What is the primary approach for damage control surgery in cases of severe liver injury?

Damage Control Surgery for Severe Liver Trauma

Primary Approach

In hemodynamically unstable patients with severe liver injury, the primary surgical approach is immediate hemorrhage control through perihepatic packing and damage control resuscitation, while explicitly avoiding major hepatic resections during the initial operation. 1

Algorithmic Approach to Damage Control Surgery

Initial Surgical Priorities

The fundamental goals during damage control surgery for liver trauma are straightforward and sequential 1:

• Control hemorrhage first - This is the immediate priority that determines survival 1
• Control bile leakage - Secondary but essential to prevent later complications 1
• Initiate damage control resuscitation - Must occur simultaneously with surgical hemorrhage control, including early activation of massive transfusion protocols 1

Hemorrhage Control Techniques (Escalating Approach)

For minor to moderate bleeding 1:

• Manual compression alone may suffice 1
• Electrocautery, bipolar devices, or argon beam coagulation 1
• Topical hemostatic agents 1
• Simple suture of hepatic parenchyma or omental patching 1

For major hemorrhage requiring aggressive intervention 1:

• Perihepatic packing - This is the cornerstone technique and should be employed early rather than late 1, 2
• Manual compression combined with hepatic packing 1
• Pringle maneuver for temporary inflow control 1
• Ligation of vessels within the wound 1
• Hepatic debridement and finger fracture technique 1
• Balloon tamponade for persistent bleeding 1

Critical "What NOT to Do" During Initial Surgery

Major hepatic resections must be avoided during the initial damage control operation 1. This is a Grade 2B recommendation that significantly impacts mortality. Formal anatomic resections should only be considered during subsequent planned operations, performed in a resectional debridement fashion for large areas of devitalized tissue, and only by experienced hepatobiliary surgeons 1.

Management of Specific Vascular Injuries

Hepatic artery injuries 1:

• Attempt primary repair if the patient's condition permits 1
• If repair fails or is not feasible, selective hepatic artery ligation is acceptable 1
• Mandatory cholecystectomy if right or common hepatic artery requires ligation to prevent gallbladder necrosis 1
• Consider post-operative angioembolization as an alternative to reduce complications 1

Portal vein injuries 1:

• Primary repair is mandatory whenever possible 1
• Avoid portal vein ligation due to high risk of liver necrosis and massive bowel edema 1
• If absolutely necessary, ligation can only be performed in patients with intact hepatic artery 1
• Liver packing or resection is preferable to ligation for lobar/segmental injuries 1

Retrohepatic caval/hepatic vein injuries 1:

• Perihepatic packing is the safest initial approach and has the lowest mortality 1
• Direct venous repair carries very high mortality rates, especially in non-experienced hands 1
• Lobar resection is a third option but rarely appropriate in the damage control setting 1

Adjunctive Techniques

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) 1:

• May be used as a temporizing bridge to definitive hemorrhage control in hemodynamically unstable patients 1
• This is a Grade 2B recommendation, indicating it should be considered when available 1

Post-operative angioembolization 1:

• Essential tool for persistent arterial bleeding after damage control procedures 1
• Should be immediately available and considered early rather than returning to the operating room 1

Temporary Abdominal Closure

Temporary abdominal closure should be utilized when 1:

• High risk of abdominal compartment syndrome exists 1
• Planned second-look operation is needed after hemodynamic stabilization 1
• Patient remains physiologically deranged despite initial hemorrhage control 1

Common Pitfalls to Avoid

The "lethal triad" must be aggressively reversed 1:

• Hypothermia, acidosis, and coagulopathy drive mortality in severe liver trauma 1
• Prolonged operative time attempting definitive repair worsens this triad 1
• Early decision to pack and get out of the abdomen is lifesaving 2, 3

Delayed decision-making on damage control 2, 3:

• Surgeons must determine early in the operation whether abbreviated laparotomy with packing is indicated 4
• Attempting complex repairs in unstable patients significantly increases mortality 2, 3
• The 2015 study showed no mortality difference between damage control and definitive repair when appropriately selected, but non-survivors had significantly more transfusions, indicating delayed hemorrhage control 2

Failure to activate massive transfusion protocols early 1:

• Simultaneous intraoperative intensive resuscitation is of paramount importance 1
• Early institution of massive transfusion protocol maintains organ perfusion and reverses physiological derangements 1