TRAUMA HEPAR

Soetamto Wibowo Bagian Bedah FK UNAIR / RSUD Dr Soetomo Surabaya

DIAGNOSIS
Riwayat Penyakit :
> Mekanisme Trauma : Trauma Tumpul

Trauma Tembus : Tusuk , Tembak

> Kejadian (waktu) > Nyeri Febris

Pemeriksaan Fisik : Manajemen ATLS Pemeriksaan Penunjang : FAST

DPL CT Scan + Kontras

BLUNT ABDOMINAL TRAUMA Peritonitis / Overt Hemoperitoneum ? No Hemodinamically Stable Hemodinamically UnStable Yes Expl. Laparotomy

Alur Penanganan Penderita Trauma Tumpul Abdomen

Hemodinamically Stable Yes Abdominal Tenderness Multiple Ribs Fracture Abdominal Wall Contusion Equivocal Findings No Admid Serial PE Yes CT Scan Free Fluid ? No Repeat USG Hollow Reliable PE ? Yes No

USG / DPL USG

DPL

Negv

Postv

Observation
Repeat DPL CT Scan No CT Scan

Organ
Injury ? Yes Expl lap

No

Solid Visceral injury ?

Yes

Solid Visceral injury ? Consider Expl. Lap

No

Consider Expl. Lap

Consider Non Operative

Hemodinamically Unstable USG Free Fluid ? DPL Aspiration of Gross Blood

RBC > 100 K/mm3

WBC > 500/mm3 Particulate matter Bile No Yes Expl lap Continue Resuscitation Evaluate Other Potential Source Repeate USG Continue Resuscitation Evaluate Other Potential Source Repeate DPL No

DPL

Liver Injury Scale : AAST (Revised 1994)

Grade I. Hematoma Laceration Injury Description Subcapsular Non expanding, <10 cm surface area Capsular tear, Non bleeding,< 1 cm parenchymal depth ICD - 9 864.01 864.11 864.02 864.12 II. Hematoma Subcapsular Non expanding, 10-50% surface area Intraparenchymal non expanding < 10 cm in diameter Laceration III. Hematoma Capsular tear, Active bleeding,1-3 cm parenchymal depth <10 cm length Subcapsular,>50% surface area or expanding Ruptured subcapsular hematoma with active bleeding intraparenchymal hematoma > 10 cm or expanding Laceration IV. Hematoma Laceration > 3 cm parenchymal depth Ruptured intraparenchymal hematoma with active bleeding Parenchymal disruption involving 25-75% hepatic lobe or 1-3 Coinaud's segment within single lobe V. Laceration Vascular VI. Vascular Parenchymal disruption involving >75% hepatic lobe 864.14 4 5 5 6 864.04 864.04 3 4 864.01 864.11 864.03 864.13 3 2 2 AIS 90 2 2

or 1-3 Coinaud's segment within single lobe

Juxtahepatic venous injuries (ie retroheaptic vena cava / central major veins Hepatic avulsion

Manajemen Non Operative

I. Dasar Keputusan
1. Hemodinamik Stabil : Saat Datang atau Rapid Response

Stabil bila : MAP > 80 mmHg, Nadi < 120 x/mt Transfusi tidak lebih dari 2 unit Whole Blood

Tidak ada tanda-tanda klinis Shock

Produksi urine > 50 cc/jam
2. Hasil CT Scan Abdomen : Grading, Pooling (AAST)

3. Tidak ada gejala Peritonitis secara klinis

4. Tidak ada tanda-tanda Perforasi Organ Berongga, Pancreas, Kandung seni atau Diafragma (CT Scan, Plain Foto Abdomen, DPL)

Manajemen Non Operative

II. Perawatan di RS
1. Bed Rest dengan NGT, sebaiknya di Ruang Intensif 2. Pemeriksaan Fisik Hb (Hct) @ 6 jam (hari I), @ 12 jam (hari II) 3. Hct < 25% : Transfusi PRC, bila transfusi > 4 unit dalam 72 jam : Laparotomi 4. Realimentasi bila fungsi saluran cerna baik 5. CT Scan dapat diulang : 3-5 hari Pasca Trauma lalu 6 minggu pasca trauma 6. Keluar RS setelah 12 hari 7. Tidak melakukan aktivitas fisik berlebihan & olah raga kontak selama 4-6 bulan.

PEMBEDAHAN
Indikasi Laparotomi :
1. Hemodinamik tidak stabil
2. Peritonitis Generalisata 3. Perlu Transfusi > 4 unit WB 4. Pada CT Scan abdomen :
> Cairan Bebas dalam abdomen tanpa perlukaan organ padat > Pooling kontrast dalam parenchym hepar,lien atau intra abdomen

Liver Rupture

Incision

ALGORITHM FOR THE INTRAOPERATIVE MANAGEMENT OF COMPLEX HEPATIC INJURIES

HEMOPERITOEUM WITH INSTABILITY
BIMANUAL COMPRESSION RESUSCITATION PRINGLE MANEUVER BLEEDING CONTINUES (CONSIDER RETROHEPATIC IVC OR HEPATIC VENOUS INJURY PACK PATIENTT BLEEDING NOT ARRESTED REPAIR SEVERED BLOOD VESELS AND BILE DUCTS VASCULAR ISOLATION BLEEDING ARRESTED LEAVE PACK IN PALCE COAGULOPATHY AND OTHER INDICATIONS FOR PACKING PACKING, RAPID ABDOMINAL CLOSURE WITH TOWEL CLIPS, PLANNED RE-EXPLORATION RE-EXPLORE WHEN HYPOTHERMIA, ACIDOSIS CORRECTED (18-36 H) REMOVE PACK

BLEEDING ARRESTED NO VASCULAR ISOLATION

FINGER FRACTURES TECHNIQUE TO SITE OF INJURY

DEBRIDEMENT OF NONVIABLE HEPATIC PARENCHYME

INTRACAVAL SHUNT (ATRICAVAL OR SAPHENOCAVAL)

OMENTAL PACK

RAPID REPAIR OF LACERATED VENOUS STRUCTURESS

NO BLEEDING IRRRIGATE, DEBRIDE, CLOSED SUCTION DRAINAGE, CLOSE

BLEEDING RECURS DEFINITIVE REPAIR, MAY REQUIRE VASCULAR ISOLATION

Liver Rupture

MANUAL COMPRESSION

Liver Rupture
Pringle Maneuver

Liver Rupture

Haemostasis

Liver Rupture

Liver Suture

Liver Rupture

Perihepatic packing for left & right lobes rupture

Liver Rupture

Dividing The Liver Ligament

Segmental Anatomy of the Liver : Described by Couinaud

Liver Rupture

Omentum : A living pack

Liver Rupture

Atrio Caval Shunt

Penetrating Liver Trauma

Gunshot
Stabwound through peritoneum >>Exp. Laparotomy

Intraparenchymal Ballon Tamponade

Sukses (8) : Mortalitas = 0

MNO (9) Gagal (1) : Laparotomi Ruptur Hepar (27)
Trauma Tumpul Abdomen (46)

Laparotomi (18) Sukses (8) Gagal (1) : Laparotomi Laparotomi (10)

Mortalitas = 2

MNO (9) Ruptur Lien (19)

Mortalitas = 0

Trauma Tumpul di Surabaya (2003 2005)

Comparison of patients with succesful vs failed NOM

(Velmahos. Arch Surg 2003 ; 56 : 537-541) NOM Success n=116 (%) 1. FAST Positive Result 2. Liver 3. Spleen 4. Renal 5. Associated Intra Abd 26 (22) 60 (52) 44 (38) 27 (23) 1 (1) NOM Failure n=33 (%) 20 (61) 12 (36) 23 (70) 6 (18) 6 (18) < 0,01 0,11 < 0,01 0,64 <0,01 p value

Factors

6. Associated Extra Abd

7. Amount of fluid on CT (mean+SD)

79 (68)
92 + 154

18 (55)
308 + 396

0,13
<0,01

Comparison of Immediate Operative & NOM Failure : Surabaya & LA

Soetamto (n=46) Compare 1. Immediate Operative Liver Spleen Renal 2. NOM Failure Liver Spleen Renal 3. Mortality 1 (11,1) 1 (11,1) 0 2 (4,3) 12 (16,7) 23 (34,3) 6 (18,2) 15 (7) 18 (66,7) 10 (52,6) 0 17 (24) 27 (33) 2 (10) 2003 - 2005 Surabaya Velmahos (n=206) 1999 - 2001 Los Angeles USA

CASE I
MRS. NS 49 YRS 21.03.2003 : CAR TRAFFIC ACCIDENT HISTORY OF AUTOIMMUNE DISEASE AND CORTICOSTEROID THERAPY PE : ABDOMINAL PAIN AND RIGIDITY BP :100/70 P 120/MIN TEMP. 37C RONTGENT : FRACTURE LEFT RIBS # 4,5,6,7,8 PELVIC FRACTURE FAST : FREE FLUID +

MRS. NS 49 YRS
HB (g/dl) 24.03.03 22.03.03 23.03.03 24.03.03 25-03.03 18.03.03 07-04.03 8.5 6.2 9.2 7.7 10.3 12.0

LIVER RUPTURE
TRANSFUSSION

HEMODYNAMIC

STABLE STABLE STABLE STABLE STABLE STABLE

3 3 1 2 -

PRC PRC PRC PRC

CT SCAN I

CT SCAN II

Mrs.NS, 49 yrs

22 Maret 2003

7 April 2003

Mr. KLT, 45 yrs

Spleen Rupture Grd IV

Mr. YY 49 yrs

Spleen Rupture Grd III

JT, Male, 29 yo 4 May 2005 : Traffic accident, car accident 5 May 2005 : 6:00 AM > BP 120/80 mmHg; Hb 11,7 g/dl FAST : Fluid + Abdomen CT Scan : Spleen Rupture grade IV Th/ : Non Operative Management 6:00 PM > Hb 10,0 g/dl

perivesical

splenorenal

paracolica

FAST

Morison pouch

Mr JT,Abdomen CT Scan ( II )

Spleen Rupture Grade IV

Abdomen CT Scan ( III )

Spleen Rupture Grade IV - NOM

Mr H, 13 yrs

Perihepatic Packing

Mr S, 18 yrs

Liver Rupture Grd III - NOM

Ms R, 25 yrs

Liver Rupture Grd IV - NOM

Terima Kasih