Liver trauma

Abstract

Management of blunt or penetrating injury to the liver remains a significant challenge to trauma surgeons. Liver injury remains common in both blunt and penetrating trauma of the abdomen. Unstable patients require immediate laparotomy. Selective patients can be managed without surgery and with careful monitoring. There has been a recent resurgence in the role of temporary packing in the management of liver trauma. Other commonly used techniques are resectional debribement and suture ligation of bleeding vessels. Complications include haemorrhage, bile leak and sepsis. Mortality is mainly due to damage to major hepatic blood vessels or other associated non-hepatic injuries. With improved understanding of the major causes of death from hepatic injury, improved resuscitation and intensive care, mortality has fallen below 10%.

Mechanisms of blunt liver trauma patterns: An analysis of 53 cases

“…There were previously two well-recognized mechanisms of blunt liver trauma: deceleration injury and crush injury (1,2,4). In the present study, acceleration injury has been identified as another mechanism.…”

“…Blunt liver trauma demands emergency treatment and remains a great challenge for surgeons (1,2). Normally, the rib cage and the vertebral column protect the liver from violent forces from outside the body; the ligaments and vena cava fix the liver in place to avoid violent movements (3).…”

“…However, under certain extreme circumstances, the rib cage and the ligaments take part in the liver trauma. There are two previously described mechanisms of blunt liver trauma, deceleration injury and crush injury (1,2,4). The patterns of blunt liver trauma are closely correlated with the characteristics of the blunt force.…”

Non-Operative Management of Liver Trauma

“…Successful management of liver trauma dates back over two centuries with various case reports and case series detailing successful surgical and non-operative management [7], although the emphasis was on surgical intervention : Tilton's series from New York in 1905 reported a 62.5% mortality in those operated on after hepatic 'rupture' [8]. In 1908 Pringle suggested that "While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference: if the laceration be extensive and vessels of any magnitude are torn, haemorrhage will, owing to the structural arrangement of the liver, go on continuously" [9].…”

“…He also described the adjunct that bears his name of compressing the portal triad to limit hepatic inflow to aid liver haemostasis. Peri-hepatic packing became the management of choice for uncontrollable liver haemorrhage during World War I but liver injury had a 66% mortality rate [7] and a high incidence of post-operative infection [10]. Madding reported improved outcomes in the Second World War, and shortly afterwards in civilian practice, using early laparotomy and liver preservation (blunt suture and direct vessel ligation) or resection aided by improvements in aseptic care and critical care [10]; mortality fell to below 30%.…”