Trauma and Critical Care—Liver Trauma
Concept
Frequently injured abdominal organ. Remember to resus- citate patient and rule out other injuries. Can consider nonoperative management in the stable patient, with no other indications for abdominal exploration.
Way Question May be Asked?
“You are called to the trauma bay to help out your partner who has a 26 y/o motor cyclist injured after impact against a guard rail who is tachycardic, hypotensive, and has con- tusions about the right side of his chest and abdomen.
What do you want to do?” May also be given the intra-op setting of multiple injuries—liver, spleen, small bowel, and ureter and asked how you will proceed.
How to Answer?
Brief H +P while resuscitating the pt:
ABCs PMHx Meds Allergies
Physical Exam
Head to toe physical exam
Algorithm
ABCs
Resuscitation (IVF, full labs including PT/PTT, T +C, NGT, Foley)
C-spine
CXR Pelvis x-ray
Nonoperative Management
For blunt trauma with minimal other injuries, no indi- cations for abdominal exploration, and no hemody- namic instability
Have low threshold to take to OR
Operative Management
Prep chin to knees Midline incision 4 quadrant packing
Rapid abdominal survey and control any intestinal spillage
Mobilize liver (divide falciform, triangular/coronary ligaments)
+/− pringle maneuver with vascular clamp if major hemorrhage (will stop hepatic artery and portal vein branch bleeding)
(1) Simple laceration—direct pressure, topical hemo- static agents, cautery, argon beam coagulator (2) Deep laceration—Pringle maneuver, ligation
individual vessels, pack laceration with vascular- ized tongue of omentum mobilized from trans- verse colon
(3) Hepatic vein injury—Pringle maneuver, Rummel tourniquet around infrahepatic (suprarenal) IVC, median sternotomy, open pericardium, Rummel tourniquet around intrapericardial IVC, +/− atriocaval shunt
(4) Extensive injuries (bilobar, hepatic venous injury, retrohepatic cava)—remember lessons from
“damage control” surgery
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(a) mobilize liver
(b) gauze packing––anteriorly and posteriorly to tamponade bleeding
(c) temporary abdominal wall closure (d) return to OR––24 hours when no longer
coagulopathic and blood products available (e) place drains
Common Curveballs
Pt will become coagulopathic intra-op Pt will have transfusion reaction
Pt will have associated intra/extra abdominal injuries Pt will have retrohepatic caval injury
Pt will have post-op abscess or biloma ( → percuta- neously drain)
No simple methods of controlling bleeding will work Questions about how to perform Pringle maneuver Pt will develop post-op hemobilia/hepatic artery
pseudoaneurysm ( → angiographic embolization) Pt undergoing nonoperative management will get septic
from small bowel injury
Strikeouts
Not performing DPL but CT scan in unstable pt Not taking pt to OR when clearly indicated
Not knowing several techniques to control bleeding Not doing “damage control” surgery when indicated Not ruling out other injuries prior to going to OR Taking unstabl pt to angiography suite for embolization
Strikeouts 135
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