**6.1. Liver injuries**

are more common in urban areas. The specific type of injury varies according to whether the trauma is penetrating or blunt. The mechanism of injury in blunt trauma is rapid deceleration, and noncompliant organs such as the liver, spleen, pancreas, and kidneys are at greater risk of

Deaths from abdominal trauma result principally from hemorrhage or sepsis. Most deaths from abdominal trauma are preventable. Patients at risk of abdominal injury should undergo prompt and thorough evaluation. In some cases, dramatic physical findings may be due to abdominal wall injury in the absence of intraperitoneal injury. If the results of diagnostic studies are equivocal, diagnostic laparoscopy or exploratory laparotomy should be consid-

Penetrating injuries may cause sepsis if they perforate a hollow viscous. Increasing abdominal tenderness demands surgical exploration. White blood cell count elevations and fever appear-

Penetrating injuries can cause severe and early shock if they involve a major vessel or the liver. Penetrating injuries of the spleen, pancreas, or kidneys usually do not bleed massively unless a major vessel to the organ (e.g., renal artery) is damaged. Bleeding must be controlled promptly. A patient in shock with a penetrating injury of the abdomen who does not respond to 2 L of fluid resuscitation should be operated on immediately following chest

The treatment of hemodynamically stable patients with penetrating injuries to the lower chest or abdomen varies. All surgeons agree that patients with signs of peritonitis or hypovolemia should undergo surgical exploration, but treatment is less certain for patients with no signs of

Most stab wounds of the lower chest or abdomen should be explored, since a delay in treatment of hollow viscous perforation can result in severe sepsis. Some surgeons have recommended a selective policy in the management of these patients. When the depth of injury is in doubt, local wound exploration may rule out peritoneal penetration. Laparoscopy may ultimately have a role in the evaluation of penetrating injuries. All gunshot wounds of the lower chest and abdomen should be explored because the incidence of injury to major intra-

Blunt abdominal trauma (BAT) comprises 75% of all blunt trauma and is the most common example of this injury. The majority occurs in motor vehicle accidents, in which rapid deceleration may propel the driver into the steering wheel, dashboard, or seatbelt causing contusions in less serious cases, or rupture of internal organs from briefly increased intraluminal pressure in the more serious, dependent on the force applied. It is important to note that initially there may be little in the way of overt clinical signs to indicate that serious internal abdominal injury has occurred, making assessment more challenging and requiring a high

ered, since they may be lifesaving if serious injuries are identified early.

ing several hours following injury are keys to early diagnosis.

peritonitis or sepsis who are hemodynamically stable [12].

abdominal structures is 90% in such cases [13].

injury due to parenchymal fracture.

**5.1. Penetrating trauma**

X-ray [11].

82 Trauma Surgery

**5.2. Blunt trauma**

degree of clinical suspicion [14].

Numerous methods for the definitive control of hepatic hemorrhage have been developed. Minor lacerations may be controlled by direct compression to the injury site. For similar injuries which do not respond to compression, topical hemostatic techniques have been successful. Small bleeding vessels may be controlled electrocautery. Microcrystalline collagen can be used. The powder is placed on a clean sponge and applied directly to the site. Pressure is maintained for 5–10 min. Fibrin glue has been used for both superficial and deep lacerations and appears to be an effective topical agent [18].

Suturing of the hepatic parenchyma remains an effective hemostatic technique. Although this treatment has been maligned as a cause of hepatic necrosis, hepatic sutures are often used for persistently bleeding lacerations less than 3 cm in depth. It is also an appropriate alternative for deeper lacerations if the patient will not tolerate further hemorrhage. The preferred suture is 2–0 or 0 chromic attached to a large and curved blunt needle. The large diameter of the suture helps prevent it from pulling through Glisson's capsule [19].

Most sources of venous hemorrhage within the liver can be managed with parenchymal sutures, and even injuries of the retrohepatic vena cava and hepatic veins have been successfully tamponaded by closing the hepatic parenchyma over the bleeding vessel [20].

Venous hemorrhage due to penetrating wounds that transverse the central portion of the liver can be managed by suturing the entrance and exit wounds with horizontal mattress sutures. Although intrahepatic hematomas may form that can become infected, this may be preferable to an intracaval shunt or deep hepatotomy. Suturing of the hepatic parenchyma is not always successful in controlling the hemorrhage particularly if it is of arterial origin [21].

Hepatic arterial ligation may be appropriate for patients with recalcitrant arterial hemorrhage from deep within the liver. However, its utility is limited since hemorrhage from the portal and hepatic venous systems will continue. Arterial ligation is a reasonable alternative to a deep hepatotomy particularly in unstable patients [22]. While ligation of the right or left hepatic artery is well tolerated in humans, ligation of the proper hepatic artery is not necessarily associated with survival. The fate of the dearterialized lobe is unpredictable [23].

An uncommon but perplexing hepatic injury is the subcapsular hematoma. This lesion occurs when the parenchyma of the liver is disrupted by blunt trauma, but Glisson's capsule remains intact. The hematoma may be recognized either at the time of the surgery or preoperatively if a CT is performed. Regardless of how the lesion is diagnosed, subsequent decision making is often difficult.

Resectional debridement is indicated for the removal of peripheral portions of nonviable hepatic parenchyma. The mass of tissue removed should rarely exceed 25% of the liver. Since additional blood loss may occur, it should be reserved for patients who are in good metabolic condition and who will tolerate additional blood loss.

Omentum has been used to fill large defects in the liver. The rationale for this is that it provides an excellent source of macrophages and that it fills a potential dead space with a viable tissue. The omentum can also provide a little additional support for parenchymal sutures and is often strong enough to prevent them from cutting through Glisson's capsule [24].

Since hemorrhage from hepatic injuries is often treated without identifying and controlling each individual bleeding vessel, arterial pseudoaneurysm may develop (**Table 3**). If the pseudoaneurysm enlarges, it will eventually rupture into the parenchyma of the liver, a bile duct, or into adjacent portal venous branch (**Figure 3**).
