What is the optimal operative management for a patient with a liver injury?

Operative Management of Liver Injury

Primary Surgical Approach

The cornerstone of operative management for liver trauma is immediate hemorrhage control through perihepatic packing and damage control techniques, while strictly avoiding major hepatic resections during the initial operation. 1, 2

Indications for Operative Management

Proceed to surgery immediately in patients with:

• Hemodynamic instability (non-responders to resuscitation) 1, 3
• Concomitant internal organ injuries requiring surgery 1
• Evisceration or impalement 1
• Peritonitis on examination 3

Algorithmic Approach to Operative Technique

Step 1: Initial Hemorrhage Control (First Priority)

Manual compression and perihepatic packing are your first-line maneuvers for major hemorrhage and should be employed immediately upon entering the abdomen. 1, 2

For minor to moderate bleeding, use:

• Manual compression alone 1, 2
• Electrocautery or bipolar devices 1, 3
• Argon beam coagulation 1, 3
• Topical hemostatic agents 1, 3
• Omental packing 1, 3

For major hemorrhage, escalate to:

• Hepatic manual compression and perihepatic packing (most successful method) 1, 2
• Pringle maneuver (portal triad clamping) 1, 2
• Ligation of vessels within the wound 1
• Hepatic debridement 1
• Balloon tamponade 1

Step 2: Simultaneous Damage Control Resuscitation

Initiate massive transfusion protocols immediately and aggressively reverse the lethal triad of hypothermia, acidosis, and coagulopathy. 1, 2 Failure to activate these protocols early significantly increases mortality. 2

Step 3: Management of Specific Vascular Injuries

If bleeding persists despite packing and Pringle maneuver:

Hepatic Artery Injuries:

• Attempt primary repair first 1, 2
• If repair impossible, perform selective hepatic artery ligation 1, 2
• Mandatory cholecystectomy if right or common hepatic artery is ligated (prevents gallbladder necrosis) 1, 2
• Consider post-operative angioembolization to reduce complications 1

Portal Vein Injuries:

• Always attempt primary repair 1, 2
• Never ligate the portal vein due to catastrophic risk of liver necrosis and massive bowel edema 1, 2
• If repair impossible, use packing and plan second-look operation 1

Retrohepatic Caval/Hepatic Vein Injuries:

• Perihepatic packing is the safest and most successful approach 1, 2
• Avoid direct repair unless you have extensive experience (high mortality in inexperienced hands) 1
• Lobar resection is a last resort 1

Step 4: What NOT to Do (Critical)

Major anatomic hepatic resections must be avoided during the initial operation. 1, 2 This is a Grade 2B recommendation that directly impacts mortality. 1, 2

• Anatomic resections should only be considered in delayed, staged fashion after patient stabilization 1, 2
• Only perform delayed resection for large devitalized liver portions 1, 2
• Only in centers with necessary expertise 1, 2
• Non-anatomic resection is safer during damage control if absolutely necessary 1

Step 5: Temporary Abdominal Closure

Leave the abdomen open when: 1, 2

• High risk of abdominal compartment syndrome exists 1, 2
• Second-look operation is planned 1, 2
• Patient remains physiologically deranged despite initial control 2

Step 6: Post-Operative Adjuncts

Angioembolization is essential for persistent arterial bleeding after damage control procedures and should be immediately available. 1, 2, 3 This is a Grade 2A recommendation. 1

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may serve as a temporizing bridge to definitive control in exsanguinating patients. 2, 3

Common Pitfalls to Avoid

• Attempting major resection during initial operation increases mortality dramatically 1, 2, 4
• Ligating the portal vein leads to liver necrosis and bowel edema 1, 2
• Delaying massive transfusion protocol activation worsens the lethal triad 1, 2
• Attempting direct repair of retrohepatic caval injuries without expertise has prohibitively high mortality 1
• Forgetting cholecystectomy after hepatic artery ligation results in gallbladder necrosis 1, 2

Nuances in Evidence

While the World Journal of Emergency Surgery guidelines from 2016 remain the definitive framework 1, recent evidence confirms that despite advances in resuscitation and surgical techniques, operative mortality for grades IV-V injuries has not significantly improved over 30 years. 4 This underscores the critical importance of damage control principles and avoiding aggressive resection during initial surgery. 1, 2, 4