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Abdominal Trauma

Liver
&
Spleen

Anatomical Consideration
B.F : 70% portal
B.D : to rt, mid & lt H.V
Form effective- pedicle
portal V & hepatic A run
with B.D. in the free edge
of the lesser omentum

Anatomical Consideration (con)1

Physiological Aspect

Maximum toleratable
duration of normal
liver Ischemia is one
hour
traumatised liver is
less

Therabutic aspect
Topical Hypothermia
& steroids
can increase time before
ischemia but caution
with unstable patient
cosistency of the liver
allows finger fracture

Mechanism of Injury
Majority is
BLUNT 90%
vehicular,assault & fall
??why
semisolid
nonmobile
surface area

Classification of Liver inj

Six grades
all are with capsular tear
avulsion is the last grade
venus injury without avulsion is the fifth
How classify according to laceration ??1
How classify according to S.C.Hematoma?2
What is the value of this staging
??3

How classify
according to the
LACERATION
more than 9 =V
four & more=IV
three&more=III
more than 1= II
less than 1 = I

lobe of
the liver
with 10 cm

How classify according to


subcapsular Hematoma???2
Less than 50% = I

More than 50% = II

REMEMBER , CLASSIFY AS
MUCH GRADE AS
AVAILABLE CRITERIA

Example
liver with subcapsular hematoma with area
more than half of the surface area
But there is avulsion
STAGE SIX NOT FOUR

the value of this staging


PROGNOSIS
&
MANAGEMENT

IV , V and VI
USU need surgical intervention

Management of L.I 1
Non-operative

Should be:
stable hemodynamic
no peritoneal signs
no head injury
no strong indic of
laproscopy :like
retroperitoneal inj or
bowel injury
BUT BUT BUT

Management of L.I. 2
Non-operative

MUST:
c&c
close monitoring in
ICU
&
CT scan assessment
of abdomen
any miss so go to
OPERATIVE MEAN

Management of L.I
2Non-operative

Blood transfusion when need

early Dx & percutaneous drainage of any


collection
percutaneous angiography & selective H.A.
Embolization can prevent need of operation

Management of L.I
operative

If shock is persistant despite repeated transfusion so


urgent laparotomy is recommended.
Direct manual compression may stop the bleeding
For I,II,&III grades ,simple suture , toilet & debridement
may be all the need.
Assesting by wrapping absorbable mesh
packing by living omentum can reduce the infection.

Management of L.I
operative ( cont..)

Otherwise:
if so sever : control by compression of I.V.C.
above & below the liver with compression of
porta hepatis, then resect non viable fragment

If there is deep laceration of hepatic vein or I.V.C.


so it is so difficult and should done under
speciality.

Trauma of the Spleen

Anatomical Consideration

B.F :celiac plexus,


short gastric arteries
& left gastroepiploic
( 6% of C.O.)

Function of Spleen
Defence against pathogens
include encapsulated
organism
Extravascular reservoir
Modulation of blood cells &
.remove non viable

Theraputic consideration
delay rupture of spleen can occur 7-10days after injury
Injury lead to major B.loss
Injury allows high amount of organism to present in blood
mainly pneumococcus, electrolyte disturbance,
.hypoglycemia & DIC
Pathological spleen is more vulnerable to trauma

Classification of spleenic inj

5 grades
all are with capsular tear
vascular is the last grade
How classify according to laceration ??1
How classify according toS.C.Hematoma?2
What is the value of this staging
??3

How classify
according to the
LACERATION ??
Completely shattered
spleen =V
four & more=IV
More than3 =III
more than 1= II
less than 1 = I

Spleen

How classify
according to
subcapsular
Hematoma???2
Less than 10%=I

10% ---50%=II

More than 50%=III

To classify properly

Dont forget to consider the


greatest grade according to
the available criteria

the value of this staging


PROGNOSIS
&
MANAGEMENT

IV & V
USU need surgical intervention

Mechanism of Injury
Majority is BLUNT
vehicular,assault & fall
??why
semisolid
nonmobile
surface area
friable

Management of S.I.
1Non-operative
Usu.. for I,II & III
Should be :
stable hemodynamic
no peritoneal signs
no head injury
no strong indic of
laproscopy :like
retroperitoneal inj or
bowel injury
+++ age younger than 56
years

Management of S.I.
2Non-operative

MUST
c&c
close monitoring in
ICU
&
CT scan assessment
of abdomen
any miss so go to
OPERATIVE MEAN

Management of S.I.
2Non-operative

Blood transfusion when need

early Dx & percutaneous drainage of any


collection

Figure 2 - This CT shows a contained splenic hematoma. This was treated by observation and gradually resolved over several weeks

Figure 8 - The splenic hematoma seen in Figure 2 has now largely resolved, without surgery.

Management of S.I.
operative
Fluid replacement & transfusion
Early exploration with splenorraphy & autologous
transfusion
Otherwise, do autologous transplantation of removed
spleen into omental pouches which can also lead to some
functional recovery so decrease infection.
Also can do urgent laparatomy & splenectomy with
preservation of some to overcome sepsis & for hope of
regeneration
Assesting by wrapping absorbable mesh & fibrillary
collagen
Immunization (if below 20) especially Antipneumococcal.

Figure 11 - This shows the successful growth of splenic implants. The splenic implants have grown into the abdominal fat