TRAUMA HEPAR

Soetamto Wibowo
Bagian Bedah FK UNAIR / RSUD Dr
Soetomo
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
Yes
Peritonitis / Overt Expl.
Hemoperitoneum ? Laparotomy
No

Hemodinamically Hemodinamically
Stable UnStable

Alur Penanganan Penderita Trauma Tumpul

Abdomen
 Hemodinamically
Yes Stable No
Reliable
PE ?
Abdominal Tenderness Yes
USG / DPL
Multiple Ribs Fracture DPL
Abdominal Wall USG
Contusion Neg Post
Free v v
Equivocal Findings
No Yes Fluid ? Repeat Hollow
No USG
Admid Serial CT Organ
PE Scan Observatio
Injury ?
n
Repeat No Yes
DPL
CT Expl
CT Scan Scan lap
Yes
Solid Visceral Solid Visceral
No injury ? injury ? No
Consider Expl. Consider Non Consider Expl.
Lap Operative Lap
 Hemodinamically
Unstable

USG DPL

Free Aspiration of Gross

Fluid ? Blood
RBC > 100 K/mm3
WBC > 500/mm3
Particulate matter
Bile
No Yes No

Expl
lap
Continue Resuscitation Continue Resuscitation
Evaluate Other Potential Evaluate Other Potential
Source Source
Repeate USG Repeate DPL
 Liver Injury Scale : AAST (Revised
1994)
Grade Injury Description ICD - 9 AIS 90
I. Hematoma Subcapsular Non expanding, <10 cm surface area 864.01 2
864.11
Laceration Capsular tear, Non bleeding,< 1 cm parenchymal depth 864.02 2
864.12
II. Hematoma Subcapsular Non expanding, 10-50% surface area 864.01 2
Intraparenchymal non expanding < 10 cm in diameter 864.11
Laceration Capsular tear, Active bleeding,1-3 cm parenchymal depth 864.03 2
<10 cm length 864.13
III. Hematoma Subcapsular,>50% surface area or expanding 3
Ruptured subcapsular hematoma with active bleeding
intraparenchymal hematoma > 10 cm or expanding
Laceration > 3 cm parenchymal depth 864.04 3
Ruptured intraparenchymal hematoma with active
IV. Hematoma bleeding 864.04 4
Laceration Parenchymal disruption involving 25-75% hepatic lobe
or 1-3 Coinaud's segment within single lobe 4
V. Laceration Parenchymal disruption involving >75% hepatic lobe 864.14 5
or 1-3 Coinaud's segment within single lobe
Vascular Juxtahepatic venous injuries (ie retroheaptic vena cava / 5
central major veins
VI. Vascular Hepatic avulsion 6
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
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
Liver
Ruptur
e
Incision
ALGORITHM FOR THE INTRAOPERATIVE MANAGEMENT OF COMPLEX HEPATIC INJURIES

HEMOPERITOEUM WITH INSTABILITY

BIMANUAL COMPRESSION RESUSCITATION

PRINGLE MANEUVER

BLEEDING CONTINUES (CONSIDER

BLEEDING ARRESTED RETROHEPATIC IVC OR
HEPATIC VENOUS INJURY
NO VASCULAR
ISOLATION
FINGER FRACTURES TECHNIQUE TO
PACK PATIENTT
SITE OF INJURY

BLEEDING NOT ARRESTED BLEEDING ARRESTED

REPAIR SEVERED BLOOD
VESELS AND BILE DUCTS VASCULAR ISOLATION
LEAVE PACK IN PALCE
INTRACAVAL SHUNT
(ATRICAVAL OR
COAGULOPATHY AND
SAPHENOCAVAL)
DEBRIDEMENT OF NONVIABLE OTHER INDICATIONS PACKING, RAPID ABDOMINAL
HEPATIC PARENCHYME FOR PACKING CLOSURE WITH TOWEL CLIPS,
PLANNED RE-EXPLORATION
RAPID REPAIR OF
OMENTAL PACK LACERATED VENOUS
RE-EXPLORE WHEN
STRUCTURESS
HYPOTHERMIA, ACIDOSIS
CORRECTED (18-36 H)
REMOVE PACK

BLEEDING RECURS
NO BLEEDING DEFINITIVE REPAIR, MAY
IRRRIGATE, DEBRIDE, CLOSED REQUIRE VASCULAR ISOLATION
SUCTION DRAINAGE, CLOSE
 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 Mortalitas =
(27) Laparotomi 2
Trauma
Tumpul
(18)
Abdomen Sukses
(46) MNO (8)
(9) Gagal (1) : Laparotomi
Ruptur
Lien (19)
Laparotomi Mortalitas =
(10) 0

Trauma Tumpul di Surabaya (2003

2005)
Comparison of patients with succesful vs failed
NOM
(Velmahos. Arch Surg 2003 ; 56 : 537-541)
NOM NOM p
Factors Success Failure value
n=116 (%) n=33 (%)
1. FAST Positive Result 26 (22) 20 (61) < 0,01
2. Liver 60 (52) 12 (36) 0,11
3. Spleen 44 (38) 23 (70) < 0,01
4. Renal 27 (23) 6 (18) 0,64
5. Associated Intra Abd 1 (1) 6 (18) <0,01
6. Associated Extra Abd 79 (68) 18 (55) 0,13
7. Amount of fluid on CT
(mean+SD) 92 + 154 308 + 396 <0,01
Comparison of Immediate Operative & NOM Failure : Surabaya &
LA

Soetamto (n=46) Velmahos (n=206)

Compare 2003 - 2005 1999 - 2001
Surabaya Los Angeles USA
1. Immediate Operative
Liver 18 (66,7) 17 (24)
Spleen 10 (52,6) 27 (33)
Renal 0 2 (10)

2. NOM Failure
Liver 1 (11,1) 12 (16,7)
Spleen 1 (11,1) 23 (34,3)
Renal 0 6 (18,2)

3. Mortality 2 (4,3) 15 (7)

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 LIVER RUPTURE

HB HEMODYNAMIC TRANSFUSSION
(g/dl)

24.03.03 8.5 STABLE 3 PRC CT SCAN I

22.03.03 6.2 STABLE 3 PRC
23.03.03 9.2 STABLE 1 PRC
24.03.03 7.7 STABLE 2 PRC
25-03.03 10.3 STABLE -
18.03.03 12.0 STABLE -
07-04.03 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 splenorena
l

FAST
paracolica 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