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Surgical techniques for managing hepatic injury
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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, about 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 about 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. (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 "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) [5]. (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 therapeutic liver packing, with or without topical hemostatic agents. (See 'Severe injury'
below.)
Once the liver injury and other intraabdominal 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 8
th
interspace for a thoracoabdominal approach, or subcostally (right or bilateral [chevron]), are
occasionally needed to increase exposure [6]. (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 over-
crowding around the operating table. For trauma surgery, we prefer an open-armed retractor (eg,
Thomson, Omni) which provides 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 auto-transfusion device. Certain topical hemostatic agents are avoided when using
intraoperative blood salvage. (See "Surgical blood conservation: intraoperative and postoperative
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 peri-colic 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'.)
Control of hepatic hemorrhage is approached in a step-wise 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.
Techniques for liver hemostasis are reviewed briefly below:
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 non-crushing 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 [7-9]. In a series of 411
patients with liver injuries, 107 patients underwent portal clamping [7]. 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 about 30 minutes of continuous clamp time may be relatively safe, we prefer to release
the Pringle clamp 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 [10], perihepatic packing appears
to lower rates of re-bleeding and reduce mortality [11]. (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 [12,13].
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 intraabdominal 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 [14].
The timing of repeat laparotomy for removal of the abdominal packs is controversial [7,15-18].
Rates of re-bleeding 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 re-packing the liver,
and re-exploration is performed after another 24 to 48 hours.
Regardless of the specific technique employed, control of bleeding from the liver must be obtained
prior to abdominal wall closure (temporary or definitive) [19,20]. If perihepatic packing fails to
control bleeding, other more aggressive methods of hemostasis are used.
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)
[21]. 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 tissues adhesives
used in the operating room".)
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 re-bleeding. 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.
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 [22-24].
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 [25]. 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 [26]. If an experienced hepatobiliary surgeon is
available, anatomic resection may be appropriate.
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) [27].
Perihepatic packing may occasionally be successful in controlling bleeding from these injuries and
should be attempted first [28,29]. Early consultation with a transplant or hepatobiliary 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 and atriocaval shunting. 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 [30-34].
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 10) . 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 11). Venous return to the heart is severely reduced and the
resultant hypovolemic state may result in cardiac arrest.
Atriocaval shunting Atrial caval shunting diverts venous flow from the infrarenal inferior
vena cava to the right atrium (figure 12) 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.
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 [35]. 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 the intraabdominal compartment syndrome
postoperatively. Temporary abdominal closure techniques and management of the open abdomen
are described in detail elsewhere. (See "Abdominal compartment syndrome" 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 [3,36]:
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.
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 [37]. Complications associated with lower grade injuries (grade I, II) are rare.
The incidence of bile leak ranges from 0.5 to 21 percent [38,39]. Other complications associated
with the management of liver injury include hepatic necrosis related to hepatic artery ligation or
angioembolization and perihepatic abscess [27].
Most complications related to liver injury can be managed nonoperatively. Postoperative
perihepatic abscess and bile collections (biloma) are treated with antibiotics and drainage [40].
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 indications for and complications of ERCP and endoscopic biliary sphincterotomy".)
The combination of severe hepatic injury and ischemia induced by embolization or hepatic artery
ligation may predispose to hepatic necrosis [41]. Major hepatic necrosis is managed with repeated
resectional debridement in conjunction with interventional drainage procedures, or hepatectomy
[41].
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 [42]. Since mortality is unusual with Grade I and II injuries, the greatest reduction in
operative mortality has occurred for higher grade liver injuries (Grade III through V). Overall
mortality for these higher grade injuries ranges from 10 to 42 percent [7,9,27,43]. However, these
studies often do not include mortality related to juxtahepatic injury, for which mortality rates
remain high (77 percent in one series) [44].
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 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 intraabdominal 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: 3.0
Release: 22.2 - C22.57