Liver trauma (management in 105 consecutive cases).
One hundred and five consecutive patients who sustained liver trauma during the period from Jan 1986 to Dec 1988 are reviewed. Of these, 82 cases suffered from blunt abdominal injury while the rest had penetrating trauma. Simple hepatorrhaphy and use of topical hemostatic agents were the only modes of treatment for 76 cases, hepato-omentorrhaphy was used in 12 cases and hepatotomy with selective vascular ligation and resectional debridement were carried out in remaining 17 cases. Mortality was 36.2% (38/105), 30 patients died of shock in the perioperative period. Uncomplicated recovery occurred in 50 cases.
This is a report of 3 years' experience (Jan 1986-Dec. 1988) with 105 consecutive patients admitted at Lokmanya Tilak Municipal General (LTMG) Hospital for hepatic injury.
The data of 105 patients sustaining liver trauma was analyzed with respect to age, sex, mode of injury, anatomical nature of injury, 16 involvement of other organs, types of repairs carried out, complications encountered and mortality observed. Patients who died on admission in the emergency ward prior to any aactive surgical intervention were excluded from this study.
Diagnosis of liver injury in cases with blunt trauma was based on (a) physical examination (b) abdominal paracentesis (c) serial hematocrit values and (d) ultrasonography. In patients with penetrating injury exploratory laparotomy was required.
The age range of patients with hepatic trauma varied from 1 to 72 years; the maximum incidence occurring between the age group of 21-40 years. Of the l05 patients, 97 were males. Eighty-two patients sustained blunt trauma, mainly as a result of railway or vehicular accidents; 23 patients had penetrating injuries (stab or gunshot). [Table - 1]. It was also observed that the incidence of concomitant injury to other intra-abdominal organs was more following penetrating wounds. Forty of the 105 patients arrived in the emergency ward in a state of shock (BP less than 90/50 mm Hg).
[Table - 2] illustrates the classification of the observed liver injuries as per their anatomical nature.
In 76 cases simple procedure such as suture hepatorrhaphy with or without application of topical hemostatic agents was adopted. Hepato-omentorrhaphy was carried out in 12 cases. In these patients a viable omental pedicle was packed into the hepatic wound and sutured to the edges of Glisson's cqpsule superficially. Deep suturing was avoided. Advanced techniques of hemostasis and repairs such as extensive hepatorrhaphy, hepatotomy or resectional debridement with selective vascular ligation were required in 17 cases [Table - 3]. Other therapeutic management included autotransfusion (16 cases) and use of antibiotics viz penicillin, ampicillin and chloramphenicol (Higher antibiotics were used in complicated cases).
Fifty of 105 cases recovered without any complications, The complications observed in patients surviving for more than 48 hours (total no. 43) are illustrated in [Table:4].
The overall mortality in the series was 36.2% (38/105). Thirty patients died of shock during the peri-operative period; 25 of these had been admitted in shock to the hospital. On analyzing the causes of death, 24 (63.2%) deaths were thought to be unrelated to the liver injury, but as a consequence of associated head or multiple bone injuries. Fourteen deaths were directly related to hepatic injury [Table - 2]. When analyzed according to the operative procedure adopted, mortality was found to be less (26.3%) in patients undergoing simple hepatorrhaphy than those undergoing advanced techniques (62%) [Table - 3].
Hepatotomy with selective vascular ligation,,,,,,,,,,,, insertion of omental packs into hepatotomy sites, adequate debridement of devitalised tissues, prompt correction of hypothermia and acidosis, and blood component therapy to prevent coagulopathy 18 constitute the management of hepatic trauma.
Operative management depends on the magnitude of parenchymal destruction and associated vascular disruption. In our set up, more than two-thirds of cases were of class I or II, necessitating only simple operative manoeuvres. Though prophylactic perihepatic drainage has shown to be unwarranted, drainage of subhepatic space was a routine part of our management. This procedure was adopted due to shortage of blood, high incidence of infection and lack of investigative scans in post-operative period in our hospital. Topically used hemostatic agents can form a nidus for secondary infection and hence a restriricted use of them is advocated.
Management of haemorrhage due to class III injury is an issue of continued debate. The Pringles' manoeuvre (temporary occlusion of the hepatic artery and portal vein) and packing of the liver are the first priorities. Although human liver tolerance to warm is chaemia was considered maximum at 15 minutes for many years, the safe period is now believed to exceed an hour. Pringles' manoeuvre timings were not recorded on papers and hence we are unable to comment on safe period of the same.
In class III injuries mattress sutures passed deeply through the lobar laceration are associated with two problems: (a) frequent failure of sutures to control haemorrhage and (b) extensive amount of hepatic necrosis that occurs underneath the tied sutures. Hepatotomy with selective vascular ligation (using 00 or 000 chromic catgut) rather than insertion of mattress sutures is now frequently done.
The use of viable pedicle of omenturn loosely placed into deep lobar laceration or hepatotomy sites after selective vascular ligation has gained widespread use since its introduction by Stone and Lamb in 1975. We have found that the omenturn can be mobllized to form a long viable pedicle because of the arrangement of omental vessels. Omental packing is very easy in relatively inaccessible areas of liver, such as postero-superior and inferior surfaces where deep suturing is difficult. Omental packing also avoids closing lobar laceration or hepatotomy sites with mattress sutures, which would cause parenchymal necrosis and also reduce post-operative drainage from parenchymal surfaces. We strongly suggest the use of omental packing in patients with severe injuries as advocated by Pachter et al.
Procedures like formal hepatic lobectomy and therapeutic abdominal packing or selective hepatic artery ligation were not carried out in our hospital. These measures were rarely required,.
The incidence of mortality was found to be less following simple hepatorrhaphy because the procedure was adopted for less severe liver injury, while hepato-omentorrhaphy and ligation procedures were cartied out for class III and IV injuries. They account for the majority of deaths attributable to the liver per se. Haemorrhage is the main cause and occurs as a result of precipitous emanguination or refractory secondary coagyulopathy,.
We are grateful to the Dean, Dr. SV Nadkarni, LTMGH and Dr. TT Changlani, for permission to use the hospital records.