Managing Liver Trauma

M. Rodiere1, F. Thony1, C. Letoublon2, P. Bouzat3 , C. Sengel1

1- Radiology Department
2- Digestive Surgery Department
3- Anesthesia Department

University hospital of Grenoble

 Mathieu Rodiere, M.D.

• No relevant financial relationship reported

 Introduction
• Liver = largest intra-abdominal solid organ
• Liver = Organ most frequently affected by trauma

• Prevalence = 1% to 8%
• Mortality rate = 4.1% to 11.7%

• CT scan = reference technique for lesion diagnosis

and aid in initial management

•
 NOM
• NOM=Nonoperative management

• 86.3% of hepatic injuries are now managed

without operative intervention
Tinkoff J Am Coll Surg. 2008

• Now the standard of care for

hemodynamically stable patients with blunt
hepatic trauma
 Guidelines
• Nonoperative management of blunt hepatic injury: An
Eastern Association for the Surgery of Trauma practice
management guideline - J Trauma Acute Care Surg-2012

• Level 1
– Patients who are hemodynamically unstable or who have diffuse
peritonitis after blunt abdominal trauma should be taken
urgently for laparotomy

= Damage control surgery

Liver packing
vascular exclusion
 Guidelines
• Level 2
– A routine laparotomy is not indicated in the
hemodynamically stable patient without
peritonitis presenting with an isolated blunt
hepatic injury.

– Angiography with embolization should be

considered in a hemodynamically stable patient
with evidence of active extravasation (a contrast
blush) on abdominal CT scan.
 Guidelines
• Level 3
– Interventional modalities including endoscopic
retrograde cholangiopancreatography,
angiography, laparoscopy, or percutaneous
drainage may be required to manage
complications (bile leak, biloma, bile peritonitis,
hepatic abscess, bilious ascites, and hemobilia)
that arise as a result of nonoperative management
of blunt hepatic injury
 CT Scan
• A CT scan of the abdomen with intravenous contrast
administration is the optimal diagnostic modality for
hemo- dynamically stable patients to aid in both the
diagnosis and management of blunt hepatic trauma.

• Liver Lesions
– Subcaps hematoma
– Intraparenchymal Hematoma
– Intraparenchymal laceration
– Active extravasation
– False aneurysm
 Intraparenchymal hematoma

Active extravasation
 Embolization principles
• Coeliac trunk must be analyse before
embolization

• selective embolization = microcatheter

• Embolic material:
– Temporary or definitive
 Results
• NOM
– Success rates ranging from 82% to 100%. (US trauma centers)
– Complications including bile leaks, hemobilia, bile peritonitis,
bilious ascites, hemoperitoneum, abdominal compartment
syndrome, missed injuries, hepatic necrosis, hepatic abscess,
and delayed hemorrhage.
– The complication rate increases with the grade of injury

• Embolization
– success rate is 95% 1
– Hepatic necrosis is rare
– First complication is gallbladder necrosis

1- Monnin- Place of arterial embolization in severe blunt hepatic trauma- 2008

For those patients who are hemodynamically unstable despite continuous re-suscitation,
laparotomy followed by embolization if needed is likely a safer approach.
 Take home message
• Nonoperative management = the gold
standard

• CT Scan = Help NOM and embolization

• Liver Embolization
– Propose when active hemorrhage in CT scan
– Good success rate