Liver trauma is divided into:
- Blunt and
- Penetrating injuries
- Blunt injury produces contusion, laceration and avulsion injury.
- Penetrating injuries (like stab and gunshot wounds are often associated with chest or pericardial involvement.
Blunt force-liver injury
- Features of shock due to severe bleeding.(pallor, hypotension, tachycardia, sweating)
- Distension of abdomen with dull flank, guarding, tenderness and rigidity.
- Tachypnoea, respiratory distress and often cyanosis.
- Rupture of right lobe is more common than the left lobe leading to haemoperitoneum.
- Occasionally can cause localised hematoma which may form an abscess.
- Bile leak from the injured site can lead to biliary peritonitis.
- Chest X-ray to look for the rib fracture.
- USG abdomen
- CT scan of chest and abdomen
- Diagnostic peritoneal lavage
- Hb%, PCV, blood groouping and cross matching.
- Arterial blood gas analysis (ABG)
- Coagulation profile.
- I.V fluids, blood transfusion (massive), FFP
- Have both central and peripheral venous access.
- Bladder catheterization to measure the urine output
- Laparotomy is done through a large abdominal incision or thoracoabdominal incision, and extent of liver injury and also other associated injuries are looked for.
- Small liver tear is sutured with absorbable sutures with placing of gel foam to control bleeding.
- To control intraoperative bleeding, from hepatic artery and portal vein, both are temporarily occluded using fingers, compressing at foramen of Winslow. Often bull-dog clamp or vascular clamps can be used.
- In deep severe injuries, following methods are used:
- Hepatic artery ligation
- Segmental resection
- Packing the liver temporarily with mops.
- Cholecystectomy and placement of “T” tube in CBD
- In associated IVC injuries , it is very difficult to manage. A veno-venous bypass between femoral vein and SVC is done and then repair of IVC is carried out.
- ICT placement to thorax and repair of diaphragmatic injury.
Post operatively patients require:
- Ventilator support
- Blood transfusion
- Electrolyte management
- FFP, cryoprecipitate
Complications and Sequelae of liver injury
- Shock and haemorrhage
- Intrahepatic haematoma
- Liver abscess and septicaemia
- Bile leak, biliary peritonitis, biliary fistulas
- Disseminated intravascular coagulation
- Hepatic artery aneurysm
- Arterio-venous fistula
- Arterio-biliary fistula
- Electrolyte imbalance
- Liver failure
- Late sequelae
- CBD stricture