Chapter 29

Liver injury occurs in approximately 5% of all trauma admissions.1 The liver’s size and anatomic location, directly under the right costal margin, make it the most susceptible organ for injury in blunt trauma and a frequently involved organ in penetrating trauma. The management of liver injury has evolved greatly over the last decade. There have been many technical advances in medicine, which now allow us to better diagnose and treat liver injuries both operatively and nonoperatively. However, the most severe liver parenchymal and venous injuries as well as those involving the portal triad continue to challenge even the most adept trauma or hepatobiliary surgeon and often lead to death. Therefore, despite our progress in liver injury management, many avenues for improvement remain to be explored.

Liver injury management has been described in many of the early surgical textbooks. We consider nonoperative management of hepatic injury a modern approach; however, a 1905 surgical text states, “If the evidences of a rupture of the liver, such as the signs of shock and hemorrhage …. the continuous increase in pain, due to progressive abdominal distention, and muscular rigidity, are absent, no operative intervention can be considered.”2 Mortality from liver injury was as high as 62.5% in these early years.3 Pringle wrote a landmark paper examining the management of severe liver injury in 1908.4 Although many authors previous to this paper had described suturing methods of liver parenchyma as well as gauze packing into the liver laceration, Pringle described a maneuver of occluding the porta hepatis with the surgeon’s fingers and thus decreasing the amount of hemorrhage from a severely injured liver. This procedure continues to be a useful tool in the management of liver trauma.

During World War II, new ideas in the management of severe liver injury surfaced. Madding et al. used the principles of early laparotomy, drainage procedures, advances in anesthetic and aseptic care, as well as transfusion technology to improve mortality to 27.7%.5 The techniques of hemorrhage control adopted at that time incorporated parenchymal reapproximation with large blunt liver needles, resection, and direct vessel ligation. These methods prevailed until approximately 10 years ago. Trends in management have now led to an emphasis on nonoperative treatment for those patients who remain hemodynamically stable and liver packing with damage control for those who are unstable.

Comprehensive knowledge of hepatic anatomy is essential to the proper management of traumatic liver injuries. The 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 in liver injuries (Fig. 29-1).

###### Figure 29-1

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 ...

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