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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 features, group 2 enrolled surgical management of liver trauma. Data were confident. Study
has been done in major surgical center nationaly
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- Coded study was approval, data was first presented
Layout of the thesis: The dissertation consists of 140 pages, 4 chapters, 46 tables, 14 charts, 45 figure, 159
references including 27 Vietnamese references, 130 English references , 2 French references
CHAPTER 1: OVERVIEW
1.1. Liver anatomy:
1.1.1. The structures to maintain hepatic fixed status:
* The ligaments:

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
* Abdominal radiograph: provide indirect signs of liver rupture
* Ultrasound: detecting peritoneal fluid with a very high sensitivity, detecting which organ is damaged,
plays important role in guiding and monitoring of lesion progression.
* Magnetic resonance imaging: MRCP can be used to assess biliary lesions.
* Scintigraphy: questioning bile leak into the abdominal cavity.
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* Angiography: usually for treatment through endovascular intervention and can also be used in cases of
biliary tract bleeding.
* Liver computerized tomography
+ Anatomy of liver in CT: based on hepatic veins and the left and right branches of the PV, virtual planes
cut through the blood vessels helping distinguishing location of lobes and segments of the liver.
+ Classification of the grade of liver injury on CT: In 1994, American Association for the Surgery of
Trauma (AAST) divided liver lesions into 6 levels.
1.2.2. The situation of computerized tomography studies in the diagnosis of liver injury
* Around the world: Researches throughout the world from the 80s and 90s so far suggests that CTis
enormously valuable in detecting hepatic trauma, allowing surgeons to be comfortable and confident in the treatment
of conservation.
* In domestic regions: In 2007, local authors had high opinions of the diagnostic ability of CT in hepatic
trauma with the absolute level of sensitivity up to 100%, accuracy 94.8%, positive predictive value 94.8%.
1.3. The method of treating liver injury
1.3.1. Inoperable conservation Treatment
* Clinical: closely monitoring whole body condition, hemodynamic and abdomen status
* Paraclinical: monitoring indicators of blood counts, biochemical and images-particularly CT

+ Liver resection: includes the method of Ton That Tung, Lortat - Jacob and Bismuth. Method of Ton That
Tung has a lot of pros and is currently widely used.
* Treatment of post-operative complications:
+ Post-operative hemorrhage: depend on particular cases, blood transfer, scintigraphy or emergency operation.
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+ Bile duct hemorrhage: intervened embolization is considered a valuable treatment.
+ Abscess inside and outside of liver: ultrasound guided puncture and drainage give good result.
+ Biliary peritonitis: immediate emergency operation.
1.3.4. Status of research on domestic and world
* Status of research on the world
+ The first stage: not paying attention to the anatomical boundaries, focus only on hemostatic treatment.
+ Modern Period of liver cutting: a deep understanding of liver anatomy to improve liver cutting techniques
with the aim of reducing bleeding when cut liver parenchyma.
The advancement of CT helped to accurately assess the degree of 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

Type of Injury Description of injury
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
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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 signs: rupture; parenchymal contusion;

* 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.
* 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.
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+ 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. Research
was accepted by Viet-Duc Hospital and the Military Medical Academy.
CHAPTER 3: RESEARCH RESULTS
3.1. General Characteristics
From January 2009 to the end of December 2011, there are 176 patients on hepatic trauma in Viet-Duc hospital
in which 166 patients were designated to assess liver CT capture and classify of hepatic trauma on
computerized tomography scans. 142 patients received conservative treatment no-surgery accounting for
78.1%. 24 patients (accounting for 15%) of the patients after taken CT to detect liver damage were emergency
surgery. 10 patients (6.9% percentage) was hospitalized in condition hemorrhagic shock, that is indicated
emergency surgery to assess liver injury without CT.
3.2. Group of patients diagnosed liver injury simply by taking CT
Table 3.5: Comparing the grade of hepatic trauma to cause injury
Kind of trauma
Grade
Traffic

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
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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.
Method
treatment
Anemia
conservation
Delaying
emergency
surgery
total
n % n %
I 123 91,8 11 8,2 134
II 17 70,8 7 29,2 24
III 2 28,6 5 71,4 7
IV 0 0,0 1 100,0 1
P p < 0,001
Table 3:12: Comparing abdominal distention status on admission
abdominal distention I II III IV V
Tota
l
No-abdominal distention 2 16 6 1 0 25
mild-abdominal distention 0 13 41 11 0 65

n % n % n % n %
I 2 2,3 0 0,0 0 0,0 0 0,0
II 18 20,7 8 19,0 2 7,7 2 18,2
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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)
SGO
T
Grade
First time Second time Third time
n
X
± SD
n
X
± SD
n
X
± SD
I 2 193,5±92,6 2 87,0±42,4 1 29,0
II 30 346,0±385,8 24 136,1±110,1 11 80,1±61,0
III 73 600,1±783,1 55 429,8±1184,5 31
259,0±665,
2
IV 47 1257,0±1476,6 42 614,1±811,8 25
200,2±275,
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V 14 907,1±550,1 13 966,2±835,2 11

grade
None less medium A lot Total
n % n % n % n % n %
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
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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
n % n % n % n % n %
contusion 2 1,2 30 18,6 69 42,9 46 28,6 14 8,7 0,002
Hematoma
subcapsular
0 0.0 2 6,5 14 45,2 12 38,7 3 9,6 0,849
Escape contrast 0 0.0 0 0.0 1 12,5 5 62,5 2 25,0
Line breaks 2 1,4 29 20,4 66 46,5 38 26,8 7 4,9 <0,001
Gallbladder
Injury
0 0.0 0 0.0 1 25,0 1 25,0 2 50,0
Table 3:23: Comparing the grade hepatic trauma and treatments
Methods
treatment
Grade

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
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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
grade
method treatment
I II III IV V
Electrocoagulation hemostasis 0 0 1 2 0
Suture liver 0 0 4 3 4
Resect liver follow lesions 0 0 1 2 3
Resect liver
by anatomy
Resect right liver 0 0 1 2 8
Resect left liver 0 0 0 0 0
Resect right lobe 0 1 0 1 0
Resect left lobe 0 0 0 0 1
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Table 3:32: Comparing the grade of hepatic trauma with intervention artery
Grade

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
Grade
Result
I II III IV V Total
good 0 1 3 7 7 18
22
medium 0 0 3 1 4 8
bad 0 0 1 2 5 8
Table 3.39: general result
result n = 176 Tỷ lệ%
good 160 91,0
medium 8 4,5
bad 8 4,5
Bảng 3.40: Mortality
Mortality n Ratio%
In-operation 2 25
Post-operation 6 75

- 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% of grade III, 80.9 % of grade IV and 92.9% of grade
V.
- Turbid lowland percussion: 49/166 (29.5%) cases of patients with perforated signs lowland including
patients had liver injury in level III (34.7%), level IV (38.3%) and the V (35.7%) .
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- Peritoneal touch: there were 18 patients with peritoneal touch (10.8%). All patients had signs were from
grade III or higher. In case of severe liver injury which had peritoneal touch should be thought of biliary lesions
included.
4.2.2 . To compare with subclinical results
* Blood tests
+ CBC: 100 % of patients at the first level of liver injury had no signs of blood loss. Blood loss was mild at a
rate of 77.7%; average blood loss percentage of 15.7 % of patients had liver injury in grade III or IV; patients had
severe blood loss ratio of 6.6 % for liver damage in grade IV; grade V was occured in 9/11 cases, accounting for
81.8 % rate .
+ Coagulation test: prothrombin ratio has prognostic value liver injury level and the risk of bleeding during
treatment. Platelet count had valuable for evaluating blood concentration phenomenon.
+ Biochemical tests : The increase in liver enzymes (SGOT and SGPT) in liver injury level I was average of
193.5 ± 92.6 and 96 ± 14.6, in the third level was 600.1 ± 783.1 and 456.4 ± 434.0, in the fifth level was 907.1 ±
550.1 and 614.7 ± 393.6. In our study found that liver enzymes increased proportional to the degree of liver injury.
The increase in liver enzymes in biochemical blood tests for patients with closed abdominal trauma that should be
considered as a marker for liver injury in patients who had unknown clinical symptoms and/or not seen lessions
under abdominal untrasound.
* Ultrasound
+ To compare the level of liver injury with peritoneal fluid detected by ultrasound: 81.9% of patients were
found to have peritoneal fluid on 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

consider conservative treatment if they met hemodynamic conditions .