Symposium

Management of liver trauma in adults

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

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

Key Words: Liver, injury, damage control surgery

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

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

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

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

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

Angiogram and angioembolization Blunt injury

Angiography plays a vital role in the conservative management
of the liver injury. Extravasation of contrast seen on CT
scan requires emergency angiography and angioembolization
in hemodynamically stable patients. Post-operative
angioembolization is also reported in damage control surgery
prior to removal of packing, if rebleeding is suspected.[30,31] The
sensitivity and specificity of angiogram identifying active bleeding
in liver injuries is 75% and the success rate of controlling the
hemorrhage is 6893%.[11,30,32] The multidisciplinary approach
to conservative management of high-grade liver injuries shows
better outcome with less blood transfusion, early recovery time
and less intensive care days. The mortality is low as well.[33]
Diagnostic peritoneal lavage
DPL was one of the most common modalities used in the
diagnostic evaluation for blunt abdominal trauma in the mid-20th
Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011
In blunt liver trauma, nonoperative management is a standard of
care in hemodynamically stable patients. It is not the grade of
the injury, but rather the hemodynamic parameters of the patient
which dictate the conservative versus operative management
decision. The patients positive response to an initial fluid bolus or
maintenance of a stable hemodynamic state allows for a CT scan
of abdomen and pelvis. If extravasation is identified, angiogram
and angioembolization should be considered. Failures of these
steps then mandate operative intervention.
The most common reasons for failure are advanced age, delayed
bleeding, hypotension and active extravasation of contrast not
controlled by angioembolization.[33,37-39]
There is an overall survival benefit and 23% reduction of
mortality for conservative approach in blunt liver injury.[40-42]
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Ahmed and Vernick: Liver injury
Operative management
Penetrating injury
Recent literature supports operative intervention only in
hemodynamically unstable patients, usually as a result of a
high-velocity gunshot wound. Other indication for operative
intervention is an associated hollow viscus injury.[43]
Trunkey has described the operative procedure for unstable
gunshot wounds to the liver.[29] If the patient is unstable or
deteriorating in the emergency room, patients should be taken
to the operating room within 15 minutes. Activation of massive
blood transfusion protocol, four quadrant packing, direct
compression and rapid control of fecal contamination are
the initial steps. Debridement, ligation of the bleeding vessel,
lobectomy and repair of venous injury under total vascular
isolation are the best strategies with good outcome. If the triad of
coagulopathy, acidosis and hypothermia are encountered during
this phase of the repair, perihepatic packing and temporary
closure of the abdominal incision with transfer to intensive care
unit (ICU) should be the priority. The patient should be taken
back to operating room as soon as the metabolic derangement
is corrected and rewarming has occurred.
Blunt injury
The main indication of the operative approach to the blunt liver
injury is hemodynamic instability, not the grading of the injury.
Although a higher grade injury has higher potential for failure of
nonoperative management, hemodynamic instability remains the
most important branch of the decision tree indicating operative
intervention.
Rebleeding, constant decline of hemoglobin and increased
transfusion requirement, as well as the failure of angioembolization
of actively bleeding vessels are a few factors which indicate the
need for laparotomy.[33,37-39]
The operative approach has also evolved over the last two
decades. Direct suture ligation of the parenchymal bleeding
vessel, perihepatic packing, repair of venous injury under total
vascular isolation and damage control surgery with utilization
of preoperative and/or postoperative angioembolization are the
preferred methods, compared to anatomical resection of the liver
and use of the atriocaval shunt.[9,44-51]
Operative procedure for liver injuries
The first and the most important step in operative management
of blunt liver injury is to pack all four quadrants with laparotomy
pads and manually compress the liver using both hands for
1520 minutes. This allows the anesthesiologist to catch up
with the resuscitation. Then remove the lower quadrant packing
first, followed by left upper quadrant and finally right upper
quadrant. If the spleen is actively bleeding, splenectomy should
be performed. Assess the liver laceration and identify the bleeding
vessel. Direct suture ligation should be performed using 3-0 or
4-0 absorbable suture. A patch of omentum can be used to fill
the gap created by the laceration. If bleeding continues, then
116
perform the Pringle maneuver (apply a noncrushing clamp
through the foramen of Winslow).[3] The clamp can be safely
applied up to 1 hour.
Operative approach for hepatic vein and/or
retrohepatic caval injuries
If bleeding continues despite the Pringle maneuver, then
retrohepatic, caval or hepatic vein injury should be suspected.
The preferred method for caval and hepatic vein injury is total
vascular isolation.[47] The procedure consists of performing a
Pringle maneuver, and clamping of the inferior vena cava above
and below the injury. Superiorly, the inferior vena cava can be
isolated just below the diaphragm or through the pericardium by
extending the incision to a median sternotomy and inferiorly, just
above the renal veins. This approach allows direct repair of the
vascular injury. Aortic clamping is not recommended for the vena
caval or hepatic vein injury.[29] The vascular isolation technique has
reported a better survival rate compared to atriocaval shunt.[47,52]
Anatomical lobectomy is rarely performed; however, in the hands
of an expert, the outcome is very good.[53,54]
During the operative repair, if the patient develops coagulopathy,
acidosis, or hypothermia, damage control surgery should be
considered.
Damage control surgery
Damage control surgery includes perihepatic packing and
closure of the abdominal incision either using a Bogata bag
or partial closure of proximal abdominal incision. Kreig et al.
recommend six folded laparatomy pads to be placed between
the liver and the abdominal wall to obtain tamponade.[44] The
patient should be transferred to the ICU as soon as possible for
continued resuscitation and warming. As soon as the metabolic
derangement is corrected, the patient should be taken back to
operating room for re-exploration. The timing of re-exploration
depends upon the correction of acidosis, coagulopathy and
hypothermia. Usually, 1224 hours is the safe period for re-
exploration and formal completion of the surgery.
Role of hemostatic agents in liver trauma
A number of commercial hemostatic agents are readily available
and can be used as an adjunct after repair of liver injuries. The
most commonly used agents are gelatin gelfoams, oxidized
cellulose, microfibrillar collagen, thrombin, thrombin with gelatin
(floseal) and fibrin sealant (tisseel).[55]
Application of extracorporeal circulation in the
massive liver and/or retrohepatic caval injury
The use of extracorporeal circulation devices during the repair
of the juxtahepatic caval injuries has been noted in the past with
variable success. The concept behind this device is to bypass the
flow from the injured area using an extracorporeal circuit, with
or without an active pump. Therefore, repair can be performed
in a bloodless field. These devices increase the complexity of the
operation, and the physician must be familiar with the technique
Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011

and concept as well. Successful use of venovenous bypass
following clamping of the inferior vena cava during anhepatic
phase of liver transplant provided the idea in the management
of retrohepatic caval injuries.[56] This technique allows blood to
be diverted from the inferior vena cava, with or without portal
vein decompression, and drain it into the right atrium either
directly or through internal jugular vein or superior vena cava.[57-60]
Liver transplantation in massive liver and hepatic
venous and retrohepatic caval injury
Orthotopic liver transplantation has been reported as an extreme
measure in massive hepatic venous and retrohepatic caval
injuries.[61-65] Since the mortality rate associated with these injuries
is extremely high and there is a shortage of organs available for
procurement as well, the indication for liver transplantation is
very restricted. Most of the indications described in the literature
are uncontrolled bleeding despite repeated previous surgery and
acute or progressive liver failure following repair of injury. In the
last two decades, less than 20 liver transplantations have been
performed for liver trauma with variable success, however, the
biggest series was reported by Delis and colleagues, in which
three out of four patients survived after liver transplantation.[66]
A case of extracorporeal repair and autotransplantation has
also been reported in the case of total avulsion of hepatic veins
and a retrohepatic caval injury.[67] This patients first operation
consisted of the ligation of hepatic veins and inferior retrohepatic
vena cava, and then transfer to another facility where the
second operation was performed. Immediately upon arrival,
extracorporeal bypass was established between left femoral vein
and left axillary vein, using a centrifugal pump. Additional cannula
was inserted into the inferior mesenteric vein threaded back to the
portal vein and connected to the bypass circulation. After cross-
clamping the hepatoduodenal ligament, the liver was removed
en bloc with the retrohepatic vena cava. After ex vivo repair of the
massive liver injury was completed, the liver was re-transplanted.
Revascularization was done just over 3 hours without using
any extension grafts for the portal vein or hepatic artery. After
establishing adequate bleeding control, the procedure was
completed with an end-to-end choledochocholedochostomy
over a T-tube.
Role of interventional radiology in liver injury
The interventional radiologist plays an integral role in the
nonoperative management of liver injuries. Angiography
and angioembolization has become the gold standard in the
management of liver injuries for hemodynamically stable
patients, if a contrast extravasation is seen on CT scan.
Furthermore, conservative management may cause vascular/or
biliary complications, particularly in high-grade injuries which
require imaging intervention. Post-traumatic pseudoaneurysm,
intrahepatic arteriovenous fistula and hemobilia are a few vascular
complications which may appear following liver injuries and
angioembolization is the first step in the management of these
complications.[68] Symptomatic biloma, liver and intra-abdominal
abscesses can also be successfully managed by CT-guided
percutaneous drainage.[69]
Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011
Ahmed and Vernick: Liver injury
CONCLUSION
Management of liver injury has evolved over the last two decades.
Hemodynamic status, not the grade of the injury, should dictate
the management. CT scan of the abdomen and pelvis is a
standard diagnostic modality in hemodynamically stable patients.
Extravasation of contrast during CT scans requires further
intervention. Unstable patients should mandate emergency
laparotomy. Direct control of bleeding vessels, vascular isolation
and damage control surgery are preferred and the most popular
approaches compare to anatomical resection of liver and the use
of an aortocaval shunt.
REFERENCES
1. Clancy TV, Gary Maxwell J, Covington DL, Brinker CC, Blackman D. A
statewide analysis of level I and II trauma centers for patients with major
injuries. J Trauma 2001;51:346-51.
2. Matthes G, Stengel D, Seifert J, Rademacher G, Mutze S, Ekkernkamp
A. Blunt liver injuries in polytrauma: results from a cohort study with the
regular use of whole body helical computed tomography. World J Surg
2003;27:1124-30.
3. Pringle JH. Notes on the arrest of hepatic hemorrhage due to trauma.
Ann Surg, 1908; 48:541-549
4. Lamb CA. Rupture of the liver. N Engl J Med 1939;221:855-9.
5. Olson WR, Redman HC, Hildreth DC. Quantitative peritoneal lavage in
blunt abdominal trauma. Arch Surg 1972;104:536-43.
6. Gourgiotis S, Vougas V, Germanos S, Dimopoulos N, Bolanis I,
Drakopoulos S, etal. Operative and nonoperative management of blunt
hepatic trauma in adults: A single-center report. J Hepatobiliary Pancreat
Surg 2007;14:387-91.
7. Pachter HL, Hofstetter SR. The current status of nonoperative
management of adult blunt hepatic injuries. Am J Surg 1995;169:442-54.
8. Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, et al.
Status of nonoperative management of blunt hepatic injuries in 1995: A
multicenter experience with 404 patients. J Trauma 1996;40:31-8.
9. Pachter HL, Spencer FC, Hofstetter SR, Liang HG, Coppa GF. Significant
trends in the treatment of hepatic trauma: experience with 411 injuries.
Ann Surg 1992;215:492.
10. Cogbill TH, Moore EE, Jurkovich GJ. Severe hepatic trauma: a multi-center
experience with 1335 liver injuries. J Trauma 1988;48:1433-8.
11. Asensio JA, Demetriades D, Chahwan S, Gomez H, Hanpeter D, Velmahos
G, etal. Approach to the management of complex hepatic injuries. J Trauma
2000;48:66-9.
12. Feliciano DV, Mattox KL, Jordan GL Jr, Burch JM, Bitondo CG, Cruse PA.
Management of 1000 consecutive cases of hepatic trauma (1979-1984).
Ann Surg 1986;204:438-45.
13. Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller
FB, et al. Interventional techniques are useful adjuncts in nonoperative
management of hepatic injuries. J Trauma 1999;46:619-22.
14. Croce MA, Fabian TC, Menke PG, Waddle-Smith L, Minard G, Kudsk KA,
etal. Nonoperative management of blunt hepatic trauma is the treatment
of choice for hemodynamically stable patients. results of a prospective
trial. Ann Surg 1995;221:744-53.
15. Carrillo EH, Platz A, Miller FB, Richardson JD, Polk HC Jr. Non-operative
treatment of blunt hepatic trauma. Br J Surg 1998;85:461-8.
16. Carrillo EH, Richardson JD. Delayed surgery and Interventional procedures
in complex liver injuries. J Trauma 1999;46:978.
117
Ahmed and Vernick: Liver injury
17. Knudson MN, Maull KI. Non-operative management of solid organ
injuries: past, present and future. Surg Clin North Am 1999;79:1357-71.
18. Farnell MB, Spencer MP, Thompson E, Williams HJ Jr, Mucha P Jr, Ilstrup
DM. Non-operative management of blunt hepatic trauma in adults. Surgery
1988;104:748-56.
19. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA,
Champion HR. Organ injury scaling, Spleen, liver. (1994 rev) J Trauma
1995;38:323.
20. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato
K, etal. Focused assessment with sonography for trauma (FAST): results
from an international consensus conference. J Trauma 1999;46:466-72.
21. Hsu JM, Joseph AP, Tarlinton LJ, Macken L, Blome S. The accuracy of focused
assessment with sonography in trauma (FAST) in blunt trauma patients:
Experience of an Australian major trauma service. Injury 2006;38:71-75.
22. Richards JR, Schleper NH, Woo BD, Bohnen PA, McGahan JP. Sonographic
assessment of blunt abdominal trauma: a 4 year prospective Study. J Clin
Ultrasound 2002;30:59-67.
23. Catalano O, Lobianco R, Raso MM, Siani A. Blunt hepatic trauma:
Evaluation with contrast-enhanced sonography. J Ultrasound Med
2005;24:299-310.
24. Poletti PA, Mirvis SE, Shanmuganathan K, Killeen KL, Coldwell D.
CT criteria for management of blunt liver trauma: Correlation with
angiographic and surgical findings. Radiology 2000;216:418-27.
25. Becker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role
of CT in the diagnosis and management of visceral injuries. Eur Radiol
1998;8:553-62.
26. Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, etal. CT in blunt
liver trauma. Radiographics 2005;25:87-104.
27. Taourel P, Vernhet H, Suau A, Granier C, Lopez FM, Aufort S. etal. Vascular
emergencies in liver trauma. Eur J Radiol 2007;64:73-82.
28. Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, etal.
Practice management guidelines for the evalluation of blunt abdominal
trauma. The EAST practice guidelines work group. J Trauma 2002;53:
602-15.
29. Trunkey DD. Hepatic trauma: Contemporary management. Surg Clin
North Am 2004;84:437-50.
30. Sclafani SJ, Shaftan GW, McAuley J, Nayaranaswamy T, Mitchell WG,
Gordon DH, etal. Interventional radiology in the management of hepatic
trauma. J Trauma 1984;24:256.
31. Johnston JW, Gracias VH, Reilly PM. Hepatic angiography in the damage
control population. J Trauma 2001;50:176.
32. Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW,
Miller FB, et al. Interventional techniques are useful adjuncts in
nonoperativemanagement of hepatic injuries. J Trauma 2000;46:619-24.
33. Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G,
etal. Blunt hepatic injury: A paradigm shift from operative to nonoperative
management in the 1990s. Ann Surg. 2000;231:804-13.
34. Nagy KK, Roberts RR, Joseph KT, Smith RF, An GC, Bokhari F, etal.
Experience with over 2500 diagnostic peritoneal lavage for suspected
intra-abdominal injury following blunt trauma. Injury 2000;31:479-82.
35. Demetriades D, Gomez H, Chahwan S, Charalambides K, Velmahos
G, Murray J, et al. Gunshot injuries to the liver: The role of selective
nonoperative management. J Am Coll Surg 1999;188:343-8.
36. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee
P, etal. Selective nonoperative management of penetrating abdominal solid
organ injuries. Ann Surg 2006;244:620-8.
37. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D.
Nonoperative treatment of blunt injury to solid abdominal organs: A
prospective study. Arch Surg 2003;138:844-51.
118
38. David Richardson J, Franklin GA, Lukan JK, Carrillo EH, Spain DA,
Miller FB, etal. Evolution in the management of hepatic trauma: a 25-year
perspective. Ann Surg 2000;232:324-30.
39. Meredith JW, Young JS, Bowling J. Nonoperative management of blunt
hepatic trauma: the exception or the rule? J Trauma 1994;36:529-35.
40. Goan YG, Huang MS, Lin JM. Nonoperative management for extensive
hepatic and splenic injuries with significant hemoperitoneum in adults. J
Trauma 1998;45:360-4.
41. Sherman HF, Savage BA, Jones LM, Barrette RR, Latenser BA, Varcelotti
JR, etal. Nonoperative management of blunt hepatic injuries: Safe at any
grade? J Trauma 1994;37:616-21.
42. Coimbra R, Hoyt DB, Engelhart S, Fortlage D. Nonoperative management
reduces the overall mortality of grades 3 and 4 blunt liver injuries. Int Surg
2006;91:251-7.
43. Marr JDF, Krige JEJ, Terblanche J. Analysis of 153 gunshot wounds of
the liver. Br J Surg 2000;87:1030-4.
44. Krige JE, Bornman PC, Terblanche J. Liver trauma in 446 patients. S Afr
J Surg 1997;35:10-5.
45. Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Blunt hepatic injury:
Minimal intervention is the policy of treatment. J Trauma 2000;49:722-8.
46. Duane TM, Como JJ, Bochicchio GV, Scalea TM. Re-evaluating the
management and outcomes of severe blunt liver injury. J Trauma
2004;57:494-500.
47. Khaneja SC, Pizzi WF, Barie PS, Ahmed N. Management of penetrating
juxtahepatic inferior vena cava injuries under total vascular occlusion. J
Am Coll Surg 1997;184:469-74.
48. Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin N Am
1996;76:763-82.
49. Beal SL. Fatal hepatic haemorrhage: an unresolved problem in the
management of complex liver injuries. J Trauma 1990;30:163-9.
50. Buechter KJ, Sereda D, Gomez G, Zeppa R. Retrohepatic vein injuries:
Experience with 20 cases. J Trauma 1989;29:1698-704.
51. Rovito PF. Atrial caval shunting in blunt hepatic vascular injury. Ann Surg
1987;205:318-21.
52. Burch M J, Feliciano V D, Mattox L K. The Atriocaval shunt: Facts and
Fiction. Ann surg 1998;207:555-66.
53. Strong RW, Lynch SV, Wall DR, Liu CL. Anatomic resection for severe
liver trauma. Surgery 1998;123:251-7.
54. Trunkey DD. Mastery of Surgery. In: Baker RJ, Fischer JE, editors.
Lippincott Williams and Wilkins; 2001. p. 1128-47. USA
55. Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Shapiro ML, Lawson
JH. A comprehensive review of topical hemostatic agents: efficacy and
recommendations of use. Ann of surg 2010;251:217-28.
56. Shaw BW Jr, Martin DJ, Marquez JM, Kang YG, Bugbee AC Jr, Iwatsuki S, etal.
Venous bypass in clinical liver transplantation. Ann surg 1984;200:524-34.
57. Horwitz JR, Black T, Lally KP, Andrassy RJ. Venous bypass as an adjunt
for the management of a retrohepatic venous injury in a child. J Trauma
1995;39:584-5.
58. Baumgartner F, Scudamore C, Nair C, Karusseit O, Hemming A.
Venovenous bypass for major hepatic and caval trauma. J Trauma
1995;39:671-3.
59. Rogers FB, Reese J, Shackford SR, Osler TM. The use of venovenous
bypass and total vascular isolation of the liver in the surgical management of
juxtahepatic venous injuries in blunt hepatic trauma. J Trauma 1997;43:530-3.
60. Biffl WL, Moore EE, Franciose RJ. Venovenous bypass and hepatic vascular
isolation as adjunts in the repair of destructive wounds to the retrohepatic
inferior vena cava. J Trauma 1998;45:400-03.
61. Ringe B, Pichlmayr R, Ziegler H, Grosse H, Kuse E, Oldhafer K, etal.
Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011

Management of severe hepatic trauma by two- stage total hepatectomy
and subsequently liver transplantation. Surg 1991;109:792-5.
62. Ringe B, Pichlmayr R. Total hepatectomy and liver transplantation: a
life saving procedure in patients with severe hepatic trauma. Br J Surg
1995;82:837-9.
63. Ringe B, Lbbe N, Kuse E, Frei U, Pichlmayr R. Total hepatectomy and
liver transplantation as two-staged procedure. Ann Surg 1993;218:3-9
64. Jeng LB, Hsu CH, Wang CS, Chen RJ, Chen SC, Chen MF. Emergent
liver transplantation to salvage a hepatic avulsion injury with disrupted
suprahepatic vena cava. Arch Surg 1993;128:1075-77.
65. Chiumello D, Gatti S, Caspani ML, Savioli M, Fassati R, Gattinoni L. A blunt
complex abdominal trauma: total hepatectomy and liver transplantation.
Intensive Care Med 2002;28:89-91.
66. Delis SG, Bakoyiannis A, Selvaggi G, Weppler D, Levi D, Tzakis AG. Liver
transplantation for severe hepatic trauma: Experience from a single center.
World J Gastroenterol 2009;15:1641-4.
Journal of Emergencies, Trauma, and Shock I 4:1 I Jan - Mar 2011
Ahmed and Vernick: Liver injury
67. Boggi U, Vistoli F, Del Chiaro M, Signori S, Sgambelluri F, Roncella M,
etal. Extracorporeal repair and liver autotransplantation after total avulsion
of hepatic veins and retrohepatic inferior vena cava injury secondary to
blunt abdominal trauma. J Trauma 2006;60:405-06.
68. Goffette P Pierre, Laterre Pierrre-Franciscois. Traumatic injuries: Imaging
and intervention in post-traumatic complication (delayed intervention).
Eur Radiol 2002;12:994-1021.
69. Owings JT, Lengle SJ. Combined hepatic abscess and arterial
pseudoaneurysms from blunt trauma: a case report and management
strategy. J Trauma 1995;38:634-8.
How to cite this article: Ahmed N, Vernick JJ. Management of liver
trauma in adults. J Emerg Trauma Shock 2010;4:114-9.
Received: 17.02.10. Accepted: 22.07.10.
Source of Support: Nil. Conflict of Interest: None declared.
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