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

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

Blood Institute – is a universal therapeutic viro-inactivated plasma that can be reconstituted in <6 min at the point-of-care and is compatible with any blood type [44]. Data suggest that French lyophilized plasma can be used more rapidly correct for the trauma-induced coagulopathy compared to fresh frozen plasma, particularly in the military setting [45]. Its role against normal saline in the management of post-traumatic coagulopathy prevention and correction in the pre-hospital civilian setting is currently under investigation (PREHO-PLYO study) [46], and it is awaited to revolutionize the current state of practice for the management of severe trauma, including liver injury.

Once the patients reach the emergency room, immediate assessment by the trauma team and damage control resuscitation is vital. The surgical and critical care teams should strive towards obtaining vascular access with two large-bore catheters, inserting nasogastric tube and urinary catheter (unless there is blood at the urethral meatus, high riding prostate or prevalent perineal hematoma), rapid induction of anesthesia, drainage of the chest (if needed), intravenous broadspectrum antibiotics and tetanus prophylaxis (if indicated), rapid rewarming and prevention of further hypothermia, and expedited transport to the operating room for DCS [30].

#### **9.2 Damage control phase I (DCI)**

DCI starts with the exploratory laparotomy, which aims to control bleeding and limit contamination, and ends with the temporary closure of the abdominal wall. After the patient is positioned in a "cruciform" lie, the patient is prepped from chin to mid-thighs and a vertical midline incision from the xiphoid process to the pubic symphysis is made [30]. If the suspicion for a severe fracture of the pelvis is high, the incision should be limited just below the umbilicus to facilitate continuous tamponade of the suspected pelvic hematoma. If the patient is unstable, the incision should not be delayed if arterial or venous lines are not in place; these can be inserted during the operation.

If the observed intra-abdominal bleeding is not considered to be major, compression on its own or the use of topical hemostatic agents, bipolar devices or electrocautery, argon beam coagulation, omental patching or even simple suturing of the liver parenchyma may be adequate to control the hemorrhage [2, 20, 47–49]. In the case of massive intra-abdominal hemorrhage, more aggressive maneuvers should be adopted, including perihepatic packing and manual compression, or even hepatic vascular isolation (i.e., intrahepatic balloon tamponade) [50, 51]. Injuries to the portal vein should be primarily repaired, while ligation of the portal vein should be considered only as an alternative – provided that the proper hepatic artery is intact – due to the increased risk of hepatic necrosis or massive intestinal edema [47]. Data suggest preferring liver packing or resection over portal vein ligation if only lobar or segmental branches of the portal vein are injured [2, 47, 52]. However, portal vein ligation is safer than arterial ligation regarding biliary complications or hepatic necrosis, and may even prepare the liver for staged extended liver resection [53]. If the surgeon comes across a proper hepatic artery injury, they should shoot for a primary repair; otherwise, selective hepatic artery ligation should be preferred, and if the common or right hepatic artery is to be ligated, cholecystectomy should follow to prevent gallbladder necrosis [1, 52]. When arterial control or the Pringle maneuver is inadequate to control the hemorrhage, the surgeon should suspect that there might be an aberrant hepatic artery [47]. If the bleeding arises from the area behind the liver, the injury is most likely to be found on the hepatic or retro-hepatic caval vein [2, 47, 54]. Inserting vascular shunts (i.e., atrio-caval shunt) might also be useful to control hemorrhage [29, 47]. In case of persistent

**45**

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

avoid abdominal compartment syndrome [30].

may help identify previously unknown injuries.

**9.4 Damage control phase III (DCIII)**

**9.3 Damage control phase II (DCII)**

bleeding and hemodynamic instability, resuscitative endovascular balloon occlusion of the aorta in the zone I and of the vena cava at the level of the retro-hepatic vena cava can serve as a bridge to more definitive procedures [47]. Liver resection should be avoided at this phase, but if absolutely necessary, non-anatomic resections should be preferred [2, 47, 48, 52], while resection of a hemorrhaging spleen or kidney can be performed, if needed in order to stop the bleeding [29]. Angioembolization should be advocated for either stable patients after the initial surgical hemostatic attempt or adjunctively in case of suspected uncontrolled bleeding despite the surgical hemostatic attempt [2, 47, 55]; data also suggest that its routine implementation immediately after DCS can significantly improve survival in grade IV or V liver injury [56]. Regarding contamination control, intrahepatic abscesses can be managed with percutaneous drainage, and bilomas may either resolve spontaneously or should also be managed with percutaneous drainage potentially with adjunct therapeutic endoscopic retrograde cholangiopancreatography and stent placement [47]. Abdominal wall closure is the final step before transitioning to DCII (transfer to the ICU) and should be only temporary without fascial closure to

DCII involves taking the patient to the ICU postoperatively, where the goal is to restore the biochemical and physiological derangements. Managing fluid administration to bring the patient back to hemodynamic stability is often achieved through invasive monitoring (i.e., transthoracic echocardiography, transesophageal Doppler, pulmonary artery catheterization, etc.) [30]. Securing adequate oxygenation and aggressive rewarming of the patient are also necessary. The management of coagulopathy is crucial for survival, and the use of rotational thromboelastometry and other tests to assess how the coagulation cascade works along with massive blood transfusion practices have led to an improvement in outcomes and a decrease in blood transfusion requirements [30, 57]. Prevention of potentially fatal complications commonly seen in the ICU, including infection, adult respiratory distress syndrome, and deep vein thrombosis, is also important for patient survival [29]. This is the perfect opportunity for treating physicians to perform a complete reassessment of the patient and a "tertiary survey", including imaging studies that

DCIII involves definite repair of the injuries once the patient is stabilized and has returned to his "physiologic normality" and commonly takes place within 24–72 hours after admission to the ICU. The patient is taken back to the operating room for re-exploration and packing removal (preferably after 48 hours) [21]. That is also the stage when an anatomic liver resection may be performed (**Figure 3**), along with the removal of devitalized tissue or vascular shunts, anastomosis of vessels or bowel, or even a feeding jejunostomy. The phase ends with the permanent closure of the abdominal wall. This should be performed with the approximation of the fascial edges if gentle adduction permits; if this is not possible due to retroperitoneal or bowel wall edema, then the abdominal wall should be again only temporarily closed with the fascia left open. In that scenario, the patient is taken back to the ICU and provided the patient is hemodynamically stable, administration of diuretics to decrease the bowel edema should be considered [30]. This situation should then be managed with washouts and re-inspection of the abdomen regularly, while primary closure should be completed within seven days, particularly in the absence of signs

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

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

including liver injury.

for DCS [30].

during the operation.

**9.2 Damage control phase I (DCI)**

Blood Institute – is a universal therapeutic viro-inactivated plasma that can be reconstituted in <6 min at the point-of-care and is compatible with any blood type [44]. Data suggest that French lyophilized plasma can be used more rapidly correct for the trauma-induced coagulopathy compared to fresh frozen plasma, particularly in the military setting [45]. Its role against normal saline in the management of post-traumatic coagulopathy prevention and correction in the pre-hospital civilian setting is currently under investigation (PREHO-PLYO study) [46], and it is awaited to revolutionize the current state of practice for the management of severe trauma,

Once the patients reach the emergency room, immediate assessment by the trauma team and damage control resuscitation is vital. The surgical and critical care teams should strive towards obtaining vascular access with two large-bore catheters, inserting nasogastric tube and urinary catheter (unless there is blood at the urethral meatus, high riding prostate or prevalent perineal hematoma), rapid induction of anesthesia, drainage of the chest (if needed), intravenous broadspectrum antibiotics and tetanus prophylaxis (if indicated), rapid rewarming and prevention of further hypothermia, and expedited transport to the operating room

DCI starts with the exploratory laparotomy, which aims to control bleeding and limit contamination, and ends with the temporary closure of the abdominal wall. After the patient is positioned in a "cruciform" lie, the patient is prepped from chin to mid-thighs and a vertical midline incision from the xiphoid process to the pubic symphysis is made [30]. If the suspicion for a severe fracture of the pelvis is high, the incision should be limited just below the umbilicus to facilitate continuous tamponade of the suspected pelvic hematoma. If the patient is unstable, the incision should not be delayed if arterial or venous lines are not in place; these can be inserted

If the observed intra-abdominal bleeding is not considered to be major, compression on its own or the use of topical hemostatic agents, bipolar devices or electrocautery, argon beam coagulation, omental patching or even simple suturing of the liver parenchyma may be adequate to control the hemorrhage [2, 20, 47–49]. In the case of massive intra-abdominal hemorrhage, more aggressive maneuvers should be adopted, including perihepatic packing and manual compression, or even hepatic vascular isolation (i.e., intrahepatic balloon tamponade) [50, 51]. Injuries to the portal vein should be primarily repaired, while ligation of the portal vein should be considered only as an alternative – provided that the proper hepatic artery is intact – due to the increased risk of hepatic necrosis or massive intestinal edema [47]. Data suggest preferring liver packing or resection over portal vein ligation if only lobar or segmental branches of the portal vein are injured [2, 47, 52]. However, portal vein ligation is safer than arterial ligation regarding biliary complications or hepatic necrosis, and may even prepare the liver for staged extended liver resection [53]. If the surgeon comes across a proper hepatic artery injury, they should shoot for a primary repair; otherwise, selective hepatic artery ligation should be preferred, and if the common or right hepatic artery is to be ligated, cholecystectomy should follow to prevent gallbladder necrosis [1, 52]. When arterial control or the Pringle maneuver is inadequate to control the hemorrhage, the surgeon should suspect that there might be an aberrant hepatic artery [47]. If the bleeding arises from the area behind the liver, the injury is most likely to be found on the hepatic or retro-hepatic caval vein [2, 47, 54]. Inserting vascular shunts (i.e., atrio-caval shunt) might also be useful to control hemorrhage [29, 47]. In case of persistent

**44**

bleeding and hemodynamic instability, resuscitative endovascular balloon occlusion of the aorta in the zone I and of the vena cava at the level of the retro-hepatic vena cava can serve as a bridge to more definitive procedures [47]. Liver resection should be avoided at this phase, but if absolutely necessary, non-anatomic resections should be preferred [2, 47, 48, 52], while resection of a hemorrhaging spleen or kidney can be performed, if needed in order to stop the bleeding [29]. Angioembolization should be advocated for either stable patients after the initial surgical hemostatic attempt or adjunctively in case of suspected uncontrolled bleeding despite the surgical hemostatic attempt [2, 47, 55]; data also suggest that its routine implementation immediately after DCS can significantly improve survival in grade IV or V liver injury [56]. Regarding contamination control, intrahepatic abscesses can be managed with percutaneous drainage, and bilomas may either resolve spontaneously or should also be managed with percutaneous drainage potentially with adjunct therapeutic endoscopic retrograde cholangiopancreatography and stent placement [47]. Abdominal wall closure is the final step before transitioning to DCII (transfer to the ICU) and should be only temporary without fascial closure to avoid abdominal compartment syndrome [30].
