Blunt Injuries to the Liver:
Problems and Management
M. BALASEGARAM,* F.R.C.S. (ENG. & EDIN.), F.R.A.C.S., F.I.C.S.
From the Department of Surgery, General Hospital, Seremban, Malaysia
IN recent years there has been an in-
creased frequency in the incidence of blunt
injuries to the liver due mainly to the high
speed automobile accidents. These injuries
are problems in diagnosis and treatment.
This paper reports the experience with 35
patients with such injuries who were
treated by the author.
Materials
Between May 1961 and April 1968, 35
patients with blunt injuries to the liver
were admitted to the General Hospital,
Seremban. Road accidents accounted for
the admissions of 32 of the 35 patients,
two of the remaining three patients fell
from heights and one was crushed by a
falling tree. Analysis of records of the 32
patients involved in road accidents showed
that 17 were drivers of motor vehicles and
were involved in head-on collisions with
on-coming vehicles or stationary objects
and 11 were passengers in auto accidents.
Four were run over by motor vehicles.
None of the drivers or passengers wore
safety belts. Of the 35 patients, 31 were
males and four females, 26 being below 35
years of age. Patients varied in age from 9
to 64 years.
Clinical Presentation and Diagnosis
The diagnoses of injuries to the liver pre-
sented great difficulties, only 17 (48.68%o)
of the 35 were diagnosed preoperatively.
Table 1 lists the main clinical features in
Submitted for publication September 13, 1968.
* Consultant Surgeon.
544
the 17 patients. In addition to a history of
trauma, all had abdominal pain, maximal
over the liver area. Shock was present to
a varying degree in 12 patients. Signs of
guarding in 13 and tenderness in 15 pa-
tients were elicited; external bruises around
the right side of the abdomen in seven,
aided in the diagnosis. Radiologic evidence
of enlarged liver was obtained in two pa-
tients with subcapsular hematomas. In five
there were associated intra-abdominal or
chest injuries. In the remaining 18 patients
associated intra-abdominal injuries, con-
comitant head, chest, pelvic and other frac-
tures clouded the picture, as illustrated in:
Case Reports
Case 1. A 23-year-old woman was admitted
following a motor vehicle accident with signs of
shock, generalized abdominal, pelvic and left loin
pain. She also complained of pain in the left chest
on breathing and difficulty in moving her left
lower leg. Her blood pressure was 70/40 mm. Hg,
pulse 130 per minute. There was abdominal dis-
tension with general guarding and tenderness,
maximal over the hypogastrium. Radiographs of
the chest, abdomen and pelvis showed fractures
of the ninth to eleventh ribs left side, fracture of
the left pubic bone with dislocations at the pubic
symphysis and left sacro-iliac joint and displace-
ment upwards of the whole of left leg. A catheter
passed into the urethra drained no urine but only
blood stains. Intraperitoneal rupture of the blad-
der was suspected. At laparotomy there was not
only a rupture of the bladder, but also of the
spleen and severe laceration of the lateral seg-
ment of the left lobe of the liver. She also had a
large retroperitoneal hematoma and the left kid-
ney and left colon were contused. The ruptured
bladder was repaired, splenectomy and left he-
patic lobectomy were performed. In all, 10 units
Volume 169 BLUNT INJURIES TO THE LIVER
Number 4 545
TABLE 1. Main Clinical Presentation TABLE 3. Pattern of Liver Injuries in
in 17 Patients 35 Patients

No. No. of
Cases Mortality
History of Trauma 17
Abdominal Pain 17 Simple linear lacerated wound 12
Shock 12 Stellate wounds 6
Guarding 13 Subcapsular hematoma with
Tenderness 15 intralobar rupture 2 1
External Bruises 7 Extensive lacerations 15 4
35 5
TABLE 2. A ssociated Injuries in 18 Patients
Not Diagnosed Preoperatizely
TABLE 4. Types of Surgical Treatment in
No. of 35 Patients
Structure Injuries
No. of
Head 8 Cases Mortality
Chest 10
Fractured pelvis 7 Exploration and drainage 3 1
Skeletal 6 Suture with drainage 12
Mesentery and omentum 4 Debridement and suture 4 -

Spleen 6 Packing 5 3
Small intestines 3 Hepatic resection 11 1
Colon 2
Kidney 2 35 5
Pancreas 1

of blood were transfused. She recovered fully and
was discharged from the hospital after 10 weeks.
In the 18 patients in whom a preopera-
tive diagnosis of injury to the liver was not
made, shock or signs of blood loss such as
pallor and sweating, abdominal pain with
tenderness, led to a suspicion of intra-ab-
dominal injury. Four patients did not com-
plain of abdominal pain, but a falling blood
pressure and a rising pulse-rate necessitated
laparotomy. The types of associated injuries
are indicated in Table 2. Several patients
had two or more associated injuries. Tears
in the viscera or mesentery were repaired,
ruptured spleens removed and partial ne-
phrectomy was performed in one of the
two patients with injuries to the kidneys.
Abdominal paracentesis, carried out in
six patients, revealed evidence of blood in
the peritoneal cavity. Blood pressure al-
terations after infusions of Ringer's lactate
in ten others were helpful in the diagno-
sis of intra-abdominal bleeding. When in
doubt laparotomy was performed.
Types of Injury
The pattern of liver injury varied with
the severity and nature of the injuring
force. Patients who were crushed by ve-
hicles and drivers of motor vehicles or
front-seat passengers who were involved
in head-on collisions suffered severe in-
juries to the liver. Twelve had simple li-
near lacerated wounds, six stellate, two had
subcapsular hematomas with intra-lobar
ruptures, and 15 had extensive lacerations
or shattering injuries (Table 3) (Figs. 1, 2).
Treatment
These patients were treated by initial re-
suscitation with massive and rapid blood
transfusions, especially those in profound
shock. Operative treatment was carried out
as early possible. The types of surgical
as
treatment illustrated in Table 4. Three
are
patients had laparotomy and drainage of
the abdomen only, for the injuries in two
were superficial lacerations and bleeding
had stopped, and one had a subcapsular

546
FIG. 1. (top) Shows extensively
almost severed left lobe of the liver before resec-
tion. FIG. 2. (bottom) Shows remaining liver after
resection.
hematoma. In twelve patients suture of the
lacerated wound with drainage, in four,
debridement of the ragged liver edges and
closure of the wounds by suture, in five,
packing of the liver with gauze packs, and
in 11 major hepatic resection were per-
formed. In all patients the abdomen was
drained as a routine measure by continu-
ous suction drainage using two rubber
tubes, one anterior and the other posterior.
In addition, a polythene tube attached to
a continuous suction pump was used when
hepatic resection was performed.
Postoperatively, when necessary, blood
transfusions were given and all patients
BALASEC__7'ARAM Annals of Surgery
April 1969
were given intravenous broad spectrum
antibiotic drugs such as tetracycline while
intravenous fluids and naso-gastric suction
were continued until bowel sounds re-
turned. Drainage tubes were shortened on
the fourth day but were removed only
when drainage of blood and bile became
minimal.
Of 11 patients on whom major hepatic
resections were performed three had left
lobectomies, three left hemihepatectomies,
three right hemihepatectomies and two pa-
tients had right lobectomies (Table 5)
(Figs. 3, 4, 5). The operative technic of
hepatic resection is complicated by the
fact that the liver has two sets of vessels
traversing it, the hepatic venous system
and the portal system consisting of the
portal veins, hepatic ducts and hepatic ar-
teries.7 For emergency hepatic resection,
the abdomen was approached through a
right upper paramedian incision. For left
lobe injuries the incision was extended to
the xiphisternum, and in injuries to the
right lobe the paramedian incision was ex-
tended to the thorax through the seventh
or eighth intercostal space, the diaphragm
being divided to the level of the inferior
vena cava. The technic of hepatic resection
lacerated and
of either the right or the left lobes requires
first detachment of the lobes from the dia-
phragm by dividing the ligamentous at-
tachments between them, hemostasis mean-
while being achieved by temporary gauze
packing of the lacerated wounds. If this is
inadequate, especially in right lobar in-
juries, temporary occlusion of the vessels
in the portal triad at the formen of Wins-
low, for 15 minutes at a time was achieved
by compression between the thumb and
index fingers. The respective lobes are then
turned forwards and to the opposite side.
Lobar branches of the portal vein, hepatic
duct and hepatic artery are then isolated,
divided and ligated. In resection of the
right anatomic lobe, the right hepatic vein
is also dissected and divided close to the
liver substance and tied. Several small he-
Volume 169 BLUNT INJURIES TO THE LIVER 547
Number 4
TABLE 5. Types of Hepatic Resection in
11 Patients

No. of
Patients
Left lobectomy 3
Left hemihepatectomy 3
Right lobectomy 2
Right hemihepatectomy 3
11

patic veins which drain mainly the right

lobe directly into the inferior vena cava
are also identified and ligated. The liver is
resected about 5 cm. medial to the lacera-
tion after application of Nakayama's crush-
ing clamps13 which crush the liver sub-
stance but leaves the capsule intact.
For left lobectomy or left hemihepatec-
tomy application of Nakayama's crushing
clamps does not require individual dissec-
tion and ligation of the left hepatic artery
or duct. In right hemihepatectomy the level
of resection extends from the gallbladder
fossa to the right of the inferior vena cava
while for left hemihepatectomy the level
of resection lies to the right of the falciform
ligament. Raw areas of the liver are closed
by several mattress sutures using 2/0 chro-
mic catgut passed through the full thick-
ness of the liver substance, after the larger
blood vessels and bile ducts in the raw
area are sorted out and ligated. None of
the 11 patients had biliary decompression
as advocated by Merendino, Dillard and
Commock.10
FIG. 3. (top) Shows the shattering injuries of
Results of Treatment the right lobe after resection. FIG. 4. (center)
Shows extensively lacerated right lobe after resec-
Mortality tion. FIG. 5. (bottom) The resected right lobe
showing multiple lacerations.
There were five deaths, a mortality of
14.3%o. Four deaths occurred in patients in the subphrenic space. One of these two
with severe lacerated injuries (Table 3), patients also had hemobilia. Of 11 patients
three of whom were treated by packing who had major hepatic resections, there
(Table 4). In one, packing failed to con- was one death. This man, aged 25, had a
trol bleeding in the lacerated right lobe, right hemihepatectomy for severe lacerated
while the other two died as a result of com- injury to the right lobe and died on the 5th
plications such as secondary hemorrhage, day of irreversible shock and acute renal
bile peritonitis, abscesses in the liver and failure, having passed only two oz. of urine
548 BALASEGARAM
TABLE 6. Cornplications Following Packing
Deaths (3) Hemorrhage, Multiple Abscesses, Haemo-
bilia, Bile Peritonitis.
Survival (2) Subphrenic Abscess, Secondary Hemor-
rhage, Wound Infection.
Complications in Others
Wound infection
Prolonged biliary discharge
Pleural effusion
Pneumonitis
Secondary hemorrhage
Jaundice
over the whole period. He had prolonged
hypotension before admission and had in
addition fractures of the eighth to twelfth
ribs on the right side with hemothorax.
Death in the fifth patient (Case 2) was due
to necrosis of the liver with abscess forma-
tion as is described in detail.
Case 2. A 20-year-old man was admitted fol-
lowing a motor vehicle accident. He had general-
ized abdominal pain maximal over the liver area.
Blood pressure was 110/80 mm. Hg and pulse 96
per minute. He appeared pale and had tenderness
and guarding over the abdomen especially in the
right hypocondrium. The liver was enlarged down-
wards three finger breadths. At operation a large
subcapsular hematoma in the right lobe of the
liver was found. There was no external bleeding
and the liver substance appeared to be of good
color. No further procedure was undertaken and
the abdomen was drained as usual. The patient
progressed well until the fifth day when he started
to have a swinging temperature which did not re-
spond to antibiotic drugs. At the second week pus
and bits of necrotic liver began to drain through
the drainage tubes. He was reoperated upon and
it was found that most of the right lobe of the
liver had necrosed. The necrotic tissues including
a subphrenic abscess, were evacuated, further
drainage tubes inserted and postoperatively he
was given several blood transfusions and anti-
biotic agents. He failed to improve, however, and
died several days later of secondary hemorrhage,
bile peritonitis and septicemia.
Comment. This patient had a subcap-
sular hematoma with intra-lobar rupture of
Annals of Surgery
April 1969
the right lobe of the liver. In retrospect,
had the right lobe been resected, he would
probably have survived.
Complications
In 30 patients who survived most post-
operative complications occurred in pa-
tients with severe lacerated wounds in
whom packing was used. Table 6 sum-
4 marizes these complications. Two patients
2
3 had subphrenic abscesses and wound in-
2 fections, one had secondary hemorrhage on
1 the tenth day. Ten others developed 14
2
complications distributed as follows: wound
infection, four; prolonged and excessive
biliary discharge, two; pleural effusions,
three; pneumonitis, two; secondary hemor-
rhage from abdominal wound, one; jaun-
dice, two. Four of five patients with res-
piratory complications had associated frac-
tures of ribs on the right side. Jaundice
occurred in one patient who had right-
lobar resection, while in another jaundice
was due to excessive blood transfusions.
Discussion
There has been an increase in the inci-
dence of blunt hepatic injuries all over the
world and Seremban is no exception. Blunt
hepatic injuries now rank as the most com-
mon closed abdominal injury in our hos-
pital, and recent reports elsewhere indicate
likewise.', 2, 3, 10
In our hospital before May 1961, the
spleen was the organ involved most fre-
quently. In contrast only four instances of
blunt injuries to the liver were encoun-
tered in five years prior to this at the Gen-
eral Hospital, Seremban. Furthermore, au-
topsies of 176 deaths at the scene of acci-
dents or during the journey to this hospital
for the past 7 years showed that 20.8%
died mainly of massive hepatic injuries.
Crosthwait 4 reported that there were twice
as many non-penetrating hepatic injuries in
the last 7 years as in the previous 15-year
period. This increase parallels the rising
Volume 169 BLUNT INJURIES TO THE LIVER
Number 4
number of high-speed automobile acci-
dents. Because of its superficial location,
the liver is prone to blunt trauma and in
this series 17 (48.576e) of 35 patients had
extensively lacerated or intra-lobar rup-
tured livers. Twenty-six patients were be-
low the age of 35 years. The high incidence
of such injuries in the young have been re-
ported by others.5' , 6 S, 9, 11, 12
That less than 50%/ of the patients were
diagnosed preoperatively emphasizes the
difficulty of diagnosis. This is complicated
by associated injuries to other viscera such
as the spleen, bladder and small intestines.
The picture is further clouded by concomit-
ant head, chest, pelvic or multiple skeletal
fractures. A history of trauma to the abdo-
men, abdominal pain especially at the right
hypocondrium, signs of shock, tenderness,
guarding or rigidity, are the main diag-
nostic features. However, shock may be
absent while abdominal pain, tenderness or
guarding may be minimal. In such in-
stances abdominal paracentesis and blood
pressure alterations while Ringer's lactate
is infused are helpful. A period of observa-
tion may be necessary during which a ris-
ing pulse rate or falling blood pressure may
be the only sign of abdominal injury. Ab-
dominal paracentesis was positive in all
six patients in whom it was performed. Mc-
Clelland and Shires 9 consider abdominal
paracentesis to be 95.4% accurate. Baker,
Taxman and Freeark,2 however, reported
37.8% false negatives in adults and 60%
false negatives in children.
Hepatic resection for subeapsular hema-
toma with intralobar rupture is recom-
mended. Extravasation of methylene blue
beneath the liver capsule following injec-
tion of the dye into the common hepatic
duct indicates intra-lobar rupture which re-
quires resection. Baker considers this type
2 rupture of the liver to avoid hepatic necro-
of injury most difficult to treat and advo-
cates operative cholangiogram through the
gallbladder or common bile duct. The au-
thor's results compare favorably with other
reported series 4. 6, 12, 16 (Table 7).
2,
549
T.A-BLE 7. Mfortality of Blunt Injuiries to the
Liver in Otler Series
No. of
Cases Death "' cMlortality
Baker et al.2 58 14 24.1
Crosthwait et al.4 67 30 44.8
Hanna et al.6 42 13 30.9
MIills12 30 18 60' c
W'ilson16 15 7 46.6
Summary
Thirty-five patients with blunt hepatic
injuries treated in a 7-year period are re-
viewed. The difficulties of diagnosis are
stressed in that only 48.6%c were diagnosed
preoperatively. Associated intra-abdominal
and concomitant head, chest, pelvic and
skeletal injuries accounted for most of these
difficulties.
Seventeen of the 35 patients had exten-
sive lacerations or intra-lobar ruptures of
the liver. Simple linear or stellate lacerated
wounds were treated by drainage, or su-
ture, or debridement of the ragged liver
edges and suture. Prior to 1964 extensively
lacerated liver wounds were treated by
gauze packing. Three (60%c) of five pa-
tients thus treated died, while the others
had multiple complications.
Since 1964, packing has been abandoned
in favor of major resection and of 11 pa-
tients who underwent such procedures only
one died. Hepatic resection for severe blunt
injuries has the advantages of removal of
all devitalized liver, control of hemorrhage,
reduction of postoperative complications
such as secondary hemorrhage, intra-
abdominal and hepatic abscesses and
hemobilia. 14 15
Hepatic resection is recommended for
subeapsular hematomas with intra-lobar
sis. These injuries are diagnosed by injec-
tion of methylene blue into the common
hepatic duct.
Low mortality and morbidity in this se-
ries is due to improved care of injured pa-
550 BALASEGARAM
tients, early surgical intervention and ade-
quate removal of devitalized lacerated and
injured tissues by debridement or major
hepatic resection.
Acknowledgment
I wish to express my gratitude to Mr. Shim
Kah Kee and Mr. V. Ganasamy for assistance in
the photography and preparation of the paper,
and to the Director of Medical Services Malaysia
for permission to publish this report.
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