Management of Liver Trauma in 811

Consecutive Patients
DONALD D. TRUNKEY,* M.D., G. TOM SHIRES, M.D., ROBERT McCLELLAND

The treatment of 811 consecutive patients having sustained From the University of Texas, Southwestern Medical
liver trauma from 1963 to 1971 is reviewed. The diag- Center, Dallas, Texas
nosis of liver injury secondary to blunt trauma where
clinical signs are minimal is aided by abdominal para-
centesis and peritoneal lavage. Emphasis on treatment of were 811 injuries of all types which involved the liver
blunt and penetrating wounds is again on drainage of all alone or in combination with one or several other visceral
wounds, resection of devitalized liver tissue, and major re- organs. These injuries were inflicted by stab wounds,
section for uncontrollable hemorrhage. Suture ligation of gunshot and shotgun missiles as well as various types of
individual vessels and hepatic ducts has replaced the use of
large mattress sutures. Increased exposure during resection blunt trauma. The current series of injuries represents a
and vascular isolation has been improved by using the sternal sequel to two previous series reported from this institu-
splitting incision. Vascular isolation by the use of an intra- tion by Sparkman and Fogelman24 covering the period
caval shunt greatly aids in the treatment of hepatic veins from 1947 to 1953, and MIcClelland and Shires15 covering
and intra-hepatic caval injuries. the period from 1953 to 1963. Data from this series will
be presented to re-emphasize established concepts and
T HE INCIDENCE OF TRAUMATIC INJURY to the liver has to analyze some changing concepts.
continued to increase each year. This is reflected in Eight hundred and eleven patients were reviewed for
statistics of the National Safety Council which showed the following aspects: age, sex, race, type of inflicting
that in 1971, 137,000 people were injured daily. Of these, agent, anatomic nature of the injury, presence or absence
32,000 were hospitalized and 1,100 remained permanently of shock on admission, presence of bleeding at the time
disabled. In this city alone there are four interstate high- of laparotomy, diagnosis, type of repair carried out, use
ways that traverse the city. In addition, violence in our of antibiotics, complications and mortality. This material
society has also increased as reflected in the number of was then analyzed and compared to other series of liver
penetrating injuries now seen. This may in part be due to injuries from this and other institutions.
increased drug traffic; however, most remain crimes of
passion. Trauma is now recognized as the number three Results
killer overall and the number one cause of death between
one and 36 years. Diagnosis
A series of liver injuries seen at Parkland Memorial All penetrating injuries to the abdomen in which the
Hospital over the period January 1, 1963 to January 1, peritoneum had been obviously violated were explored.
1971, was reviewed. During the period reviewed, there These included penetrating injuries below the fifth inter-
costal space in the thorax. Where there was a question of
Presented at the Annual Meeting of The Southern Surgical Asso- whether the peritoneum had been violated, exploration
ciation, December 3-5, 1973, Hot Springs, Virginia. of the wound under local anesthesia was performed. If
* Present address: Department of Surgery, San Francisco Gen- the peritoneum had been penetrated, then formal ab-
eral Hospital, San Francisco, California 94110.
Reprint requests: G. Tom Shires, M.D., Professor and Chair- dominal exploration was carried out under general an-
man, Department of Surgery, University of Texas, Southwestern esthesia. With injuries from blunt trauma cases, a history
Medical Center, Dallas, Texas 75235. of a direct blow to the abdornen was very helpful. Physi-

722
Vol. 179 * No. S MANAGEMENT OF LIVER TRAUMA

cal examination often revealed muscular spasm or rigid- TABLE 2. Incidence of Types oj Injury and Age
ity. Other useful parameters included blood pressure de- Ages Stab Woound Guinshot Wouind Blunt
terminations, a falling hematocrit in an otherwise stable 22
0-10 1 3
patient and abdominal paracentesis. During the later 11-20 36 58 30
period of this study, peritoneal lavage proved useful as 21-30 83 198 55
an adjunctive procedure when negative paracentesis was 31-40 56 82 23
41-50 17 52 16
obtained. Most blunt trauma patients (61.2%) were in 51-60 7 25 12
shock. After initial resuscitation with Ringers lactate so- 61-70 2 7 7
lution, any further drop in blood pressure was interpreted 71- 3 3 2
as continuing intra-abdominal hemorrhage, in the absence
of other apparent causes. broken down into the type of wounding agent in each
Peritoneal taps were performed in 78 of the patients series.
with blunt trauma injuries. There were 17 false negatives No suture and no drains were used in two patients,
of which four were eventually positive on second taps. both representing blunt trauma victims who had super-
In addition, three underwent peritoneal lavage after ficial linear capsular lacerations with no bleeding. No
negative taps and all of these were positive for non- suture repair with drainage was carried out in 565 cases
clotting blood. Peritoneal taps were also performed in (69.1%). Most of these represented small, simple lacera-
penetrating wounds particularly in penetrating wounds tions or perforations which had stopped bleeding at the
of the low thorax. Two of the penetrating wounds were time of laparotomy or stopped during laparotomy after
stab wounds and were both positive and nine wounds temporary gauze packs had been applied and the rest
were gunshot wounds and revealed eight positive taps. of the exploration carried out or other injuries attended
There was* one false negative. A policy has now been to. Drainage was carried out by several soft one-inch
adopted wherein if an abdominal tap is negative then Penrose drains placed next to the wound and brought
a peritoneal lavage is performed, if there is any indica- out the tip of the twelfth rib or through a resection of the
tion of abdominal injury.25 twelfth rib. These drains were left in for 5-10 days, being
Table 1 shows the incidence of injuries according to slowly removed over a 3-day period. They were never
the number of patients by sex and race and according removed in the presence of bile drainage or any drainage
to the type of traumatic agent. Table 2 represents the at all, unitil a good track had been formed around the
age distribution as well as the type of inflicting agent. drains which was thought to be no sooner than two
The bulk of the injuries were in the young age group as weeks.
commonly seen in other series. For the usual laceration which was rather extensive
The right lobe of the liver was involved 543 times, the and continued to bleed, which represented 167 (20.4%)
left lobe was involved 204 times and both lobes were in- of the total number of cases, suture was necessary. Dur-
volved in 64 of the cases. Bleeding was present from the ing the early part of this series this consisted usually of
liver at laparotomy in 30 of the stab wounds, 109 of the interlocking horizontal mattress sutures of 0 to 1 chromic
gunshot wounds and 79 of the blunt trauma (total 28%). catgut set back about 2 cm from the edge of the lacera-
Of the 432 gunshot wounds, 36 of these represented shot- tion. During the latter periods, however, most bleeding
gun blast injury which had a mortality rate of 25%.
points were managed by direct suture to the offending
vessel. It is thought that this technique reduces the
Surgical Therapy chances of necrosis between the interlocking horizontal
Table 3 indicates the various methods of treatment that
have been carried out on these patients. This is further TABLE 3. Methods of Treatment
Treatment Stab Wound Gunshot Wound Blunt
TABLE 1. Incidence of Types of Injury, Race and Sex No suture, no drains 2
No suture, drained 177 309 79
Stab Wound Gunshot Wound* Blunt Suture, drained 38 82 47
Black male 107 221 32
Debridement 6 4
White male 53 100 61
Sublobar resection 8 11
Lobar resection 11 23
Black female 18 44 22
Hepatic veins 3 8
White female 7 30 36 repaired
Latin American male 21 35 19 Portal injury 2 12 1
Latin American CBD 5 1
female 2 3 Vessel 2 7
*
36 shotgun blasts. Biliary drainage 13 10
 Ann. Surg. * May 1974
724 TRUNKEY, SHIRES AND McCLELLAND
mattress sutures, and therefore reduces the chances of though not all of these represented resections. Biliary
hematobilia. There were ten cases of liver injury which drainage was performed in all common duct injuries and
required debridement. This is not to be interpreted as in some patients who also had associated pancreatic in-
formal resection as this usually meant some segment had juries. There were only t-xo instances where Gelfoam
been removed by the initial injury or the blast effect. was used.
Necrotic liver was simply removed and bleeding points Almost all patients were treated with antibiotics, us-
ligated. ually penicillin and tetracycline. If wound complications
There were 53 (6.5%) either sub-lobar or lobar resec- or sepsis developed, appropriate changes were made with
tions. In addition, there were 11 cases requiring hepatic respect to the culture and sensitivity. During the last half
vein repair and an additional 15 patients had isolated po,r- of this study there was a tendency to start the patients
tahepatic injuries. Of the latter injuries, six involved the initially on cephalothin if there was an associated colon
common bile duct alone and nine either involved the injury. All antibiotics were started either in the emer-
hepatic artery or portal vein or a combination of the two. gency department or during the operation. All patients in
Common duct drainage was carried out in 23 cases al- shock received antibiotics.
Complications
'FABLE 4. Complications 235 patients (29%) had one or more complications for
(235 patients (29%) had onie or more complications for a total of a total of 278 non-fatal complications. Table 4 lists all of
278 nonfatal complications)
these complications and further identifies them by eti-
Penetrating Bltunt ology of wounding agent. The most common complica-
F.U.O. 7 1 tions were pulmonary in origin (11%) and consisted of
Suiperficial wotund inif. 21 4 either atelectasis, pneumonia, or pleural effusion.
Atelectasis 48 4
Pneumonia 20 5 There were 25 superficial wound infections and four
U.T.I. 4 2 wound dehiscences. There were five instances of biliary
Prolonged iletus 4 fistula that persisted more than four weeks. Four of these
Subphrenic abscess 9 5
Fecal fistula 1 eventually closed; however, one is persistant seven years
S.B.O. 12 2 after the original right lobectomy. There was one in-
Pancreatitis 10 9 stance of common duct stricture.
Pleural effusion 10 3
Hemo-pneumo (p op) 10 1 It should be noted that there were 11 postoperative
SB-fistuLla 1 occurences of either a pneumothorax or hemothorax. All
Jaundice 2 3 of these were associated with thoracic injury; however,
Renal failure
Stress ulcer 7 1 the hemothorax or pneumothorax did not develop until
Biliary fistutla 3 2 after operation. In no instance was this a fatal compli-
Hemobilia 1
cation.
Thrombophlebitis 2
Postop. bleeding 4 4
Drain tract inf. 12 1 Mortality
M.I. 2 The overall mortality in this series was 13% (106 pa-
Bile peritonitis 1 2
Resp. ilsuff. 4 4 tients). 313 patients (38.6%) arrived in the emergency
DIC 1 1 room either in clinical shock or with a blood pressure
Transient liver failure 1
Diaphragmatic hernia 1 below 80/40. Of those patients arriving in shock, 32.2%
Septicemia 3 1 (101 patients) eventually died. There were only five
CHF 2 deaths in patients who arrived in the emergency room
Duiodenal fistula 1
Pancreatic fistuLla 1 normotensive. The causes of death in the 106 fatal cases
Pelvic abscess 2 are tabulated in Table 5 and in addition are classified in
Dehiscence 4 relation to the inflicting agent and also to whether a
Necrosis R kidney 1
Bronchobiliary fistuLla 1 lobectomy was performed. Similarly the cause of death
Cardiac arrest 1 was recorded as related or unrelated to the liver injury.
Breakdown vascular repair 1 If the death was clearly related to an associated injury
Duodenal pyelo fisttula 1
Empyema 1 then it was listed in the unrelated column. Conversely,
Perirectal abscess 1 if the cause of death was clearly related to the liver in-
Common duct stricture 1 jury then it was so listed. Seventy-two of the deaths
Uretero cutaneouis fistula 1
Delerium tremens 1 (67.9%) were thought to be unrelated to the liver in-
Intrahepatic abscess 1 jury. The bulk of these deaths (29) were secondary to
Parotid pseudocyst 1 hemorrhage and most were associated with aorta, in-
VTol. 1 79 * No. S MANAGEMENT OF LIVER TRAUMA 725
ferior vena cava, or major vessel injuries. Eight deaths 1'ABLE 5a. C(auses of Death Unrelated to Liver Injutry
were related tc closed head injury seen only in the blunt No
trauma cases. Seven deaths were related to sepsis and Cauise of Death Lobectomy Portal Lobectomy
seven deaths were related to pulmonary insufficiency.
Hemorrhage I 26P 2B
Within the 34 deaths directly related to liver injury, IutlmoInary isuIff. 213 113 3P 4B
26 (76.5%) were due to hemorrhage. In addition there Sepsis 2I' 7P
were five patients who died from bleeding and dissemi-
Closed head 8B
Aspirationi 2P 1B
nated intravascular clotting associated with massive Myocardial conitusionl 1B lB
transfusion. Five of the hemorrhage deaths were thought DIC IP lB
Unexplained IB lB
to be secondary to irreparable liver injuries such as com- Postop. MI IP
plete avulsion of the liver from the cava or bilobar lac- Pancreatico-duod.
erations of such an extent that repair could not be under- fisttula 1P
CHF IP
taken. Of the 34 deaths, four sustained cardiac arrest in Aortic aneturysm IP
the emergency department during resuscitation. All of Inifected prosthesis 1P
these patients underwent open cardiac massage in the Broncho-ctut. fist. iP
Pulmonary emboluis iP
emergency room and were taken immediately to the op- Pancreatitis IP
erating room where attempted repair or resection was Air embolism 1I'
undertaken. An additional 13 patients sustained cardiac Total 5P 3B I 471P 16B
standstill before control of the liver hemorrhage was ac- P = penietrating; B = blunt.
complished.
The mortality in liver trauma was in direct relation be found. The pulmonary insufficiencies were secondary
to the number of other organs involved. Table 6 shows to flail chest. In those deaths related to the lobectomy,
the rising mortality when organs in addition to the liver twelve were secondary to hemorrhage, three secondary
were injured. In addition, analysis was made of the differ- to disseminated intravascular clotting, two to sepsis and
ent associated organ involvement. In blunt trauma when one to pulmonary insufficiency.
the inferior vena cava, aorta, right colon and heart were
involved the risk was higher, (P greater than .05). As- Discussion
sociated organ injuries in penetrating trauma that in- Penetrating wounds of the abdominal cavity usually
creased mortality included stomach, aorta, pancreas, in- do not present a diagnostic problem and these wounds
ferior vena cava, major vessels and colon (P greater are explored. Only stab wounds of questionable depth
than .05). are explored locally and if penetration of the peritoneum
The highest mortality was associated with shotgun is established by this procedure a formal laparotomy is
b)lasts which has a 25% mortality. Next was blunt trauma then performed. Penetrating wounds of the thorax below
which had a mortality rate of 20.2%. Miscellaneous deaths the 5th intercostal space may violate the peritoneal cav-
that are noteworthy include two patients who died from ity and laparotomy is the most conservative therapy. In
sepsis secondary to missed injuries. One was a missed patients with blunt trauma when there are clear-cut clini-
stomach injury and the other a missed pancreatic injury. cal signs such as rigidity, distention, or unstable vital
One patient died following a right lobectomy and combi- signs (without other evident blood loss) laparotomy is
nation Whipple operation. One patient died from dis- performed. In patients where the findings are ill-defined.
ruption of a suture line in the thoracic aorta five weeks then peritoneal tap may be helpful. In all negative-taps,
following repair at the time of the initial operation for peritoneal lavage is then performed as this will greatly
liver injury. One patient died secondary to a duodenal increase the accuracy of diagnosis.25
fistula and he represented one of two of the entire as- Since the last review of liver injuries at Parkland, the
sociated duodenal injuries (60) who had not had a methods of treatment have remained essentially the same
duodenostomy. but the incidence of treatment modalities has changed.
The mortality rate for the 53 patients who underwent
either sub-lobar or lobar resection was 47.2% which is an
TABIF 5b. Causes oj Death Related to Liver Injury
increase from the previously reported series. Seven of
the deaths were unrelated to the liver injury and were No
secondary to associated injuries. One of these was sec- Cauise of Death Lobectomv Portal Lobectomy
ondary to a myocardial contusion, two were due to sepsis, Hemorrhage 5P 7B 1 8P 5B
three to pulmonary insufficiency and one patient died on DIC 2P 1B 1 lB
Sepsis 2P
the fifth post-operative day from a sudden cardiac arrest Pulmonary insuiff. lB
and at post mortem examination no explanation could Total 9P 9B 2 8P 6B
726 TRUNKEY, SHIRES AND McCLELLAND
TABIAI 6. Relationship oj Associated Injutries to Mortality Rate
I njuiries Deaths
Liver
alonie 189 6 3.1
Liver plhs one inijury 134 11
ILiver pluts two injniries 201 16
Liver plus three inijuries 153 25
Liver plus four injuries 53 11
Liver plus five or more 81 37
injuries
Total 811 106
Most injuries (69.1%) were managed simply by evacuat-
ing the blood and draining the injury for possible bile
leak. In the prior series only 28.9%; were managed by this
means. At that time, it was pointed out that suturing may
create dead spaces and lead to abscess formation, hemo-
bilia and strangulation or necrosis of surrounding liver
tissue. An extension of this concept is the modification
of suturing of bleeding lacerations. In the previous
series, this was accomplished by mattress sutures. How-
ever, more recently, direct suture ligation of the bleeding
vessel has proven more efficacious. This reduces the
chance of strangulation, subsequent necrosis and de-
velopment of hematobilia. It may be necessary to extend
or unroof a laceration to gain control of bleeding points
by this method.
Biliary drainage was performed in 23 cases and most
involved portal injuries. There were only three instances
of bile peritonitis and none were fatal. There was a single
persistant bile fistula and whether this could have been
prevented by common duct drainage is doubtful. Lucas
et al.10 have demonstrated that biliary drainage and de-
compression cannot be equated. It is not reasonable to
drain the common bile duct in all major liver injuries un-
less there is a common duct injury or associated duodenal
or pancreatic injury.
Blunt trauma continues to be the most difficult liver
wound to treat and although it is second in overall mor-
tality to shotgun blasts, there were more total patients
(34) dying secondary to blunt trauma injuries. The pa-
tients with blunt trauma were more difficult to manage
surgically as only 45.6% were treated with drainage alone,
compared to penetrating injuries (76.1%). Suture of a
bleeding laceration was necessary in 27.1% of the blunt
trauma injuries compared to 18.8% in the penetrating in-
juries. Of all the patients with blunt trauma 19.69% re-
quired either a sub-lobar or lobar resection compared
TABLEF 7. Mortality
Overall mortality 106 patients (13%)
313 patients (38.6%) arrived in shock*
101 patients (32.2%) in shock eventually succuimbed
25% mortality in shotgun blasts
* BP < 80/40 or clinically in shock
Ann. Surg. * May 1974
with 2.9% of the penetrating injuries. Hepatic vein injury
% was more common in blunt trauma whereas portal in-
jury was inore common in penetrating trauma.
8.2 The method of resection remains unchanged since the
7.9 last report. This is basically the same as described by
16.3 Quattlebaum.21 Exposure has been enhanced by perform-
20.7
45.6 ing a sternal split instead of the traditional right thora-
coabdominal hockey stick incision. This has been pre-
13 viously described by Miller.16 Hemorrhage is controlled
by temporary guaze packs or the Pringle20 maneuver.
This latter method may be used for 15-20 minutes in
the normothermic individual. However, longer periods
are possible with hypothermia or by intermittent release
of arterial occlusion. The line of resection for the right
lobe (Fig. 1) is usually chosen to pass from the edge of
the gall bladder fossa to a point just to the right of the
vena cava. The line of resection for the left lobe is 1-2
cm to the left of this point. The middle hepatic vein, as
Healy6 and Braasch2 have shown, lies between the right
and left lobes in the plane through the middle of the gall
bladder bed down to the vena cava. By staying a little
to one side of this vein, the lobar resections may be
carried out in an anatomic fashion. It may also be help-
ful, provided there is no hepatic vein injury, to leave a
cuff of liver tissue (1-2 cm) on the vena cava. In addi-
tion to the major hepatic veins, there are 10-15 smaller
hepatic veins from the right lobe and leaving a cuff obvi-
ates dissection of each of these. If there is any question of
hepatic vein or vena cava injury the liver must be dis-
sected free from the vena cava.
To resect the lateral segment of the left lobe, the line
.. --
~ Medial Lateral
L seg4ment it se_ _ent_
I
Right lobe 11 Left lobe I
"After Healey, from Broasch, J. W.: The Surgical Anatomy of
the Liver and Pancreas. Surg. Clin. N. Amer. (June) 1958."
FIG. 1. Line of resection for the right lobe.
Vol. 179 * No. S MANAGEMENT OF LIVER TRAUMA 727
of resection should be carried 1 or 2 cm to the left or
right of the falciform ligament in order to avoid the left
branches of the hepatic artery, the portal vein and the
hepatic ducts which run deep to the groove in the liver
demarcated by the attachment of the falciform ligament.
This methodology has been quite successful in the
emergency hepatic resection.5 --RUMMEL
PORTAL
TAPE OCCLUDING
VEIN, HEPATIC
After the line of resection has been chosen, the liver ARTERY AND COMMON DUCT
is divided either sharply or bluntly (finger fracture tech-
nique of Lin ) .9 Large vessels and hepatic ducts are RUMMEL TAPES OCCLUDING
CAVA TEMPORARILY UNTIL
clamped. The assistant may significantly reduce bleeding INTRACAVAL SHUNT INSERTED
AND UNTIL CAVAL INCISION
by compressing the nonresected liver between his hands. IS SUTURED AFTER SHUNT
REMOVAL
Individual bleeding points are then suture ligated. After
all hemorrhage is controlled, omentum may then be
sutured over the raw surface if available.
The technique of vena cava isolation has been recently
described'4 and other methodologies also exist.3'23 Briefly,
the intra-caval shunt is inserted in a stepwise fashion as
follows:
1. Hemorrhage is initially controlled by gauze pack FIG. 2. Intracaval shunt insertion in suprarenal inferior vena cava.
tamponade until the shunt is inserted.
2. Afferent hepatic blood flow is arrested by an oc- cated selective ligature of branches of the hepatic artery
clusive umbilical tape tourniquet or suitable vascular or portal vein as an adjunct to control of hemorrhage.
clamp around the hepatoduodenal ligament (Fig. 2). This may have value in isolated injuries of intra-hepatic
3. Umbilical tape tourniquets are placed around the vessels and was used one time in this series when the
suprarenal inferior vena cava after it is rapidly exposed right portal vein was ligated secondary to injury from
by medial mobilization of the duodenum and. head of the a deep stab wound. This was not used as a replacement
pancreas (Kocher maneuver). for resection in those patients sustaining blast injury with
4. The shunt is then cut to the proper length as esti- large segments of devitalized tissue, or where major
mated for a particular patient, filled with saline, and hemorrhage is a problem. This is particularly true when
clamped to avoid introduction of air into the vena cava. there is associated hepatic vein or vena cava injury. Such
The tube is introduced into the vena cava through the injury may be strongly suspected when the Pringle ma-
longitudinal venotomy made between the two tourniquets neuver abates but does not control the hemorrhage.
and advanced superiorily until it is estimated that the It has been recently reported'2 that a non-operative
shunt tip is just above the diaphragm.
5. The other end of the tube is quickly introduced
into the inferior vena cava after momentarily releasing
the inferior occlusive tape (Fig. 3). Bleeding from the
venotomy is controlled by firmly applying the tape tourni- INFLATED BALLOON CATHETER
quets about the cava and indwelling shunt after its in- IMPACTED AGAINST DIAPHRAGMATIC
VENA CAVA HIATUS ABOVE CAVO-\
HEPATIC VEIN LACERATION TO
sertion. COMPLETE ISOLATION OF
LACERATION FROM CAVAL
6. After insertion of the shunt the midline abdominal BLOOD FLOW
incision is extended cephalad and a sternal split accom-
plished. Sufficient water is then injected through the CLAMP ON SIDE ARM
separate small side channel of the shunt or an occlusive BALLOON INFLATION

umbilical tape may be placed around the supra-hepatic

inferior vena cava and the shunt thus accomplishing total SYRINGE ATTACHED TO
hepatic vascular isolation. This technique has been used UMBILICAL TAPE AROUND
INTRACAVAL SHUNT FOR
SIDE ARM OF CATHETER
COMING OUT OF CAVAL
APPLYING TRACTION TO _
successfully four times in seven hepatic vein injuries in IMPACT BALLOON
AGAINST DIAPHRAGM
INCISION FOR BALLOON
INFLATION
this series.
Other adjuncts to treatment of liver injuries have been
advocated. It has not been the policy to use a trans-hepa-
tic heptostomy'9 as this may aggravate bleeding. Mays,'2
Madding"' and more recently Lewis et al.7 have advo- FIG. 3. Intracaval shunt insertion in suprarenal inferior vena cava.
 *
728 TRUNKEY, SHIRES AND McCLELLAND Anni. Surg. May 1974
approach to sub-capsular hematomas may be warranted. 3. Davis, E. A., Falk, G., Yarnoz, NI., and LeVeen, H. II.: An
Caution must be exercised in such an approach for sev- Improved Technique for the Repair of the Intrahepatic
Inferior Vena Cava and Hepatic Veins. J. Trauma, 11:738,
eral reasons. There is often associated extensive paren- 1971.
chymal damage which necessitates debridement. A sec- 4. Donovan, A. J., Michaelian, M. and Yellin, A. E.: Anatomical
ond reason is illustrated by a patient who was observed Hepatic Lobectoiny in Trauma to the Liver. Surgery, 73:
by the pediatric service in the emergency department 833, 1973.
until the patient had cardiac arrest from volume loss. 5. Fischer, R. P., Stremple, J. F., McNamara, J. J. and Guernsey,
Laparotomy revealed an 800 cc sub-capsular hematoma. J. M.: The Rapid Right Hepatectomy. J. Trauma, 11:742,
1971.
The patient expired during a lobectomy. Liver scans 6. Healey, J. E., Jr.: Clinical-anatomic Aspects of Radical He-
probably do not portray an accurate picture of the patic Surgery. J. Intern. Coll. Surg., 22:542, 1954.
amount of blood loss into the hematoma or the amount of 7. Lim, R. C., Knudson, J. and Steele, M.: Liver Trauma: Cur-
devitalized liver which usually is present. Containment rent Method of Management. Arch. Surg., 104:544, 1972.
of a liver injury by subcapsular hematoma should not be 8. Lin, R. K. and Chen, Liu, T. K.: Total Right Hepatic Lobec-
a deterrent to exploration and evacuation. tomy for Primary Hepatomas. Surgery, 48:1048, 1960.
Mortality rates following major resection for liver in- 9. Lucas, C. and Alexander, M.: Analysis of Randomized Biliary
juries in recent series1' 4'5'813'17,18'26'27 vary from 7% to 69%. Drainage for Liver Trauma in 189 Patients. J. Trauma,
12:719, 1972.
The mortality rate in this series was 47.2% which com- 10. Madding, G. F. and Kennedy, P. A.: Hepatic Artery Ligation.
pares very favorably with other large recent series (San Surg. Clin. N. Amer., 52:719, 1972.
Francisco General 56%, Los Angeles County 43%, Viet- 11. Mays, E. T.: Observation and Management after Hepatic Ar-
Nam 43.1%, Ben Taub Hospital, Houston 69%). This is, tery Ligation. Surg. Gynecol. Obstet., 124:801, 1967.
however,' an increase from the previous Parkland series 12. Mays, E. T.: Lobectomy, Sublobular Resection, and Resec-
of 20%. This is probably accounted for by several factors. tional Debridement for Severe Liver Injuries. J. Trauma,
Ambulance service has increased in efficiency and compe- 12:309, 1972.
tency thus bringing more critical patients who had previ- 13. McClelland, R., Canizaro, P. and Shires, C. T.: Repair of
Hepatic Venous, Intrahepatic Vena Cava and Portal Vein
ously died at the scene of the accident to the emergency Injuries. In Trauma to the Liver. Chapter 10. Madding and
department. A very aggressive policy of resuscitation Kennedy, editors. Philadelphia, W. B. Saunders, 1971.
has been established. Moribund patients have vigorous 14. McClelland, R. N. and Shires, G. T.: Management of Liver
volume replacement with crystalloid solution and whole Trauma in 259 Consecutive Patients. Ann. Surg., 161:248,
blood. All patients that sustain cardiac arrest from hypo- 1965.
volemia have an immediate left thoracotomy as it is im- 15. Miller, Don R.: Median Sternotomy Extension of Abdominal
Incision for Hepatic Lobectomy. Ann. Surg., 175:193, 1972.
possible to resuscitate an empty heart with closed chest
massage. The supradiaphragmatic aorta may be clamped 16. Morton, J., Roys, G. and Bricker, D.: The Treatment of Liver
Injuries. Surg. Gynecol. Obstet., 134:298, 1972.
to maintain aedquate volume to the brain and heart. Im- 17. Payne, W., Terz, J. and Lawrence, W.: Major Hepatic Resec-
mediate laparotomy is subsequently performed to control tion for Trauma. Ann. Surg., 170:929, 1969.
hemorrhage. In this series seven patients sustained 19. Pickleman, J. and Block, G.: Adjuncts to the Operative Man-
cardiac arrest in the emergency room and two eventually agement of Penetrating Liver Injuries. Arch. Surg., 106:
survived. Thirteen arrested during surgery before control 402, 1973.
of hemorrhage was attained and eight arrested after con- 20. Pringle, J. H.: Notes on the Arrest of Hepatic Hemorrhage.
trol was obtained but before a definitive procedure could Ann. Surg., 48:541, 1908.
be performed. All of these patients represent a very high 21. Quattlebaum, J. K. and Quattlebaum, J. K., Jr.: Technique of
Hepatic Lobectomy. Ann. Surg., 149:648, 1959.
risk group and salvage was not high.
Overall mortality in this series has increased slightly 22. Richie, J. P. and Fonkalsrud, E.: Subcapsular Hematoma of
the Liver. Arch. Surg., 104:781, 1972.
from the previous series from 11.2% to 13%. Most of these 23. Shrock, T., Blaisdell, F. W. and Mathewson, C.: Management
deaths (67.9%) were unrelated to the liver injury and the of Blunt Trauma to the Liver and Hepatic Veins. Arch.
bulk of these were secondary to associated major vessel Surg., 96:698, 1968.
injury. Increased mortality was also noted in those pa- 24. Sparkman, R. S. and Fogelman, M. J.: Wounds of the Liver.
tients with one or more other associated injuries. Ann. Surg., 139:690, 1954.
25. Thal, E. R. and Shires, G. T.: Peritoneal Lavage in Blunt
References Abdominal Trauma. Am. J. Surg., 125:64, 1973.
1. Amerson, R. J., and Stone, H. H.: Experiences in the Man- 26. Walt, A. J.: The Surgical Management of Hepatic trauma and
agement of Hepatic Trauma. Arch. Surg., 100:150, 1970. its Complication. Ann. Roy. Coll. of Surg., 45:319, 1969.
2. Braasch, J. W.: The Surgical Anatomy of the Liver and Pan- 27. White, P. and Clevland, R.: The Surgical Management of
creas. Surg. Clin. N. Amer., 38:747, 1958. Liver Trauma. Arch. Surg., 104:785, 1972.