Symposium

Management of liver trauma in adults

Nasim Ahmed, Jerome J Vernick
Department of Surgery & Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center 1945 State Rt. 33 Neptune, US

ABSTRACT
The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and
enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative
management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture
ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage
control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of
the liver and use of atriocaval shunt are rarely indicated.

Key Words: Liver, injury, damage control surgery

INTRODUCTION with conservative management.[7,8] Though there is a broader

consensus regarding the nonoperative approach even in high-
The liver is one of the most frequently injured organs in grade injuries, however, some controversies still exist.[8-18]
abdominal trauma.[1,2] The anterior location in the abdominal
cavity and fragile parenchyma with easily disrupted Glissons This review discusses the diagnostic modality and therapeutic
capsule make this organ vulnerable to injury. approach to liver trauma.

There is a paradigm shift in the management of liver trauma CLASSIFICATION OF THE LIVER INJURIES
due to advancements of diagnostic and therapeutic modalities.
About a century ago, Pringle conducted an animal experiment, Liver injury is classified based on severity of the injury
occluding the porta hepatis in liver trauma while repairing the [Table1].[19]
injuries.[3] However, application of the same principle in trauma
victims led to high mortality.[4] Since 1965, the introduction
DIAGNOSIS
of diagnostic peritoneal lavage (DPL) has led to many
nontherapeutic laparotomies in previously unsuspected low-
Imaging studies are the main diagnostic modality of evaluation
grade injuries.[5] Operative intervention in high-grade injuries
of presence or absence of liver trauma.
may result in high mortality as well.[4,6] Introduction of computed
tomography (CT) scan, use of ultrasonography in trauma, Ultrasonography
availability of angiography, enhanced critical care monitoring Ultrasonography is a noninvasive procedure and highly operator-
and damage control surgery have revolutionized the management dependent. Focused assessment by ultrasound for trauma
of liver trauma. Numerous studies have shown better outcome (FAST) has been advocated in initial trauma evaluation.[20] The
purpose of this exam is to provide a quick bedside assessment
Address for correspondence: for hemoperitoneum and hemopericardium. A FAST exam
Dr. Nasim Ahmed, E-mail: nahmed@meridianhealth.com consists of sonographic evaluation of pericardium, right upper
quadrant, including Morrisons pouch, left upper quadrant
Access this article online
and the pelvis. This evaluation is not designed to identify the
Quick Response Code:
Website:
degree of organ injuries, but rather the presence of blood. The
www.onlinejets.org sensitivity and specificity of this examination are 63100%
and 95100%, respectively.[20-22] Negative FAST examination
DOI:
does not exclude intra-abdominal injuries or hemoperitonium.
10.4103/0974-2700.76846 Retroperitonial injuries and hollow viscus injuries can also be
missed by ultrasound evaluation.
114 Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011
 Ahmed and Vernick: Liver injury

Table 1: Grading of liver injury based on American Association of Surgery for trauma (AAST)[19]
Grade Type Injury description
I Hematoma Subcapsular, nonexpanding, <10 cm surface area
Laceration Capsular tear, nonbleeding, <1 cm parenchymal depth
II Hematoma Subcapsular, nonexpanding, 1050% surface area; intraparenchymal nonexpanding <10 cm diameter
Laceration Capsular tear, active bleeding, 13 cm parenchymal depth <10 cm in length
III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma >10 cm or expanding
Laceration >3 cm parenchymal depth
IV Hematoma Ruptured intraparenchymal hematoma with active bleeding
Laceration Parenchymal disruption involving 2575% of hepatic lobe or one to three Couinauds segments within a single lobe
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinauds segments within a single lobe
Vascular Juxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic veins)
VI Vascular Hepatic avulsion

Recent advancement of contrast-enhanced sonography century.[29] This procedure is very sensitive for hemoperitoneum.
improved the diagnostic accuracy in terms of conspicuity, size Positive DPL led to a rate of almost 30% non-therapeutic,
and completeness of the injury, as compared to non-contrast unnecessary laparotomies.[5,34] Widely available CT scans and the
sonography. It is also similar to CT scan in terms of identification introduction of FAST have generally replaced the invasive DPL.
of ongoing hemorrhage in the liver.[23] However, the Advanced Trauma Life Support course (ATLS)
still includes this modality and it remains one of the skills that
Computed tomography scan physicians need to learn for ATLS certification.
CT scan is the first imaging study which gives relatively detailed
delineation of solid organ injuries and retroperitoneal injuries as
MANAGEMENT
well. CT scan is the standard imaging study for hemodynamically
stable patients following blunt trauma.[24,25] Severity of injuries is
Management of liver injury has evolved in the last 25 years.
also graded based on CT scan examination.[19] Extravasation of
Advancement of imaging studies plays a key role in the
contrast demonstrated on CT scan (3540 HU) indicates active
conservative approach. In early 1970, more than 80% of the
bleeding from the injury site and further intervention is needed.[26,27]
liver injuries were managed operatively. In late 1990, 8090% of
The sensitivity and specificity of the CT scan for liver injuries these injuries were successfully managed by nonoperative means.
are 9297% and 98.7%, respectively.[28]
Nonoperative management
CT scan plays an integral role in the nonoperative management of Penetrating injury
liver injuries. Follow-up CT scan is recommended for high-grade Nonoperative management is now recommended for stab wound
injuries (grades IVV) in 710 days to determine the injury status as well as low-velocity gunshot wound to right upper quadrant in
and complications as well.[8,29] CT scan-guided percutaneous stable patients, if other injuries have been excluded which require
drainage may also be performed when complications such as laparotomy.[35,36] Most of the injuries which fall in this category
biloma and intra-abdominal collections occur. are grade I and grade II injuries.

Angiogram and angioembolization Blunt injury

Angiography plays a vital role in the conservative management In blunt liver trauma, nonoperative management is a standard of
of the liver injury. Extravasation of contrast seen on CT care in hemodynamically stable patients. It is not the grade of
scan requires emergency angiography and angioembolization the injury, but rather the hemodynamic parameters of the patient
in hemodynamically stable patients. Post-operative which dictate the conservative versus operative management
angioembolization is also reported in damage control surgery decision. The patients positive response to an initial fluid bolus or
prior to removal of packing, if rebleeding is suspected.[30,31] The maintenance of a stable hemodynamic state allows for a CT scan
sensitivity and specificity of angiogram identifying active bleeding of abdomen and pelvis. If extravasation is identified, angiogram
in liver injuries is 75% and the success rate of controlling the and angioembolization should be considered. Failures of these
hemorrhage is 6893%.[11,30,32] The multidisciplinary approach steps then mandate operative intervention.
to conservative management of high-grade liver injuries shows
better outcome with less blood transfusion, early recovery time The most common reasons for failure are advanced age, delayed
and less intensive care days. The mortality is low as well.[33] bleeding, hypotension and active extravasation of contrast not
controlled by angioembolization.[33,37-39]
Diagnostic peritoneal lavage
DPL was one of the most common modalities used in the There is an overall survival benefit and 23% reduction of
diagnostic evaluation for blunt abdominal trauma in the mid-20th mortality for conservative approach in blunt liver injury.[40-42]
Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011 115
Ahmed and Vernick: Liver injury

Operative management perform the Pringle maneuver (apply a noncrushing clamp

Penetrating injury through the foramen of Winslow).[3] The clamp can be safely
Recent literature supports operative intervention only in applied up to 1 hour.
hemodynamically unstable patients, usually as a result of a
high-velocity gunshot wound. Other indication for operative Operative approach for hepatic vein and/or
intervention is an associated hollow viscus injury.[43] retrohepatic caval injuries
If bleeding continues despite the Pringle maneuver, then
Trunkey has described the operative procedure for unstable retrohepatic, caval or hepatic vein injury should be suspected.
gunshot wounds to the liver.[29] If the patient is unstable or
deteriorating in the emergency room, patients should be taken The preferred method for caval and hepatic vein injury is total
to the operating room within 15 minutes. Activation of massive vascular isolation.[47] The procedure consists of performing a
blood transfusion protocol, four quadrant packing, direct Pringle maneuver, and clamping of the inferior vena cava above
compression and rapid control of fecal contamination are and below the injury. Superiorly, the inferior vena cava can be
the initial steps. Debridement, ligation of the bleeding vessel, isolated just below the diaphragm or through the pericardium by
lobectomy and repair of venous injury under total vascular extending the incision to a median sternotomy and inferiorly, just
isolation are the best strategies with good outcome. If the triad of above the renal veins. This approach allows direct repair of the
coagulopathy, acidosis and hypothermia are encountered during vascular injury. Aortic clamping is not recommended for the vena
this phase of the repair, perihepatic packing and temporary caval or hepatic vein injury.[29] The vascular isolation technique has
closure of the abdominal incision with transfer to intensive care reported a better survival rate compared to atriocaval shunt.[47,52]
unit (ICU) should be the priority. The patient should be taken Anatomical lobectomy is rarely performed; however, in the hands
back to operating room as soon as the metabolic derangement of an expert, the outcome is very good.[53,54]
is corrected and rewarming has occurred.
During the operative repair, if the patient develops coagulopathy,
Blunt injury acidosis, or hypothermia, damage control surgery should be
The main indication of the operative approach to the blunt liver considered.
injury is hemodynamic instability, not the grading of the injury.
Although a higher grade injury has higher potential for failure of Damage control surgery
nonoperative management, hemodynamic instability remains the Damage control surgery includes perihepatic packing and
most important branch of the decision tree indicating operative closure of the abdominal incision either using a Bogata bag
intervention. or partial closure of proximal abdominal incision. Kreig et al.
recommend six folded laparatomy pads to be placed between
Rebleeding, constant decline of hemoglobin and increased the liver and the abdominal wall to obtain tamponade.[44] The
transfusion requirement, as well as the failure of angioembolization patient should be transferred to the ICU as soon as possible for
of actively bleeding vessels are a few factors which indicate the continued resuscitation and warming. As soon as the metabolic
need for laparotomy.[33,37-39] derangement is corrected, the patient should be taken back to
operating room for re-exploration. The timing of re-exploration
The operative approach has also evolved over the last two depends upon the correction of acidosis, coagulopathy and
decades. Direct suture ligation of the parenchymal bleeding hypothermia. Usually, 1224 hours is the safe period for re-
vessel, perihepatic packing, repair of venous injury under total exploration and formal completion of the surgery.
vascular isolation and damage control surgery with utilization
of preoperative and/or postoperative angioembolization are the Role of hemostatic agents in liver trauma
preferred methods, compared to anatomical resection of the liver A number of commercial hemostatic agents are readily available
and use of the atriocaval shunt.[9,44-51] and can be used as an adjunct after repair of liver injuries. The
most commonly used agents are gelatin gelfoams, oxidized
Operative procedure for liver injuries cellulose, microfibrillar collagen, thrombin, thrombin with gelatin
The first and the most important step in operative management (floseal) and fibrin sealant (tisseel).[55]
of blunt liver injury is to pack all four quadrants with laparotomy
pads and manually compress the liver using both hands for Application of extracorporeal circulation in the
1520 minutes. This allows the anesthesiologist to catch up massive liver and/or retrohepatic caval injury
with the resuscitation. Then remove the lower quadrant packing The use of extracorporeal circulation devices during the repair
first, followed by left upper quadrant and finally right upper of the juxtahepatic caval injuries has been noted in the past with
quadrant. If the spleen is actively bleeding, splenectomy should variable success. The concept behind this device is to bypass the
be performed. Assess the liver laceration and identify the bleeding flow from the injured area using an extracorporeal circuit, with
vessel. Direct suture ligation should be performed using 3-0 or or without an active pump. Therefore, repair can be performed
4-0 absorbable suture. A patch of omentum can be used to fill in a bloodless field. These devices increase the complexity of the
the gap created by the laceration. If bleeding continues, then operation, and the physician must be familiar with the technique
116 Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011
 Ahmed and Vernick: Liver injury

and concept as well. Successful use of venovenous bypass CONCLUSION

following clamping of the inferior vena cava during anhepatic
phase of liver transplant provided the idea in the management Management of liver injury has evolved over the last two decades.
of retrohepatic caval injuries.[56] This technique allows blood to Hemodynamic status, not the grade of the injury, should dictate
be diverted from the inferior vena cava, with or without portal the management. CT scan of the abdomen and pelvis is a
vein decompression, and drain it into the right atrium either standard diagnostic modality in hemodynamically stable patients.
directly or through internal jugular vein or superior vena cava.[57-60] Extravasation of contrast during CT scans requires further
intervention. Unstable patients should mandate emergency
Liver transplantation in massive liver and hepatic laparotomy. Direct control of bleeding vessels, vascular isolation
venous and retrohepatic caval injury and damage control surgery are preferred and the most popular
Orthotopic liver transplantation has been reported as an extreme approaches compare to anatomical resection of liver and the use
measure in massive hepatic venous and retrohepatic caval of an aortocaval shunt.
injuries.[61-65] Since the mortality rate associated with these injuries
is extremely high and there is a shortage of organs available for
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Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011 119
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