C u r re n t M a n a g e m e n t

o f H e p a t i c Tr a u m a
a b,
Greta L. Piper, MD , Andrew B. Peitzman, MD *

KEYWORDS
 Hepatic trauma  Liver resection  Trauma  Liver injury
 Operative techniques

The liver is the most commonly injured abdominal organ. With the sweeping shift
toward nonoperative management, most hepatic injuries are successfully
observed.1–9 In addition, the mortality from hepatic injury has declined over the past
several decades. Richardson and colleagues8 proposed that the major reasons for
the decrease in mortality for hepatic trauma over the past 25 years are: improved
results with packing and reoperation, use of arteriography and embolization,
advances in operative techniques for major hepatic injuries, and decrease in the
number of hepatic venous injuries undergoing surgery. Patients with blunt hepatic
injury tend to present either hemodynamically stable and can be observed, or hemo-
dynamically unstable, requiring urgent laparotomy to control hemorrhage from a major
hepatic injury. Because most injuries to the liver are minor (grade I or II), most blunt
hepatic injuries can be safely observed (Table 1).10 On the other hand, as many as
two-thirds of higher-grade hepatic injuries (grades III, IV, V) may require laparotomy
for control of hemorrhage.2–4,7,11,12 Even at busy trauma centers, high-grade hepatic
injuries, particularly juxtahepatic venous injuries, are uncommon. Thus, operations
required for liver injury can be challenging in decision making and operative technique.

MECHANISM OF INJURY AND ANATOMIC CONSIDERATIONS

The liver is suspended by superior attachments to the diaphragm, and anterior attach-
ments of the coronary ligaments, triangular ligaments, and the falciform ligament. It is
also attached to the lesser curve of the stomach.13 Deceleration injuries result in tears
at these sites of fixation. A common deceleration injury creates a fracture between the
posterior segments and the anterior segments of the right lobe. A crushing mechanism
or a focused blunt injury to the right upper quadrant compresses the ribs into the liver
causing a stellate-type laceration across the dome and anterior surface of the right
lobe, often termed a ‘‘bear-claw injury.’’ Anterior-posterior forces can produce

a
Department of Surgery, University of Pittsburgh, F-1265, UPMC-Presbyterian, Pittsburgh, PA
15213, USA
b
Department of Surgery, University of Pittsburgh, F-1281, UPMC-Presbyterian, Pittsburgh, PA
15213, USA
* Corresponding author.
E-mail address: [email protected]

Surg Clin N Am 90 (2010) 775–785

doi:10.1016/j.suc.2010.04.009 surgical.theclinics.com
0039-6109/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.

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776 Piper & Peitzman

Table 1
Liver organ injury scale

Grade Description
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth
II Hematoma Subcapsular, 10%–50% surface area; intraparenchymal, <10 cm in
diameter
Laceration 1–3 cm parenchymal depth, <10 cm in length
III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or
parenchymal hematoma
Laceration >3 cm parenchymal depth
IV Hematoma Parenchymal disruption involving 25%–75% of hepatic lobe or 1–3
Couinaud segments within a single lobe
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud
segments within a single lobe
Vascular Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major
hepatic vein
VI Hepatic avulsion

Data from Moore EE, Shackford SR, Pachter HL. Organ injury scaling: spleen, liver and kidney. J
Trauma 1995;38:323–4.

a split-liver, often through the line of Cantlie. In general, blunt trauma more commonly
affects the right hepatic lobe.

INITIAL PRESENTATION AND ASSESSMENT

Patients with abdominal trauma who are unstable at presentation or become unstable
in the trauma bay despite resuscitative efforts should be taken immediately to the
operating room for laparotomy. In contrast, the stable patient should undergo a rapid
physical examination and portable chest radiography. Although outward signs of
injury are nonspecific and the absence of such findings do not exclude injury, seatbelt
signs or other marks, regions of tenderness, and obvious penetrating wounds must be
noted. Patients with a seatbelt sign have a 3.1-fold higher incidence of liver injury than
those patients presenting without a seatbelt sign.14 Right-sided rib fractures or pulmo-
nary contusion should also raise suspicion for hepatic injury.
The focused assessment by ultrasound for trauma (FAST) has become a routine
diagnostic tool in the trauma bay. The hemodynamically unstable patient with a posi-
tive FAST is transported immediately to the operating room for laparotomy.
Diagnostic peritoneal lavage (DPL) is a sensitive but nonspecific study that can be
performed rapidly in the trauma bay or in the operating room. An unstable patient who
has sustained blunt abdominal trauma belongs in the operating room. However, in the
patient with blunt injury with another reason for hypotension, pelvic fracture, or a signif-
icant extremity fracture, DPL can accurately identify significant intraabdominal
injuries.15 DPL has 98.5% accuracy for detection of hemoperitoneum.16
Computerized tomography (CT) is the standard diagnostic modality for stable
trauma patients with a suspected abdominal injury. CT has a sensitivity of 92% to
97% and a specificity of 98.7% for detection of liver injury.1 The type and grade of liver
injury, the volume of hemoperitoneum, and differentiation between clotted blood and
active bleeding can be identified. CT scan also allows diagnosis of associated intra-
peritoneal and retroperitoneal injuries, including splenic, renal, bowel, and chest
trauma, and pelvic fractures.

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 Liver Resection for Trauma 777

NONOPERATIVE MANAGEMENT

The current approach to hepatic trauma has evolved to nonoperative management in

more than 80% of cases.2 Several contributing factors have been recognized: (1) real-
ization that more than 50% of liver injuries stop bleeding spontaneously, (2) the prece-
dent of successful nonoperative management in pediatric patients, (3) knowledge that
the liver has tremendous capacity to heal after injury, and (4) improvements in liver
imaging with CT.3
Criteria for nonoperative management include foremost, hemodynamic stability,
absence of other abdominal injuries that require laparotomy, immediate availability
of resources including a fully staffed operating room, and a vigilant surgeon. In
general, any patient who is stable enough to have a CT scan performed is likely to
be successfully managed nonoperatively.1,2 Grade I and II hepatic injuries should be
observed in a monitored setting with serial hematocrit evaluations and bed rest.
Higher-grade injuries in stable patients should be observed in an intensive care unit
setting with optimization of all coagulation factors.
The current reported success rate of nonoperative management of hepatic trauma
ranges from 82% to 100%. Twenty-five percent of patients with blunt hepatic injury
managed nonoperatively, 92% of whom have grade IV or V injury, will require an inter-
vention for complications.6,7 Interventional radiology may be needed to perform an
angiogram and embolization for bleeding or to percutaneously drain an abscess or
biloma. An endoscopic retrograde cholangiopancreatogram (ERCP) and stent place-
ment may be required for biliary leak. Even when such complications of the liver injury
develop, only 15% require operative intervention. Hepatic artery angiography with
embolization is an important tool for the stable patient with contrast extravasation
who is being managed nonoperatively. It can also be invaluable for the postoperative
patient who has been stabilized by perihepatic packing or who has rebled after an
initial period of stability. Angioembolization has a greater than 90% success rate in
the control of bleeding with a low risk of rebleeding and a reduction in required volume
of transfusion.6,17–20
Bile leaks are a frequent complication in the nonoperative management of liver
injuries, occurring in 6% to 20% of cases. Biliary complications are variable in their
time of presentation and may require multiple treatment strategies (Fig. 1). Ultrasound
and CT scan are used to diagnose a biloma, whereas a hepatobiliary iminodiacetic
acid scan is used to show an active bile leak. Most collections can be managed by
simple ultrasound- or CT-guided percutaneous drainage. Carillo and colleagues6
determined that one-third of patients diagnosed with a biloma required ERCP and
stent placement in addition to radiologic drainage to manage the bile leak.
A less common complication is hemobilia, caused by an abnormal communication
between an intrahepatic blood vessel, usually an artery, and the biliary tree. The inci-
dence after trauma is less than 3% and is more often associated with blunt trauma
than with penetrating injuries. Hemobilia presents as gastrointestinal bleeding with
or without abdominal pain and jaundice caused by bile ducts occluded by blood clots.
It has been reported immediately after the initial trauma or up to 4 months later,21 and
Croce and colleagues22 noted that 80% of patients with hemobilia also had bile leaks
detected on hepatobiliary scans. Angiography permits precise identification and
selective embolization of the appropriate branch vessel as opposed to the surgical
alternative of ligation of a main hepatic artery or hepatic resection, thereby preserving
more functional hepatic parenchyma.21
Reported predictors of failure of nonoperative management include hypotension on
admission, high CT grades of injury, and the need for blood transfusion. Fang and

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778 Piper & Peitzman

Fig. 1. MRI of a 23-year-old woman sent to us 4 years after injury to her liver from a motor
vehicle crash. At the outside facility, she had multiple stents placed across the injury to her
left hepatic duct and repeated bouts of cholangitis. The study shows a stricture in the left
hepatic duct with associated dilatation. A left lobectomy was performed for her atrophic
left lobe.

colleagues23 regard hemodynamically stable patients with intraperitoneal contrast

extravasation and hemoperitoneum in 6 compartments on CT at high risk for the
need of operation after blunt hepatic trauma. The risk for failure of nonoperative
management approaches 96% in the presence of (1) a splenic or renal injury with
a positive FAST result, (2) an estimated amount of free fluid on CT of greater than
300 mL, and (3) the requirement for blood transfusion. If all of these factors are absent,
the risk for nonoperative management failure is only 2%.5

OPERATIVE MANAGEMENT

Operations for liver injury are necessary in the setting of complex hepatic injury and
generally indicated for hypotension and significant bleeding; these operations are
often challenging. In part, because of this difficulty, paradigm shifts have occurred
in our operative approach to hepatic trauma. Madding and Kennedy24 wrote that
before World War II, ‘‘house surgeons advocated expectant or conservative treat-
ment, or no treatment at all for the majority of wounds of the liver.’’ During World
War II, drainage of liver injuries and abandonment of the use of gauze packs
decreased mortality from 30% to 17%. Temporary packing and damage control
with the goals to control bleeding and gastrointestinal contamination with an abbrevi-
ated laparotomy have made a resurgence and are invaluable when appropriately
used.25–28 It is critical that surgical bleeding is controlled before truncating any oper-
ation on the liver. Damage control with packing is appropriate only for medical
bleeding (coagulopathy, acidosis, hypothermia).
Anesthesia must ensure that blood products are already in the room. The massive
transfusion protocol should be activated so that the blood bank is always ahead of the
patient’s needs for packed red blood cells, fresh frozen plasma, platelets, and cryo-
precipitate. Adequate vascular access and arterial blood pressure monitoring are

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 Liver Resection for Trauma 779

essential. It is important to preferentially have venous access above the diaphragm.

Resuscitation fluids infused under pressure through femoral access will exacerbate
hepatic venous bleeding, at times dramatically so. Massive transfusion protocols
should be activated early to prevent any delay in resuscitation with blood products.
As with every trauma laparotomy, the patient should be widely prepped, chin to
knees and table to table laterally. A generous midline incision is made. For injuries
to the right lobe or right hepatic vein, a transverse incision branched to the right off
the midline incisions is essential.29 Although others have reported use of sternotomy
or thoracotomy for exposure of hepatic injury, we have found these are rarely needed.
Self-retaining retractors are essential. The most easily and quickly used retractor in the
patient exsanguinating from a liver injury is the Rochard retractor. In a less critically ill
patient, many self-retaining retractors will work. Exposure is needed in a cephalad
direction, but equally importantly, lifting the ribcage anteriorly.
The 4 quadrants are quickly packed with lap pads. This allows anesthesia to achieve
effective intraoperative resuscitation. The lower quadrants are unpacked first, the
bowel is quickly examined, and contamination is quickly temporized. The left upper
quadrant is evaluated next. If an injury to the spleen is noted, it is removed. The right
upper quadrant packs can then be removed to allow evaluation of the liver injury.
If significant liver bleeding is seen, initial methods to temporize the hemorrhage can
also be diagnostic. The liver should first be manually closed and compressed. How
this is conceptualized and performed is important. Packs placed in an anterior-
posterior axis will often distract the injured liver further and worsen the bleeding.
The lobes of the liver must be compressed back to normal position, essentially
back toward midline. Simultaneously, the liver is pushed toward the diaphragm. Main-
tenance of this anatomic compression by the first or second assistant is critical to
reduce bleeding as the surgeon assesses the liver injury or mobilizes the liver. Perihe-
patic packing can help to maintain this tamponade. Most minor venous bleeding and
small lacerations to the parenchyma can be temporized by this maneuver. Hemostatic
agents such as surgicell, thrombin-soaked gel foam, or fibrin glue are useful adjuncts.
The argon beam coagulator is also an effective means of hemostasis in this case.
Omentum can be placed over the liver defect as a more permanent packing method.
If these simple maneuvers are effective, the operation should be truncated and the
patient taken to the intensive care unit for further resuscitation (Box 1).
In an unstable patient, delay to control of hemorrhage will negatively affect
outcome. As an independent predictor of outcome, the mortality doubles (25%–
50%) as the patient’s transfusion requirement increases from 10 to 20 units of packed
red blood cells acutely. Ideally, the bleeding should be staunched as early as possible
within this time frame. Avoidance of hypothermia, acidosis, and coagulopathy is best
accomplished by early control of hemorrhage. Once the decision has been made to
operate on an unstable patient with a known or suspected liver injury, the procedure
of choice is often damage-control laparotomy.30 The goals of a damage-control

Box 1
Goals in the operating room

Control hemorrhage
Control bile leak
Debride/resect devitalized liver
Drainage

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780 Piper & Peitzman

laparotomy are twofold: to control hemorrhage and to control contamination. Perihe-

patic packing will control bleeding in up to 80% of patients undergoing laparotomy
and allow for transfer to the intensive care unit for resuscitation and warming. Folded
laparotomy packs are inserted over the diaphragmatic surfaces of the liver, never
within a laceration, to promote a tamponade effect. Underpacking or inappropriate
packing lead to worsened patient outcomes.28 Excessive packing can also be detri-
mental, leading to renal vein and vena caval compression and subsequent abdominal
compartment syndrome.
If hemorrhage continues in the operating room, the Pringle maneuver should be
applied with placement of an atraumatic vascular clamp across the porta hepatis. If
this controls the bleeding, an injury to a branch of the portal vein or hepatic artery is
the likely source. A major injury to the hepatic veins or vena cava is less likely.
However, when the Pringle maneuver fails to control bleeding from within a liver injury
or dark venous bleeding persists from behind a hepatic lobe, a juxtahepatic venous
injury is likely. If simple sutures and compression are performed and bleeding is still
profuse, experienced judgment is crucial to decide whether to proceed with further
exploration and attempted repair or perihepatic packing (Box 2).
Once the decision is made to perform a major operation, adequate exposure of the
liver is essential. Injury high in the dome of the liver will likely require mobilization of the
right lobe. The falciform and triangular ligaments are taken down with simultaneous
compression of the liver. If the midline incision has not been extended to a subcostal
incision, it can be extended at this time.
Hepatotomy and selective vascular ligation is one technique for management of
major hepatic venous, portal venous, and arterial injuries. With Pringle control, the
injured portion of the liver is further fractured with the surgeon’s finger or with a Kelly
clamp or the stapling devices to allow direct ligation of the bleeding vessels. This must
be done, and should be done early and expediently in the operation. The finger frac-
ture technique has been well described by Pachter and colleagues.4 We commonly
use the stapling devices to perform this hepatotomy. Intermittent release of the Pringle
clamp with effective suction may allow identification of deep bleeding sites and control
by direct suture.4,11,25
Nonanatomical resection refers to removal of injured parenchyma along the line of
the injury rather than along a standard anatomic plane. In many cases, this involves the
completion of an already extensive avulsion injury. Vascular stapling devices are the
most rapid means of dividing tissue and controlling major veins. As with elective
hepatic surgery, the stapling devices have been a major advance in the treatment of
hepatic trauma. A case is presented to make this important point (Fig. 2A, B). A
20-year-old woman is involved in a motor vehicle crash. She is hypotensive and

Box 2
Major hepatic injury: critical decisions for the surgeon

 Do not be in the operating room unless clearly indicated.

 In hemodynamically unstable patients, do only what is essential to stop bleeding at the first
operation. If simple maneuvers work, pack and truncate the operation (damage control).
 If major resection is required, the decision must be made early in the operation.
 Once you are committed to a major resection, technical/clinical expertise and speed are
critical.
 Plan delayed resection in selected patients.

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 Liver Resection for Trauma 781

Fig. 2. (A) A nonanatomic right lobectomy was performed rapidly using the stapling device.
The right lobe has essentially imploded with all vascular structures bleeding through the 3-
cm laceration high on the dome of the liver. Once the right lobe was resected, bleeding sites
were controlled with sutures or the GIA. (B) CT scan on postoperative day 1 showing the
nonanatomic right lobectomy and the packed abdomen following the damage-control
laparotomy.

collapses at the scene. She is intubated, lines are placed, intravenous fluids including
blood are started during her helicopter flight. Despite this, she arrives in the trauma
resuscitation area with a systolic blood pressure of 68 mm Hg and heart rate of 100
beats/min. Her chest radiograph is normal and her FAST is positive for hemoperito-
neum. She leaves the Emergency Department for the operating room within 7 minutes.
At laparotomy, she has 1 L of hemoperitoneum. Her abdomen is quickly packed with
temporary control of bleeding. She has no visible abdominal injury on first look.
However, on palpation, she has a 3-cm cruciate hole high on the dome of the right
lobe of her liver, which we can feel but cannot visualize. She bleeds twice through
packing. What do we do at this point? We quickly mobilized the right lobe of the liver
and used the GIA stapling device to perform a nonanatomic right lobectomy within
minutes. We could then clearly see that her right lobe had imploded and she was
exsanguinating from all structures within the right lobe (see Fig. 2A). With the liver
bisected and exposure provided, we then sutured or stapled all vascular and biliary
structures. We packed her abdomen, closed it definitively in 2 days, and she was dis-
charged home 14 days after injury (see Fig. 2B).
Anatomic resection involves removal of injured liver segments along standard
anatomic places.13,31,32 Hepatic resection for an injured segment of the liver defini-
tively controls bleeding, potential bile leak, and removes devitalized tissue. However,
the role of hepatic resection in the management of liver injury remains controversial.
Trunkey stated in 2004, ‘‘there is a disturbing trend in the literature for too many liver
injuries to be managed nonoperatively or without debridement or resection. This has
led to increased morbidity.’’7 This is corroborated by a report from Menegaux and
colleagues,9 evaluating the impact of a protocol that emphasized a conservative
approach, with less frequent use of resection, whether anatomic or nonanatomic.
The perioperative mortality increased from 24% to 34% with the less aggressive oper-
ative approach. The frequency of liver resection is 2% to 5% in most series, including
our own from 2008.2,4,8
The mortality for liver resection was 80% in 1900.7 With advances in operative tech-
nique, McClelland and Shires33 reported in 1965 that 10% of 259 patients were treated
by liver resection, with 20% mortality. Twenty years ago, Cogbill and colleagues34 and
Beal11 reported greater than 50% mortality for liver resection for trauma, with an oper-
ative mortality of 46% for grade IV injury and 80% for grade V injury. As recently as

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782 Piper & Peitzman

2004, Duane and colleagues35 reported an operative mortality of 66% for trauma
patients undergoing laparotomy for grade IV and V liver injury; 59% of these were
from uncontrolled bleeding. As outlined in the articles in this issue, our understanding
of liver anatomy, technologic advances (diagnostic and operative), have made hepatic
resection routine and safe in many centers. Strong and colleagues36 reported a liver-
related mortality of 8% and hepatic complication rate of 19% following liver resection
for trauma. Tsugawa and colleagues37 reported on 100 patients undergoing liver
resection for trauma, 20% of the liver injuries in their series, which is unusually high.
After resection, liver-related mortality was 24% and morbidity was 25%.
We recently reported a 15-year series of 1049 adults with liver injury from the Univer-
sity of Pittsburgh.2 Two hundred and sixteen of these patients had complex hepatic
injury (grades III, IV, V). Two-thirds of these high-grade liver injuries underwent surgery;
33% were managed nonoperatively. Fifty-six of this series underwent liver resection;
25% of the patients required surgery for these complex liver injuries. In this group
undergoing liver resection, the mechanism of injury was blunt in 62.5% and pene-
trating in 37.5%. The average injury severity score was 34  11, indicating the severity
of their injuries. The mean systolic blood pressure on presentation was 95  38 mm
Hg. Most of these patients had multiple abdominal injuries requiring operative repair.
Sixteen of the 56 (29%) had concomitant hepatic venous injury. The median transfu-
sion requirement in the first 24 hours for the patients undergoing liver resection was 14
units of packed red blood cells (range 7–211 units). The resections included 21 seg-
mentectomies, 8 right lobectomies, 3 left lobectomies, 23 nonanatomic resections,
and 1 total hepatectomy with liver transplantation. It is not essential to perform liver
resection at the first laparotomy, if bleeding has been effectively controlled. Planned
delayed reoperation for resection was applied in 16% of our patients. Seven patients
underwent reoperation for planned removal of liver packing, 3 for bleeding and 2
patients for major bile leak. Morbidity related to liver resection was 30%. The mortality
related to liver resection was 9%; overall mortality was 17.8%.
The mortality for grade IV and V hepatic injuries, which generally comprise only 15%
of liver injuries, is greater than 50% in most series.2,4,12,34,35,38 As a rule, these patients
are hypotensive on presentation and require urgent laparotomy. The corollary is that
most blunt hepatic injuries requiring surgery are hemodynamically unstable patients,
with grade IV or V injury, a third of whom have an associated hepatic vascular injury.2
Exsanguination is the cause of death, usually on the operating room table. Grade V
hepatic injury has 2 subtypes, which are very different in anatomy and outcome. A
grade V laceration is parenchymal disruption involving more than 75% of the hepatic
lobe or more than 3 Couinaud segments within a single lobe. The patients may be
hemodynamically stable and some will do well with nonoperative management. A
grade V vascular injury is a juxtahepatic venous injury (retrohepatic inferior vena
cava [IVC]/central major hepatic veins). These patients are exsanguinating and require
urgent operation in 92% of cases. These hepatic venous and retrohepatic injuries are
technically difficult to manage in the operating room and carry 50% to 80% mortality in
most series, particularly when from blunt injury.4,38,39 Presumably, high-grade liver
injury from a blunt mechanism produces more severe parenchymal disruption than
penetrating injury from low-velocity civilian weapons.2,12,38–40
In an interesting paper in 2000, Buckman discussed 2 types of juxtahepatic injury.
Most juxtahepatic venous injuries involve an intraparenchymal laceration of a hepatic
vein with associated parenchymal injury (type A juxtahepatic venous injury).38 Type A
venous injuries bleed through the injury in the liver. Reinforcement and restoration of
torn containment around a type A juxtahepatic venous injury, either by packing or
suturing, is generally effective. This approach is also safer and easier than direct

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 Liver Resection for Trauma 783

exposure and vascular control. Several authors have reported intrahepatic vascular
clamping with these type A injuries, leaving the clamps in situ, and packing the
abdomen.41 We have not found this approach to be necessary. Type B juxtahepatic
venous injury is avulsion of the extrahepatic portion of the hepatic vein with uncon-
tained hemorrhage around the liver. Type B injuries require direct exposure and
control. Applying these principles for the 2 types of hepatic venous injury, mortality
for these grade V injuries was 25% in a recent series from our institution.2
Approach to these injuries may require total vascular isolation of the liver by clamp-
ing the suprahepatic IVC, the suprarenal IVC, and the porta hepatis.32 The liver can
then be fully mobilized allowing exposure of the venous injuries followed by primary
repair or ligation. Rapid control of the suprahepatic IVC can be obtained by incising
the peritoneum between the esophagus and IVC at the diaphragm, follow the plane
between the crura and the esophagus to the patient’s left, and caudate lobe/IVC on
the patient’s right. The plane can be followed with your index finger around and
then encircling the suprahepatic IVC. Another technique for rapid control of the supra-
hepatic IVC is incision in the central diaphragm/pericardium and a vascular clamp
placed on the intrapericardial IVC. We do not advocate venovenous bypass or the
atriocaval shunt in the management of these injuries. Adequate exposure through
sufficient incisions (broad subcostal or midline with right subcostal extension), self-
retaining retractors, and help experienced in hepatic surgery are necessary and suffi-
cient. Assistance from an experienced liver or liver transplant surgeon is invaluable in
these cases.
If the decision is made to truncate the operation after initial damage control, the
abdomen is temporarily closed with a rapid skin-only closure or a negative-pressure
vacuum-assisted closure dressing, and the patient is transferred to the intensive
care unit. Aggressive resuscitation and warming is required to correct coagulopathy.
On the other hand, maintenance of a low central venous pressure may minimize
hepatic bleeding and swelling. Once the patient has been stabilized, reexploration
and possible definitive repair in the operating room must be planned. Suggested
end points of resuscitation include a systemic lactate concentration less than 2.5
mmol/L, base deficit less than 4 mmol/L, core temperature greater than 35 C and
an internationalized normalized ratio of less than 1.25.22 Optimal timing for pack
removal is controversial. Caruso and colleagues26 showed that rebleeding from the
liver was significantly increased when packs were removed within 36 hours rather
than waiting until after 36 hours. In addition to rebleeding, packing for liver trauma
has also been associated with increased rates of abdominal sepsis and bile leaks.
Nicol and colleagues.27 demonstrated that the duration of packing is not associated
with these complications and that a second-look laparotomy should only be per-
formed after 48 hours. We generally return these patients to the operating room for
pack removal 48 hours after damage-control laparotomy.

SUMMARY

A multidisciplinary approach to the management of hepatic injuries has evolved over

the last few decades, but the basic principles of trauma continue to be observed.
Diagnostic and therapeutic endeavors are chosen based mainly on the stability of
the patient. Stable patients with reliable examinations and available resources can
be managed nonoperatively. Unstable patients belong in the operating room and
should never be taken to the CT scanner. Once in the operating room, simple maneu-
vers are attempted first followed by an early decision to proceed with resection if
necessary. More experienced liver surgeons are invaluable resources when they are

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784 Piper & Peitzman

available. Interventional radiological techniques can prevent and treat complications

of nonoperative and operative management of liver injuries. Successful management
of patients with complex liver trauma depends on aggressive correction of hypo-
thermia, coagulopathy, and acidosis, and rapid critical decision making and experi-
enced judgment. Liver resection, either anatomic or nonanatomic, should be used
in appropriate patients with complex liver injury (25% in our series), and can be
accomplished with low morbidity and mortality. The stapling devices and clear under-
standing of hepatic anatomy facilitate operative management.

REFERENCES

1. Hoff WS, Holevar M, Nagy KK, et al. Practice management guidelines for the
evaluation of blunt abdominal trauma: the EAST practice management guidelines
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