**8.2 Intra-abdominal packing**

Damage control surgery by intra-abdominal packing has shown to be effective and able to significantly decrease morbidity and mortality, both in trauma and nontraumatic massive intra-abdominal hemorrhage [34]. In the last decades, consensus has been reached about considering the accomplishment of an effective perihepatic packing [35] to be the most effective and quickest way in order to obtain hemorrhage control [21].

This procedure consists in the placement, after fast and complete mobilization of the right liver lobe, of a total number of eight lap pads all around the posterior paracaval surface (avoiding vena cava compression), the lateral right side, the anterior surface, and posteroinferior visceral surface of the liver (avoiding any intrahepatic packing) [36, 45]. The diaphragmatic surface must remain free in order to avoid any respiratory compromise. Reoperation after appropriate resuscitation allows packing removal and definitive repair of liver injuries.

### **8.3 Indications for damage control surgery**

Regarding the indications for damage control surgery, it is known that there is a wide range of conditions in which it can be used, and the decisive moment for the use of these techniques is not preoperative adequacy, but the intraoperative becomes essential for the evaluation [37].

Overall, in the context of severe trauma with hemodynamic instability, the rationale of performing a "shortened laparotomy" is usually based upon the concept of the lethal triad [25], composed of hypothermia (due to inadequate environmental conditions, deficient thermal protection, blood loss, and infusion of unheated liquids), metabolic acidosis (inadequate tissue perfusion, caused by hemorrhage and shock, which predisposes to anaerobic metabolism and metabolic acidosis), and coagulopathy (metabolic acidosis with interference on coagulation factors and volume replacement).

In a practical manner, there are some absolute indications for the procedure, such as estimated blood loss greater than 4 L and the administration of more than 10 red blood cell concentrates [37]. Although there are classic indications for performing damage control surgery, new studies have questioned these indications and proposed other observations to better elucidate the cases eligible for the procedure [37]. Among them, those who presented moderate accuracy were systolic blood pressure (BP) < 90 mmHg or central body temperature < 34°C, and five indications produced major and conclusive changes in the pretest probability of performing damage control surgery during emerging laparotomy: discovery of pancreas, duodenum, or pancreatic-duodenal complex devascularized or completely ruptured;


#### **Table 3.**

*Traditional indications of damage control surgery.*

estimated intraoperative blood loss >4 L; administration of >10 U of concentrate and red blood cells; and systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during the operation [37]. The traditional indications [38] to perform this surgery are explained in **Table 3**. The factors related to almost 100% of mortality [25] are temperature (value <32°C), advanced age (70 years), and drop in pH.

Damage control surgery can be performed in three basic and sequential steps [25], which consist of the following:


Although it is often the only option in severe trauma, surgery to control damage should be considered, since it is related to serious complications [39], such as enteric fistulas, readmissions, multiple surgical interventions, and reduced quality of life.

In a study carried out in a trauma center in the city of Sao Paulo, Brazil, from a total of 392 patients, 207 had liver damage, and in cases it was necessary to perform the DCS (6.54%), which showed 100% survival, reaffirming the role of damage control surgery in severely traumatized patients with the lethal triad [6].

## **9. Liver transplantation in hepatic trauma**

Considering that the causes of death following severe hepatic trauma are uncontrollable bleeding due to vascular and liver laceration injury and acute liver failure, it is possible to cogitate liver transplantation as an option, since the procedure could treat both conditions; however, indications are still very restricted [40–42].

The indications for liver transplantation in this scenario described in the literature are uncontrollable continuous bleeding after damage control operation; extensive complex liver lacerations not amenable to surgical correction; extensive

**61**

*Liver Trauma Management*

**10. Complications**

tion, infrequently operative [3].

*DOI: http://dx.doi.org/10.5772/intechopen.92351*

may contraindicate the transplant [40–43].

viable alternative to the majority of liver traumas.

respiratory distress syndrome, and multiple organ failure.

the liver parenchyma to vascular and biliary system injuries.

predictor of biliary and nonvascular complications [44].

lesions of the portal vein, hepatic vein, or bile duct that cannot be repaired by surgery; progressive liver failure due to trauma; and hepatic necrosis [40–42]. It is important to keep in mind that this procedure should only be considered once all other therapies were attempted, making it imperative to adopt damage control measures in order to promote temporary hemostasis until an organ becomes available for transplantation [38–41]. Also, not all patients are candidates for transplant and that the choice should be conducted carefully and individually. Situations such as severe sepsis, multiple organ failure, and other associated serious injuries

There are two types of procedures described in the literature: transplantation in one step and staged transplantation. The first consists in the immediate removal of the native liver with subsequent implantation of a new organ, whereas the latter consists in creating a temporary vascular portocaval shunt to allow the patient to wait for the organ and avoid congestion in mesenteric splanchnic system [40, 42]. It is important to keep in mind that this is the last alternative to serious hepatic lesions. Even when indicated, this treatment presents a low success rate not being a

Trauma patients, especially those requiring a staged surgical approach, are subjected to multiple operations and prolonged ICU stays and are at high risk of developing complications such as abdominal compartment syndrome (ACS), acute

Generally, the incidence of complications is related to the degree of the hepatic trauma and the type of treatment used in the process, being directly proportional to the severity of the trauma presented by the patient, ranging from small changes in

Since the majority of the liver injuries are managed nonoperatively, it is important to bear in mind that approximately a quarter of the patients with blunt hepatic injury managed nonoperatively will manifest complications that impose interven-

There is evidence that conservative treatment for extensive liver injuries results in a higher incidence of biliovascular complications [44]. In a recent article carried out in Italy with 56 young patients with liver injury AAST III or greater, mostly due to blunt trauma, 17 patients had 21 liver complications: 4 biliary, 12 vascular, and 1 combined biliary and vascular. Liver complications increased with the highest degree of liver trauma, with 3.5% in grade III, 52% in grade IV, and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization, while other arterial pseudoaneurysms 7.23 ± 5.14 days after the trauma were detected. Angioembolization was successful in 83% of patients. The work highlighted that the main predictors of biliovascular complications were the requirement for blood transfusion and the degree of injury. Portal vein laceration was a

When considering radiological intervention, as portrayed previously, the main complication of hepatic angioembolization is the presence of massive hepatic necrosis (MHN). In a study carried out with 538 patients who had high-grade traumatic liver injuries [6], 16 patients (22.5%) had grade III injuries, 44 (62%) grade IV injuries, and 11 (15.5%) grade V injuries, with 71 (13%) having undergone therapeutic liver angioembolization, with 8 patients (11.3%) from the latter group dying as a result of liver damage. Complication rates were 18.8%, 65.9%, and 100% in patients with grade III, IV, and V injuries, respectively, for an overall complication rate of

#### *Liver Trauma Management DOI: http://dx.doi.org/10.5772/intechopen.92351*

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

a. Large abdominal vascular lesions with multiple visceral lesions

d. Blunt trunk trauma, resulting from high-energy impact e. Operating and resuscitation time greater than 90 minutes f. Bulky transfusion (>10 red blood cell concentrates)

b. Diffuse bleeding of a nonmechanical nature

i. Lesions of the retrohepatic vena cava j. Pancreatic lesions that require resection k. Significant hemodynamic instability

*Traditional indications of damage control surgery.*

c. Multiple trunk penetrations

g. Severe liver damage h. Ruptured pelvic hematomas

**Table 3.**

estimated intraoperative blood loss >4 L; administration of >10 U of concentrate and red blood cells; and systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during the operation [37]. The traditional indications [38] to perform this surgery are explained in **Table 3**. The factors related to almost 100% of mortality [25] are temperature (value <32°C), advanced age (70 years), and drop in pH. Damage control surgery can be performed in three basic and sequential steps

a.Performing lifesaving procedures, such as stopping bleeding, controlling

c.New surgical approach intended to review the lesions and to attempt definitive

Although it is often the only option in severe trauma, surgery to control damage should be considered, since it is related to serious complications [39], such as enteric fistulas, readmissions, multiple surgical interventions, and reduced quality

In a study carried out in a trauma center in the city of Sao Paulo, Brazil, from a total of 392 patients, 207 had liver damage, and in cases it was necessary to perform the DCS (6.54%), which showed 100% survival, reaffirming the role of damage

Considering that the causes of death following severe hepatic trauma are uncontrollable bleeding due to vascular and liver laceration injury and acute liver failure, it is possible to cogitate liver transplantation as an option, since the procedure could

control surgery in severely traumatized patients with the lethal triad [6].

treat both conditions; however, indications are still very restricted [40–42]. The indications for liver transplantation in this scenario described in the literature are uncontrollable continuous bleeding after damage control operation; extensive complex liver lacerations not amenable to surgical correction; extensive

evisceration, and avoiding resections and reconstructions.

b.Resuscitation in an intensive care unit (ICU).

**9. Liver transplantation in hepatic trauma**

[25], which consist of the following:

treatment.

of life.

**60**

lesions of the portal vein, hepatic vein, or bile duct that cannot be repaired by surgery; progressive liver failure due to trauma; and hepatic necrosis [40–42].

It is important to keep in mind that this procedure should only be considered once all other therapies were attempted, making it imperative to adopt damage control measures in order to promote temporary hemostasis until an organ becomes available for transplantation [38–41]. Also, not all patients are candidates for transplant and that the choice should be conducted carefully and individually. Situations such as severe sepsis, multiple organ failure, and other associated serious injuries may contraindicate the transplant [40–43].

There are two types of procedures described in the literature: transplantation in one step and staged transplantation. The first consists in the immediate removal of the native liver with subsequent implantation of a new organ, whereas the latter consists in creating a temporary vascular portocaval shunt to allow the patient to wait for the organ and avoid congestion in mesenteric splanchnic system [40, 42].

It is important to keep in mind that this is the last alternative to serious hepatic lesions. Even when indicated, this treatment presents a low success rate not being a viable alternative to the majority of liver traumas.
