**8. Conclusion**

Operative intervention is most commonly preferred for penetrating abdominal or thoracic injuries with hemodynamically unstable patients. If the injury is a result of a high-velocity gunshot wound and if there is associated hollow viscus injury, it is always the preferred approach [51]. Hemodynamic status rather than grade of injury is more important indication for operative management in patients with blunt abdominal and chest injuries. As a general rule, a higher-grade injury usually has higher potential for failure of nonoperative manage‐ ment. Emergency laparotomy is also indicated in NOM if there is rebleeding, constant decline of hemoglobin, and increased transfusion requirement, as well as the failure of angioemboli‐

Various surgical methods that are described include direct suture ligation of the parenchymal bleeding vessel, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative, and/or postoperative angioembolization and perihe‐ patic packing. Less preferred methods include anatomical resection of the liver, vascular

Damage control or damage limitation surgery is the concept originated from naval strategy, whereby a ship which has been damaged can be managed with minimal repairs to prevent it from sinking and definitive repairs can wait until it reaches port. One of the approaches includes perihepatic packing and closure of the abdominal incision using either a Bogata bag or a partial closure of proximal abdominal incision. With the similar approach, a minimum surgery is needed to stabilize the patient's condition, and in the meantime, the physiological derangement can be corrected. Damage control surgery is done with main objectives, including stopping any active surgical bleeding and controlling any contamination. The timing of reexploration depends upon many factors, including the correction of acidosis, coagulopathy, and hypothermia (i.e. trauma's lethal triad). The window considered safe during damage control surgery is 12-48 hours for reexploration and formal completion of the surgery [54, 55].

Mortality rates for hepatic injury vary as per grade of the injury, associated injuries, and general condition of the patient. The outcome has improved over the years, and the major contributing factors are the new approaches in form of nonoperative management strategies, damage control, and use of perihepatic packing. Since mortality is rarely seen with Grade I and II injuries, the reduction seen was difficult to perceive. However, reduction in operative mortality has seen a great decline especially for higher-grade liver injuries (Grades III, IV, and V). The overall mortality rate may vary from 10% to 42% as per the higher grade of injuries [31].

Many studies have evaluated factors determining the mortality of hepatic injury treated by surgical management. Various factors have been found to have strong association with rate of

The algorithm for blunt liver trauma management is depicted in Figure 5.

zation of actively bleeding vessels [52].

312 Recent Advances in Liver Diseases and Surgery

ligation and use of the atriocaval shunt [53].

**6.6. Damage control surgery**

**7. Morbidity and mortality**

