Overview
Definition:
Non-anatomical resection, often termed a wedge resection or limited resection, for liver lacerations involves removing the damaged liver tissue without strict adherence to anatomical liver segments
This approach is primarily employed in managing blunt or penetrating hepatic trauma when significant hemorrhage or devitalized parenchyma is present, but complete anatomical hepatectomy is deemed too extensive or technically challenging.
Epidemiology:
Liver lacerations are common in blunt abdominal trauma (up to 50% of severe liver injuries) and penetrating trauma (up to 30% of stab wounds to the abdomen)
The incidence of surgical intervention, including non-anatomical resection, varies based on injury severity and hemodynamic stability
however, it remains a crucial technique in the armamentarium for managing hepatic trauma.
Clinical Significance:
Effective management of liver lacerations is vital to control hemorrhage, prevent sepsis, and preserve liver function
Non-anatomical resection offers a less morbid approach than formal anatomical resection when indicated, allowing for rapid control of bleeding and removal of non-viable tissue, thereby improving patient outcomes in emergent settings and is frequently tested in surgical postgraduate exams.
Clinical Presentation
Symptoms:
Right upper quadrant (RUQ) abdominal pain
Tenderness in the RUQ
Abdominal distension
Signs of hypovolemic shock: hypotension, tachycardia, pallor, diaphoresis
Hematemesis or melena if associated with gastrointestinal injury.
Signs:
Abdominal tenderness and guarding
Rebound tenderness
Palpable mass in RUQ
Ecchymosis or bruising in the flank (Grey-Turner's sign) or around the umbilicus (Cullen's sign) in severe cases
Hemodynamic instability (hypotension, tachycardia).
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion in a trauma patient with hemodynamic instability or significant abdominal findings
Imaging confirmation is usually required
No specific "criteria" exist for diagnosing the need for non-anatomical resection
rather, it is a surgical decision based on the intraoperative findings of the extent of injury and the presence of ongoing bleeding or devitalized tissue.
Diagnostic Approach
History Taking:
Mechanism of injury: blunt (high-speed motor vehicle accident, fall, assault) or penetrating (stab, gunshot)
Associated injuries
Pre-existing medical conditions (coagulopathy, liver disease)
Medications (anticoagulants, antiplatelets)
Last meal
Allergies.
Physical Examination:
Assess for signs of hypovolemic shock
Perform a thorough abdominal examination, noting tenderness, guarding, distension, and any signs of peritoneal irritation
Examine the chest, pelvis, and extremities for associated injuries
Re-assess vital signs frequently.
Investigations:
Focused Assessment with Sonography for Trauma (FAST) scan: initial rapid assessment for free fluid in the abdomen, pelvis, and pericardium
Computed Tomography (CT) scan with intravenous contrast: the gold standard for evaluating liver injury severity, extent of laceration, presence of active bleeding (blush), and associated injuries
Laboratory tests: complete blood count (CBC) to assess hemoglobin and platelet count, coagulation profile (PT, PTT, INR) to assess hemostasis, liver function tests (LFTs) to assess baseline hepatic function and detect injury, serum lactate to assess tissue perfusion.
Differential Diagnosis:
Other intra-abdominal organ injuries (spleen, kidney, bowel)
Retroperitoneal hematoma
Diaphragmatic rupture
Gastric or duodenal perforation
Mesenteric hematoma.
Management
Initial Management:
ATLS (Advanced Trauma Life Support) principles
Resuscitation with intravenous fluids and blood products to achieve hemodynamic stability
Airway, breathing, and circulation management
Placement of nasogastric tube
Foley catheter insertion
Pain control.
Medical Management:
Correction of coagulopathy: administration of fresh frozen plasma (FFP), cryoprecipitate, prothrombin complex concentrate (PCC), or platelets as indicated
Tranexamic acid administration in bleeding trauma patients
Titration of vasopressors and inotropes if hemodynamic instability persists despite fluid resuscitation.
Surgical Management:
Indications for operative intervention include hemodynamic instability refractory to resuscitation, ongoing significant bleeding, extensive devitalized tissue, or associated hollow viscus injury
The goal is to achieve hemostasis and debride non-viable tissue
Non-anatomical resection involves excising the lacerated edge of the liver parenchyma using cautery, harmonic scalpel, or simple dissection, with careful ligation of visible bleeding vessels and bile ducts
Packing the raw surface with hemostatic agents (e.g., Surgicel, Gelfoam) may be employed
In some cases, simple hemostatic sutures may suffice for superficial lacerations.
Supportive Care:
Close monitoring of vital signs, urine output, and abdominal girth
Blood product transfusions as needed
Nutritional support, often initiated early
Management of pain and sedation
Prophylaxis against deep vein thrombosis (DVT) and stress ulceration
Antibiotic prophylaxis for intra-abdominal infections, guided by injury pattern and local protocols.
Complications
Early Complications:
Hemorrhage: continued bleeding from the resection site or other injured vessels
Biliary leak or fistula: leakage of bile from transected bile ducts
Intra-abdominal abscess or hematoma formation
Sepsis
Acute liver failure.
Late Complications:
Post-traumatic hepatic cyst or pseudocyst formation
Biliary strictures
Adhesions
Chronic pain
Hepatic venous outflow obstruction (rare).
Prevention Strategies:
Meticulous hemostasis during surgery
Careful identification and ligation of bile ducts
Adequate debridement of devitalized tissue
Prompt and aggressive management of coagulopathy
Judicious use of hemostatic agents
Early mobilization and nutritional support
Close postoperative monitoring.
Prognosis
Factors Affecting Prognosis:
Severity of liver injury (AAST classification)
Presence and severity of associated injuries
Hemodynamic stability at presentation and response to resuscitation
Promptness of diagnosis and intervention
Patient's underlying comorbidities (e.g., liver cirrhosis, coagulopathy).
Outcomes:
With timely and appropriate management, including non-anatomical resection when indicated, the prognosis for liver trauma can be favorable
Morbidity and mortality are significantly influenced by the degree of shock and the presence of other life-threatening injuries
Patients undergoing non-anatomical resection for isolated liver injury often have good functional recovery.
Follow Up:
Postoperative follow-up typically involves serial physical examinations, laboratory monitoring (CBC, LFTs), and imaging (ultrasound or CT) to assess for complications such as abscesses, bilomas, or recurrent bleeding
Duration of follow-up depends on the severity of the injury and the presence of complications.
Key Points
Exam Focus:
Non-anatomical resection is reserved for specific situations in liver trauma, primarily to control hemorrhage and debride devitalized tissue when anatomical resection is not feasible or necessary
Indications are usually hemodynamic instability and active bleeding
AAST injury grading is crucial for management decisions.
Clinical Pearls:
Always consider associated injuries in polytrauma
Intraoperative ultrasound can be invaluable for assessing the extent of injury and identifying bleeding sources
Ligate all visible bleeding vessels and bile ducts encountered during resection
Pack the liver bed judiciously if oozing persists, but avoid excessive packing that can compromise outflow.
Common Mistakes:
Delaying operative intervention in hemodynamically unstable patients
Undertreating coagulopathy
Inadequate debridement of necrotic tissue, leading to infection or abscess
Attempting complex anatomical resections in unstable patients
Neglecting associated injuries.