Liver Trauma in Surgery

1. Epidemiology and Mechanisms

• Direct compression causing parenchymal damage
• Shearing forces tearing hepatic tissue and disrupting vascular and ligamentous attachments
• Deceleration forces (especially relevant in high-grade injuries)

2. Types of Liver Injury

• Intraparenchymal lacerations and haematomas — usually elliptical or linear in shape
• Subcapsular haematoma — blood collection between the liver capsule and parenchyma
• Capsular rupture with intraperitoneal haemorrhage
• Major vascular injury — lacerations involving major branches of the hepatic veins or IVC; relatively rare but life-threatening

3. AAST Liver Injury Grading Scale (2018 Revision)

4. Initial Evaluation and Diagnostics

Primary Survey and Resuscitation

• Follow ATLS primary survey (Airway, Breathing, Circulation)
• Early blood product resuscitation for suspected ongoing haemorrhage
• Patients with peritonitis or ongoing hypotension with suspected abdominal haemorrhage belong in the operating room

FAST Examination

• The Focused Assessment with Sonography in Trauma (FAST) detects free intraperitoneal fluid (hemoperitoneum)
• Positive FAST + haemodynamic instability = operative intervention
• Positive FAST alone does not mandate surgery
• US demonstrates free fluid or thrombus but does not reliably identify all lacerations

CT Scan (Gold Standard)

• Accurate delineation of injury architecture and grade
• Amount of intraperitoneal blood
• Detection of active arterial extravasation ("blush")
• Identification of pseudoaneurysms or arteriovenous fistulas
• Assessment of hilar/vascular involvement
• Associated injury inventory

REBOA

5. Non-Operative Management (NOM)

Historical Evolution

• 1960–1975: Aggressive operative management (resection, hepatic artery ligation, T-tube choledochostomy); morbidity/mortality 27–65%
• 1976: Lucas and Ledgerwood shifted focus to bleeding control → mortality fell to 22%
• Modern era: NOM with selective angioembolisation; dramatically reduced in-hospital mortality

Criteria for NOM

• Haemodynamic stability or response to initial resuscitation
• No peritonitis
• Absence of associated injuries mandating laparotomy
• Grade I–III injuries are highly amenable; Grade IV–V can be attempted in stable patients

Failure Rates of NOM by Grade

• Grade I–II: failure rate <5%
• Grade III: ~10%
• Grade IV: 14–30%
• Grade V: 50–75%

Monitoring During NOM

• ICU admission for high-grade injuries
• Serial haemoglobin/haematocrit monitoring
• CT scan follow-up for grade III–V injuries to exclude pseudoaneurysm or progression

6. Angioembolisation

• CT evidence of active arterial extravasation ("blush")
• Pseudoaneurysm or arteriovenous fistula on CT
• Patients who can be temporarily stabilised with volume resuscitation but are not candidates for immediate laparotomy

7. Operative Management

Indications for Surgery

• Haemodynamic instability not responding to resuscitation
• Peritonitis
• Active haemorrhage demonstrated on CT in an unstable patient
• Failure of NOM
• Associated injuries mandating laparotomy (hollow viscus injury, diaphragmatic injury)

Initial Operative Steps (Damage Control Philosophy)

1. Manual compression of the liver and packing of the perihepatic space for temporary haemostasis
2. Rapid assessment of the entire abdomen for life-threatening associated injuries
3. Pringle manoeuvre (manual or tourniquet compression of the hepatoduodenal ligament) to reduce hepatic inflow

Haemostatic Techniques

Simple Bleeding Control (Low-Grade Injuries, Grades I–III)

• Direct pressure and packing — the most reliable initial manoeuvre
• Electrocautery or argon beam coagulator for surface bleeding
• Topical haemostatic agents (Gelfoam, oxidised cellulose, thrombin, fibrin glue)
• Suture hepatorrhaphy — mattress sutures across lacerations to compress parenchymal vessels
• Omental pack — plugging the laceration with a pedicle of omentum

Deeper Bleeding Control

• Hepatotomy with selective vascular ligation: the laceration is opened (finger fracture technique) to directly identify and ligate bleeding vessels and bile ducts
• Balloon tamponade (Foley catheter inflated within a tract for penetrating wounds)
• Pringle manoeuvre: occlusion of the portal triad (portal vein + hepatic artery) by compression or tourniquet; safe for up to 60 minutes (longer with ischaemic preconditioning)

Hepatic Resection

• Debridement resection (non-anatomic resection): removal of devitalised tissue while following the injury plane; most common resective technique in trauma
• Anatomic hepatic resection (lobectomy, segmentectomy): reserved for selected cases with massive injury along a segmental or lobar plane; technically demanding and time-consuming — generally avoided in unstable patients

Juxtahepatic Venous Injuries (Grade V Vascular)

• Atriocaval shunt (Schrock shunt): a large-bore tube inserted via the right atrial appendage and advanced into the IVC to divert IVC blood flow while the retrohepatic IVC/hepatic vein injury is repaired
• Veno-venous bypass
• Total hepatic vascular isolation: hepatic inflow occlusion (Pringle) combined with suprahepatic and infrahepatic IVC clamping
• Mortality remains >50% despite these approaches

Damage Control Surgery (DCS)

1. Phase I — Haemorrhage and contamination control only; pack perihepatic spaces; temporary abdominal closure (damage control laparotomy)
2. Phase II — ICU resuscitation: correction of coagulopathy, acidosis, hypothermia; massive transfusion protocol
3. Phase III — Planned re-exploration at 24–72 hours for pack removal, definitive repair, and abdominal closure

8. Complications

9. Special Situations

Penetrating Liver Trauma

• Gunshot wounds carry higher mortality than stab wounds due to greater energy transfer
• The liver is the most commonly injured organ in penetrating abdominal trauma
• Stable patients with gunshot wounds to the abdomen may be managed with NOM in select centres with serial clinical monitoring

Figure — Gunshot injury to the liver successfully managed nonoperatively:

— Mulholland and Greenfield's Surgery, p. 1280

Hepatic Trauma in the Context of Coagulopathy / Anticoagulation

• Pre-existing coagulopathy (anticoagulants, liver disease, haematological disorders) significantly worsens haemorrhage control
• Early reversal agents and massive transfusion protocols are essential

Role of MRI

10. Summary of Management Algorithm

Liver Trauma Suspected
        │
        ▼
ATLS Primary Survey + Resuscitation
        │
   ┌────┴────┐
Unstable    Stable
   │            │
FAST (+)      CT Abdomen (IV contrast)
Operative     ↓
Room      Grade + Vascular Injury?
          │              │
     No blush         Blush/PSA
     Grade I–III      Grade IV–V
     ↓                ↓
     NOM           Angioembolisation
     ICU            ± NOM if stable
     Monitoring          │
                    Failure / Unstable
                          ↓
                     Laparotomy:
                   Packing → DCS → ICU
                   Definitive repair at 48–72h

Key References

• Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice — Chapter 36, Hepatic Injuries (p. 692–695)
• Mulholland and Greenfield's Surgery: Scientific Principles and Practice, 7e — Chapter 25 (p. 1279–1284)
• Current Surgical Therapy, 14e — Liver Trauma chapter (p. 1341–1346)
• Grainger & Allison's Diagnostic Radiology — Hepatic Trauma, Chapter 23 (p. 661)
• Moore EE et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995;38:323–324 (AAST OIS scale)