjunction
with a bolster of haemostatic material. They can be
used to approximate a fissured parenchymal injury
and thus control haemorrhage as an alternative
to exploration of the depths of the injury. The
disadvantages of this technique are that vessels
may continue to bleed, resulting in a cavitating
haematoma, bile duct injuries may not be detected
and the suture itself may cause further bleeding,
ischaemia or intrahepatic bile duct injury (
and therefore this technique is not advocated.
Haemostatic adjuncts are a valuable part of the
arsenal for liver injury. Fibrin glue has been used as
an adjunctive measure; however, there are concerns
regarding the use of fibrin glue in humans. Fatal
hypotension following application of fibrin glue into a
deep hepatic laceration has been reported.
a number of absorbable haemostatic patches available
Techniques for hepatic surgical
haemostasis
that have the advantage of allowing pressure to be
applied and a number of them are impregnated with
thrombin and fibrin to augment local coagulation.
Exposed bleeding vessels can be suture-ligated, clipped
or repaired to achieve haemostasis. The ultrasonic
dissector is useful in removing damaged and nonviable hepatic parenchyma whilst exposing blood
vessels. Diathermy coagulation can also be used.
Resectional debridement
This technique involves removal of devitalised liver
tissue down to normal parenchyma using the lines
of the injury, rather than anatomical planes, as the
Fig.18.5)
49
There are
50
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307
Chapter 18
Figure18.4 • Occlusion of the structures in the portal triad using a soft non-crushing clamp.
boundaries of the resection.51 The optimum timing
may be to combine debridement with pack removal,
as necrotic tissue will be well demarcated at 48 hours
post-injury. Resectional debridement is by definition
‘non-anatomical’ and may expose segmental bile ducts
Fig.18.6). Disrupted bile ducts exposed in the periphery
(
of the liver should be sutured or ligated in order to
prevent postoperative bile leaks, as this troublesome
complication will not necessarily be treatable by
endoscopic transampullary biliary stenting. It is better
to anticipate and avoid this complication.
Anatomical liver resection
Figure18.5 • Operative photograph demonstrating a
liver injury with necrosis at the site of previously inserted
liver sutures that had been applied in an attempt to arrest
haemorrhage.
308
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The practical difficulties of undertaking formal
anatomical liver resection in a patient with a significant
liver injury, who will frequently have associated
shock, coagulopathy and concomitant injury, are
Figure18.6 • Debridement of a liver injury managed
3days before by packing has left the branches of the
right portal pedicle exposed.
such that this type of treatment is not used widely. It is
generally accepted that anatomical resections should
be reserved for situations in which no other procedure
adequately achieves haemostasis, such as with deep
liver lacerations involving major vessels and/or bile
ducts, where there is extensive devascularisation, or if
there is major hepatic venous bleeding.
Strong et al. reported a single-centre series of
37 patients that underwent anatomical resection
for liver trauma from an institutional experience
of 287 patients with liver injury treated over a
13-year period.
52
Twenty-seven of these patients
underwent right hemihepatectomy and overall
there were three postoperative deaths (8% mortality
rate). However, these excellent results achieved
by a technically skilled liver surgeon and his unit
may not be reproduced if the technique were more
widely used.
Management of hepatic venous and
retrohepatic caval injury
Suspicion that one of these serious injuries is present
should be raised if the Pringle manoeuvre fails to
arrest haemorrhage. In this situation, it is vital
that a systematic approach be adopted. Injudicious
mobilisation of the liver can cause exsanguination
or embolisation of air or detached fragments of
liver parenchyma. Therefore it is important to
exclude anatomical vascular variants as a source
of persistent bleeding. For example, there may be
bleeding from the left liver due to the presence of a
left hepatic artery arising from the left gastric artery
or there may be bleeding from the right liver due to
an aberrant right hepatic artery. These anatomical
variants should be considered.
Persistent bleeding may then indicate the presence
of hepatic venous or retrohepatic caval injury.
These injuries account for about 10% of liver
trauma cases, and there is no clear consensus on
Hepatobiliary and pancreatic trauma
an optimal management strategy. Total vascular
exclusion (clamping of the inferior vena cava
and suprahepatic cava in addition to the Pringle
manoeuvre) may be used. However, clamping the
vena cava will seriously compromise venous return
in a situation of major trauma and may be unwise.
Veno-venous bypass (shunt from common femoral
vein to left internal jugular or axillary vein) has
the advantage of preserving venous return but is
unlikely to be available. Atriocaval shunting has
also been described and, combined with a Pringle
manoeuvre, allows total vascular isolation of the
liver; however, the reported mortality is such that
the technique is no longer applied. Chen et al.
reported on a series of 19 patients with blunt
juxtahepatic venous injury from a group of 92
patients with blunt liver trauma over a 2-year
53
period.
Ten of the 20 patients with isolated right
hepatic vein injury were treated using an atriocaval
shunt but the mortality in these 20 patients was
18 (80%), with one survivor in both the shunted
and non-shunted groups. Of four patients with
combined right and left hepatic vein injury, one
was treated by liver transplantation but all four
patients in this group died. The overall mortality
rate in patients with juxtahepatic vein injury was
63%. The opportunity to optimise the outcome in
patients with these serious injuries probably lies in
packing followed by transfer to a specialist liver
surgery unit.
Exvivo surgery and liver transplantation
Ringe and Pichlmayr54 reported a consecutive
series of eight patients with severe liver trauma
treated by total hepatectomy followed by liver
transplantation. These patients had all undergone
prior surgery for trauma, which had been followed
by severe complications – uncontrollable bleeding
in four and massive necrosis in four. Where
a donor liver was not immediately available
a temporary portocaval shunt was used as a
bridging procedure. There was a high mortality
in this group, with six out of eight patients
dying from multiple organ failure or sepsis. The
authors concluded that total hepatectomy can be
a potentially life-saving procedure in exceptional
emergencies in patients with major liver injuries.
Heparinised coated tubes such as the Gott
shunt can be used to bridge caval defects if total
hepatectomy and excision of a caval segment is
required in order to obtain haemostasis.
shunt acts as a temporary bridge during the
anhepatic phase and has been reported to remain
patent over an 18-hour period. Whilst experience
of this sort of surgery is extremely infrequent,
awareness of the therapeutic potential is useful
and small series continue to report encouraging
56
results.
55
The
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309
Chapter 18
Complications of liver trauma
Complications of non-operative
management
Complications of non-operative management
of liver trauma can be considered in three main
categories. First, it should be borne in mind that
complications can arise as a result of inappropriate
selection of a patient for conservative management.
If a patient has continued bleeding this may present
as episodes of hypotension requiring fluid and blood
replacement, impaired renal function and there
may be evidence of coagulopathy. These features
represent not so much a ‘complication’ as the natural
progression of a patient with continued active intraabdominal bleeding, and in such a case the policy of
non-operative intervention will require reappraisal.
The second group of complications are those relating
to coexisting injuries that have not been recognised
at the time of initial presentation or become
apparent after initial delay. Bile leaks may manifest
as biliary peritonitis or as a localised bile collection.
Endoscopic retrograde cholangiopancreatography
(ERCP) is useful in diagnosing the source of a bile
leak in patients with liver trauma treated nonoperatively and also in postoperative patients.
Perforations of the intestine are also at risk of being
missed as the signs of abdominal tenderness may be
attributed to intra-abdominal blood from the liver
injury. The risk of missing this type of injury can
be minimised by regular careful clinical observation.
Intestinal perforation may become apparent on
CT by the presence of free intraperitoneal fluid
or gas. In Sherman etal.'s series of patients with
liver trauma treated non-operatively, 4 of 30 (13%)
patients initially treated without operation required
subsequent laparotomy.
injury in three patients and renal injury in one
patient. Although the grade of injury to these organs
is not specified, in all cases the injuries became
apparent after a period of clinical observation.
However, the authors concluded that this risk
of missed solid organ injury does not obviate the
benefits of initial non-operative management.
The third category of complication relates to the
late complications of liver injury. Liver injury may
give rise to a transient increase in liver transaminase
enzymes. Their persistent elevation suggests
significant liver injury. Septic complications such as
intra-abdominal abscess and bile leak are recognised
late complications and may require radiological,
endoscopic or surgical intervention.
Postoperative complications after surgery
for liver trauma
The complications after liver surgery for trauma
are similar to those encountered after any
39
These were due to splenic
form of hepatic surgery. Haemorrhage in the
immediate postoperative period may be due to
coagulopathy related to large-volume transfusion
and may require correction with fresh-frozen
plasma and platelet concentrates. If there is no
evidence of a significant coagulopathy and bleeding
continues, CT angiography may provide diagnostic
information. Selective mesenteric angiography
may permit therapeutic embolisation, but if this
is unsuccessful, re-laparotomy will be indicated to
assess and control the source of bleeding and to
remove retained blood and clot. Bleeding in the later
postoperative period may be due to haemobilia or
bleeding from the biliary tree into the gut. It has
been reported to occur in 1.2% of patients with
liver trauma.
57
Postoperative sepsis may be due to infected
collections of bile or blood, or related to devitalised
segments of liver parenchyma. CT is of value in
diagnosis and may be used to guide placement
of drains. Bile leakage from a drain site is not
uncommon and usually ceases spontaneously;
however, if it persists, ERCP may be all that is
required to define the site of the leak and allow
temporary stent placement. Arteriovenous fistula
is not an uncommon complication after liver injury
and can manifest as an arterioportal fistula resulting
in portal hypertension.
Outcome after liver injury
The outcome after liver trauma is related not
only to the severity of the injury but also to the
severity of any associated injury. Most series
report mortality rates of approximately 10–15%;
however, the large variation in case mix between
different centres makes comparison difficult. In
a large series of 1000 cases of liver trauma from
Houston, an overall mortality of 10.5% was
reported.
similar mortality rate, with eight deaths occurring
in a consecutive series of 126 patients (6.3%).
The results in the series reported by Schweizer
etal. recorded an overall mortality rate of 12% (21
deaths in 175 patients), with a progressively higher
mortality rate associated with an increasing grade
of liver injury.
etal. reported 37 hepatic-related complications in
25 patients; 63% (5 of 8) of patients with grade
V injuries developed complications, 21% (19 of
92) of patients had grade IV injuries, but only 1%
(1 of 130) of patients had grade III injuries.
mechanism of injury has an important bearing on
the mortality rate, with blunt trauma carrying a
higher mortality rate (10–30%) than penetrating
liver trauma (0–10%). While most early deaths
seem to be due to uncontrolled haemorrhage
8
White and Cleveland documented a
58
In a series of 337 patients, Kozar
59
The
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Hepatobiliary and pancreatic trauma
and associated injuries, most late deaths result
from head injuries and sepsis with multiple organ
failure.
Extrahepatic biliary tract
trauma
Non-iatrogenic injury to the extrahepatic biliary
tract is uncommon and encountered only rarely by
surgeons outside specialist hepatobiliary centres.
Most injuries are due to penetrating rather than
blunt abdominal trauma. Biliary tract injury is
diagnosed infrequently before operation and is
often only recognised incidentally at laparotomy.
Extrahepatic bile duct injury due to blunt trauma
is only rarely associated with injury to the portal
vein or hepatic artery. This may be explained
by the increased length, tortuosity and elasticity
of the vascular structures. Furthermore, a
vascular injury, especially portal vein rupture,
is likely to be associated with a high immediate
mortality.
Incidence of biliary injury
The reported incidence of injury to the extrahepatic
biliary system varies between 1% and 5% of
patients who sustain abdominal trauma.
review of 5070 patients who sustained blunt and
penetrating abdominal trauma, Penn reported a
1.9% incidence of gallbladder injury.
etal. identified 31 patients (2.1%) with gallbladder
injury in a group of 1449 patients who sustained
blunt abdominal trauma and underwent
exploratory laparotomy.
62
In a further review of 949
patients undergoing laparotomy for acute trauma,
there were 32 injuries to the gallbladder (3.4%)
and five to the common bile duct (0.5%).
Burgess and Fulton reported that, over a 5-year
period, 24 of 184 patients with abdominal trauma
had extrahepatic bile duct or gallbladder injury as
well as liver injury.
64
They reported that this injury
was often seen with severe hepatic trauma and in
association with multiple organ injury. Dawson
etal. reviewed the results of treatment of all patients
with porta hepatis injuries presenting to a level I
trauma centre in Seattle over an 11-year period.
A total of 21 patients (0.21% of 10 500 admissions)
had injuries to the portal triad, of whom 11 (52%)
died. Isolated extrahepatic bile duct injury occurred
in four of these patients. Injuries to the portal vein
or hepatic artery, either in isolation or in association
with extrahepatic bile duct injury, were associated
with the worst prognosis. Of note is the fact that in
none of the 21 cases was the diagnosis of the injury
made preoperatively.
66
Most series report a median
60
In a
61
Soderstrom
63
65
age of approximately 30years and there are many
reports in children.
Classification of biliary injury
The gallbladder is the most frequently injured
part of the extrahepatic biliary tract. The largest
reported series of extrahepatic biliary tract injuries
consists of 53 patients, of whom 45 (85%) sustained
injury to the gallbladder and eight (15%) had an
injury to the bile duct.
the gallbladder to be involved in 32 (80%) of 40
patients, while ductal injury occurred in 12 (30%),
some patients having multiple injuries.
Injury to the gallbladder resulting from blunt
trauma can be classified as contusion, avulsion or
perforation. In addition to these three main types
of injury, Penn added traumatic cholecystitis as a
pathological entity.
gallbladder injury is perforation. Avulsion of the
gallbladder may refer to the organ being partially
or completely torn from the liver bed while still
attached to the bile duct, or it may signify complete
separation from all attachments with the organ
lying free in the abdomen. Contusion is probably
under-reported, as it will be recognised only if
laparotomy is performed. The natural course of
an untreated gallbladder contusion is not known,
although it is likely that the majority resolve without
further complication. It has been speculated that
an intramural haematoma might result in necrosis
of the gallbladder wall and result in a subsequent
perforation. There have been a number of reports of
delayed rupture of the gallbladder, and it is plausible
that unrecognised contusion of the gallbladder
might lead to such a delayed presentation.
Bile duct injury is classified according to the site
of injury and according to whether the transection
is partial or complete. Partial duct injuries are often
referred to as ‘tangential’ wounds. Penetrating
injuries can affect any part of the extrahepatic biliary
system; however, the commonest sites of injury due
to blunt trauma are at the point where the common
bile duct enters the pancreas and where the biliary
confluence exits from the liver. These sites are at
points of maximum fixation, which accounts for
their propensity to injury.
Isolated injury to the extrahepatic biliary tract
is very uncommon. The liver is the organ most
commonly injured in association with biliary tract
trauma (approximately 80% of cases), with the
duodenum, stomach, colon and pancreas being the
next most frequently reported. Associated vascular
injuries are relatively rare; however, inferior vena
cava and portal vein injuries are more commonly
reported than those to the hepatic artery, renal vessels
or aorta.
66
Kitahama etal. reported
67
68
The most common type of
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