REVIEW

Emergency strategies and trends in the management of liver

trauma
Hongchi Jiang
1,2
, Jizhou Wang ()
1,2
1
Department of Hepatic Surgery, the First Afliated Hospital of Harbin Medical University, Harbin 150001, China;
2
Key Laboratory of
Hepatosplenic Surgery, the First Afliated Hospital of Harbin Medical University, Harbin 150001, China
Higher Education Press and Springer-Verlag Berlin Heidelberg 2012
Abstract The liver is the most frequently injured organ during abdominal trauma. The management of hepatic
trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to
nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial
assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo
focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the
standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation,
and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability
with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent
operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is
associated with signicant survival advantages compared with traditional prolonged surgical techniques.
Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma
surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such
as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The
present review presents emergency strategies and trends in the management of liver trauma.
Keywords liver trauma; nonoperative management; operative management
Introduction
The liver is the most frequently injured abdominal organ,
despite its relatively protected location [1,2]. The manage-
ment of hepatic trauma has undergone a paradigm shift over
the past several decades with signicant improvement in
outcomes, shifting from mandatory operation to selective
nonoperative treatment, and, presently, to nonoperative
treatment with selective operation [3]. The present review
considers the consensus of emergency strategies and trends
regarding trauma of the liver.
The literature works cited were mainly reviewed if the
work discussed is an original research or highly cited article,
if it reports research nding based on the systematic
collection of data, if it uses statistical methods for data
analysis, and if it was published within the last ve years. The
following keywords were used to search the PubMed: liver
trauma and resuscitation, liver trauma and sonography,
liver trauma and computed tomography, liver trauma and
angiography, liver trauma and nonoperative treatment,
liver trauma and packing, liver trauma and Pringle
maneuver, liver trauma and damage control, limited to
Humans, English, and All Adult. The broad consensus
regarding most aspects of liver trauma management is based
on available published prospective, observational, retro-
spective data and expert opinions because of the limited
number of published prospective randomized trials.
Mechanisms of liver injury
A better understanding of the mechanisms aids in the initial
assessment and establishment of a management strategy.
Road trafc accidents and violent behavior account for the
majority of liver injuries. Farming and industrial accidents
also account for a signicant number [4]. The liver consists of
a fragile parenchyma within the thin Glissons capsule, which
makes the liver very susceptible to blunt or penetrating
Received October 25, 2011; accepted January 10, 2012
Correspondence: wangjizhou1984@hotmail.com
REVIEW
Front. Med. 2012, 6(3): 225233
DOI 10.1007/s11684-012-0186-6
trauma. The vasculature consists of wide-bore, thin-walled
vessels with a high blood ow, and injury usually causes
signicant blood loss. Liver trauma should be suspected in all
patients with penetrating or blunt thoracoabdominal trauma,
particularly in shocked patients with penetrating or blunt
trauma on the right side [4].
Penetrating injuries are usually associated with a signi-
cant vascular injury. A stab injury may cause major bleeding
from the portal vein, hepatic artery, hepatic vein, or vena cava
[5]. Gunshots may similarly disrupt these major vessels, and
are probably much more marked than stab wounds due to
their cavitation effect [6]. Blunt trauma more usually affects
the right hepatic lobe, particularly the posterior sector, while
the caudate lobe is rarely affected. Blunt trauma in a road
trafc accident or fall from a height may result in a
deceleration injury, which leads to tears at sites of the liver
xed to the diaphragm and abdominal wall. This type of
injury usually involves a fracture between the posterior sector
and the anterior sector of the right lobe, which may be
associated with a signicant vascular injury of the right
hepatic vein. In contrast, a direct blow (from a st or weapon)
to the abdomen may produce a central crush injury, which
may cause an extensive laceration involving segments IV, V,
and VIII. This type of injury may lead to major vascular
injury, such as damage to the hepatic arteries, portal veins, or
hepatic veins [4].
Grade of liver injury
The severity of liver injuries ranges from minor capsular tear
to extensive disruption of both lobes with associated portal
vein, hepatic vein, or vena caval injury. Among the various
classication systems of liver injury, that of the American
Association for the Surgery of Trauma is probably the most
widely used (Table 1) [7]. According to the system, grade I or
II injuries are generally considered as minor injuries, while
injuries of grades III to V are usually considered as severe
injuries. Signicant vascular injuries usually occur with major
parenchymal laceration (grades IV and V). High-grade
hepatic injuries are associated with a higher surgical
intervention rate and a poorer prognosis.
Initial assessment
Initial resuscitation and examination
The initial resuscitation of liver trauma should follow the
Advanced Trauma Life Support principles of aggressive uid
resuscitation, guided by the monitoring of central venous
pressure and urinary output [8]. Special attention should be
paid to the patients abdominal examination, vital signs, and
response to resuscitation (Fig. 1). Peritonitis remains the
indication for exploration after abdominal trauma. In
addition, emergency management should also be directed
toward the avoidance of the sinister triad of hypothermia,
coagulopathy, and acidosis, all of which signicantly increase
mortality. Managements to avoid hypothermia are now
commonly used in major emergency centers and include
rewarming blankets and heat exchanger pumps for rapid
infusion of resuscitation uid and blood. The early use of a
massive transfusion protocol, rather than the excessive use of
crystalloids, is encouraged for patients with ongoing transfu-
sion needs and has been shown to avoid coagulopathy and to
reduce mortality [9,10]. Data from recent study also support
the early use of plasma to red blood cells at a ratio
approaching 1:1, which improves outcomes in massively
transfused civilian trauma patients [11]. Meanwhile, patients
receiving massive transfusion are also at risk for hypocalce-
mia, which results from the binding of calcium by citrate
found in stored blood, particularly in patients with impaired
hepatic function [12].
Focused abdominal sonography for trauma
The traditionally accepted denition of hemodynamic
instability is a systolic pressure of 90 mmHg, although a
truly well accepted denition has not yet been achieved [13].
Hemodynamically unstable patients should undergo a
Table 1 American Association for the Surgery of Trauma liver injury scale
Grade Description of injury
I
Hematoma: subcapsular, nonexpanding, <10% surface area
Laceration: capsular tear, nonbleeding, <1 cm in parenchymal depth
II
Hematoma: subcapsular, 10%50% surface area; intraparenchymal, <10 cm in diameter
Laceration: 13 cm in parenchymal depth, <10 cm in length
III
Hematoma: subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal hematoma. Intraparenchymal, >10 cm or
expanding
Laceration: >3 cm in parenchymal depth
IV
Hematoma: ruptured intraparenchymal hematoma with active bleeding
Laceration: parenchymal disruption involving 25%75% of a hepatic lobe or one to three Couinaud segments within a single lobe
V
Laceration: parenchymal disruption involving >75% of a hepatic lobe or more than three Couinaud segments within a single lobe
Vascular: juxtahepatic venous injuries (i.e. retrohepatic vena cava or central major hepatic veins)
VI
Vascular: hepatic avulsion
226 Emergency treatment of liver trauma
focused abdominal sonography for trauma (FAST), as shown
in Fig. 1 [14]. A positive FAST examination in hemodyna-
mically unstable patient is an indication for operation. The
delay in surgery and control of bleeding in unstable patient
must be very strongly emphasized as bleeding is associated
with signicantly higher mortality [15]. If patients with
persistent hemodynamic instability have a negative FAST,
extraabdominal injuries contributing to shock should be
suspected [16]. Extraabdominal sources of hemorrhagic
shock usually include massive hemothorax, severe pelvic
fracture, or multiple long bone fractures; nonhemorrhagic
shock from cardiogenic (tension pneumothorax, cardiac
tamponade, and myocardial contusion or infarct) or neuro-
genic (spinal shock) causes may also be present. If
extraabdominal sources of exsanguinating hemorrhage are
not present or if hemoperitoneum remains a concern in a
hemodynamically unstable patient with a negative FAST, a
diagnostic peritoneal aspirate should be considered (Fig. 1). A
positive diagnostic aspirate greater than 10 ml of gross blood
is an indicator for operative exploration in unstable patients
[17]. For hemodynamically stable patients, however, surgery
is not the immediate priority. Appropriate further investiga-
tion may ultimately lead to nonoperative management. The
main investigative and therapeutic strategy includes ultra-
sonography, computed tomography (CT), and interventional
vascular radiological techniques.
CT and angiography
Ultrasound scan is very accurate for penetrating and blunt
abdominal injuries, with specicity reported from 95% to
100% and sensitivity from 63% to 100% [4]. FAST has
largely replaced the diagnostic peritoneal lavage in the initial
assessment of blunt truncal injuries [18]. However, FAST is
highly operator-dependent. Therefore, it must be emphasized
that a negative FASTscan does not safely rule out injury [19].
The exclusion of liver injury in the event of signicant blunt
trauma should be based on the combination of a negative
ultrasound scan and normal clinical examination and
observation [20]. Additionally, ultrasound cannot accurately
calculate the extent of hepatic parenchymal or vascular injury
and cannot take the place of CTscan. CTscan has become the
standard examination for stable patients with an abdominal
injury (Fig. 1) [21]. The decreased mortality associated with
nonoperative management can be attributed to the use of CT
to aid in the diagnosis of hepatic trauma [22]. CT has
particularly high sensitivity and specicity for detecting liver
injuries (Fig. 2). The type and extent of liver injury can be
Fig. 1 Schematics for the diagnosis of liver trauma. FAST, focused abdominal sonography for trauma; CT, computed tomography.
Hongchi Jiang and Jizhou Wang 227
precisely identied by CT; such injuries may include
subcapsular and intraparenchymal hematomas, lacerations,
and vascular injuries. CT could also detect active ongoing
hemorrhage, which is visible as an extravasation of contrast
material and is a strong predictor of failure in nonoperative
treatment [23]. The presence of ongoing hemorrhage on CT
has been considered to be an indicator for intervention [24].
The use of CT usually requires resuscitation facilities being
moved away from the patient to get into the X-ray
department; therefore, CT examination is recommended for
hemodynamically stable patients. Interventional radiological
techniques provide a new dimension to the treatment of
complex hepatic injuries and push the boundaries of
nonoperative management of liver trauma. Angiography
allows the intervention at difcult-to-access locations,
which is important in both pre- and post-operative stages of
treatment [25]. Arterial embolization is an important element
in modern management of high-grade liver injuries (Fig. 1).
There are two principal indications in the acute post-injury
phase: (1) primary hemostatic control in hemodynamically
stable or stabilized patients with radiologic computed
tomography evidence of active arterial bleeding and
(2) adjunctive hemostatic control in patients with uncon-
trolled suspected arterial bleeding despite emergency lapar-
otomy [26].
Nonoperative management
Hogarth Pringle rst described the operative management of
liver trauma in 1908. However, all patients who underwent
operations died and Pringle recommended conservative
nonoperative management in patients of liver trauma.
Nonoperative management was rst reported in 1972; it is
considered one of the most signicant changes in the
treatment of liver injuries over the past two decades [27].
The paradigm shift from operative management to nonopera-
tive management is ascribed to several factors: (1) the
observation that 50%to 80%of all liver injuries stop bleeding
spontaneously, (2) the success of nonoperative management
in children, and (3) the signicant development of CT
techniques to provide precise diagnosis of liver trauma. A
recent review of the National Trauma Data Base in America
showed that 86.3% of all hepatic injuries are now managed
without operative intervention and that although organ
specic operative rates are associated with increasing grade,
grade alone does not accurately predict the need for operation
[28]. Nonoperative management has been popular for high-
grade injuries (grades III to V) [29].
Indications of nonoperative management
In the appropriate environment, selective nonoperative
management of penetrating abdominal solid organ injuries
has high success and low complication rates [30]. Non-
operative management is usually recommended for stable
patients with stab injuries. There is also increasing evidence
to support the use of nonoperative management in gunshot
liver injuries [6,31]. The traditional fears in nonoperative
management of liver trauma, such as increased sepsis rates
due to infection of bile and blood collections, have been
shown to be inaccurate [32]. The rate of resorting to open
surgery in patients with nonoperative managements is
signicantly higher in severe grade injuries (grades IV and
V); however, the open surgery is rarely due to liver-related
complications [33]. The most common reason for surgical
intervention in patients with initial nonoperative management
is coexisting abdominal injury, such as delayed bleeding from
the kidney or spleen [34]. The failure of nonoperative
management due to delayed liver bleeding is rare (03.5%)
[34]. There has always been a debate on the selection criteria
of nonoperative management for liver trauma, but it is
generally accepted that the key assessment criteria for
nonoperative management should include: (1) hemodynamic
stability, (2) absence of other visceral or retroperitoneal
injuries that need surgery, and (3) the availability of an
effective multidisciplinary team, which could provide good-
quality CT imaging, intensive care facilities, and experienced
surgeons.
Complications of nonoperative management
Not surprisingly, as more nonoperative management is
pursued, more liver-related complications are being diag-
nosed. The role of repeat CT scans is limited in nonoperative
management of liver trauma. Follow-up CTwas not helpful in
clinically stable patients [35]. An 8-year retrospective review
showed that no patients developed hepatic complications in a
no follow-up abdominal CT group (40%), and only 3%
patients received later operation based on repeat CTscans, all
of which were prompted by a change in clinical status [36].
Hemodynamic instability during nonoperative management
of liver trauma may be an indication for surgery irrespective
of CT ndings. Although routine follow-up CT scans are not
Fig. 2 A computed tomography scan of a blunt liver trauma.
228 Emergency treatment of liver trauma
necessary, an evaluation by CT scan should be prompted in
the situation of persistent systemic inammatory response
syndrome, abdominal pain, jaundice, or an unexplained drop
in hemoglobin. Complications of nonoperative management
are primarily related to the grade of liver injury and the need
for transfusion [37]. The management of hepatic complica-
tions is a multimodality treatment strategy that includes
endoscopic retrograde cholangiographic embolization, stent-
ing, transhepatic angioembolization, and image guided
percutaneous drainage techniques. Operative intervention
also plays an important role in the successful management of
complications. Complications that require operative inter-
vention usually include bleeding, abdominal compartment
syndrome, and failure of percutaneous drainage techniques.
Delayed hemorrhage from blunt hepatic injuries usually
occurs within the rst 72 h post-injury. The incidence of
hepatic or perihepatic abscess is low and could be managed
by percutaneous catheter drainage. Biliary complications
usually include biloma, bile leak, biliary stula, and bile
peritonitis [38], and commonly present in a delayed fashion in
patients with grade IV injuries. When bile leaks into the
hepatic parenchyma with necrosis led by the increasing
pressure, a biloma is formed. The common management of
biloma is percutaneous catheter drainage, although asympto-
matic bilomas do not require management. Bile peritonitis
typically presents several days after injury [39]. Laparotomy
is an option, but drainage can also be safely and effectively
performed by laparoscopy [38,40]. A missed bowel injury
may be suspected with the signs of peritonitis, but the
incidence is very low even in high-grade injuries. Continued
high output biliary drainage may need adjunctive endoscopic
retrograde cholangiopancreatography (ERCP) to aid in
healing [41]. A nonoperative-treated patient should stay at
the hospital for at least two weeks because of complications
of nonoperative management.
Operative management
Packing and resuscitation
When nonoperative management is unfeasible, or fails, the
surgeon must be prepared to conduct a resuscitative
laparotomy. Minor liver bleeding is usually present in liver
injuries of grades I and II and can usually be managed by
packing alone. If needed, simple techniques, such as
electrocautery, argon beam coagulation, or topical hemostatic
agents, can be used (Fig. 3). Balloon catheter tamponade can
be used in multiple anatomic regions and for variable patterns
of injury to arrest ongoing hemorrhage. Placement for central
hepatic gunshot wounds is particularly useful [42]. The rst
step in the management of patients with major hepatic
hemorrhage is manual compression followed by perihepatic
packing. The surgeon compresses the injured parenchyma
between two hands and places laparotomy pads around the
Fig. 3 Schematics for management of hemostasis. ICU, intensive care unit.
Hongchi Jiang and Jizhou Wang 229
liver to compress the injury and accelerate hemostasis.
Perihepatic packing will control profuse hemorrhaging in
most patients undergoing laparotomy when done correctly
and expeditiously [43]. Packing is also extremely useful for
the general surgeon in a district hospital, as it can be life-
saving during transfer to a major trauma center to undergo
further surgery; otherwise, the patients may possibly lose the
chance to survive.
The measures to rapidly control bleeding are vital and
should be maintained to help the anaesthetist achieve
restoration of the blood volume and effective intraoperative
resuscitation. The patient should undergo intraoperative
resuscitation with blood component therapy as discussed
above. A massive transfusion protocol should be strongly
considered, as early massive transfusion has been proven to
reduce mortality [10]. Attempts to identify and repair hepatic
vascular injuries before effective resuscitation should be
avoided as they always lead to further hemorrhage, hypoten-
sion, acidosis, and coagulopathy, which increase mortality.
Rapid and systematic abdominal exploration should be
performed to identify the sources of nonhepatic hemorrhage
and areas of contamination. If the bleeding is under control,
temporary abdominal closure is performed. The patient is
then transported to the intensive care unit (ICU) for
resuscitation, as shown in Fig. 3.
Leaving packs around the liver is known to cause
signicant cardiopulmonary compromise and increase the
risk of abdominal compartment syndrome [44]. Liver packs
should be removed as soon as the patient is stable and
coagulopathy, hypothermia, and acidosis have been corrected
[45]. However, the cardiopulmonary benets of pack removal
should be weighed against the risk of re-bleeding requiring
repeat liver packing. Re-bleeding from the liver has been
demonstrated to be greater when liver packs were removed
within 36 h [46]. A retrospective review of 534 liver injuries
showed that the rst relook laparotomy following packing
should be performed after 48 h and when hypotension,
hypothermia, coagulopathy, and acidosis have been cor-
rected. An early relook at 24 h is associated with re-bleeding
and may not lead to the successful removal of liver packs
[47].
Damage control surgery
The concept of damage control was introduced by Stone et al.
in the 1980s [48] and promulgated by Burch et al. in 1992
[49]. The term damage control was popularized by the
group at the University of Pennsylvania in 1993 [50]. The
concept of damage control surgery includes three principle
phases. Phase 1 involves the initial control of hemorrhage and
contamination followed by packing and rapid wound closure,
without immediate concern for restoration of anatomical
integrity. Phase 2 involves further resuscitation and stabiliza-
tion in the intensive care unit for 24 h to 48 h period until
normal physiologic parameters have been restored. Phase 3
involves re-exploration and denitive operation [51]. The
sinister triad that interact to produce a deteriorating metabolic
situation are hypothermia, coagulopathy, and acidosis.
Patients in this condition are at the limit of their physiological
reserves, while prolonged and complex surgical repair
attempts may cause exceptionally high mortality [52]. Early
recognition of hypothermia, coagulopathy, and acidosis is
essential in the damage control approach.
The damage control concept is quite appropriate for the
treatment of major liver injuries, as described by Halsted in
1908 for the control of liver bleeding by packing. The concept
was re-popularized in the early 1980s, and was more widely
adopted throughout the next two decades. The common
criteria to use damage control surgery in patients with liver
trauma should include: (1) blunt abdominal trauma of high
energy, multiple abdominal penetrating trauma, hemody-
namic instability, (2) major vessel injury of abdomen or
thorax, multiple visceral injury, and severe craniocerebral
injury, (3) severe metabolic acidosis (pH 7.30), hypother-
mia (temperature 35C), resuscitation, and operation
time > 90 min, coagulopathy, and massive transfusion
( > 10 U), (4) continuous bleeding from wound surface
after resectional debridement, hepatectomy, and vessel
ligation, (5) extensive parenchymal laceration or extensive
subcapsular hematoma expending, and (6) intraoperative
uncontrolled hemorrhage and intrahepatic/extrahepatic major
vessel injury [53].
Pringle maneuver
If the bleeding cannot be controlled by packing alone,
complex hepatic injury must be suspected. Pringle maneuver
should be performed immediately, with the placement of a
vascular clamp on the porta hepatis to control portal vein and
hepatic artery bleeding (Fig. 3). Additionally, the mobiliza-
tion of the liver with the takedown of the falciform, coronary,
and triangular ligaments can be used to optimize exposure.
Hepatotomy is performed under Pringle control and involves
nger fracture to allow ligation of the bleeding vessels.
Despite the risk of tissue necrosis or injury to intact vessels
and bile ducts, deep parenchymal sutures is still an option for
hemostasis. However, in major hepatic venous injuries,
severe hemorrhage may occur while extending a deep liver
laceration, which cannot be controlled by a Pringle clamp and
may increase morbidity. In such cases, hepatotomy should be
abandoned and an alternative, such as total vascular exclusion
or denitive packing, should be adopted. For hepatic
parenchymal devascularization or destruction, resectional
debridement should be performed. Resectional debridement
refers to the removal of inviable parenchyma using the line of
injury as the boundary of the resection rather than standard
anatomical planes [54]. The patient should be hemodynami-
cally stable and not have a coagulopathy. The principle of
resectional debridement is to minimize the extent of
parenchymal dissection so that operating time is short and
230 Emergency treatment of liver trauma
tissue with further potential for bleeding is not created.
Anatomical resection is now rarely performed, especially at
the time of initial surgery.
The Pringle maneuver was initially introduced to reduce
hepatic hemorrhage after abdominal trauma at the beginning
of the 20th century. However, the maximal ischemic time
tolerated by the liver is still controversial. At the beginning of
the 1960s, experimental studies showed that the human liver
was thought to tolerate no longer than 20 min of continuous
ischemia. The time limit was subsequently extended to over
an hour [55]. Intermittent Pringle maneuver gradually
replaced the continuous maneuver to improve liver tolerance
to ischemia. There is enough evidence to show that
intermittent maneuver allows the liver to better tolerate
ischemia for prolonged duration and reduces both the risk of
massive bleeding and postoperative liver failure [56].
However, no consensus regarding the time limits of
intermittent maneuver has been reached. According to the
study of Man et al. [57], 120 min was the safer upper limit for
intermittent maneuver. Meanwhile, Ishizaki et al. [58]
showed how the limit could be extended to 325 min in a
normal liver without major complications. A recent study
showed that hepatectomies done with intermittent clamping
exceeding 120 min are as safe as those performed with shorter
times [59].
If the bleeding persists after a Pringle maneuver, the
existence of juxtahepatic venous injury must be suspected
(Fig. 3). Packing is the best choice to control bleeding
because there is a strong argument against any type of direct
repair, which may increase mortality [60]. Dismal results
from direct repair alone may lead to the introduction of
vascular isolation with shunting. Atriocaval shunts have
largely been abandoned because of their poor survival gures.
Venovenous bypass can be a useful adjunct if performed prior
to signicant shock, hypothermia, and coagulopathy [2]. This
procedure entails vascular isolation along with establishment
of femoral to axillary or jugular veno-veno bypass.
Delayed laparotomy
After the patient has been adequately resuscitated, including
correction of hypothermia, acidosis, and coagulopathy,
delayed laparotomy may be performed (Fig. 3). Packs are
removed and ongoing bleeding, biliary leak, and associated
nonhepatic injuries are assessed. If nonviable parenchyma is
found, resectional debridement is frequently all that is
required. There is no evidence to support routine drainage
for elective uncomplicated liver resection [61]. A closed
suction drain should be considered when obvious bile leak is
identied at the time of trauma laparotomy. Liver transplanta-
tion for trauma is a rare condition, with only 19 cases
described in the literature. Emergent liver transplantation after
liver trauma is a last-resort option and is only suggested when
all other means fail [62].
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Hongchi Jiang and Jizhou Wang 233