**6. Indications**

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

sensitivity to detect active bleeding in a solid abdominal organ. In recent years, US using contrast agents could greatly improve the detection of bleeding. Recently, contrast US has mainly depended on two-dimensional ultrasound (2DUS). With the development of imaging technology, three-dimensional static ultrasound (3DSUS) and real-time three-dimensional ultrasound (RT3DUS) can provide more accurate images and additional information in some assessments of abdominal disease. Thus, there are new technologies and possibilities for measuring the degree of hepatic impairment, but these are not always available, and sometimes just the physical

*Active bleeding. Active contrast leakage (arrow) is observed in a patient with severe hepatic trauma. Associated* 

*Extension to the inferior vena cava. There is a large hepatic termination with extension to the inferior vena cava (arrow), which appears to be free of perihepatic primary fluid and active for bleeding (asterisk).*

The treatment for liver trauma has been modified over the years, since the beginning of the twentieth century, when aggressive surgical treatment

examination is possible as a diagnostic tool [8].

*perihepatic fluid (hemoperitoneum). Splenic infarction (\*).*

**56**

**5. Treatment**

**Figure 2.**

**Figure 3.**

"Miss nothing and fix everything" has long been the dogma for emergency management of visceral trauma, which imposed obligatory emergency laparotomy for any hemoperitoneum. For blunt hepatic trauma, that attitude has been gradually transformed since the 1970s, moving toward avoidance of emergency laparotomy whenever possible [9–11]. Introduction nonoperative management of blunt liver injury has been proven to be an effective treatment option since the late 1990s, regardless of the degree of injury as long as the patient's condition remains stable [12–14].

Currently, nonoperative management is undertaken in 60–80% of blunt traumatic liver injuries, and [15, 16] the success rate is 82–100% [8, 15, 17]. The overall mortality and morbidity of those cases is 5–8 and 14–18%, respectively [15–17]. The overall mortality in surgically managed patients is 9–18%, but in high-grade injuries (grades III–V) the mortality is around 40%, and the overall morbidity in operated patients is 30–40% [15, 17]. Coimbra et al. [18] have reported that nonoperative management reduces the overall mortality of grade III and IV blunt liver injuries [19].

This approach has been supported by not only the contribution of contrastenhanced CT [9–11] but the endoscopic and radiological adjunctive interventional procedures as well, which have expanded its scope and helped managing postoperative complications [15].

A review of the literature about the indications and effectiveness of liver angioembolization in the context of trauma showed that the main indications for this procedure are the presence of contrast blush on CT scan (the most common) and failure in nonoperative management and control of continued bleeding after damage control surgery. The authors included 11 articles related to the topic, with the rate of effectiveness of hepatic angioembolization being 93%, and the main complications highlighted were the presence of liver necrosis (15%), abscess formation (7.5%), and biliary leakage [20].
