Hapatobilliary trauma
Dr awad al dumour
Al basheer hospital
Background
 Largest solid abdominal organ,fixed
position
 Second most common injured, but most
common cause of death after abdominal
trauma
 Blunt MVA most common
 80% adults, 97% children-conservative rx
Locate your liver
Upper right quadrant deep to
inferior ribs
Dome of liver abuts aganst
inferior diaphragm
surface
Left/right lobes
Gall bladder is thin muscular
sac on inferior surface
where bile collects (1
above)
1. ANATOMY
Percuss your liver
Easiest organ to percuss
Dense tissue gives rocksolid sound/feel on
percussion
Mid-clavicular line
moving inferiorly from
mid-chest to lower right
quadrant
Measuring liver span by percussion: variation in liver span
Variation in liver span according to the vertical plane of examination. Since there is
variability in where clinicians determine the mid-clavicular line to be, the inevitable
consequence is that liver span may also vary even if multiple observers are
perfectly accurate in measuring it.
Portal Triad
- Common Bile duct
- Proper Hepatic Artery
- Portal Vein
LIVER
Anatomy
 Cantile described main divisions along a
main plane from GB fossa to IVC. Divides
liver into equal halves.
 Couinaud developed 4 sectors and 8
segments, divided into vertical and oblique
planes, defined by the 3 main hepatic veins
and transverse plane thru right and left
portal branches.
Anatomy
 Hepatic veins lie between segments.
 Left hepatc vein divides left lobe into
medial and lateral segments.
 Middle hepatic vein divides liver into left
and right lobes.
Anatomy
 Right hepatic vein divides right lobe into
anterior and posterior segments.
 A horizontal line thru left and right main
portal veins is used to divide lobes into
inferior and superior segments.
 The 8 liver segments are numbers
clockwise on the frontal view.
Liver Segments
Liver Segments
Injuries
 Subcapsular hematoma or intrahepatic
hematoma.
 Laceration
 Contusion
 Hepatic vascular disruption
 Bile duct injury
 86% of injuries have stopped bleeding at time of
exploration.
 Decreased transfusion req.With conservative.
Injuries
 Subcapsular hematoma or intrahepatic
hematoma.
 Laceration
 Contusion
 Hepatic vascular disruption
 Bile duct injury
 86% of injuries have stopped bleeding at time of
exploration.
 Decreased transfusion req.With conservative.
CLASSIFICATION



1.
2.
3.
4.
5.
Penetrating wounds
Stabs wounds , gunshots….
Level of injury
Frequency of organ injury :
Liver
37%
Small bowel
26%
Stomach
19%
Colon
17%
Major vessels & retroperitoneal structures
Penetrating wounds
CLASSIFICATION



1.
2.
3.
4.
5.
Blunt trauma
RTAs , direct blows , falls , …..
Sudden application of pressure , seat belt syn
Frequency of organ injury
Spleen
25%
Kidney
12%
Intestine
15%
Liver
15%
Retro peritoneal haematoma
13%
CLASSIFICATION
Iatrogenic injury
Due to diagnostic & therapeutic procedures
1. Endoscopy
2. External cardiac massage
3. Peritoneal dialysis
4. Paracentesis
5. PTC
6. Liver biopsy
Classification
 I-Subcapsular hematoma<1cm, superficial
laceration<1cm deep.
 II-Parenchymal laceration 1-3cm deep,
subcapsular hematoma1-3 cm thick.
 III-Parenchymal laceration> 3cm deep and
subcapsular hematoma> 3cm diameter.
Classification
 IV-Parenchymal/supcapsular hematoma>
10cm in diameter, lobar destruction, or
devasularization.
 V- Global destruction or devascularization
of the liver.
 VI-Hepatic avulsion
LIVER INJURIES



1.
2.
3.
4.
5.
6.
Incidence
Clinical picture
Management
Non operative
Drainage of deep lacerations Sump drain
Removal of devitalized tissue
Pringle maneuver , ? HA ligation where ?
Segmentectomy ? Lobectomy ? Packing
Repair CBD over T- tube
Pathophysiology
 Friable parenchyma, thin capsule, fixed
position in relation to spine.
 Right lobe gets hit more since its larger,
and closer to ribs.
 85% injuries involve segments 6,7,8 from
compressioin against ribs, spine, abd wall.
 Shear forces at attachments to diaphragm
 Transmission thru right hemithorax.
Pathophysiology
 Liver injured easily in children since ribs
are compliant, force transmitted.
 Liver not as developed in children, with
weaker connective tissue framework.
 Iatrogenic injuries by biopsies, biliary
drainage, TIPS, can cause capsular tears
and bile leaks, fistulas, hemoperitoneum.
Clinical Details
 Symptoms of injury are related to blood
loss, peritoneal irritation, RUQ tenderness,
and guarding.
 Unrecognized delayed abcess
 Bilomas
 Signs of blood loss may dominate the
picture.
Clinical Details
 Elevated liver tests
 Biliary peritonitis (nausea, vomiting, abd
pain).
 DPL has high sensitivity, 1-2%
complication rate.
 Plain x-rays non-specific.
 CT scan diagnostic procedure of choice.
 Hida for leaks, angio for hemorrhage.
Physical examination
 Ecchymosis or abrasions ,respiratory pattern
 inspect urethra & perineum
 Examine the back ,sprung the pelvis.
 PR exam why ?
 Bowel sounds
 Palpation spasm & rigidity ? Rebound
 Foley catheter Why ? when?
 Re evaluations why ?
Limitations
 FAST sensitivity highest (98%) for grade 3
injuries or greater. Negative findings do not
exclude hepatic injury.
 Emergency sono findings demonstrating free
fluid, parenchymal injury, or both demonstrate
overall sensitivity for detection of blunt
abdominal trauma of 72%.
 Angiogram may fail to detect active bleeding.
ADJUVANT STUDIES FOR
ASSESSMENT
 Laboratory studies
Hct , UA , S amylase , other tests baseline
 Radiological studies
PFA , Erect CXR ,US , CT ? Contrast , IVU,
Urethrogram , Cystogram and Angiography .
 Four quadrant tap test
DIAGNOSTIC PERITONEAL
LAVAGE
 Indications of DPL
 Contraindications
 Technique , precautions
Results are positive IF
1. RBCs > 100,000/cubic mm
2. WBCs > 5000/cubic mm
3. Amylase >200 units
4. Presence of bacteria ,bile, faeces
5. Rough index
CT Scans
 Accurate in localizing the site of liver
injury, associated injuries.
 Used to monitor healing.
 CT criteria for staging liver trauma uses
AAST liver injury scale
 Grades 1-6
 Hematoma,laceration,vascular,acute
bleeding,gallbladder injury,biloma.
Angiography
 Demonstrates active bleeding
 Transcatheter embolization may be the
only treatment required.
 Findings include contusion, laceration,
hematoma, pseudoaneurysms, fistulas.
 Embolization can reduce transfusion
requirements, stenting for fistulas.
Angiography
Grade I Liver Injury
Grade II Liver Injury
Grade III
Grade IV
Grade V
MANAGEMENT
Pre hospital care
Little can be done
 ABC
 Sterile dressing
 Don't remove FB from trunk
 Saline dressing over evisceration
MANAGEMENT cont…



1.
2.
3.
4.
Hospital care
Detailed history specially in blunt trauma
Physical examination
Resuscitation
ABC
Basic blood tests, cross match, amylase
Closed monitoring
If patient is stable complete investigation
Biliary Injury &
Laparoscopic
Cholecystectomy
Causes of Biliary Injury in LC
 Failure to properly occl. the cystic duct
 Injury to the ducts in the liver bed caused
by entering a plane too deep to the
gallbladder
 Cautery Misuse – thermal necrosisductal
tissue loss
 Pulling forcefully up on the gallbladder
when clipping the cystic duct  tenting
injury to the junction of the CBD &
Biliary Injuries During Cholecystectomy (CCY)
 Reviews revealed the incidence of biliary
injury during open CCY to be 0.1-0.3%
 1995 – Strasberg’s study which incl. more
than 124,000 laparoscopic
cholecystectomies (LC) reported in the
literature found the incidence of major bile
duct injury to be 0.5%.
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury
during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 180 (1) :
101-25.
Diagnosis of Bile Leaks
 Persistent fullness, anorexia, abdominal
pain, fever & tenderness,jaundice, elev
WBC
 High level of suspicion following surgery
 Bile draining from a drain left in the
operative field
Radiographic Diagnosis of Biliary
Injury
 US/CT – detect bilomas (poss. perc drainage)
Radiographic Diagnosis of Biliary
Injury
 US/CT – detect bilomas (poss. perc drainage)
 HIDA – presence of active bile leak
(physiologic)
ERCP
 Provides exact anatomical diagnosis of bile
duct leak; while allowing treatment w/
decompression of the biliary tree.
 Principal of treatment is to establish a
pressure gradient that will favor flow into
the duodenum not the leak site; may entail
removal of retained stone or internal
stenting +/- sphincterotomy
 Internal stenting is currently the procedure
of choice for treating bile duct leaks ( types
A & D)
 Cessation of bile extravasation in 70-95%
of cases w/in 7 days
Percutaneous Transhepatic
Cholangiography
 Another method of non-surgical mgmt of
bile leak
 Usually reserved for when ERCP
unsuccessful; since bile ducts of normal
caliber increasing the difficulty of the
procedure
Plastic surgery meets GI surgery
 BOTOX injection to sphincter of Oddi
Intraoperative Injury
 Strasberg D injury - (partial injury to a major
duct) should be repaired at initial operation w/ Ttube drainage
 Strasberg E injury - (complete transection of
major duct) may be reconstructed at the initial
operation w/ a R-Y hepaticojejunostomy.
 *** No primary re-anastomosis secondary to
ischemic factors***
Detection in post-op period
 Abx, nutrition support, percutaneous
drainage of bile collex (US or CT)
 MRCP, PTC or ERCP to delineate location
of injury.
 Once sepsis and leaks are controlled, then
may perform definitive reconstruction w/
R-Y
hepaticojejunostomy
Kaman et al.
Management
of Major Bile Duct Injuries following
LC. Surg Endosc (2004)18:1196 –1199
Gallblader injury
 Blunt trauma
 Penetrating injury
 Investigation
 Ultrasound
 CT SCAN
PANCREATIC INJURIES
 Blunt or penetrating injury
 Associated with other injuries
 Persistent elevation of S. amylase
 Laparotomy usually for other injuries
 Select the surgical procedure ,
Debridment
Good drainage , Sump drain