**5. Initial assessment and investigation**

A liver injury should always be suspected in all patients suffering from a blunt or penetrating thoracoabdominal trauma, especially at the right site. Initial management of these patients should be based on the Advanced Trauma Life Support (ATLS) guidelines with fluid resuscitation and close monitoring being the first priorities [22]. Depending on the underlying injury mechanism, other concurrent injuries should also be evaluated and treated accordingly. The management of multi-trauma patients should take into consideration all the affected organs, and a multidisciplinary team is essential for the optimal treatment approach of these patients.

As far as hepatic trauma is concerned, in hemodynamically unstable patients, despite adequate fluid resuscitation, an immediate operation for bleeding control is indicated, whereas in stable patients, an appropriate workup protocol using ultrasonography or computerized tomography scanning (CT) can be followed. Hemodynamic instability is characterized by the following: heart rate > 120 bpm, systolic blood pressure < 90 mmHg, low urine output, increased respiratory rate (>30 respirations/minute), signs of skin vasoconstriction and altered level of consciousness [22]. Non-operative management necessitates medical centers capable of an accurate injury severity diagnosis, intensive management of patients, and prompt access to diagnostic modalities, interventional radiology, operation theater, and blood–blood products [20, 23].

**Figure 2.** *Computed tomography scan demonstrating a severe liver injury.*

Ultrasound plays a significant role in the proper investigation of abdominal injuries. Focused Assessment with Sonography for Trauma (FAST) can be performed immediately at the emergency department and can help assess the pericardium, hepatorenal space (Morison's pouch), perisplenic space and Douglas pouch to identify the presence of free fluid [22]. More detailed ultrasonography by an experienced radiologist is necessary for a more accurate investigation of liver parenchyma. Ultrasonography has widely replaced diagnostic peritoneal lavage (DPL) and has a high specificity of 95–100% [24]. Nevertheless, ultrasound examination is highly operator-depended and should be performed by experienced clinicians.

Computerized tomography (CT) scan is a valuable tool for the evaluation of stable patients with an abdominal injury [25]. A contrast-enhanced, multi-slice CT scan is reported to have a sensitivity and specificity of over 95% for detecting liver injuries [26, 27]. Subscapular and intraparenchymal hematomas, lacerations, and vascular injuries can be recognized. Furthermore, an active hemorrhage can be visualized as an extravasation of contrast medium. A CT scan can also successfully elucidate other abdominal injuries involving the spleen, kidneys, and bowel [26]. Finally, a follow-up CT scan can be utilized for the detection of delayed liver injury complications, including delayed hemorrhage, bile leak, biloma, arteriovenous malformations, and liver abscesses [4, 28].

### **6. Damage control surgery - general**

Damage control surgery refers to the immediate steps taken in order to reduce blood loss, the risk of sepsis, morbidity, and mortality instead of a thorough patient workup in the intensive care unit (ICU) [29]. DCS has significantly improved the outcomes of patients presenting at the hospital with severe organ injuries, including liver injuries, and hemodynamic instability due to maneuvers to control the bleeding [1]. Uncontrolled bleeding can lead to coagulopathy secondary to the dilution and depletion of the coagulation factors, hypothermia, and acidosis, the so-called "lethal triad" or "medical bleeding" [21]. The onset of this series of events may necessitate the need for DCS, including temporary (perihepatic) packing of the bleeding sites, where physiological recovery is prioritized over anatomical repair [30].

### **7. Damage control surgery – history**

The earliest report on perihepatic packing to prevent uncontrolled bleeding from injuries to the liver dates back to 1908 by James Pringle [31], while later in 1913, Halstead described the use of a rubber sheet between the injured liver and the gauze packs [32]. Despite the improvements in outcomes, perihepatic packing was sparsely described in the literature [33] until Stone et al. [34] reported a survival rate of 76% in patients managed with "truncated laparotomy" compared to 7% in patients managed with definitive surgical repair. Rotondo et al. [35] introduced the term "damage control laparotomy" and demonstrated that this approach could improve survival in hemorrhaging trauma patients (requiring transfusion of >10 units of packed red blood cells) with multiple visceral penetrating injuries and major vessel injuries. The authors described the three steps of their approach, and the same research group later modified it by introducing a fourth pre-operative phase (**Table 3**) [36]. Since then, DCS has been successfully implemented for the management of major liver injury with optimal outcomes. The use of angioembolization in more recent series has been proposed as the logical augmentation

**43**

*Damage Control Surgery for Liver Trauma DOI: http://dx.doi.org/10.5772/intechopen.94109*

**Description**

• Recognition of injury pattern

• Rewarming maneuvers

• Abdominal packing • Temporary wound closure

• Immediate blood component replacement

• Physiological and biochemical stabilization • Thorough tertiary examination to identify all injuries

• Immediate exploratory laparotomy • Rapid bleeding and contamination control

• Re-exploration in operating room • Definitive repair of all injuries

DC0 • Truncated scene times

DCI • Once in the operating room

DCII • Once in the intensive care unit

DCIII • Once physiology is normalized

injured

**Damage control (DC) Phase**

**Table 3.**

of damage control approaches to control bleeding, but particularly in the case of

*The four Phases of damage control for exsanguinating penetrating abdominal injury by Johnson et al.*

• May require multiple visits to the operating room if multiple systems are

As mentioned earlier, DCS can play a vital role in the setting of the "lethal triad" and thus metabolic acidosis (pH <7.2), hypothermia (<34°C), and coagulopathy (prolonged activated partial thromboplastin time and prothrombin time > two times normal) constitute absolute indications for DCS. Uncontrolled major intraabdominal bleeding, association with extra-abdominal injury, >10 units of blood transfusion, and hemodynamic instability (low blood pressure and tachycardia) are

DC0 constitutes the first phase of the DCS process and takes place in the prehospital setting and in the emergency room. The most crucial aspects of this phase are injury pattern recognition in order to determine which patients will most likely benefit from DCS according to the absolute and relative indications, and the "scoop and run" concept to truncate scene times. The administration of blood products and tranexamic acid in the pre-hospital setting has been increasingly used [38, 39]. Given the significant improvements in trauma resuscitation strategies aiming at rapid bleeding control, management of coagulopathy, and diversion away from the over-resuscitation with crystalloids, the use of DCS may be required to a lesser extent in the future [40–42]. There is a growing body of evidence that the use of a high plasma to packed red blood cell ratio can lead to a decrease in hemorrhage-related mortality [43]. French lyophilized plasma – manufactured by the French Military

high-grade injuries, it may lead to major hepatic necrosis [37].

**8. Damage control surgery – indications**

relative indications for DCS [29].

**9. Damage control surgery – phases**

**9.1 Damage control phase 0 (DC0)**

### *Damage Control Surgery for Liver Trauma DOI: http://dx.doi.org/10.5772/intechopen.94109*


**Table 3.**

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

Ultrasound plays a significant role in the proper investigation of abdominal injuries. Focused Assessment with Sonography for Trauma (FAST) can be performed immediately at the emergency department and can help assess the pericardium, hepatorenal space (Morison's pouch), perisplenic space and Douglas pouch to identify the presence of free fluid [22]. More detailed ultrasonography by an experienced radiologist is necessary for a more accurate investigation of liver parenchyma. Ultrasonography has widely replaced diagnostic peritoneal lavage (DPL) and has a high specificity of 95–100% [24]. Nevertheless, ultrasound examination is highly

Computerized tomography (CT) scan is a valuable tool for the evaluation of stable patients with an abdominal injury [25]. A contrast-enhanced, multi-slice CT scan is reported to have a sensitivity and specificity of over 95% for detecting liver injuries [26, 27]. Subscapular and intraparenchymal hematomas, lacerations, and vascular injuries can be recognized. Furthermore, an active hemorrhage can be visualized as an extravasation of contrast medium. A CT scan can also successfully elucidate other abdominal injuries involving the spleen, kidneys, and bowel [26]. Finally, a follow-up CT scan can be utilized for the detection of delayed liver injury complications, including delayed hemorrhage, bile leak, biloma, arteriovenous

Damage control surgery refers to the immediate steps taken in order to reduce

blood loss, the risk of sepsis, morbidity, and mortality instead of a thorough patient workup in the intensive care unit (ICU) [29]. DCS has significantly improved the outcomes of patients presenting at the hospital with severe organ injuries, including liver injuries, and hemodynamic instability due to maneuvers to control the bleeding [1]. Uncontrolled bleeding can lead to coagulopathy secondary to the dilution and depletion of the coagulation factors, hypothermia, and acidosis, the so-called "lethal triad" or "medical bleeding" [21]. The onset of this series of events may necessitate the need for DCS, including temporary (perihepatic) packing of the bleeding sites, where physiological recovery is

The earliest report on perihepatic packing to prevent uncontrolled bleeding from injuries to the liver dates back to 1908 by James Pringle [31], while later in 1913, Halstead described the use of a rubber sheet between the injured liver and the gauze packs [32]. Despite the improvements in outcomes, perihepatic packing was sparsely described in the literature [33] until Stone et al. [34] reported a survival rate of 76% in patients managed with "truncated laparotomy" compared to 7% in patients managed with definitive surgical repair. Rotondo et al. [35] introduced the term "damage control laparotomy" and demonstrated that this approach could improve survival in hemorrhaging trauma patients (requiring transfusion of >10 units of packed red blood cells) with multiple visceral penetrating injuries and major vessel injuries. The authors described the three steps of their approach, and the same research group later modified it by introducing a fourth pre-operative phase (**Table 3**) [36]. Since then, DCS has been successfully implemented for the management of major liver injury with optimal outcomes. The use of angioembolization in more recent series has been proposed as the logical augmentation

operator-depended and should be performed by experienced clinicians.

malformations, and liver abscesses [4, 28].

**6. Damage control surgery - general**

prioritized over anatomical repair [30].

**7. Damage control surgery – history**

**42**

*The four Phases of damage control for exsanguinating penetrating abdominal injury by Johnson et al.*

of damage control approaches to control bleeding, but particularly in the case of high-grade injuries, it may lead to major hepatic necrosis [37].
