Liver and Spleen Trauma


Liver Trauma

  1. Anatomy
    1. Ligaments
      • Division of the hepatic ligaments is necessary to fully mobilize the liver
      Hepatic Ligaments
    2. Blood Supply
      3. Blood Supply to the Liver
  2. Diagnosis
    • usually made during laparotomy of unstable patients or on abdominal CT scan of stable patients

  3. Grading
    • CT with IV contrast allows quantification of the degree of liver injury
    • nonoperative management is more likely to fail with increasing severity of liver injury

    Liver Trauma Grading
    1. Grade I Injury

      2. Grade I Liver Injury
      Small Subcapsular Hematoma

    2. Grade II Injury

      3. Grade II Liver Injury
      Laceration < 3 cm deep

    3. Grade III Injury

      4. Grade III Liver Injury
      Laceration > 3 cm Deep

    4. Grade IV Injury

      5. Grade IV Liver Injury
      Significant Lobe Disruption with Active Bleeding

    5. Grade V Injury

      6. Grade V Liver Injury
      Major Hepatic Vein Injury

  4. Nonoperative Management (NOM)
    1. Blunt Trauma
      • the liver is a low pressure system, and most injuries stop bleeding spontaneously
      • 80% of cases of isolated blunt liver trauma will be managed successfully nonoperatively
      • criteria for nonoperative management of blunt liver injury includes:
        • hemodynamic stability
        • no peritoneal signs
        • no associated intraabdominal injuries requiring laparotomy
        • no ongoing unexplained transfusion requirements
      • patients are admitted to the ICU, kept NPO and at bedrest
      • serial exams by the same examiner and serials hematocrits are performed every 4 – 6 hours
      • indications for laparotomy include the development of hemodynamic instability or peritonitis, continued transfusion requirements
      • serial lactate levels and base deficits are useful to gauge the success of resuscitation
      • complications of nonoperative management include delayed rebleeding, biloma, hemobilia, and liver abscess

      1. Angiography/embolization
        • of limited utility in hepatic trauma
        • unstable patients belong in the OR, not the IR suite
        • stable patients with a contrast blush on CT (from a pseudoaneurysm) may benefit from embolization since they have a higher rate of rebleeding
        • best approach for evaluating hemobilia

    2. Nonoperative Management of Penetrating Hepatic Trauma
      • in stable patients with minimal abdominal pain, the injury may be limited to the liver
      • risk is missing an injury to the colon, duodenum, diaphragm, or biliary system
      • diagnostic laparoscopy can be used in a stable patient to assess whether the liver injury is truly isolated

  5. Operative Management of Hepatic Trauma
    1. Simple Injuries (Grades I and II)
      • injuries that have stopped bleeding require no specific treatment
      • electrocautery or suture ligation suffices for most of these injuries
      • hemostatic agents such as Avitene or Gelfoam and thrombin are also useful adjuncts
      • routine drainage is not necessary

    2. Complex Injuries (Grades III to V)
      • surgeon’s goal is to rapidly control exsanguination to prevent the fatal combination of hypotension, hypothermia, acidosis, and coagulopathy
      • initial maneuvers to control bleeding are manual compression of the liver and perihepatic packing with anteriorly and posteriorly placed laparotomy pads
      • liver should be fully mobilized by dividing its ligamentous attachments (round and falciform ligaments, triangular and coronary ligaments
      • deep wound tracts may be tamponaded with Gelfoam and thrombin plugs or stuffed with multiple penrose drains
      • in the case of ongoing bleeding, the hepatoduodenal ligament should be clamped (Pringle maneuver)
      • safe occlusion time is up to 60 minutes
      • if there is no further bleeding after the portal triad clamp has been removed, then the surgeon must decide whether it is safe to proceed with definitive repair of the injuries or whether ‘damage control’ principles should be applied

      1. Damage Control Surgery
        • goal is to prevent the ‘spiral of death’: hypothermia, acidosis, and coagulopathy
        • consists of 3 phases:
          • rapid control of all surgical bleeding using packing or ligation, control of enteric contamination with sutures or staples, and temporary abdominal closure by closing only the skin
          • rewarming, fluid resuscitation, and correction of coagulopathy in the ICU
          • return to the OR in 48 to 72 hours for pack removal and definitive repair of injuries

        Hepatic Packing
        Hepatic Packing

      2. Definitive Repair of Complex Liver Parenchymal Injuries
        • bleeding site must be exposed by extending the wound (finger-fracture hepatotomy), allowing ligation under direct vision
        • resectional debridement should be done to remove grossly nonviable tissue
        • rarely, ligation of a lobar artery is necessary to control hemorrhage
        • hepatic lobectomy is rarely indicated and has a high mortality (60%)
        • after the bleeding has been controlled, omentum can be placed into the defect to tamponade venous oozing
        • closed-suction drains should be used in all complex liver injuries because of the high likelihood of a bile leak

      3. Control of Major Hepatic Venous Injuries
        • actively bleeding injuries to the retrohepatic vena cava or major hepatic veins require total vascular occlusion for visualization and repair
        • after inflow occlusion has been achieved (Pringle maneuver), control of the distal IVC must be obtained above the renal veins
        • to gain proximal IVC control, a sternotomy must be performed to access the IVC within the pericardium
        • the classic atriocaval (Shrock) shunt using a chest tube placed into the right atrium is another method to isolate the retrohepatic vena cava

        Pringle Maneuver
        Pringle Maneuver

Splenic Trauma

  1. Anatomy
    1. Ligaments

      2. Ligaments of the Spleen
    2. Blood Supply
      3. Anatomy and Blood Supply of the Spleen
  2. Diagnosis
    1. CT Scan
      • in stable patients, CT scan with IV contrast is the mainstay of diagnosing and characterizing splenic injuries after blunt trauma
      • splenic injuries appear as disruptions in the splenic parenchyma, often with surrounding hematoma or free intraperitoneal blood
      • occasionally a blush can be identified, indicating a pseudoaneurysm or free intra-peritoneal bleeding

    2. Laparotomy
      • CT scan is contraindicated in hemodynamically unstable patients
      • in unstable blunt trauma patients with a positive FAST exam, exploration is mandatory

  3. Grading

    4. Splenic Trauma Grading
    1. Grade I Injury

      2. Grade I Splenic Injury
      Splenic Laceration < 1 cm deep

    2. Grade II Injury

      3. Grade II Splenic Injury
      3 cm Splenic Laceration

    3. Grade III Injury

      4. Grade III Splenic Injury
      >3 cm Splenic Laceration

    4. Grade IV Injury

      5. Grade IV Splenic Injury
      Intraparenchymal Hematoma and Devascularization

    5. Grade V Injury

      6. Grade V Shattered Spllen
      Shattered Spleen

  4. Nonoperative Management (NOM)
    • 85% of blunt splenic injuries are managed nonoperatively, with a 90% success rate
    • grades 4 and 5, large hemoperitoneum, and a vascular blush are all risk factors for failure of NOM
    • of patients who fail NOM, 75% fail within 48 hours, and 93% within one week of injury
    • NOM is more labor and resource intensive than operative treatment

    1. Angiography and Embolization
      • allows an improved splenic salvage rate but is associated with many complications
      • some indications include contrast blush on CT, grades 4 and 5, moderate hemoperitoneum
      • only stable patients should be considered for angiography and possible embolization
      • major complication is ongoing bleeding
      • embolization does not affect the immune function of the spleen

    2. Hospital Management
      • multiple management decisions must be made, with no clear guidelines:
        • floor vs ICU
        • frequency of serial H/H and abdominal exams
        • when to begin diet
        • length of bedrest
        • when to resume ambulation
        • length of ICU and hospital stay
        • repeat imaging?
        • restriction of activity after discharge
      • retrospective studies show bed rest is unnecessary and early ambulation is not associated with delayed hemorrhage

  5. Operative Management
    1. Splenectomy
      • most prudent operation, since most patients will be hemodynamically unstable
      • key maneuver is to divide the splenorenal and splenophrenic ligaments, allowing the spleen to be mobilized to the midline
      • after dividing the short gastrics, the spleen is mobile on its vascular pedicle
      • splenic vessels are then divided, taking care to avoid injury to the pancreas
      • drains are not necessary unless there is concern about pancreatic injury
      • prior to discharge, patients should receive pneumococcal, meningococcal, and haemophilus vaccines

    2. Splenic Salvage
      • rarely done anymore because of the success of nonoperative management
      • patient must be hemodynamically stable with no other higher priority injuries requiring attention, and transfusion requirements must not be increased
      • most applicable for grade 1 – 3 injuries
      • surgical techniques include direct repair over pledgets, partial splenectomy, mesh wrapping of the spleen
      • electrocautery, topical hemostatic agents, argon beam coagulation may be sufficient for grade 1, 2 injuries







References

  1. Sabiston, 20th ed., pgs 435 - 439
  2. Cameron, 11th ed., pgs 1032 – 1036, 1049 – 1053
  3. Liver and spleen CT scans from www.radiopaedia.org