CLOSED LIVER INJURIES: THE ALGORITHM OF SURGEON'S ACTIONS IN A FIRST-LEVEL TRAUMA CENTER Maskin S.S., Aleksandrov V.V., Matyukhin V.V., Ermolaeva N.K.
Volgograd State Medical University, Volgograd, Russia
For closed abdominal injury (CAI), the incidence of liver injuries achieves 20-47 % of all abdominal injuries, and it does not show a trend to decrease [1, 2, 7].
The proportion of severe liver injuries (LI) is increasing. It is associated with increasing number of concomitant injuries [1, 5, 24]. 2-3 % of cases are associated with injuries to big vessels, resulting in death in 30-50 % [6]. Mortality reaches 50-100 % for injuries to hepatic veins and retrohepatic part of the inferior vena cava (IVC), for injuries to the portal vein – 54-71 % [9, 12], for closed concomitant LI – 28-72 %. Among all patients with severe LI, 40 % die at the prehospital stage; among survivors, 70 % return to professional activity, 30 % become disabled [8]. Postsurgical mortality for single LI is 17-36 %, for concomitant injury – 39-44 % [1, 5, 6, 7, 8, 13].
Conservative management of closed LI, which is confirmed by ultrasonic examination or CT with intravenous contrasting (A2) [4], is indicated for the following conditions:
1. Stable hemodynamic values (SAP > 90 mm Hg, pulse < 120 per minute) in single abdominal injury at the background of infusion and hemostatic therapy, absence of clinical signs of shock (evidence level – A, recommendation strength – 2) (A2) [9, 22, 23]. Hemodynamic status plays the more important role for selection of conservative management as compared to instrumentally confirmed degree of an organ injury (A1), which only predicts success of non-surgical management [4]. Hommes M. et al. (2015) estimated 134 patients with severe LI [12]. The efficiency of conservative management was 95 %. Unstable hemodynamics after initial anti-shock measures presents the absolute contraindication for conservative management (A2) [4, 6, 8, 13].
2. Stable levels of erythrocytes, hemoglobin and hematocrit (B1) [4, 21].
3. Absence of injuries to hollow organs, no peritonitis (A2) [4, 12, 13].
4. Abdominal volume of the blood – up to 500 ml, without trend to increase [6, 7].
5. Absence of extravasation of contrast medium into abdominal cavity or hepatic parenchyma on CT angiography [6, 9]; injuries of degrees 1-2 according to AAST [7]. According to data from Ermolov A.S. et al. (2015) [7], patients with LI of degrees of 1 and 2 have no indications for urgent surgery in 85 % of cases.
6. Absence of severe concomitant injuries, not high blood loss, no signs of coagulopathy [8].
7. Clear consciousness since consciousness disorders cause the risk of missing of injuries, which require for urgent laparotomy.
8. Availability of medical equipment and trained staff for dynamic observation in ICU, CT with angiocontrasting, angiography and angioembolization, fast approach to blood agents (A2) [4, 13].
In case of CAI, conservative management is conducted for patients with internal organ (II AAST) and small subcapsular (I AAST) non-tension stable hepatic hematomas (absence of turbulent blood flow in USDG or absence of extravasation of contrast media into parenchyma on CT-angiography image) [7, 21] in case of absence of distribution of central hematoma under the organ’s capsule or in absence of increasing sizes of the organ [7, 8, 12].
According to the recommendations from World Society of Emergency Surgery, patients with stable hemodynamics, with closed LI, with absent other abdominal injuries, and with need for surgery should receive conservative management regardless of an injury severity (A2) [4].
For negative time trends of ultrasonic examination and CT, the use of ultrasonic doppler sonography and angiography is indicated. Angiography allows realization of endovascular hemostasis [5, 9, 10, 22].
X-ray endovascular occlusion of branches of hepatic artery is conducted by transfemoral or transaxillary approach. The catheter is conducted to bleeding source. The blood flow is reduced by means of introduction of emboli into vessel lumen. Occlusive helix and peripheral plug are often introduced into the afferent vessel [3, 5, 10, 12].
Indications for endovascular embolization (EE):
1. CT signs of ongoing bleeding in absence of hemorrhagic shock (A2) [4, 5, 22].
2. Persistent hypotonia after tamponade/packing [4, 9, 14].
3. Posttraumatic false aneurysm of the hepatic artery and its branches [4, 7], arteriovenous fistula or their combination. EE of hepatic artery branches prevents recurrent surgical interventions in 80 % of cases [3, 10].
4. Instable hematomas [5, 7], intrahepatic hematomas complicated by hemobilia [3]. Ermolov A.S. et al. consider presence of blood flow in the hematoma as the indication for angiography and endovascular hemostasis. Absence of doppler signs of blood flow, no clinical signs of arterial biliary fistula, and small sizes of hematoma give a possibility for puncture under ultrasonic control; external draining is indicated for hematomas > 5 cm [7, 21].
Green C.S. et al. (2016) [10] conducted a systematic review of 459 publications from MEDLINE, SCOPUS and Cochrane Library. The general efficiency of angioembolization for LI is 93 %.
Urgent surgery is indicated in presence of signs of ongoing intraabdominal bleeding in patients with unstable hemodynamics with closed liver injury and without other causes of shock (A2) [4, 6, 7, 8, 22].
Laparoscopic operations with low probability of conversion are performed for patients with hemoperitoneum up to 500 ml and without signs of ongoing intense intraabdominal bleeding and shock [7, 9] in LI of severity degree 1-2 [5, 9, 22].
The indications for laparotomy are hemoperitoneum > 500 ml with unstable hemodynamics [7, 8]; ongoing intraabdominal bleeding when endovideosurgical or endovascular hemostasis is impossible or insufficient [7]; absence of visualization of source of ongoing bleeding [9, 12, 21, 22].
Physical methods are widely used for bleeding arrest (the table).
Table
Advantages and disadvantages of some physical methods of hemostasis
|
Method |
Ïðåèìóùåñòâà Advantages |
Íåäîñòàòêè Disadvantages |
|
Laser coagulation |
Precise tissue dissection Minimal heat transmission Light wave lengths with tissue selectiveness |
Expensiveness of the device and consumable materials Necessity of training and certification Technical limitations Smoke formation decreases visualization in laparoscopic approach Risk of injuries to adjacent organs and tissues during long term exposure Eye protection is required Coagulation effect is reduced in serious bleeding |
|
Ultrasonic coagulation |
Decrease in heat distribution Variety of use Low smoke formation Exclusion of tissue burn and current passage through a patient No neutral electrode is required |
High price of the device and consumable materials Limitation by vessels - 2-3 mm or less, and low strength on bigger vessels [1, 9] User-specific (technical) limitations Relatively slow functioning
|
|
Unipolar coagulation |
Low costs Convenient use in tissues Solid experience of use |
Limitation by vessels - 2 mm or lower Sparkage, adhesion, soot deposit Technical limitations Lateral thermal injury Tools cause slight pressure, without deformation of vascular wall collagen Smoke formation decreases visualization in laparoscopic use [8] |
|
Bipolar electrocoagulation |
Low costs Lower risk of additional electric injuries Solid experience of use in surgery No neutral electrode is required
|
Coagulation of vessels with diameter up to 2 mm; strength of coagulate is not predictable for bigger vessels Use for small (up to 2 cm) superficial injuries [7] Recurrent applications are often required. Lateral heat distribution Coagulation necrosis with depth up to 5 mm with possible detachment and recurrent bleeding; rough scar and evident adhesion process |
|
Thermal action |
Homogenous thermal coagulation of vessels with diameter up to 7 mm Absent tissue carbonization Minimal influence in lateral directions Fast and safe coagulation and dissection No aerosol formation Low smoke formation Good visualization of surgical site [8]
|
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|
|
Argon plasma coagulation |
Maximal depth of coagulation - 3 mm Multidirectionality of stream No smoke Lower tissue acidification (promotes faster recovery) No contact Mobility Simplicity of use |
Impossibility of bleeding arrest from a big artery No technical possibility for local influence on a vessel Need for cooling of plasmotron with clean influent water, current supply 380 V, filling of balloons with deficient argon [7, 8] |
On the basis of the hospital surgery department of Volgograd State Medical University, a possibility of use of local cryohemostasis for liver and spleen injuries [1] by means of tissue edema, small vessels compression, intravascular stasis of formed blood elements with clot formation was shown. Cryoeffect for liver trauma promotes bile stasis. For LI, cryohemostasis is indicated in case of ongoing bleeding from parenchyma, with preservation of magistral blood flow and absence of need for organ resection [1].
Local hemostatic materials are well known. However, wise implementation in surgery is often hindered by high price. They are used in combination with other surgical methods or packing in venous or moderate parenchymal bleeding (B1) [8, 9].
Biopolymers of collagen and gelatin are widely used for local hemostasis. The hemostatic collagen sponge is used for capillary and parenchymal bleeding and is contraindicated for injuries to big vessels. It causes scarring, shows antigenic activity and can promote contamination with viruses of hepatitis and HIV [19]. Thrombocol collagen biocomposition with platelet concentrate and antibacterial agents is efficient for capillary parenchymal bleedings in conditions of hypocoagulation and hyperfibrynolysis.
Hemostatic effect of the gelatin sponge (Spongostan, Gelfoam, Hemasept) is associated with its mesh structure and absorption of high amount of blood, destruction of blood cells with release of thromboplastin [15].
The hemostatic action of cellulose-based agents (Surgicel) is determined by an ability of oxycellulose to interact with hemoglobin. Cellulose promotes formation of fibrin clot and activation of platelets.
Tissucol and Tachocomb are often used. The main components of Tissucol glue (thrombin, fibrinogen, clotting factor XIII) are separated from donor plasma. Polymerization appears, and elastic fibrin film of white color forms after application onto the wound surface. As result, diffuse bleedings arrest, tissues adhere, and wounds heal. Its use require for warming and mixing of components before application, as well as the special device for application onto the wound surface [8, 9].
Tachocomb is presented by the collagen plate covered with aprotinin, fibrinogen, thrombin and riboflavin. When contacting with the wound surface, thrombin converts fibrinogen into fibrin, and a fibrin clot appears. Aprotinin prevents fibrinolysis by plasmin. Platelet aggregation is stimulated by collagen. It has high adhesive ability. It adheres to the wound surface within 3-5 minutes. In profuse bleeding, it can be washed from the wound surface. The plate is poorly fixed on unsmooth wound surface due to rigidity of collagen fibers.
Quick Clot presents porous mineral powder, which absorbs water, increases the level of blood clotting factors, and accelerates the clot formation. Celox, which is based on chitosan, shows high adhesion to formed elements of blood and tissues. It closes a bleeding wound and does not cause the exoergic reaction [9. 23].
When ruptures in site of fixing of ligamentum teres hepatis, the hemostasis with electrocoagulation is sufficient. For liver parenchyma rupture with depth > 2 cm, it is possible to use the hemostatic sponge, Tachocomb (for moderate bleeding) or suturing (for strong bleeding) with use of endosurgical technique or with mini-laparotomy/laparotomy approaches [20].
Subcapsular hematoma is presented by a floating flat formation of dark color under Glisson's capsule. If it is stable, it takes less than 10 % of surface, without need for revision. Diagnostics is supplemented by intrasurgical ultrasonic examination for estimation of blood flow and subsequent follow-up. For unstable subcapsular hematoma of any size or for stable one taking more than 10 % of liver surface, and for tension hematoma, the capsule should be opened, and bleeding is to be arrested. It is possible to cover the decapsulated part of the liver with Surgicel [22].
Hematomas of porta hepatic should be properly examined for exclusion of injuries to magistral vessels and extrahepatic bile ducts. Intrahepatic hematoma is hardly diagnosed even during surgery. If it is stable, it should be treated with conservative techniques and observed over time.
For abdominal trauma, the uniform approach is superior-middle-median laparotomy [8, 20, 21, 24]. If injuries to retrohepatic part of IVC and hepatic veins are found, it is possible to extend an incision towards the right side of the chest in the – 8th intercostals space with use of diaphragmotomy [7, 9].
During laparotomy, bleeding intensifies by means of decrease in intraabdominal pressure. The anesthesiologist tries to stabilize hemodynamics, the surgeon carries out temporary hemostasis (B2) [4, 20], and the assistant evacuates the blood with use of the reinfusion device [7]. If hypotonia is critical (SAP < 70 mm Hg), and revision of abdominal organs is hindered by high hemoperitoneum, it is appropriately to use the fist or the vascular fork to pressure the aorta to the spine immediately below the diaphragm during 20-30 minutes [7, 24]. This maneuver allows stabilizing the patient’s condition, arresting the arterial and parenchymal bleeding, and giving more time for intensive care (C1) [9, 24].
The alternative technique is installation of the obturator-balloon (C2) through the femoral artery under radiological control at the level of the first zone of the abdominal part of the aorta [12, 16]. In the clinic of Kirov Military Medical Academy, 22 endovascular balloon aortal occlusions were carried out for 5 years [16]. Higher survival for the first 12 hours was achieved with use of this technique [16].
In presence of intensive bleeding from the liver parenchyma and deep ruptures with injuries to segmental vessels, the assistant performs bimanual compression of the organ [8, 22], and the surgeon performs Pringle’s maneuver with pressure to the hepatoduodenal ligament (HDL) to arrest bleeding [9, 20, 22]. To decrease hepatic failure one should perform the following procedures:
1) to press HDL not more than 20 minutes, with 5-minute recovery of blood flow in 10 minutes of occlusion, and not more than 10 minutes – for complete vascular isolation of the liver [7];
2) to perform infusion of perftoranum during correction of compression of HDL (20 ml/kg of body mass). Isotonic solution of natrium chloride (30 ml/kg) with rheopolyglucin (15 ml/kg) can be used in its absence. Glucocorticoids are also efficient [7];
3) to carry out slow restoration of blood flow after this maneuver.
A bleeding vessel is identified, and targeted hemostasis is performed [9, 22]. If bleeding is arrested after Pringle’s maneuver, then its source is elements of portal triad. Finger fracture technique by Ton That Tung, a Vietnamese surgeon, which has been called Eastern by I. Littmann, is used for identification of a bleeding vessel [22]: “…separation of liver parenchyma with the handle of the scalpel, or compression of parenchyma with fingers 1 and 2. The scalpel handle or the surgeon’s finger meets with big vessels or bile ducts, which are ligated before crossing in parenchyma.
Bleeding from hepatic vessels is optimally arrested with clips. If the clip applicator is absent, 8-shaped sutures (USP 3/0) are applied with the atraumatic needle. After suturing and clipping of big vessels and ducts, parenchymal bleeding is arrested with physical methods, local application hemostatic techniques or with suturing.
Liver ruptures are carried out by surgeons in more than 50 % of operations [6, 8]. A disadvantage of hepatic suture is impossibility of high pressure. It can lead to bleeding from segmental, subsegmental or lobar vessels. Suturing cause complications in 12.8-30 % of patients: formation of ischemic necrosis regions, secondary bleedings – 2.3 %, purulent septic complications [6, 7], bile outflow and bile fistulas – in 1.1 % [9, 12]. For lineal ruptures up to 5-6 cm of length and depth up to 3 cm, U-shaped sutures are used in transverse direction to vessels and bile ducts [7, 20] in the manner of capture of the whole depth of a rupture, receding 0.5 cm from borders. For longer rupture, it is preferable to use the mattress suture. Vycril, polidioxanone, polysorb or catgut No. 4 are used with the atraumatic needle. Non-absorbable suture materials cause long term inflammatory response and abscessation [7, 8, 9]. For suture cutting, it is possible to underlay synthetic bioabsorbable materials (prolene).
The necessary stage of surgery for severe opened closed injury to the liver is removal of non-vital and freely lying parts of parenchyma (debridement) [6, 8].
In some cases, it is difficult to close the borders of the liver rupture with sutures. The cavity is filled with blood, bile, with formation of hematoma, biloma or abscess. To prevent this, a part of greater omentum of required size is taken and put into the liver rupture [7, 22], and the distal end of the part is sutured to the capsule. The indications for tamponade with omentum on the stem are:
1) difficult capture of the bottom of a rupture during suturing without strong bleeding [21];
2) formation of a big defect in liver tissue after resection of a segment, and a subsegment, when closing of its borders by means of hepatization is impossible due to suture cutting and development of ischemia in bordering regions;
3) central ruptures with formation of big cavity through narrow channel with abdominal cavity [8, 21].
For big and deep ruptures on the diaphragmal or inferior dorsal surface of the liver without injuries to big vessels, hepatopexy is used for creation of closed space according to Kiari-Alferov-Nikolaev (superior) or Shapkin (posterior). A free border of the liver is fixed from the round ligament to triangle ligament to the peritoneum along the costal arch, along the line of adherence of the diaphragm to the chest wall (for lacerations on the diaphragmal surface of the liver) or to the posterior leaf of the peritoneum (in presence of a rupture along inferior dorsal surface) after closure of a rupture with Tachomb plate or after its suturing [7, 8].
Atypical resection is prescribed for liver crushing injury, liver fragmentation, injuries to lobular and segmental vessels with high probability of liver tissue necrosis [5, 20]. This procedure is considered as a forced procedure in surgery of polytrauma (B3) [2, 4, 9, 14] due to mortality up to 70 % because of intrasurgical bleeding, hepatic failure or parenchyma necrosis.
In case of sufficient hemostasis in temporary ligation of HDL, after confirmation of arterial bleeding, one can try to perform embolization during surgery [10, 14] or ligation of hepatic artery [7]. It is necessary to clamp the hepatic artery in the tourniquet. If bleeding continues, it supposes an injury to venous system. Then ligation of the artery is not conducted. Surgery causes death in 20-25 % of cases owing to multiple segmental necrosis. Therefore, it is conducted only in emergency cases [4, 7].
If bleeding intensity is not decreased after HDL compression, and a liver rupture is located along the posterior surface of the organ, then the probable source of bleeding is an injury to retrohepatic part of the inferior vena cava or hepatic veins [8, 22].
Packing of ruptures within damage control concept with final hemostasis after condition stabilization is conducted for liver injuries of degrees 2-4, higher blood loss, hypothermia, acidosis, coagulopathy and hemodynamic instability [2, 4, 5, 6, 13, 14, 19, 22]. In big trauma centers, gauze packing is used as the main technique at the first stage of treatment in 48 % of cases, with mortality of 52 % [11, 19]. Realization of extensive interventions increases mortality to 60-88 % [7, 19, 23, 24]. A decision on liver packing is made as early as possible after revision of abdominal organs [2, 13, 14] since probability of success decreases after DIC [13, 22]. The required amount (10-20) of sponges is toughly applied onto diaphragmal and visceral surface of the liver up to the moment of bleeding arrest above and lower (or posteriorly and anteriorly) the injured lobe in order that vectors of pressure of sponges will recreate planes of tissue [13, 18, 22]. For decreasing of traumatic potential in the postsurgical period, it is better to put sponges over the hemostatic sponge, which is on the wound surface [11, 19, 23]. Liver mobilization with dissection of ligaments should not be conducted since it decreases the efficiency of tamponade due to increasing distance between the liver and diaphragm.
The terms of removal of sponges vary from 3 to 14 days [7]. According to Sigua B.V. et al. (2015) [20], the use of gauze packing as a part of damage control allows decrease in mortality from 100 to 50 %. Segura-Sampedro JJ et al. (2019) [18] developed and tested the vacuum device Vac Bag Pack for liver packing. The device has no such negative effects of common gauze such as abdominal compartment syndrome in excessive tamponade or ongoing bleeding and hypovolemic shock in insufficient tamponade.
Efficient coverage of the liver with catgut mesh or with polyglactin mesh 910 (Vicryl) is efficient. The functioning part of parenchyma is preserved, a probability of secondary bleeding decreases, and the organ function restores by the third day after surgery [8, 9].
Treatment with damage control is complicated by recurrent intraabdominal bleeding in 16.7 % of cases [5, 6], bile outflow through drains or bile peritonitis in 25 % [2, 18], intraabdominal purulent complications, abdominal compartment syndrome [4].
Insufficient efficiency of packing can be in arterial bleeding. Combination of packing with selective ligation of the hepatic artery or EE [10, 13, 14] increases the survival of patients to 65.5 % [4, 6, 10]. If bleeding continues, three variants can be used; each of them is the last chance to save the patient, but without warranty and with mortality at least 50 %.
The first way: vascular isolation of the liver [4, 7, 22]. The method is difficult. It takes up to 30 minutes for realization. The incision is extended before thoracophrenolaparotomy [7]. The inferior vena cava is exposed above and below the liver. The right side of the middle intestine is mobilized and adducted, and the infrarenal part of the inferior vena cava becomes visible for manipulations [20, 22].
For separation of the suprahepatic part of IVC, the right lobe of the liver is turned frontwards and leftwards. The inferior vena cava and short hepatic veins can be visualized [22]. If a venous defect is found, it is sutured with continuous twisted suture with non-absorbable monofilament fiber USP 4/0-5/0. If injuries are not found, complete vascular isolation of the liver is performed [4, 8, 22], and the tourniquet is applied onto this part of the vessel. The mortality reaches 80 %.
The second way: finger fracture technique for identification of bleeding source. The tourniquet is not removed from HDL [8, 20].
The third way is atriocaval shunting (AS) [11]. A purse suture is applied onto the right atrial appendage. In the center of purse, the appendage is dissected, and the intubation tube No. 8-9 with additional holes (7-9 mm) is introduced or the thoracic drain (36-40 Fr diameter) is introduced to suprarenal part of the inferior vena cava. The purse is tightened, and the projected part of the tube is ligated. Tourniquets are applied around IVC above the liver and hepatic veins (under and above a vascular defect). It preserves the venous return into the right atrium, bypassing the injured part of the vessel [19, 20]. After condition stabilization, the search and suturing of vein rupture is performed.
Such surgery requires for extension of approach and liver mobilization, but there are few chances in case of high blood loss, shock and increasing coagulopathy [9, 19]. The number of successful operations is 19-22 % [4, 7, 22]. Hazelton JP et al. (2015) [11] compared efficiency of liver packing and AS in combination with packing with modeling of an injury to suprahepatic part of the inferior vena cava. The survival of animals with liver packing was reliably higher that in AS. Liver packing is more preferable as compared to shunting interventions [13].
Previously, liver transplantation in trauma was presented only by anecdotal reports [8, 9, 22]. However, Ribeiro MA Jr et al. (2015) [17] analyzed the results of 46 patients who could not receive other variants of hemostasis owing to severity of injuries. The survival was 76 %. The main indications were tissue necrosis after packing or resection with increasing liver failure [5, 17].
For severe LI, draining of subdiaphragmal and subhepatic space is performed with dual-lumen tubes, and decompression of bile ducts with draining of choledoch according to Ker or with application of cholecystotoma (for LI of degree 3 and higher, in presence of bile in abdominal cavity, for central ruptures of the liver (intrahepatic hematomas), after liver resection [20]).
Complications of LI are intraabdominal abscess (4-9 %), bile fistula (3-7 %), liver cysts, secondary bleeding (14.9 % [19]), hemobilia (0.7-3.4 % [19]), bile peritonitis. Hepatic failure develops almost in all patients [4, 9].
CONCLUSION
Management of patients with closed liver injury is mainly determined by hemodynamic status of the patient. For stable condition, it is possible to perform conservative management, with endovascular hemostasis, if required. For surgical management of LI and profuse bleeding, fast temporary hemostasis is required, with subsequent final hemostasis. If indicated, damage control is supplemented by liver packing.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any potential conflicts of interests relating to publication of this article.