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Surgical techniques for managing hepatic injury

Surgical techniques for managing hepatic injury
Literature review current through: Jan 2024.
This topic last updated: Feb 24, 2022.

INTRODUCTION — The liver is the most frequently injured abdominal organ. Most hepatic injuries are minor and heal spontaneously with nonoperative management, which consists of observation and the adjunctive use of arteriography and embolization. However, approximately 14 percent of patients with hepatic injury will require surgical intervention [1-4].

When surgery is needed, a systematic approach is used to control bleeding while conserving liver parenchyma; hepatic resection is reserved for severe injuries. The use of damage control techniques during the initial laparotomy, specifically perihepatic packing, reduces the extent of subsequent surgical procedures.

The surgical management of hepatic injury will be reviewed here. The diagnosis and nonoperative management of hepatic injury is discussed in detail elsewhere. (See "Management of hepatic trauma in adults".)

LIVER ANATOMY — The liver is divided into two lobar segments (right and left) and further subdivided into eight segments based upon the vascular or bile duct distribution (figure 1). Access to these segments can only be achieved through complete mobilization of the organ by incising its various ligamentous attachments (coronary ligament, left and right triangular ligaments) (figure 2).

The liver has a dual blood supply from the portal vein and the hepatic arteries (figure 2). The portal vein, which is a confluence of the splenic and superior mesenteric veins, supplies approximately 80 percent of the blood to the liver, while the remainder of the blood is supplied by the hepatic arteries.

Injury grading — The severity of liver injury (grade I through V) is determined by the nature (hematoma, laceration), depth, and extent of liver injury (number of involved liver segments) based upon the American Association for the Surgery of Trauma (AAST) injury grading scale. Increasing grades of hepatic injury correlate to increasing rates of morbidity and mortality. The grading scheme is presented elsewhere. (See "Management of hepatic trauma in adults", section on 'Hepatic injury grading'.)

APPROACH TO SURGICAL MANAGEMENT — The operative management of liver injuries can be a challenge even for experienced surgeons due to the complex nature of the liver, its size, vascularity, dual blood supply, and difficult-to-access venous drainage. The goal of surgery is to control hemorrhage from the liver, which may require simple or more complicated surgical techniques depending upon the extent of injury [5,6]. (See 'Liver anatomy' above.)

Operative management of liver injuries generally occurs under one of two circumstances. The diagnosis (and perhaps the severity) of the injury may have been established prior to undertaking laparotomy, or the surgeon discovers the injury at trauma laparotomy undertaken for shock, peritonitis, or penetrating injury. Regardless of how the diagnosis has been established, the American Association for the Surgery of Trauma (AAST) grade of injury plays a minor role in surgical decision making with respect to the liver injury.

A thorough exploratory laparotomy should always be performed whenever liver injury requires surgical intervention. Damage control principles are followed, controlling hemorrhage first and then controlling any gastrointestinal contamination. Damage control allows time for the anesthesia staff to resuscitate the patient. Definitive management of the liver injury can be performed immediately in hemodynamically stable patients, or in a delayed manner following stabilization of injuries and subsequent resuscitation in the intensive care unit (algorithm 1). Occasionally, arteriography with embolization may be used adjunctively for controlling hemorrhage preoperatively or postoperatively. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Management of hepatic trauma in adults", section on 'Hepatic embolization'.)

Superficial liver lacerations may respond to conservative techniques such as compression, topical hemostatic agents, electrosurgical techniques, or packing. Deep lacerations, large open tract lacerations, and larger parenchymal avulsions will typically require direct ligation or clipping of bleeding vessels (figure 3), augmented with suture plication and liver packing, as needed. When bleeding is apparent from within a deep missile tract through the liver, and the overlying liver substance is intact, a balloon tamponade technique can be used (figure 4) [7]. (See 'Techniques for liver hemostasis' below.)

Severe injuries require more aggressive means for controlling bleeding, including hepatic artery ligation and resectional debridement, followed by suture approximation of the raw edges of the liver or temporary liver packing, with or without topical hemostatic agents. (See 'Severe injury' below.)

Once the liver injury and other intra-abdominal injuries have been managed, drains are placed, as needed, and the abdomen is closed, or allowed to remain open depending upon the risk for abdominal compartment syndrome or the need for further operative procedures in the abdomen. (See 'Other considerations' below.)

LIVER EXPOSURE AND MOBILIZATION — A midline laparotomy with extension of the incision 1 to 2 cm superior to the xiphoid process provides sufficient exposure to manage most liver injuries. Extension of the incision superiorly in conjunction with a median sternotomy along the eighth interspace for a thoracoabdominal approach, or subcostally (right or bilateral [chevron]), is occasionally needed to increase exposure [8]. (See "Incisions for open abdominal surgery", section on 'Midline incision' and "Incisions for open abdominal surgery", section on 'Thoracoabdominal' and "Incisions for open abdominal surgery", section on 'Subcostal'.)

A self-retaining retractor significantly aids exposure, reduces surgeon fatigue, and avoids overcrowding around the operating table. For trauma surgery, we use a retractor that has is easy and quick to set up (eg, Bookwalter), which should provide ample exposure (figure 5).

The liver is quickly and completely mobilized by ligation and division of the falciform ligament and incision of the triangular and coronary ligaments while taking care to avoid injury to the hepatic veins posteriorly (figure 2).

Hemoperitoneum is evacuated from the abdomen and, whenever possible, returned to the patient using an autotransfusion device. Certain topical hemostatic agents are avoided when using intraoperative blood salvage. (See "Surgical blood conservation: Intraoperative blood salvage", section on 'Contraindications'.)

TECHNIQUES FOR LIVER HEMOSTASIS — Control of bleeding is the first priority in managing liver injury. After rapid evacuation of hemoperitoneum, laparotomy pads are placed systematically into all four quadrants of the abdomen, along the pericolic gutters, and into the pelvis. These packs are then removed sequentially while looking for distinct sources of hemorrhage. Coexistent splenic injury can usually be managed with rapid splenectomy for severe injuries, or left upper quadrant packing for lesser degrees of injury, while the liver is being managed. (See "Surgical management of splenic injury in the adult trauma patient", section on 'Packing' and "Overview of damage control surgery and resuscitation in patients sustaining severe injury", section on 'Damage control laparotomy'.)

Control of hepatic hemorrhage is approached in a stepwise fashion, initially using simple measures and progressing to more aggressive techniques, as needed. Initial control of bleeding is performed with manual compression, portal clamping, or perihepatic packing. Ongoing mild-to-moderate bleeding from the parenchyma can be controlled using topical hemostatic agents, electrosurgical techniques, and ligation of the parenchymal vessels. For more severe injuries, liver suturing techniques or hepatic artery ligation may be needed. If these techniques fail, the segment of liver may need to be resected.

Glissonean pedicle transection followed by anatomic resection has also been described as a potentially life-saving damage control technique for patients with severe liver injury involving the Glissonean pedicles near the hepatic hilus [9]. This technique is not typically in the surgical armamentarium of the trauma surgeon but may be useful in the hands of an experienced hepatobiliary surgeon.

Commonly used techniques for liver hemostasis are reviewed below. Circumferential wrapping of the injured liver with a large piece of absorbable mesh was used in the past to manage hepatic injuries [10-12]. However, the technique is not applicable or effective for all types of liver injuries, and experience with the technique is important to position the mesh and secure it properly and rapidly. This technique has largely been replaced by perihepatic packing for the management of severe liver injuries.

Manual compression — Manual compression of the liver between both hands may help tamponade bleeding from the raw liver surfaces (figure 6). The hands are placed on either side of the liver fracture and the liver parenchyma is pushed together. This maneuver provides rapid temporary control of liver bleeding to allow sufficient time for resuscitation. It is not meant as a definitive means to control hepatic hemorrhage. Liver compression can be reapplied, as needed, throughout the procedure as the circumstances require.

Portal clamping (Pringle maneuver) — If manual compression of the liver fails to control hemorrhage, a noncrushing vascular clamp can be placed across the structures in the porta hepatis (Pringle maneuver) (figure 7), interrupting hepatic arterial and portal venous flow into the liver.

Portal clamping should be performed early in cases where manual compression of the liver is ineffective. Portal clamping may arrest or significantly reduce hepatic hemorrhage and helps to differentiate bleeding due to hepatic inflow vessels (hepatic artery, portal vein) from bleeding due to outflow vessels (hepatic veins, inferior vena cava). If clamping the porta hepatis results in reduced bleeding from the liver, hemorrhage is related to hepatic inflow, whereas ongoing bleeding indicates a hepatic outflow source. These two distinct sources of hepatic bleeding require different surgical approaches. (See 'Severe injury' below.)

The maximum duration of portal clamping is not universally agreed upon [13-15]. In a series of 411 patients with liver injuries, 107 patients underwent portal clamping [13]. The warm ischemia time ranged from 10 to 75 minutes (mean 30 minutes). No complications related to hepatic necrosis or permanent hepatic dysfunction occurred in the 73 patients who survived the initial procedure. Although approximately 30 minutes of continuous clamp time may be relatively safe, we prefer to temporarily release the Pringle clamp for 30 to 60 seconds every 30 to 45 minutes to allow intermittent perfusion of the liver parenchyma.

Perihepatic packing — Perihepatic packing has become a core technique for managing bleeding from hepatic injury. Although some have questioned its efficacy [16], perihepatic packing appears to lower rates of rebleeding and reduce mortality [17]. (See "Management of hepatic trauma in adults", section on 'Morbidity and mortality'.)

Perihepatic packing is generally used to temporarily control mild-to-moderate bleeding from the liver while attending to bleeding or contamination from coexistent abdominal injuries. Perihepatic packing alone is not likely to be successful if manual compression has failed to control hemorrhage. In some patients, perihepatic packing may serve as a definitive method of hemorrhage control, although the packs will ultimately need to be removed at a subsequent laparotomy.

The technique of perihepatic packing involves compressing the liver from multiple directions by placing laparotomy pads into the space between the diaphragm and liver, between the anterior and lateral abdominal walls and liver, and between hepatic flexure of the colon and the liver. Intrahepatic packing, in which packs are placed into deep fractures, should not be used (figure 8), because it can extend the injury and lead to increased bleeding [18,19].

For superficial injuries, the packs can be carefully removed after 5 or 10 minutes of compression to determine whether or not bleeding has stopped. If hemorrhage has been controlled, no further packing is required, and the laparotomy can be terminated once other intra-abdominal injuries have been addressed. If bleeding resumes when the packs are removed, the liver can be repacked or the other techniques discussed below used to control bleeding.

More severe liver injuries may require a damage control approach. Perihepatic packs that have successfully controlled the bleeding are left in place to provide tamponade. The abdomen is then closed temporarily and a plan made to return to the operating room to remove the packs at a subsequent laparotomy [20].

The timing of repeat laparotomy for removal of the abdominal packs is controversial [13,21-24]. Rates of rebleeding are higher when packs are removed less than 24 hours after the initial laparotomy; however, the incidence of perihepatic sepsis is higher when a longer period of time has elapsed. Pack removal between 24 to 48 hours following the initial laparotomy is a reasonable compromise, and if no bleeding recurs when the packs are removed, definitive closure of the abdominal wall may be possible. Hepatic bleeding that resumes necessitates repacking the liver, and reexploration is performed after another 24 to 48 hours.

Regardless of the specific technique used, control of bleeding from the liver must be obtained prior to abdominal wall closure (temporary or definitive) [25,26]. If perihepatic packing fails to control bleeding, other more aggressive methods of hemostasis are required.

Topical hemostatic agents — Topical hemostatic agents are often used in conjunction with perihepatic packing and electrocautery to control bleeding from the raw surface of the liver. Many topical hemostatic agents are available, each with individual strengths and weaknesses (table 1) [27]. Absorbable hemostatic agents do not require removal prior to abdominal wall closure. The application of topical hemostatic agents prior to perihepatic packing often allows removal of perihepatic packs during the initial laparotomy. The various hemostatic agents and their uses are discussed in detail elsewhere. (See "Overview of topical hemostatic agents and tissue adhesives".)

Electrocautery — Conventional electrocautery or argon beam coagulation can be used to control mild bleeding from the raw liver surface that is not controlled using perihepatic packing or topical hemostatic agents. Cautery is probably only effective for vessels up to 0.5 mm in diameter; anything larger should be clipped or suture ligated. The argon beam coagulator does not require actual contact with the liver surface to provide hemostasis, which is an advantage over conventional electrocautery. The tip of the electrocautery pen often adheres to the surface of the liver and, when withdrawn, can remove the surface eschar, leading to rebleeding. The basic principles and general use of these devices are discussed in detail elsewhere. (See "Overview of electrosurgery" and "Instruments and devices used in laparoscopic surgery", section on 'Devices for hemostasis'.)

Parenchymal vessel ligation — Deeper lacerations of the liver parenchyma are managed by ligating or clipping the vessels and biliary radicals directly through the laceration as they are encountered (figure 3). This method generally requires repeated application of a portal clamp, which provides a relatively bloodless field to more readily identify and control smaller vessels and bile ducts. (See 'Portal clamping (Pringle maneuver)' above.)

Occasionally, an area of uninjured liver parenchyma may need to be divided (hepatotomy) to access an area of active hemorrhage. The simplest method to accomplish this involves using a finger (ie, finger fracture technique) or the back end of an empty scalpel holder. Once the visible vessels and bile ducts have been controlled, residual bleeding from small ducts and vessels emanating from the liver surface can be controlled with topical hemostatic agents, electrocautery, or direct suturing of the liver parenchyma as discussed in the next section.

Direct liver suturing — Approximation of the raw liver edges can be used as a primary means to promote hemostasis following division of hepatic parenchyma and parenchymal vessel ligation, or in conjunction with perihepatic packing (described in the preceding sections). Direct liver suturing should only be used to control ongoing oozing from the liver parenchyma, not to control major hepatic hemorrhage. A modification, the full-thickness interrupted ligation with transhepatic suturing (FILTH) technique, uses a suture-passing device [28].

The edges of the liver are brought together using pledgeted (eg, Teflon), absorbable suture (#1 or #2 chromic catgut) placed in a mattress fashion using a large blunt-tip needle. It is important to remember that the liver capsule is thin and easily tears, and thus, undue tension should be avoided.

A topical hemostatic agent can be placed into the injured site prior to approximating the liver parenchyma. Alternatively, omentum can be mobilized and placed within the laceration prior to bringing the liver edges together. Omental packing may result in a lower incidence of ischemic and infectious complications [29-31].

SEVERE INJURY

Hepatic artery ligation — Selective hepatic artery ligation, which refers to ligation of the left or right hepatic artery just beyond the bifurcation of the proper hepatic artery, can be used to manage hepatic bleeding limited to one lobe of the liver and may be useful when the Pringle maneuver controls the majority of bleeding. If occlusion of the right or left hepatic artery controls hemorrhage after releasing the Pringle clamp, then ligation of that hepatic artery may be indicated.

In some circumstances, nonselective ligation of the common hepatic artery may be needed, and provided portal venous flow to the liver is intact, the development of significant hepatic ischemia is unlikely. However, it is important to remember that hepatic artery ligation (selective and nonselective) limits future options for percutaneous hepatic embolization. Thus, when a hepatic arterial source of hemorrhage is suspected but hemorrhage can be controlled temporarily with perihepatic packing, we use embolization over arterial ligation.

Liver resection — More severe injuries to the liver may require liver resection to effectively manage bleeding or remove ischemic or dead liver tissue.

Resectional debridement – Resectional debridement refers to the removal of devitalized portions of liver along nonanatomic planes. As an example, high-velocity blunt-force trauma often results in large stellate-type lacerations that involve several segments of liver; anatomic resection of each of the involved segments would remove an excessive amount of liver. Following resectional debridement, residual bleeding from the raw surfaces of the liver can be controlled using one or more of the hemostatic techniques described previously. (See 'Techniques for liver hemostasis' above.)

Anatomic resection – Anatomic resection refers to the removal of a segment or lobe of the liver in the anatomic plane (figure 9). Mortality rates as high as 60 percent have been reported for liver resection performed for trauma [32]. Mortality may be lower for experienced hepatobiliary surgeons. In a series of 37 patients who underwent anatomic resection by a hepatobiliary surgeon for severe liver injuries, the mortality rate was 8 percent and there were no intraoperative deaths [33]. If an experienced hepatobiliary surgeon is available, anatomic resection may be appropriate.

When Glissonean pedicle transection is used to manage severe liver injury involving the Glissonean pedicles near the hepatic hilus, formal anatomic resection will need to be performed promptly due to ischemia of the involved liver segments [9]. The use of surgical stapling devices, which has been described for both traumatic as well as elective hepatic resections, appears to offer the advantage of reduced operative time in hemodynamically unstable patients [34,35]. (See 'Techniques for liver hemostasis' above and "Open hepatic resection techniques".)

Juxtahepatic venous injuries — Juxtahepatic venous injuries (grade V) are challenging injuries to manage due to inaccessibility of the hepatic veins and retrohepatic inferior vena cava. The mortality associated with juxtahepatic injuries remains very high (77 percent in one study) [36]. (See "Traumatic and iatrogenic injury to the inferior vena cava".)

Perihepatic packing may occasionally be successful in controlling bleeding from these injuries and should be attempted first [37,38]. Early consultation with a transplant or hepatobiliary surgeon or a vascular surgeon is appropriate when these infrequent injuries are encountered. If perihepatic packing fails to control retrohepatic venous hemorrhage, diversion of blood away from the site of injury is necessary to provide a sufficiently bloodless operative field so that the injury can be adequately seen and repaired.

The options for vascular control include venovenous bypass, total vascular exclusion, atriocaval shunting, endovascular balloon occlusion, or a combination of these (figure 10). Despite the risks associated with venovenous bypass and total vascular exclusion, these techniques are used more commonly than atriocaval shunting, which has largely been abandoned [39-43].

Atriocaval shunting – Atrial caval shunting diverts venous flow from the infrarenal inferior vena cava to the right atrium (figure 11) using one of several conduits that can be adapted for this purpose (chest tubes, endotracheal tubes). Commercially developed devices are also available, but these techniques are infrequently used due to very poor outcomes.

Venovenous bypass – The inferior vena cava is clamped and venous flow below the clamp is diverted to the superior vena cava though an extracorporeal circuit (similar with liver transplantation) (figure 12). Venovenous bypass is associated with complications that include vascular injury or thrombosis, and air embolism, which can be fatal.

Total vascular exclusion – Total vascular exclusion occludes all the inflow and outflow vessels of the liver (figure 13). Venous return to the heart is severely reduced, and the resultant hypovolemic state may result in cardiac arrest. The successful use of this technique in combination with formal right hepatic lobectomy has been described for the management of complex liver trauma [44].

Endovascular techniques – Both arterial (resuscitative endovascular balloon occlusion of the aorta [REBOA]) and venous (resuscitative endovascular balloon occlusion of the inferior vena cava [REBOVC]) endovascular balloon occlusion techniques have been described as adjuncts to hemorrhage control in patients with juxtahepatic venous injuries. A combined approach using an aortic balloon (REBOA) and two vena caval balloons (REBOVC) was successful in controlling hemorrhage from a suprahepatic inferior vena cava (IVC) injury in an experimental pig model [45], while successful deployment of a single aortic/single IVC balloon approach has been described in human studies [46].

Liver transplant — Rarely, total hepatectomy with immediate post-hepatectomy transplantation is the only option for a severe, devastating liver injury, including hepatic avulsion (grade V injury). Favorable outcomes in highly selected cases have been reported using this approach despite the obvious logistic issues related to procuring a donor liver in a timely fashion and maintaining the hepatectomized patient in an acceptable physiologic condition [47]. Compared with nontrauma transplant recipients, post-trauma transplant recipients have shorter graft survival, resulting in higher retransplantation rates. In a multicenter study of 73 patients undergoing liver transplantation for severe liver trauma, 90-day mortality was 42.5 percent and graft loss occurred in 46.6 percent [48]. Survival rates have generally improved over time, with similar short-term and long-term survival for trauma and nontrauma transplant recipients [49,50].

Issues related to liver support systems and liver transplant are discussed in detail elsewhere. (See "Acute liver failure in adults: Management and prognosis".)

OTHER CONSIDERATIONS

Abdominal closure — Following exploration, a decision to close the abdomen primarily or use a temporary closure technique depends upon whether definitive control of hepatic hemorrhage has been achieved. When perihepatic packing or a balloon tamponade technique has been used, a temporary abdominal wall closure technique is necessary. Even when definitive control of hepatic hemorrhage has been achieved, temporary abdominal closure may still be preferred as primary fascial closure can result in the development of intra-abdominal compartment syndrome postoperatively. "Hemostatic" resuscitation with a 1:1:1 PRBS's:FFP:platelets with limited crystalloid administration transfusion protocol appears to result in higher rates of abdominal wall fascial closure [51]. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

Temporary abdominal closure techniques and management of the open abdomen are described in detail elsewhere. (See "Abdominal compartment syndrome in adults" and "Management of the open abdomen in adults".)

Perihepatic drainage — The availability and effectiveness of radiologically guided perihepatic drainage procedures has greatly reduced the need for routine drain placement. Based on clinical experience in the absence of clinical trials, our treatment approach is as follows [3,52]:

Low-grade injuries (grade I and II, and perhaps even grade III) do not require drainage.

We use a selective approach for higher-grade (grade IV or grade V) liver injuries.

Significant bile leak identified intraoperatively should be identified and controlled. If the leak has not been identified or controlled with certainty, we place a drain.

When drainage is selected, we use only closed-suction drains. Gravity drainage (eg, Penrose) is associated with a higher incidence of perihepatic sepsis and should not be used. Sump type drains are no more effective than closed-suction drains and may also be associated with a higher incidence of perihepatic sepsis.

Postoperative imaging — Postlaparotomy abdominal imaging, typically computed tomography (CT) scanning, may be useful for managing patients deemed at high risk for ongoing or delayed hepatic hemorrhage. High-risk indicators include blunt injury mechanism, high injury severity score (ISS), and low base deficit. A multicenter study conducted by the Western Trauma Association concluded that early postoperative CT identifies clinically relevant persistent bleeding and is sufficiently sensitive and specific to guide a decision for angioembolization [53]. Perhaps more importantly, on multivariate analysis, early postoperative CT was associated with reduced mortality.

COMPLICATIONS — Complications are common following the surgical management of liver injuries. The incidence of complications increases with the grade of liver injury. In a series of 669 patients, complications developed in 5, 22, and 52 percent of patients with grade III, IV, and V injuries, respectively [54]. Complications associated with lower-grade injuries (grades I, II) are rare. The incidence of bile leak ranges from 0.5 to 21 percent [55,56]. Other complications associated with the management of liver injury include hepatic necrosis related to hepatic artery ligation or angioembolization and perihepatic abscess [36].

Most complications related to liver injury can be managed nonoperatively. Postoperative perihepatic abscess and bile collections (biloma) are treated with antibiotics and drainage [57]. Percutaneous or endoscopic drainage techniques are typically used for initial management of perioperative fluid collections; however, on occasion, repeat operation may be needed. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

The combination of severe hepatic injury and ischemia induced by embolization or hepatic artery ligation may predispose to hepatic necrosis [58]. Major hepatic necrosis is managed with repeated resectional debridement in conjunction with interventional drainage procedures or hepatectomy [58].

Laparoscopy may be useful for the management of patients with intra-abdominal complications following severe liver injury, particularly those initially managed nonoperatively [59-62]. Laparoscopically guided drainage of retained bile and blood is particularly useful in the management of higher-grade liver injuries, and laparoscopic hepatic lobectomy has been described for persistent massive post-traumatic bile leak.

MORTALITY — Mortality rates for hepatic injury vary according to the grade of the injury and have improved over time with the introduction of nonoperative management and perihepatic packing [63]. Since mortality is unusual with grade I and II injuries, the greatest reduction in operative mortality has occurred for higher-grade liver injuries (grades III through V). Overall mortality for these higher-grade injuries ranges from 10 to 42 percent [13,15,36,64]. Many of these higher-grade injuries, however, have been successfully managed nonoperatively with overall low mortality rates ranging from 0 to 8 percent. Mortality rates for patients with high-grade injuries requiring surgical management are significantly higher (30 to 68 percent) [65]. However, these studies often do not include mortality related to juxtahepatic injury, for which mortality rates remain high (77 percent in one series) [66]. Mortality rates for grades III to V penetrating injuries to the liver correlate with the grade of injury and are significantly higher when hepatotomy with parenchymal vessel ligation is required [67].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Traumatic abdominal and non-genitourinary retroperitoneal injury".)

SUMMARY AND RECOMMENDATIONS

The liver is the most commonly injured organ following blunt trauma and may result from blunt, chest, or abdominal trauma. Penetrating injury to the liver is associated with injuries to important adjacent structures (eg, vena cava, aorta) that can be lethal. (See 'Introduction' above.)

Hepatic injury is graded (I through VI) depending upon the extent and depth of liver hematoma and/or laceration as identified on computed tomography (CT) scan, or at the time of surgery. Higher grades of injury correlate with increased morbidity and mortality. (See "Management of hepatic trauma in adults", section on 'Hepatic injury grading' and "Management of hepatic trauma in adults", section on 'Morbidity and mortality'.)

Exploratory laparotomy for trauma consists of initial control of hemorrhage by four-quadrant abdominal packing, followed by systematic inspection of all intra-abdominal organs, and exploration of the retroperitoneum, if indicated. Active bleeding is managed prior to addressing gastrointestinal injury. (See 'Approach to surgical management' above.)

Control of hemorrhage from liver injury is performed initially using manual compression, portal clamping, and perihepatic packing. If packing is successful at controlling bleeding, the packs can be left in place as part of a damage control strategy or an attempt at removal made. Definitive measures to control bleeding from the liver include the use of topical hemostatic agents, coagulation techniques, ligation of intraparenchymal vessels, and direct liver suturing. Low-grade injuries generally respond to conservative techniques for hemostasis. (See 'Techniques for liver hemostasis' above.)

Higher-grade injuries may require hepatic artery ligation to control bleeding or debridement (resectional debridement, anatomic resection) of the liver to remove devitalized tissue. Juxtahepatic injuries (grade V) may require hepatic shunting techniques to identify and repair hepatic vein or inferior vena cava injuries; however, mortality associated with shunting remains high. Patients with devastating injuries (including avulsion) may require hepatectomy and liver transplant. (See 'Severe injury' above.)

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Topic 16729 Version 17.0

References

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