1
BACKGROUND
Abdominal trauma in general and liver injury in special are
considered intensive emergency which is increased nowadays. The
liver is one of the most commonly injured organs in abdominal
trauma It is together with the urbanization, developed transportation
and the development of civilization.
Most of liver trauma was indicated surgery many years ago. Surgery
of liver required advanced knowledge of anatomy, physiology of liver as
well as good technique of recovery and surgeon. However the
complication in surgery and post opereation is in high rate.
Recent advancements in imaging studies and enhanced critical
care monitoring strategies have shifted the paradigm for the
management of liver injuries. and the advent of damage control surgery
have all improved outcomes in the hemodynamically unstable patient
population.
The precise indication for liver trauma would guide clinician
classify the grade of liver injury. At this present no previous study
reviewed and compared grade of clinical liver trauma and CT images
and the early result of surgery after liver trauma injury have been
reviewed.
“The correlation between clinical and CT imaging features of
liver trauma and evaluation of surgical management of liver
trauma” Purposes:
1.Correlate clinical and CT grading features of liver trauma
2. Evaluate of surgical management of liver trauma
Significance of study:
- Study show the practical and sientific benefits by correlating
clinical and CT imaging features
- Methodology was done in sientific manner. Sample were
matching in 2 groups: group included clinical and CT imanging

anterior segment.
+ Left hepatic vein: receives blood from the left lobe and lobe IV.
+ Spiegel Veins: receives blood directly from Spigel segment and
consists of two groups: the small veins pouring directly into IVC and
relatively large and pretty regular veins.
+ The minor right hepatic vein (Makuuchi vein) guides blood
directly from the right liver sections (V, VI, VII, VIII) poured straight
into the side of IVC. If there is severe injury, these positions could be
torn violently, ensuing excessive bleeding.
1.1.2. Application in hepatic resection surgery
* According to British-American authors: In 1953, Healey and
Schroy divided liver into 2 lobes – left and right. 4 segments include:
medial, lateral, posterior, anterior segments. Caudate segment is also
known as back segment. Each segment is divided into 2 smaller parts:
3
superior and inferior. Caudate segment has 3 sections: right, left and
caudate.
* According to French authors: Couinaud in 1957 divided into 2
halves: right and left. 4 parts include: right, right portal and left portal, left.
Caudate lobe makes the back segment. 8 segments are numbered clockwise
on the diaphragmatic surface.
* Vietnam school: In 1963, Tôn Thất Tùng the combined 2 views of
British-American and French with experiences of Vietnam to suggest a
particular uniform view of Vietnam. As dividing 2 halves of liver, 8
subsegments is based on Couinaud theory and 4 segment following
British-American authors. In our study, we use Ton That Tung’s school.
In 2000, at Brisbane (Australia), the liver surgery conference come
to an agreement on liver operation and hepatic resesction surgery.
1.2. The methods of diagnostic imaging of liver injury
1.2.1. The visual probe methods

* Paraclinical: monitoring indicators of blood counts, biochemical
and images-particularly CT
* Treatment: intensive care, estate resting in hospital bed ward
* During the follow-up, detecting complications so as to have
management on intervention or surgical procedure:
1.3.2. Embolization treatment
* Indication: From hepatic trauma grade III or beyond, there is
vein damage,stable hemodynamic
* Contra-indication: blood pressure decrease shock and there is
vein damage in which surgery is inevitable
*Intra-vesel intervention for treatment of hepatic artery damage:
Using the material to cause embolism, according to damage
1.3.3. The methods of surgery treatment
* Surgical indication: fatal shock and failed conservation treatment
* Surgical rules: processing vessels, biliary tract, cut off dead hepatic
parenchyma
* Main techniques:
+ Simple liver sewing and cauterization: for insignificant hepatic
trauma
+ Selective hepatic artery embolism: selective embolism of either
right or left branch or hepatic artery
+ Mickulic’s method: for deep and wide lesions, not thorough
hemostatic
+ Liver packing: severe shock patient can’t put up any longer with
surgery
+ Simple hepatic draining tube: rarely applied
+ Hepatic venous repair
- Repairing venous lesion without using shunt: includes the method
of Ton That Bach, Heaney’s method and method of Dale coln.
- Repairing venous lesion using shunt: includes the Buckberg’s

liver damage, alter attitudes in patients treated hepatic trauma, treatment
rate increased non-operative conservation.
* Status of Research domestic:
Ton That Tung’s liver cutting method was first published in 1962 in
Berlin. Trinh Hong Son’s study of hepatic trauma in Vietnam-Germany
Hospital for 6 years from 1990 to 1995, emphasized the hemodynamic
status when patient come in hospital have prognostic significance and
summarize the accompanying lesions, method of treatment and
postoperative complication rate. Most recently, Nguyen Ngoc Hung’s study
showed that treatment of liver preservation injury is applied to the 84.4%,
89% achieved good results.
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Chapter 2: SUBJECTS AND METHODS
2.1. Research Subjects
* For Objective 1: To compare the clinical presentation and liver
injury grade in CT of simple liver trauma.
* For objective 2: Results of surgical treatment of simple liver trauma
2.2. Methodology of research: descriptive study with prospective analysis.
During the period from January 2009 to the end of December 2011.
Research’s Steps:
+ Diagnosis and management of simple hepatic trauma comply with a
uniform regimen of treatment indications, assessment of liver injury on CT
and in operation.
+ The level of hepatic trauma was assessed by CT.
+ Decide between non-operative conservation management or
emergency surgery.
The content of research:
* Compare hepatic trauma grade in CT with the general
characteristics of the study groups: including the causes, mechanism of
injury, age, gender, occupational status prior to hospitalization and time

I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1cm
parenchymal depth
II Hematoma Subcapsular, 10% to 50% surface area
intraparenchymal <10 cm in diameter
Laceration Capsular tear 1-3 parenchymal depth, <10
cm in length
III Hematoma Subcapsular, >50% surface area of
ruptured subcapsular or parenchymal
hematoma; intraparenchymal hematoma >
10 cm or expanding
Laceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25% to
75% hepatic lobe or
1-3 Couinaud’s segments
V Laceration Parenchymal disruption involving >75%
of hepatic lobe or >3
Couinaud’s segments within a single lobe
Vascular Juxtahepatic venous injuries; ie,
retrohepatic vena
cava/central major hepatic veins
VI Vascular Hepatic avulsion
+ Machine: single - receiver array CT in diagnostic imaging departments of
Vietnam-Germany Hospital. Slice thickness can vary 1mm - 10mm.
+ Technique: patient supine, hands raised to the top. Slices were taken
from the top of the diaphragmatic dome to the ischium joint with 10mm
thickness, if small lesions is suspicious conduct shooting 3 - 5mm thin
layer on the damaged area. Slices were taken before and after contrast
agent injection
+ Read the result: Location of lesions (Ton That Tung). Hepatic trauma

- Cut the liver according anatomy (Ton That Tung method) including
left liver, right liver, left lobe, right lobe, segments cutting.
- Packing:
- Handle the hepatic artery lesions: Sewing HA or selective ligation.
- The handling of surgical lesions hepatic veins, portal vein, IVC: Fix
direct venous injury using shunt and circulation outside the body.
- The surgical drainage of the bile ducts, the processing techniques of
biliary lesions: drainage of common bile duct, cholecystis stomy, hepatic
duct on-sonde sewing, choledo-jejunum stomy, or liver cutting.
* Subscribe to detect postoperative complications: postoperative
hemorrhage, biliary duct hemorrhage, biliary peritonitis, bilioma, liver
abscess, abscess under the diaphragm, bile leakage after surgery,
complications in the lungs and pleura, liver failure, multi-organ failure
* Treatment of complications: indication of surgery or procedure is
depended on developments, complications.
9
* Number of days in hospital
* Results of surgical treatment soon after
+ Good: No complication present or minor complications present but
have been treated without intervention.
+ Average: patients with complications were stably handling.
+ Bad: Death, serious complications.
2.2.5. Gathering and processing data
All selected patients have complete individual profile with all necessary
parameters mentioned. Data processing program according to medical
statistics software SPSS 15.0.
2.2.6. Research Ethics
The patient's personal information in the records completely confidential
and used only for research. The research program is through a review board
of the Military Medical Academy, Department of Defense decision.

10
P p = 0,011
Table 3.8: Comparing the grade of hepatic trauma and pulse at
admission
pulse
grade
≤ 90 90 – 120 ≥ 120
N % n % n %
I 2 2,0 0 0,0 0 0,0
II 20 20,4 10 16,9 0 0,0
III 48 49,0 24 40,7 1 11,2
IV 23 23,5 20 33,9 4 44,4
V 5 5,1 5 0,5 4 44,4
total 98 59,0 59 35,6 9 5,4
P p = 0,001
Table 3.9: Comparing the grade of hepatic trauma with the grade of
initial anemia
anemia
grade
grade I grade II grade III grade IV
n % n % n % n %
I 2 1,5 0 0,0 0 0,0 0 0,0
II 27 20,1 3 12,5 0 0,0 0 0,0
III 63 47,0 9 37,5 1 14,4 0 0,0
IV 34 25,4 9 37,5 3 42,8 1 100,0
V 8 6,0 3 12,5 3 42,8 0 0,0
Tổng 134 80,7 24 14,5 7 4,2 1 0,6
P p = 0,005
Table 3.10: Relation between the initial grade of anemia and methods
of treatment.

n % n %
No-abdominal
distention
25 100,0 0 0,0 25
mild-abdominal
distention
65 100,0 0 0,0 65
moderate-abdominal
distention
44 74,6 15 25,4 59
serious-abdominal
distention
8 47,1 9 52,9 17
P p < 0,001
Table 3.14: Comparing the degree of hepatic trauma and blood loss
Blood
loss
grade
no mild moderate Serious
n % n % n % n %
I 2 2,3 0 0,0 0 0,0 0 0,0
12
II 18 20,7 8 19,0 2 7,7 2 18,2
III 43 49,4 21 50,0 7 26,9 2 18,2
IV 21 24,1 9 21,4 15 57,7 2 18,2
V 3 3,5 4 9,6 2 7,7 5 45,4
Table 3:15: Comparing the grade of hepatic trauma with blood
biochemical tests (SGOT)
SGOT
Grade

± SD
I 2 96,0±14,6 2 67,0±12,7 1 40,0
II 30 264,0±288,0 24 183,5±201,7 11 132,7±71,5
III 73 456,4±434,0 55 361,8±361,4 31 259,1±272,7
IV 47 799,9±623,4 42 526,7±413,4 25 310,0±292,0
V 14 614,7±393,6 13 818,5±551,8 11 315,9±349,2
Total 166 530,9±507,0 136 420,6±412,4 79 263,0±274,4
P < 0,001 < 0,001 < 0,05
Table 3:20: Comparing the grade of hepatic trauma with abdominal
fluid on CT
Abdominal
fluid
grade
None less medium A lot Total
n % n % n % n % n %
13
I 2 7,7 0 0,0 0 0,0 0 0,0 2 1,2
II 10 38,5 9 25,0 6 17,6 5 7,1 30 18,1
III 12 46,1 20 55,6 14 41,2 27 38,6 73 44,0
IV 2 7,7 5 13,9 11 32,4 29 41,4 47 28,3
V 0 0,0 2 5,5 3 8,8 9 12,9 14 8,4
Total 26 15,7 36 27,7 34 20,5 70 42,1 166 100,0
P p<0,001
14
Table 3:22: Comparing the grade of hepatic trauma with the type of
liver injury on CT
Hepatic
traumatic
I II III IV V
p

III 7 20,6
IV 10 29,4
15
V 16 47,1
Total 34 100,0
Table 3:29: Comparing the hepatic trauma indications for treatment
with surgery
Method
treatment
Grade
conservation emergency total
n % N % n %
I 0 0,0 0 0,0 0 0,0
II 1 41,0 0 0,0 1 2,9
III 7 29,2 0 0,0 7 20,6
IV 9 37,5 1 10,0 10 29,4
V 7 29,2 9 90,0 16 47,1
Total 24 70,6 10 29,4 34 100,0
Table 3:30: Position liver injury in surgery
Location liver damage n Ratio%
Sub-segment I 5 4,6
Sub-segment II 3 2,7
Sub-segment III 2 1,9
Sub-segment IV 14 13,0
Sub-segment V 19 17,6
Sub-segment VI 23 21,3
Sub-segment VII 22 20,4
Sub-segment VIII 20 28,5
Table 3:31: Comparing the grade of hepatic trauma treatment with
liver damage

Gallbladder drainage 2 5,9
Packing 1 3,0
Bilio-intestinal anatomoses 1 3,0
Table 3.35: Comparing grade of hepatic trauma with postoperative
complication
Grade
Postop
complication
I II III IV V Total
Postoperative hemorrhage 0 0 1 1 1 3
Biliary hemorrhage 0 0 1 0 0 1
Peritonitis 0 0 0 0 1 1
Bili leakage 0 0 0 1 2 3
17
Subdiaphragm abscess 0 0 1 1 0 2
Coagulation disorders 0 0 1 0 0 1
Hepatic failure 0 0 1 0 0 1
pneumonitis 0 0 0 0 1 1
Multi-organ failure 0 0 0 1 3 4
Incision infection 0 0 0 0 1 1
Table 3.37: Comparing the grade of hepatic trauma with postoperative
hospitalization
Grade
Hospital
(days)
I II III IV V Total
< 10 0 1 1 2 5 9
10 – 20 0 0 3 5 6 14
> 20 0 0 3 3 5 11
Table 3.38: Comparing the grade of hepatic trauma

* To compare the hemodynamic status
Our results found that patients with high blood pressure ≤70mmHg
had liver damage from level III or higher and who had maximum blood
pressure <90 mmHg had liver damage from level II or higher. In our study,
there were 158 patients with mild anemia (grade I or II) among which
11.4% required surgical treatment. There were 71.4% of patients of anemia
level III needed operation, and 100% of patients had anemia level IV had
operation.
* To compare with the abdominal symptoms
+ Scatching, abdominal contusion: 62/166 cases of patients (37.3%)
had right upper quadrant contusion. It was difficult to determine abdominal
pain due to injury or damage of the abdominal organs .
+ Abdominal pain: pain of right upper quadrant was the most
common sign in 163/166 cases (98.2 %) of patients had liver damage.
However, this was subjective signs of disease so the surgeon needed to
examine more accurately .
+ Distention: the proportion of patients have abdominal distention of
84.9 %, mainly located in the patients with liver injury from grade II or
higher. Number of patients with abdominal distention in liver injury were
46.7 % of grade II, 91.8% of grade III, 97.9 % of grade IV, and 100 % of
grade V. Most of patients with mild abdominal distention and bloating had
liver damage in level I, II or III and all cases were successful conservative
treatment. The more severe liver injury, the heavier abdominal distension
and higher surgical intervention.
+ The signs of the abdominal wall
19
- Reaction abdominal wall: 27.7 % of patients with no signs of the
abdominal wall, in this group the majority of patients in the liver injury at
grade II, III. Abdomial symptom localized in liver occured 72,3% of
patients in which 72.3 % of liver injury in level I, 50 % of grade II, 72,3%

ultrasound. The sensitivity of ultrasound in detecting peritoneal fluid
proportional to the degree of liver injury. Therefore, the determination of
the extent of peritoneal fluid and peritoneal fluid on ultrasound was very
important for the surgeon combined with clinical and CT in order to
appropriate treatment.
+ To compare the level of liver injury with liver lesions detected on
ultrasound: detection rate of liver damage was 96.4% on Ultrasound. There
20
were 4 patients (3.6%) patients with undetectable by ultrasound including 1
patients with grade I and 3 patients with grade III.
* Computerized tomography
+ Signs of free fluid in the abdomen: 26/166 patients without
peritoneal fluid on CT, which mainly patients with level I, II, and III
(92.3%). Peritoneal fluid wes considered to be representative of the level of
serious liver damage. Patients with liver injury in level IV or higher and
more peritoneal fluid on CT had risk of treatment failure.
+ Location liver lesions on CT: right liver injury had met with more
than 336 patients, left liver injury had met in 57 patients at all the damage,
which was more common lesions located in the posterior lobe division
(accounting for 52,1% had liver damage), where the liver is fixed to the
abdominal wall by ligaments and tendons triangular rim; left liver lobe
lesions having only 3.0% of cases; left lower liver I met 17 times (4.1%)
but the majority of lessions due to wide-spread injury of left liver lobe and
right liver lobe
+ To compare the degree of liver damage: liver lesions most
commonly on the CT were contusion, hematoma liver parenchyma with
161/166 patients accounting for 97.0%. Parenchyma contusion can be
alone or in combination with hematoma or parenchymal broken line,
because contusion and parenchymal hematoma usually considered together
so we could detect that contusion and hematoma is a mark on the CT film.

* Method of operation: 97.1% of patients underwent surgical laparotomy.
Only 2.9% of patients had laparoscopy. The indication for laparoscopy
should be considered hemodynamically stable, liver damage was not too
severe, full equipment, surgeon’s skill and experience .
* Surgala trace: The patient was in the supine position and endotracheal
anesthesia. Incision superior umbilical commonly used. Incision under the
ribs on the sides and Mercedes also for a wide surgical field to handle
complex lesions in the liver or surround processor regeneration and
conservation of vascular injury. In our study, there were 52.9% of patients
underwent laparotomy with superior umblical incision. Mercedes incision
had been applied for 8 patients (23.5%).
* The amount of blood loss: We need assess blood loss and blood
transfusion immediately and wait until resuscitation in surgery conducted
entirely to handle injuries. 23 patients had intra-abdominal blood > 1000ml
(67.7%). 5 cases had intra-abdominal blood ≤ 500ml (14.7 %).
* To probe damage: To evaluate well and easy management of hepatic
injury required extensive liver freed by cutting the ligaments fixed liver to
the diaphragm and colon. If the lesion was positioned in the top of the liver
spread posterior it could potentially damage the liver veins .
+ The liver lesions : In this study, there was no lesions in grade I. All
patients had liver damage from grade II including 2.9% of grade II, 20,6%
of grade III, 29.4% of grade IV and 47.1% of grade V.
+ Location of liver damage: In 108 cases of lobe lower liver, there
were 4.6% of lobe lower liver I, 2.7% of lobe lower liver II, 1.9% of lobe
lower liver III, 13.0% of lobe lower liver IV, 17.6% of lobe lower liver V,
21.3% of lobe lower liver VI, 20.4% of lobe lower liver VII, 18.5% of lobe
lower liver VIII. 84/24 cases had right liver injury, as a result, the number
of patienst of right liver lesions had more than 3,5 times the left liver.
* Handling of liver damage
+ Stop the bleeding temporarily

for liver damage due to right liver damage were more than the left.
- Handle vascular lesions : Hepatic arteria could be sutured
hemostasis with an X or U suture just do not spend 3/0 - 4/0. If bleeding
was still conducted hepatic artery ligation. Portal vein crushed must be
placed one stage vascular graft with autologous vein or synthetic vein, or
create a shunt portal-vena cava. For small lessions of hepatic veins and
inferior vena cava, we could compress and proceed holes stitched with
vascular sutures. For large wounds speed of ICV part after liver or hepatic
veins, we need to implement techniques to isolate the hepatic veins can
better tackle the wound.
- Handling of biliary injury: Many of cases were gallbladder lesions
that need cholecystectomy. The vulnerability stems Glisson lobed and lobe
lower liver with peritonitis due to bile duct injury which so far according to
the classic open surgery in order to repair of biliary injury during surgery as
23
suture immediately restore liver injury. The surgeons need biliary drainage
to avoid detection and drainage of abdominal bile widely.
4.3.3. Early postoperative complications of liver injury
Many reports have indicated the rate of early complications in liver
injury from 30% to 50%. Factors for postoperative complications increases
were closely related to the severity of the injury as well as apply techniques
in management.
* Postoperative Bleeding: Postoperative bleeding were serious
complications including blood loss, shock and death threats. These was a
consequence of hemostatic techniques fatally, but coagulopathy due to
severe blood loss also played an important role in the formation of
pathogenic mechanisms. Common causes were flowing from the liver
break area had not been handled well, especially in deep lesions in tissue or
gauze after temporary insertion. When you had identified the bleeding,
operation must be conducted soon for rescue patients.

resuscitation in the intensive care unit. Multi-organ failure could be
considered as the final result of surgical and trauma especially in most
severe cases if treatment liver injury had been uncontrolled bleeding,
coagulopathy and shock
4.3.4. Length of hospital stay after surgery
Length of hospital stay related to liver damage, in our study the
average hospital stay was 16.7 days. In this research, the reason for the
heavy liver injury in grade IV and V had the time average postoperative
hospital stay no higher than grade III because most serious complication
had been handed-off by families’ requirement. All deaths during and after
surgery were located in serious liver damage, making the hospital stay
decreased significantly heavier in this group.
4.3.5. Surgical Results
Good results proportion of 53.0% (18 patients), resulting in an
average of 23.5% (8 patients), adverse outcome of 23.5% (8 patients).
Number of patients with complications was 14 patients accounting for
41.2% ,
4.3.6. Results of treatment of liver injury
In total 176 patients were emergency with liver injury in Viet-Duc
Hospital in 2009-2011 accounted for 91.0% good results with 160 case.
8 cases of patients with complications were treated stable .
8 cases with serious complications and deaths .
4.3.7. Deaths
Death was usually the result of uncontrolled bleeding, sepsis or
multi-organ failure. Total number of patients died in the study was 8 cases
(4.5%). Among them, 2 cases were intraoperative mortality (1.1%).
However, the mortality rate was quite high during the operation in the case
of death as well as proven cause injury mechanisms was complex and
patients were too heavy though management has been very active
resuscitation in the operating room when combined with surgery

rupture path (85.5%), arterial contrast drug drainage (4,8%). Common
injury location was posterior hepatic lobe (52.1%). The more severe the
liver injury was, the higher the fluid volume was seen on CT scan image.
Conservative treatment accounted for 85.5%. The rate of preservative
treatment that required surgery was proportional with the severity of liver
injury.
2. Result of surgical treatment of simple liver injury
- Classic laparotomy was 97.1%; laparoscopy was 2.9%; and abdominal
mid line (linea alba) opening was 52.9%.
- Liver resection was the main treatment for lever lesions, accounted for
58.8% with 32.4% of the operated patients had right liver resection.
Hepatic vein lesion accounted for 17.6%; lesion of the inferior vena cava
was 11.8% which was sutured.