Tag Archives: liver

Anatomy, General

Trauma Residents: How To Remember Liver Anatomy

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In trauma surgery, operative management of liver injury is usually messy business, with little time for nice anatomic resections. However, an understanding of the basic anatomy, especially that of the vascular supply is crucial for saving your patient.

A cool tool for remembering Couinaud’s segments and the overall layout of liver anatomy was published in the Archives of Surgery recently. It makes use of a model, which consists of your hand! Just make a fist with your right hand and tuck the thumb behind the other fingers.

 

The fingers can then be numbered according to the Couinaud segments, with the caudate lobe (segment 1) represented by the thumb that is tucked away. The PIP joints represent the plane that the portal vein runs through, with branches going to upper and lower segments. Note how the ring finger normally lies a little more anterior than the little finger in this position, just like the sectors of the right lobe.

The creases between the fingers represent the left, middle and right hepatic veins.

 

The right hepatic vein is located between the right anterior and posterior sectors and the left hepatic vein sits between the left medial and lateral sectors. The middle hepatic vein is in between the left and right hemi-liver.

Bottom line: This “handy” liver model is available immediately in the OR and is already sterile. It can help visualize liver structures that may be injured quickly and accurately to speed your operative approach to the problem.

Reference: A Handy Tool to Teach Segmental Liver Anatomy to Surgical Trainees. Arch Surg 147(8):692-693, 2012.

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DVT Prophylaxis After Solid Organ Injury

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Nonoperative management of solid organ injury is the norm, and has reduced the operative rate significantly. At the same time, the recognition that development of deep venous thrombosis (DVT) in trauma patients is commonplace creates uncertainty? Is it safe to give chemical prophylaxis with low molecular weight heparin (LMWH)? How soon after injury?

The trauma group at USC+LAC published the findings of a retrospective review of 312 patients undergoing nonoperative management for their liver, spleen or kidney injuries. They looked at chemical prophylaxis administration and its relationship to failure of nonop management of solid organ injury.

As expected, as the grade of the solid organ injury increased, so did the failure rate of nonoperative management. Administration of low molecular weight heparin, such as enoxaparin, did not increase failure rate in this study. All but one failure occurred in patients who had not yet received the injections. Likewise, two DVT and two pulmonary embolisms occurred, but only in patients who had not yet received prophylaxis. 

Bottom line: This small study offers some assurance that early prophylaxis is okay, and a few prospective studies do exist. UCSF / San Francisco General is comfortable beginning chemical prophylaxis 36 hours postop, regardless of solid organ injury. Look for more guidance on this issue in the near future. Until then, consider starting LMWH prophylaxis early to avoid complications from DVT or PE.

Reference: Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma 70(1): 141-147, 2011.

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Algorithm For Nonoperative Management of Blunt Hepatic Trauma

Yesterday, I posted the Western Trauma Association’s algorithm for operative management of blunt liver trauma. Click here to view it. Today, I’m going to discuss their algorithm for nonoperative management. 

The algorithm is fairly self-explanatory. Click on the image above to read the annotated text for details on each step. Note: this requires full access to the Journal of Trauma.

Some key points in this algorithm:

  • Unstable patients need rapid identification of the cause. If the FAST is positive ©, then you need to go to the OR and use the operative algorithm.
  • CT scan is used for diagnosis in stable patients (F), but if a liver injury is seen and they become unstable at any time, go to the OR.
  • Contrast extravasation in a stable patient should prompt an evaluation and possible embolization by interventional radiography (G).
  • If complications develop (SIRS, abdominal pain, fever, jaundice), a repeat CT is indicated (K).
  • Abscesses and focal collections of bile may be managed by interventional radiology (L,M). Persistent bile leak may be decreased by ERCP and sphincterotomy (O).
  • Bile ascites or large hemoperitoneum may be managed using laparoscopy with drainage (N).

Reference: Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. J Trauma. 67:1144–1148, 2009.

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Algorithm For Operative Management of Blunt Hepatic Trauma

The Western Trauma Association has just published guidelines on decision-making when faced with hepatic injury in the OR. The algorithm is based on the available literature, which contains little prospective, randomized trial data. Nonetheless, it is a valuable tool that can be used to develop your own institution-specific protocol.

The algorithm is fairly self-explanatory. Click on the image above to read the annotated text for details on each step. Note: this requires full access to the Journal of Trauma.

Some key points in this algorithm:

  • Simple hemostatic maneuvers are usually successful with minor bleeding (A).
  • Sequential use of more involved maneuvers is indicated for major bleeding. In order, they are packing (B), Pringle maneuver (D), selective vessel ligation within the liver (E), and finally selective hepatic artery ligation (F).
  • Damage control laparotomy and interventional radiology are useful adjuncts.

Tomorrow I’ll write about the nonoperative blunt hepatic trauma algorithm. Click here to view it.

Reference: Western Trauma Association/Critical Decisions in Trauma: operative management of adult blunt hepatic trauma. J Trauma 71(1):1-5, 2011.

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EAST Guidelines Update: Liver Injury

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The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for liver injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:

Level I recommendations (best quality data): 

  • none

Level II recommendations (good data):

  • Initial management of hemodynamically stable patients should be nonoperative
  • CT of the abdomen with IV contrast is the most reliable method to assess severity of liver injury in the hemodynamically stable patient
  • Unstable patients should undergo operative or endovascular management of their injury, not imaging
  • Patients with peritonitis should go to the operating room
  • Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
  • Angiography with embolization should be considered if a contrast blush is seen on CT
  • Angiography with embolization may also be considered if there is evidence of ongoing blood loss without blush on CT
  • Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed

Level III recommendations (weak data):

  • Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
  • Interventional modalities may be used to treat complications (ERCP, percutaneous drainage, laparoscopy, etc)
  • If a patient transiently responds to fluid initially, try angiography with embolization while they are still stable

On Monday, I’ll present the updated guidelines for management of spleen injury.

Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.