**10. Complications**

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 respiratory distress syndrome, and multiple organ failure.

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 the liver parenchyma to vascular and biliary system injuries.

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 intervention, infrequently operative [3].

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 predictor of biliary and nonvascular complications [44].

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

60.6%. Thirty patients (42.2%) developed MHN [45]. Patients who developed MHN were compared with those who did not. It was observed that patients with MHN had higher-grade lesions, significantly needed more transfusions, and had a significantly longer hospital stay (all p < 0.001). Patients who developed MHN were more likely to undergo surgical intervention (96.7% vs. 41.5%, p < 0.001), with 87% undergoing damage control laparotomy [45].

As for the surgical treatment, many complications can occur depending on the type of procedure. The most frequent postoperative complication is related to infection such as pneumonia, peritonitis, and intra-abdominal abscess, and it represents almost three quarters of all immediate complications. The survival rate in patients with blunt liver trauma (60%) may be lower than the ones with penetrating trauma (87.5%), possibly due to the higher rate of head injuries associated with blunt trauma, as a consequence of severe traumatic brain injury [6].

In a recent study [6] carried out in a university hospital, in Sao Paulo, from 392 trauma patients who underwent laparotomy, 107 had liver injuries, 78.5% with penetrating trauma, in severe firearm injuries. The incidence of postoperative complications was 29.9%, and the most frequent were infections, including pneumonia, peritonitis, and intra-abdominal abscess. The survival rate of patients with blunt trauma was 60% and of penetrating trauma, 87.5% (p < 0.05). Another retrospective work carried out at the Department of Hepatobiliary Surgery and Liver Transplantation Unit of A.O.R.N.A. Cardarelli from Naples, Italy, considered 50 patients with liver trauma and assessed the main complications related to the type of trauma and treatment employed [46]. A wide range of complications is observed and is associated with five pathophysiological findings: acute bleeding after packing the cavity with compresses, liver hematoma, arteriovenous fistula, sepsis, biliary fistula, and coleperitoneum [46].

With the implementation of DCS, patients previously considered as beyond help turned capable of surviving their initial injuries, and as they were transferred to ICUs for physiological stabilization prior to surgical reconstruction, they were submitted through a supranormal resuscitation [1]. Later it was observed that this practice resulted in many of these patients receiving excessive volumes of crystalloid and experiencing subsequent problematic tissue edema of the lungs and gut during attempts at physiological restoration [47]. The combination of shock, large volume resuscitation, intestinal edema, and a tightly packed and closed abdomen led to increased intra-abdominal pressures and the development of virtual epidemics of abdominal compartment syndrome [47]. With an initial reported prevalence of more than 30% and mortality rate greater than 60% [48] in the major trauma population, many patients died not from their initial injuries but from lethal respiratory, renal, and cardiac failure due to increased abdominal pressure. Prospective observational studies soon identified the association between abdominal compartment syndrome and traumatic shock resuscitation [1, 49].

The aggravated physiologic derangement caused by intra-abdominal hypertension (IAH) can rapidly result in multiorgan failure in a vicious circle unless interrupted by abdominal decompression [50–52] such as open abdomen management (OA). OA consists of intentionally leaving the abdominal fascial edges of the paired rectus abdominis muscles unapproximated (laparostomy) in order to abbreviate operation, prevent IAH, and facilitate reexploration without damaging the abdominal fascia. Temporary abdominal closure (TAC) refers to the method for providing protection to the abdominal viscera during the time the fascia remains open [50, 52] Patients undergoing OA management are at risk of developing entero-atmospheric fistula (EAF) and a "frozen abdomen," intra-abdominal abscesses, and lower rates of definitive fascial closure [53, 54]. The risk-benefit ratio must be kept in mind, and measures to mitigate complications are necessary. In all patients with an OA,

**63**

*Liver Trauma Management*

improved outcomes [1].

morbidity rates.

**11. Conclusion**

ferred since it presents less morbidity.

patient's long-term prognosis.

after correcting the lethal triad.

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

patient can physiologically tolerate it [50].

every effort should be exerted to achieve primary fascial closure (i.e., fascia-tofascia closure of the abdominal wall within the index hospitalization) as soon as the

Through the liberal use of open abdomen surgery and systematic evidencebased modifications to traumatic shock resuscitation techniques, the concept of damage control resuscitation was created. Damage control resuscitation differs from previous resuscitation approaches by attempting an earlier and more aggressive correction of coagulopathy as well as metabolic derangements. It embraces several key concepts, including permissive hypotension, the restriction of isotonic fluid for plasma volume expansion, and the early and rapid administration of component transfusion therapy to support correction of postinjury coagulopathy [1, 55]. Damage control resuscitation restores physiological reserve facilitating more definitive surgical treatment resulting in decreased perioperative complications and

Liver injury management has been changed in recent years with the advancement of technology, newer diagnosis, and therapeutic tools. The indications of nonoperative treatment are increasing with improvement of survival and lower

The liver is the second most common affected organ in abdominal trauma and therefore has a prominent role in all the abdominal traumas. During the past decade, the management presented a significant evolution especially with the growth of interventional radiology. Procedures such as arteriography and arterial embolization helped to manage once difficult lesions with poor prognosis. Nevertheless, when it is possible, the nonoperative management should be pre-

Hepatic lesions classified as grade IV are a cause for anguish and anxiety for the surgeons, since they present a higher morbidity and mortality. The first concern in severe liver trauma should be the patient stabilization, which can be done through damage control surgery, which consists of executing the crucial and strategically ordered steps (shortened surgery, correction of physiological measurements in intensive care and proposed reoperation) to reduce operational time, correct a loss of death (medicated by acidosis, hypothermia, and coagulopathy), and improve the

In the context of trauma, control damage surgery appears as an alternative for severely injured patients, who have multiple injuries to the abdominal viscera. After clinical stabilization in an intensive care unit, the patient will be reoperated, and less severe injuries will be corrected, with the patient's gradual recovery

In the same perspective, this chapter reviewed liver trauma centered on damage control surgery, providing the main content related to the topic, from its causes, trauma mechanism, classification, bibliographic review, therapeutic options, and current statistics to prognosis and the role of damage control surgery in this context. Thus, it is expected that at the end of the chapter, the reader will be able to organize the main topics related to liver trauma and consider making difficult decisions in practice in trauma hospital, always seeking the best prognosis for patients.

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

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

trauma, as a consequence of severe traumatic brain injury [6].

ment syndrome and traumatic shock resuscitation [1, 49].

87% undergoing damage control laparotomy [45].

fistula, and coleperitoneum [46].

60.6%. Thirty patients (42.2%) developed MHN [45]. Patients who developed MHN were compared with those who did not. It was observed that patients with MHN had higher-grade lesions, significantly needed more transfusions, and had a significantly longer hospital stay (all p < 0.001). Patients who developed MHN were more likely to undergo surgical intervention (96.7% vs. 41.5%, p < 0.001), with

As for the surgical treatment, many complications can occur depending on the type of procedure. The most frequent postoperative complication is related to infection such as pneumonia, peritonitis, and intra-abdominal abscess, and it represents almost three quarters of all immediate complications. The survival rate in patients with blunt liver trauma (60%) may be lower than the ones with penetrating trauma (87.5%), possibly due to the higher rate of head injuries associated with blunt

In a recent study [6] carried out in a university hospital, in Sao Paulo, from 392 trauma patients who underwent laparotomy, 107 had liver injuries, 78.5% with penetrating trauma, in severe firearm injuries. The incidence of postoperative complications was 29.9%, and the most frequent were infections, including pneumonia, peritonitis, and intra-abdominal abscess. The survival rate of patients with blunt trauma was 60% and of penetrating trauma, 87.5% (p < 0.05). Another retrospective work carried out at the Department of Hepatobiliary Surgery and Liver Transplantation Unit of A.O.R.N.A. Cardarelli from Naples, Italy, considered 50 patients with liver trauma and assessed the main complications related to the type of trauma and treatment employed [46]. A wide range of complications is observed and is associated with five pathophysiological findings: acute bleeding after packing the cavity with compresses, liver hematoma, arteriovenous fistula, sepsis, biliary

With the implementation of DCS, patients previously considered as beyond help turned capable of surviving their initial injuries, and as they were transferred to ICUs for physiological stabilization prior to surgical reconstruction, they were submitted through a supranormal resuscitation [1]. Later it was observed that this practice resulted in many of these patients receiving excessive volumes of crystalloid and experiencing subsequent problematic tissue edema of the lungs and gut during attempts at physiological restoration [47]. The combination of shock, large volume resuscitation, intestinal edema, and a tightly packed and closed abdomen led to increased intra-abdominal pressures and the development of virtual epidemics of abdominal compartment syndrome [47]. With an initial reported prevalence of more than 30% and mortality rate greater than 60% [48] in the major trauma population, many patients died not from their initial injuries but from lethal respiratory, renal, and cardiac failure due to increased abdominal pressure. Prospective observational studies soon identified the association between abdominal compart-

The aggravated physiologic derangement caused by intra-abdominal hypertension (IAH) can rapidly result in multiorgan failure in a vicious circle unless interrupted by abdominal decompression [50–52] such as open abdomen management (OA). OA consists of intentionally leaving the abdominal fascial edges of the paired rectus abdominis muscles unapproximated (laparostomy) in order to abbreviate operation, prevent IAH, and facilitate reexploration without damaging the abdominal fascia. Temporary abdominal closure (TAC) refers to the method for providing protection to the abdominal viscera during the time the fascia remains open [50, 52] Patients undergoing OA management are at risk of developing entero-atmospheric fistula (EAF) and a "frozen abdomen," intra-abdominal abscesses, and lower rates of definitive fascial closure [53, 54]. The risk-benefit ratio must be kept in mind, and measures to mitigate complications are necessary. In all patients with an OA,

**62**

every effort should be exerted to achieve primary fascial closure (i.e., fascia-tofascia closure of the abdominal wall within the index hospitalization) as soon as the patient can physiologically tolerate it [50].

Through the liberal use of open abdomen surgery and systematic evidencebased modifications to traumatic shock resuscitation techniques, the concept of damage control resuscitation was created. Damage control resuscitation differs from previous resuscitation approaches by attempting an earlier and more aggressive correction of coagulopathy as well as metabolic derangements. It embraces several key concepts, including permissive hypotension, the restriction of isotonic fluid for plasma volume expansion, and the early and rapid administration of component transfusion therapy to support correction of postinjury coagulopathy [1, 55]. Damage control resuscitation restores physiological reserve facilitating more definitive surgical treatment resulting in decreased perioperative complications and improved outcomes [1].

Liver injury management has been changed in recent years with the advancement of technology, newer diagnosis, and therapeutic tools. The indications of nonoperative treatment are increasing with improvement of survival and lower morbidity rates.
