SEMINAR 1

LIVER, PANCREAS, SPLEEN & RENAL TRAUMA

 Anatomy of
Liver &
Liver Trauma
Prepared by: Thulasi
Gnanavel (BMS20106353)
Liver
• largest intraperitoneal organ in the body
• weighing 1.7 kg in the average 80-kg man.
• sits in the right upper quadrant beneath the diaphragm
• protected by the rib cage (7th-11th ribs)
• liver parenchyma is entirely covered by a thin capsule
(Glisson’s capsule)
• visceral peritoneum on all but the posterior surface of the
liver, termed the ‘bare area’.
• The liver is divided into:
➢ large right lobe (constitutes three-quarters of the liver
volume) Major lobes
➢ smaller left lobe
➢ Caudate lobe
Accessory lobes
➢ Quadrate lobe
 Ligaments and peritoneal reflections of Liver

The liver is fixed in the right upper quadrant by peritoneal reflections that form ligaments.
left triangular ligament → superior surface of the left lobe
• left lobe to be mobilised from the diaphragm and the left lateral wall of the inferior vena cava
(IVC) to be exposed.
Right triangular ligament
• Fixes the entire right lobe of the liver to the undersurface of the right hemidiaphragm
Falciform ligament → runs from the umbilicus to the liver between the right and left lobes,
passing into the interlobar fissure.
• From the fissure, it passes anteriorly on the surface of the liver, attaching it to the posterior
aspect of the anterior abdominal wall.
Lesser omentum → 2 layers of peritoneum passes from the liver to the stomach + duodenum

a. Hepatogastric ligament → form groove of ligamentum venosum to lesser curvature

of stomach

a. Hepatoduodenal ligament → from porta hepatis to 1st part of duodenum

• Anterior and posterior coronary ligament
Structures in the
hilum of the liver
• The porta hepatis, a transverse fissure on the visceral surface of the liver, is the
hilum of the liver.
• The hepatic artery, portal vein and bile duct are present within the free edge of the
lesser omentum (the hepatoduodenal ligament) and together with nerves and
lymphatics enter the liver at the porta hepatis.
• The usual anatomical relationship of these structures is for the bile duct to be within
the free edge, the hepatic artery to be above and medial, and the portal vein to lie
posteriorly.
• Within this ligament, the common hepatic duct is joined by the cystic duct (draining
the gallbladder) at a varying level to form the common bile duct (CBD).
• The common hepatic artery branches at a variable level within the ligament, with the
right hepatic artery crossing the bile duct either anteriorly or posteriorly before giving
rise to the cystic artery.
• The portal vein arises from the confluence of the splenic vein and the superior
mesenteric vein behind the neck of the pancreas.
Liver blood supply
• 80% being derived from the portal vein (blood rich in product of digestion)
• 20% from the hepatic artery.
• Hepatic artery → derived from the coeliac trunk of the aorta, where the
hepatic artery arises along with the splenic and left gastric artery.
• The hepatic artery (oxygenated blood) branches into right and left hepatic
arteries.
• Right hepatic artery → supplies the majority of the liver parenchyma
• The blood supply to the right lobe of the liver may be partly or completely
supplied by a right hepatic artery arising directly from the superior
mesenteric artery.
• The arterial blood supply to the left lobe of the liver → derived from a branch
of the left gastric artery. This vessel runs between the lesser curve of the
stomach and the left lobe of the liver in the lesser omentum.
• Venous drainage of the liver → Via the hepatic veins into the Inferior vena
cava
Lymphatic
Drainage of
Liver
Relations of the liver

Posterior:
Anterior:
1. Right kidney
1. Diaphragm 2. right suprarenal gland
2. Right and left costal margins 3. right colic (hepatic)
3. Right and left pleura flexure
4. Right and left lung 4. Duodenum
5. Xiphoid process 5. Gallbladder
6. Anterior abdominal wall 6. IVC
7. Esophagus
8. Fundus of stomach
Liver Trauma
Prepared by: Thulasi Gnanavel
(BMS20106353)
 Liver Trauma

Contusion, laceration
• The liver is the second most and avulsion injuries.
common organ injured in abdominal
trauma after the spleen. Blunt injuries
• Blunt injuries are more common and
Associated with splenic,
have a higher mortality than mesenteric or renal
penetrating injuries. injuries
• Right lobe more commonly injured

Liver trauma
than left Stab and gunshot
wounds
Types of injury that can be seen in
liver trauma: Penetrating injuries
Associated with chest or
1. Hematoma pericardial involvement
2. Laceration

3. Juxtahepatic injury Percutaneous liver

Iatrogenic
biopsy
4. Hepatic avulsion

5. Bile duct injury

 Liver Trauma
Clinical Features:

1. Right upper quadrant pain and tenderness

2. Abdominal distention with dull flank, guarding, tenderness and rigidity
→ suggestive of hemoperitoneum
3. Signs of hemorrhagic shock
• narrow pulse pressure
• hypotension
• tachycardia
• pallor
• Diaphoresis
4. History of abdominal trauma
5. Generalized peritonism:
• Hemoperitoneum → due to rupture right lobe and left lobe
• Biliary peritonitis → due to bile leak from injured site
6. Oliguria
7. Tachypnoea, respiratory distress and often cyanosis
8. Intraabdominal abscess from localized hematoma (Delayed effect)
 Liver Trauma
Investigation:

Blood FBC, BUSE, LFT, RP, Coagulation profile, Glucose,

Amylase
Chest X ray Rib/vertebral fractures, pneumoperitoneium, major
diaphragmatic injury
Ultrasound Abdomen • FAST (Focused assessment with sonography in
trauma)
• hematomas, contusion, and hemoperitoneum
• Detects free intraperitoneal fluid
Contrast enhanced CT • Gold standard (95% sensitive & 99% specific)
• identification and extent of injury
• grading of severity
• parenchymal damage
Thromboelastography coagulation status
(TEG)
Diagnostic peritoneal unstable patients with blunt abdominal injury
lavage
Arteriography visualize the bleeding vessel in the liver →
embolization

Thromboelastography (TEG) is a diagnostic assay to measure patients’

coagulation profiles and guide management with transfusions and hemostatic
therapies.
 Liver Trauma
Diagnosis of liver injury:

• Focused assessment sonography in trauma (FAST) performed to diagnose free

intraperitoneal fluid.

• Patients with free intraperitoneal fluid on FAST and haemodynamic instability, and patients
with a penetrating wound → laparotomy and/or thoracotomy once active resuscitation.

• Patients who are haemodynamically stable should have a contrast- enhanced CT scan of the
chest and abdomen as the next step.

• This scan will demonstrate evidence of parenchymal damage to the liver or spleen, as well as
associated traumatic injuries to their feeding vessels. Free fluid can also be clearly
established. The chest scan will help to exclude injuries to the great vessels and demonstrate
damage to the lung parenchyma.
 Hepatic Trauma Classification (AAST)

The AAST
(American
Association for
the Surgery of
Trauma) liver
injury scale, is
the most widely
used liver
injury grading
system.
WSES Liver Injury Classification
 Initial management of liver injuries
Penetrating:

• Maintenance of airway patency, breathing and circulation (ABC) following the principles of advanced trauma life support (ATLS).
• Peripheral venous access → two large-bore cannulae
• Send blood for cross-match of 10 units of blood, full blood count, urea and electrolytes, liver function tests, clotting screen, glucose and amylase.
• Arterial blood gases should be obtained.
• Patient need to be intubated and ventilated if the gas exchange is inadequate.
• Intercostal chest drains → associated pneumothorax or haemothorax is suspected.
• Once initial resuscitation has commenced, the patient should be transferred to the operating theatre, with further resuscitation performed on the
operating table.
• fresh frozen plasma and cryoprecipitate → rapidly develop irreversible coagulopathies due to a lack of fibrinogen and clotting factors.
• Standard coagulation profiles are inadequate to evaluate this acute loss of clotting factors, and factors should be given empirically, aided by the
results of thromboelastography (TEG), if available.
• A contrast CT prior to laparotomy should be considered if the patient is haemodynamically stable.
 Initial management of liver injuries

Blunt trauma:

• resuscitation and management as for penetrating injuries.

• Haemodynamically unstable → immediate laparotomy

• Haemodynamically stable → imaging by CT should be performed to further evaluate the nature of the injury, manage conservatively.

• Indication for discontinuing conservative treatment:

➢ development of haemodynamic instability,

➢ evidence of ongoing blood loss despite correction of any underlying coagulopathy

➢ development of signs of generalised peritonitis.

• Interventional radiology → management of liver trauma and embolisation to control hepatic artery bleeding is safe and effective in a stable patient with no
evidence of hollow viscus perforation.
 Surgical Approach To Liver Trauma
Indications of laparotomy: 3Ps of OM
• Presence of free intraperitoneal fluid in FAST
1. PUSH
AND Hemodynamically unstable
• Penetrating wound • Liver is bimanually compressed to stop bleeding for 15-20
• Signs of peritonitis minutes
• WSES grade IV 2. PACK
• Failed Non-operative management • Perihepatic packing → compression of the bleeding site
using laparotomy pads
3. PRINGLE
• Placing an atraumatic clamp across the foramen of
Winslow for vascular inflow occlusion
• Control arterial and portal vein hemorrhage from the liver

Pringle’s maneuver:
clamping of hepatic artery +
surgical approach in managing severe bleeding of the liver portal vein
 Surgical Approach To Liver Trauma

• A ‘rooftop’ incision with midline extension to the xiphisternum and retraction of the costal margins gives
excellent access to the liver and spleen.
• Compression of the liver with packs and correction of coagulopathy, if present, will control most of the
active bleeding.
• If bleeding persists, further control can be achieved by vascular inflow occlusion → placing an
atraumatic clamp across the foramen of Winslow (the Pringle manoeuvre).
• A stab incision in the liver → sutured with a fine absorbable monofilament suture.
• Lacerations to the hepatic artery → identified and repaired with 6/0 Prolene suture. (If unavoidable, the
hepatic artery may be ligated)
• Portal vein injuries → repaired with 5/0 Prolene.
 Surgical Approach To Liver Trauma (cont.)

• Diffuse parenchymal injuries should be treated by packing the liver to achieve haemostasis.
• large parenchymal haematomas and diffuse capsular lacerations → perihepatic packing, which
involves placing packs above, behind and below the liver; providing haemostasis.
• If packing is necessary, the patient should have the packs removed after 48 hours, and usually no
further surgical intervention is required.
• Antibiotic cover is advisable
• If a major liver vascular injury (hepatic vein or vena cava, grade V or VI) is suspected → packing
and referral to a specialist should be considered (venovenous bypass)
• A rapid infuser blood transfusion → delivery of large volumes of blood instantaneously.
• patient is re-laparotomised via the rooftop incision with a midline extension to the xiphisternum.
 Complications of liver trauma

NOM Complications Post-operative complications

1. Biliary fistula Early Postoperative complication

2. Abdominal compartment 1. Abscess formation
syndrome 2. Biliary fistula
3. Hepatic failure
Late postoperative complication
1. Hepatic artery aneurysm
2. Portal Hypertension
3. AV fistula
 • The capacity of the liver to recover from extensive trauma is
remarkable, and parenchymal regeneration occurs rapidly.
• Late complications are rare, but the development of biliary
Long-term strictures many years after recovery from liver injury may
occur.

Outcome Of • The treatment depends on the mode of presentation and the

extent and site of stricturing.
Liver Trauma • A segmental or lobar stricture, associated with atrophy of the
corresponding area of liver parenchyma and compensatory
hypertrophy of the other liver lobe, may be treated expectantly.
• A dominant extrahepatic bile duct stricture associated with
obstructive jaundice may be treated initially with endobiliary
balloon dilatation or stenting, but will usually require surgical
correction using a Roux-en-Y hepatodochojejunostomy.
REFERENCES
• Schwartz’s Principles of Surgery (10th Ed)
• Bailey & Love’s Short Practice of Surgery (27th Ed)
• Davidson’s Principles and Practice of Medicine (23rd Ed)
Anatomy of
Pancreas and
Pancreas
Trauma
Prepared by: Thulasi
Gnanavel (BMS20106353)
 Anatomy of Pancreas

• The name ‘pancreas’ is derived from the Greek ‘pan’ (all) and
‘kreas’ (flesh).

• situated in the retroperitoneum. It is divided into a head, which

occupies 30% of the gland by mass, and a body and tail, which
together constitute 70%.

• The head lies within the curve of the duodenum, overlying the body
of the second lumbar vertebra and the vena cava.

• The aorta and the superior mesenteric vessels lie behind the neck
of the gland.

• Coming off the side of the pancreatic head and passing to the left
and behind the superior mesenteric vein is the uncinate process of
the pancreas.

• Behind the neck of the pancreas, near its upper border, the
superior mesenteric vein joins the splenic vein to form the portal
vein.

• The tip of the pancreatic tail extends up to the splenic hilum

 Anatomy of Pancreas

• The pancreas weighs approximately 80 g.

• Of this, 80–90% is composed of exocrine acinar tissue, which is

organised into lobules.

• The main pancreatic duct branches into interlobular and

intralobular ducts, ductules and, finally, acini.

• The main duct is lined by columnar epithelium, which becomes

cuboidal in the ductules.

• Acinar cells are clumped around a central lumen, which

communicates with the duct system.

• Clusters of endocrine cells, known as islets of Langerhans, are

distributed throughout the pancreas.
• Islets consist of different cell types:
➢ 75% are B cells (producing insulin);
➢ 20% are A cells (producing glucagon);
➢ the remainder are D cells (producing somatostatin) and a
small number of pancreatic polypeptide cells.
➢ Within an islet, the B cells form an inner core surrounded by
the other cells.

• Capillaries draining the islet cells drain into the portal vein,
forming a pancreatic portal system.
 Pancreas- Blood Supply
• The pancreatic arteries come from both the celiac artery and the superior Comparable to arteries, the anterior and posterior pancreaticoduodenal
mesenteric artery. veins are located in front of and behind the pancreatic head,
• Both the superior and inferior pancreaticoduodenal arteries respectively. They drain into the portal vein and the superior mesenteric
have anterior and posterior branches that run close to the duodenal C vein. Venous blood from the body and tail of the pancreas empties into
near the pancreas head. They supply numerous branches to both the the splenic vein.
pancreatic head and the duodenum.
• The body and tail of the pancreas are supplied by splenic artery branches.
 Lymphatic drainage and Innervation- Pancreas
Lymphatic Drainage of the Pancreas Innervation of the Pancreas
• There is a diffuse and widespread lymphatic network. As a ● Thoracic splanchnic nerves-> sympathetic effect
result, lymph nodes in pancreatic cancer are frequently Sympathetic fibers have a predominantly inhibitory effect
invaded, and the local recurrence rate after resection is high.
• Lymphatic spread can occur along the lymph nodes of the ● Vagus nerves -> Parasympathetic effect
superior mesenteric vein, hepatic artery, porta hepatis, Parasympathetic fibers stimulate both exocrine and endocrine
transverse colon, and splenic vein. secretions
 Pancreas
Trauma
Prepared by: Thulasi
Gnanavel (BMS20106353)
 Trauma of Pancreas
• Not frequently damaged in blunt abdominal trauma.
Injuries to
pancreas
• If there is damage to the pancreas, it is often
concomitant with injuries to other viscera, especially the
External Iatrogenic liver, the spleen and the duodenum.
injury injury
• Occasionally, a forceful blow to the may crush the body
Penetrating of the pancreas against the vertebral column.
trauma
• Penetrating trauma to the upper abdomen or the back
carries a higher chance of pancreatic injury.

Blunt trauma • Pancreatic injuries may range from a contusion or

laceration of the parenchyma without duct disruption to
major parenchymal destruction with duct disruption
(sometimes complete transection) and, rarely, massive
destruction of the pancreatic head.

• The most important factor that determines treatment is

whether the pancreatic duct has been disrupted.
 Trauma of Pancreas
Blunt Trauma Penetrating Trauma
• Presents with epigastric pain, which may be • Especially if other organs are injured and the
minor at first, with the progressive development patient’s condition is unstable, there is a greater
of more severe pain due to the sequelae of need to perform an urgent surgical exploration.
leakage of pancreatic fluid into the surrounding
• Haemostasis and closed drainage is adequate
tissues.
for minor parenchymal injuries. If the gland is
• A rise in serum amylase occurs in most cases. transected in the body or tail, a distal
pancreatectomy
• A CT scan of the pancreas will delineate the
damage that has occurred to the pancreas
• Urgent ERCP → duct disruption
• MRCP
 Iatrogenic injury

This can occur in several ways:

• Injury to the tail of the pancreas during splenectomy, resulting in a pancreatic
fistula.
• Injury to the pancreatic head and the accessory pancreatic duct (Santorini),
which is the main duct in 7% of patients, during Billroth II gastrectomy.
• A pancreatogram → cannulating the duct at the time of discovery of such an
injury will demonstrate whether it is safe to ligate and divide the duct.
• If no alternative drainage duct can be demonstrated, then the duct should be
re-anastomosed to the duodenum or alternatively resection of the pancreatic
head should be considered.
• Duodenal or ampullary bleeding following sphincterotomy. This injury may
require duodenotomy to control the bleeding
 Pancreas Trauma- Investigation
1. Focused assessment sonography for trauma ( FAST ) Other tests:
2. CT scan of abdomen
3. Diagnostic peritoneal lavage ( DPL) ● FBC and Urine sampling - serum amylase levels. increased
4. Laparotomy in pancreatic trauma.
5. Others: ● Supine CXR - air under the diaphragm may be seen.
- FBC and Urine sampling ● Direct laparoscopy - It can be used for screening
- Supine CXR ○ exclude penetrating injury that breaches the
- Direct laparoscopy peritoneum & diaphragm,
- Doppler assessment of major vessels ○ diagnostic (check for injury to the organs)
○ therapeutic (to repair the injured organ).
○ cannot be done in unstable patient.
○ Bowel and retroperitoneal injuries are more likely to be
missed.
● Doppler assessment of major vessels - IVC, aorta, iliac
vessels, and portal system; but with hemoperitoneum
visualisation window may be poor and vessels can be better
identified by contrast CT scan.
Spleen Trauma Classification
 Trauma of Pancreas- Initial Management
Blunt Trauma Penetrating Trauma
• Support with intravenous fluids • Haemostasis and closed drainage is
adequate for minor parenchymal injuries.
• ‘nil by mouth’ regimen should be instituted
• If the gland is transected in the body or tail,
• Operation is indicated if there is disruption a distal pancreatectomy should be
of the main pancreatic duct performed, with or without splenectomy.
• If damage is purely confined to the head of
the pancreas, haemostasis and external
drainage is normally effective.
• If there is severe injury to the pancreatic
head and duodenum, then a
pancreatoduodenectomy may be
necessary.
 Trauma of Pancreas- Management
Proximal pancreatic injury (injury that lies to right of closed suction drainage
superior mesenteric vessel)

Distal pancreatic injury ● management depend on ductal integrity

● pancreatic duct disruption -> direct exploration of
Determine location of
parenchymal laceration, operative pancreatography,
parenchymal damage
● identify intrapancreatic ERCP, MRCP
common bile duct and ● distal duct disruption-> undergo distal
main pancreatic duct pancreatectomy. ***preserve spleen
intact ● major ductal disruption-> pancreatic resection
done in more distally located injuries
Based on type of damage
● contusion (injuries with
ductal system intact) Pancreatic head injury ● complex management due to intrapancreatic
treated non-operatively or portion of common bile duct transverses this area
with closed suction and often converges with pancreatic duct
drainage (laparotomy) ● identify intrapancreatic common bile duct
disruption
○ USG: squeeze gallbladder and check for bile
leaking from pancreatic wound or,
○ cholangiography via cystic duct *** highly
diagnostic
● Definitivie tx: division of common bile duct superior
to first portion of duodenum
○ ligation of distal duct and reconstruction
with Roux-en-Y choledochojejunostomy
 Trauma of Pancreas- Management (cont.)

Pancreatic head injury involving main pancreatic duct but not ● distal pancreatectomy
intrapancreatic bile duct ○ rarely indicated due to extended resection (normal gland
resection which causes pancreatic insufficiency)
● central pancreatectomy
○ preserves common bile duct
● pancreaticogastrostomy
○ mobilization of pancreatic body permits drainage into posterior
wall
○ Avoid whipple procedure

Pancreatic head trauma not involving either pancreatic or common bile if no clear ductal injury present -> initiate drainage with necessary local
duct debridement

Extensive injuries of pancreas Indicated for Whipple’s procedure (pancreaticoduodenectomy)

Injuries of pancreatic body and tail ● stable patient- distal pancreatectomy (preserve spleen) or Roux-en-Y
choledochojejunostomy or pancreaticogastrostomy
● unstable patient- distal pancreatectomy with splenectomy
 Prognosis

• The most common cause of death in the immediate period is bleeding, usually from associated
injuries.
• Once the acute phase has passed, the mortality and morbidity related to the pancreatic injury itself are
treatable, with a complete return to normal activity the usual outcome.
• The trauma that has been treated conservatively, duct stricturing develops, leading to recurrent
episodes of pancreatitis.
• The appropriate treatment in such cases is resection of the tail of the pancreas distal to the site of duct
disruption.
• A pancreatic pseudocyst may develop. If the main duct is intact, the cyst can be aspirated
percutaneously in the first instance;
• If the cyst develops in the presence of complete disruption of the pancreas, there is no alternative but
to undertake a distal resection or, occasionally, a pancreatojejunostomy with a Roux-en-Y loop.
• In a patient who presents with a peripancreatic cyst and a history of previous blunt abdominal trauma,
do not assume that it is a post-traumatic pseudocyst.
• The possibility of a cystic neoplasm should be considered and excluded.
REFERENCES
• Schwartz’s Principles of Surgery (10th Ed)
• Bailey & Love’s Short Practice of Surgery (27th Ed)
• Davidson’s Principles and Practice of Medicine (23rd Ed)
Splenic trauma
By Daksh Vora
Anatomy and functions

• The spleen is the largest organ of your lymphatic system and is

roughly the size of a
clenched fist
• It has a slightly oval shape and is covered by a weak capsule that
protects the organ whilst
allowing it to expand in size. • Filters abnormal
• Located in the upper left quadrant of the abdomen, under cover of RBC • Fetal
the diaphragm and
erythropoiesis •
the ribcage
• Therefore, cannot normally be palpated on clinical examination Sequestration of
(except when enlarged). platelets • Mounts
• It is an intraperitoneal organ except at the splenic hilum. immune response to
antigens and
infections
Mechanism of Injury

The following mechanisms of injury include :

1. Penetrating trauma = gunshot or knife stab wounds
2. Blunt trauma = rapid deceleration as in motor vehicle crashes or direct blows to
abdomen as in domestic violence, or physical activities
3. Iatrogenic = post colonoscopy (66% pts in literature w 4.5% mortality rate)
4. Spontaneous rupture = malaria, infectious mononucleosis
Associated injuries :
• Fracture of left lower ribs (30%)
Types of injuries
• Left sided hemothorax
• Splenic hematoma = subcapsular and
intraparenchymal (delayed rupture is seen in • Left lung & diaphragm injury
subcapsular hematoma) • Left lobe liver injury
• Lacerated wound • Tail of pancreas injury
• Clean incised wound • Left kidney
• Hilar/vascular injuries • Left colonic injury
• Small bowel injury
Renal Trauma

Injury to the parenchyma or the renal vasculature which can cause bleeding or injury to the
collecting system with possible leakage of urine

Epidemiology

• 10% of all abdominal trauma cases involve the Genitourinary Tract

• Most common affected organ:
• Renal trauma accounts for 1 to 5% of all trauma
• 80-90% of it is due to blunt injuries
• 10-20% of it is due to penetrating injuries
Anatomy of Kidney
Bilateral bean-shaped organs
• lie retroperitoneally
• typically extend from T12 to L3, although the right kidney
is often situated slightly lower due to the presence of the
liver
• Adrenal glands sit immediately superior to the kidneys
Functions of the kidney
Mechanism of Injury
 Clinical Evaluation
History Taking
A) History of trauma
1. Mechanism of injury
• Blunt/ Penetrating/ Deceleration trauma
2. What type of weapon was used?
• Bullet: what was the velocity, calibre,
distance
of patient from weapon
3. Was there seat belt usage?
4. Speed of the vehicle
• Ejection of victim
B) Prehospital condition and treatment of
patient.
C) Pre-existing renal anatomic abnormality
Management of Renal Trauma
Management of Renal Trauma
Nephrectomy
It is the surgical removal of a kidney.
Complications