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KEY POINTS

KEY POINTS

  • Sixty to ninety percent of hepatic injuries are treated nonoperatively.

  • A contrast-enhanced computed tomography scan documenting extravasation in the liver may require angioembolization or operation.

  • Organ Injury Scale grade I or II hepatic injuries do not require drains at laparotomy; for higher grade injuries with evidence of biliary leak at laparotomy, drainage should be considered.

  • Partial disruption of hepatic segments II/III or VI/VII are managed with resectional debridement at the time of laparotomy.

  • Perihepatic packing is useful in selected patients with intraoperative coagulopathies or ongoing bleeding.

INTRODUCTION

Due to its large size, the liver is one of the most commonly injured organs after trauma.1 The size of the organ and its position under the right costal margin make the liver susceptible to both blunt and penetrating trauma to the right thoracoabdomen and right upper quadrant of the abdomen. The management of hepatic injuries continues to evolve with improved modes of diagnosis and nonoperative and operative management. The most severe hepatic parenchymal and retrohepatic venous injuries, as well as those involving the portal triad, continue to have a high mortality; therefore, despite progress, the opportunity for further improvements in management exists.

ANATOMY

A comprehensive knowledge of hepatic anatomy is essential to the proper treatment of trauma to the liver (See Atlas Figure 41). An understanding of the ligamentous attachments, parenchyma, and intraparenchymal and extraparenchymal vascularity of the liver is key to the effective application of methods for control and repair of hepatic injuries (Fig. 33-1).

FIGURE 33-1

Surgical anatomy of the liver: (1) inferior vena cava; (2) right hepatic vein; (3) middle hepatic vein; (4) left hepatic vein; (5) portal vein; (6) right branch portal vein; (7) left branch portal vein; (8) right triangular ligament; (9) coronary ligament; (10) left triangular ligament; (11) falciform ligament; (12) ligamentum teres.

Lobes

The liver is divided into two lobes by a 75° angle line traversing from the gallbladder fossa inferiorly to the left side of the inferior vena cava superiorly. The left lobe includes the hepatic tissue to the left of the falciform ligament along with the quadrate and caudate lobes, whereas the right lobe consists of the remaining parenchyma.

Functional Anatomy

The functional anatomy of the liver separates the liver into segments pertinent to resection (See Atlas Figure 42). Couinaud provided the basis of modern resection planes by dividing the liver into eight segments (I–VIII) based on the distribution of the portal vein (horizontal plane) and hepatic veins (vertical planes).2 The horizontal plane divides the sections of the liver into superior and inferior segments, as follows:

  • Right anterior (or medial) section: Segment V below the portal plane and segment VIII ...

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