Blunt Trauma to the Liver
Analysis of Management and Mortality in 323 Consecutive Patients
EVERARD F. COX, M.D., F.A.C.S., LOUIS FLANCBAUM, M.D., F.A.C.S., ALTON H. DAUTERIVE, M.D.,
and RICHARD L. PAULSON, M.D.
This study represents a 6 year 4 month experience with blunt
trauma to the liver of patients from the Maryland Institute for
Emergency Medical Services Systems, a major regional
trauma center. The significance of this study is that it describes
a large, relatively homogeneous population and analyzes what
the state of the art for liver trauma has been in a center dedi-
cated solely to trauma that has a full-time staff of trained
traumatologists. Three hundred twenty-three consecutive pa-
tients with blunt liver trauma are presented, representing 3.5%
of 9271 patients admitted to the institute over the period of this
study. Ninety per cent had associated traumatic injuries re-
quiring operative intervention. A mortality rate of 31% (101
patients) was noted; 41.5% of the deaths, due primarily to liver
injury, occurred intraoperatively during the initial operation
following admission. The use of simple suture techniques and
resectional debridement to control hemorrhage are advocated.
Anatomic lobectomy, intracaval shunting, and hepatic artery
ligation were uniformly unsuccessful. The use of drains was
associated with a significantly increased incidence of infectious
complications (p < 0.00002).
"Rupture ofthe liver is fortunately an accident not often met with
but one which, when it is seen, may be associated with a condition
of the patient as serious as anyone can meet in the surgical prac-
tice. While small lacerations of the liver substance may be, and no
doubt are, recovered without surgical interference; if lacerations
are extensive and vessels of any magnitude are torn hemorrhage
will, owing to the structural arrangement of the liver, go on con-
tinuously and by the time such a patient comes under the care of a
surgeon, the general state is almost invariably bound to be ex-
tremely grave from the hemorrhage alone or from hemorrhage
and shock combined. This is perhaps especially the case in that
class of injury due to contusing violence in which there is often
gross injury inflicted on parts other than the liver and when shock
is liable to be more severe than in localized injuries caused by
sharp instruments" (J. Hogarth Pringle, 1908)'
Reprint requests: Louis Flancbaum, M.D., Division of Trauma
Surgery, UMDNJ-Robert Wood Johnson Medical School, One Rob-
ert Wood Johnson Place, New Brunswick, NJ 08903.
Correspondence: Everard F. Cox, M.D., 4510 Mt. Carmel Road,
Hampstead, MD 21074.
Submitted for publication: July 2, 1987.
126
From the University of Maryland, Maryland Institute for
Emergency Medical Services Systems, Department of
Surgery, Shock Trauma Center, Baltimore, Maryland
N THE INTERVENING YEARS since Pringle's notes on
hepatic trauma, the surgeon's frustration in manag-
ing serious "contusing" injury to the liver along
with the mortality rate associated with it has remained
virtually unchanged. Numerous large series dealing with
the management of complex hepatic trauma have been
reported. Most of these have come from large urban
trauma centers treating a large percentage of penetrating
injuries. Often the liver injury is an isolated one, and
associated extra-abdominal injuries are not present. In
contrast, this study represents the experience gained
over a 6-year period ending in 1985 from 323 consecu-
tive patients with liver injury caused exclusively by
blunt trauma treated at Maryland Institute for Emer-
gency Medical Services Systems, Shock Trauma Center,
a regional center for major trauma. It is a combined
experience of an institutional staff of trauma surgeons.
Patient Profile
There were 211 males (65%) and 112 females (35%)
comprising 3.48% of 9271 patients admitted during this
period. The average age was 29 years. Automobile acci-
dents accounted for 79%, motorcycles 10%, and pedes-
trians 8% of the injuries. The remaining 3% resulted
from industrial, farm, or home accidents. Thirty per
cent of these patients had abnormal elevation of their
blood alcohol on admission. Except for a few patients
from the immediate urban center who came by ambu-
lance, the majority of these patients were transported
directly from the scene of the accident by helicopter and
Vol. 207 * No. 2 BLUNT TRAUMA TO THE LIVER
transferred to the admitting area where immediate re-
suscitation, diagnostic evaluation, and management
protocols were instituted by full-time traumatologists.
Any patient who had injury to other systems, namely,
closed head injuries, fractures of the skeleton, blunt
chest injury, maxillofacial trauma, or extensive soft tis-
sue contusion that could require a prolonged general
anesthesia during their care, or who may have been un-
able to react reliably with normal physical signs because
of inhibition by alcohol or other drugs, or were hemody-
namically unstable, as well as those with clinical signs
that led to the suspicion that there was organ injury
within the abdomen, were subjected to diagnostic peri-
toneal lavage. The diagnosis of hemoperitoneum was
established using diagnostic peritoneal lavage alone, ex-
cept in seven instances wherein the urgency of the pa-
tient's condition precluded it and diagnostic celiotomy
was carried out. Another four patients were transferred
from other hospitals after celiotomy disclosed liver in-
jury deemed beyond the capability of those facilities.
With an occasional exception, criteria for celiotomy was
50,000 red blood cells/mL3 in the effluence of the diag-
nostic lavage.
Results
Group I-S (Table 1) consisted of 120 survivors (37%)
who in the opinion of the operating surgeon required no
surgical intervention to the liver at the time of the celi-
otomy. Injuries in this group were described by the sur-
geons as minor capsular tears, minor lacerations, lacera-
tions with clots in place, not bleeding, or bleeding con-
trolled with pressure, etc. In analyzing these patients
other distinctive features became apparent. Ninety-
seven patients (81%) were hemodynamically stable at
the time of admission, with systolic blood pressure
greater than 90 mmHg and pulse less than 1 10/min. An
average of 3 units (U) of blood was given during the
admission and perioperative periods. The use of drains
was studied as related to complications, slightly more
than half (56%) had no drains. The average stay in the
hospital was 15.15 days, excluding patients with pro-
longed stays for closed head injury or complicated or-
thopedic problems.
The 60 patients in group II-S (Table 2) (18.5%) were
treated using simple surgical techniques such as the
placement of simple or mattress sutures, topical hemo-
static agents, or both. They were slightly less hemody-
namically stable (75%) than those patients in group I-S
and required an average of 6 U of blood during the
resuscitative and perioperative periods. Two thirds were
not drained, and a one day longer hospital stay was
recorded for these patients.
127
Forty-two patients (13%) were assigned to group III-S
(Table 3). Patients so designated were more severely in-
jured and required more aggressive surgical measures.
Seventy-four per cent of these patients were hemody-
namically unstable at the time of admission. Three
fourths had associated extra-abdominal injuries, includ-
ing thoracic in 26 patients, orthopedic in 16 patients,
maxillofacial in 13 patients, and neurologic in 11 pa-
tients. Associated abdominal injuries, spleen in 16 pa-
tients, pancreas in 4 patients, bowel in 3 patients, gall-
bladder in 3 patients, and diaphragm in 2 patients oc-
curred in half of the patients. The clear difference from
survivors in groups I-S and II-S appeared to be the
amount of blood replacement. Excluding one patient
who used 100 U of whole blood, an average of 22 U of
PRBCs per patient was given. Fresh frozen plasma was
used liberally in this group of patients to enhance blood
clotting. Drains were not used in 30% of this group. The
hospitalization increased to 24 days if two patients with
prolonged stays are excluded. The only three survivors
of hepatic artery ligation are in this group. Fifteen pa-
tients had some degree of liver resection, limited in all
instances to resectional debridement of the injured frag-
ment of the liver. Suture technique was the most often
used and most effective method of gaining control of the
hemorrhage. One patient was treated successfully with
packing only of a major liver injury. Thirty of the 42
patients in this group recovered without complications
related to the abdomen.
The 17 patients (5.26%) in group I-D (Table 4) were
clinically similar to those in group III-S except that they
died. Though the liver was considered to be a major
factor in the death of these patients, this is primarily
based on the impression that the extensive blood loss
from the liver and the accompanying shock aggravated
the recovery of other organ functions. Excluding two
patients with 105 days and 125 days, respectively, the
interval between injury and death in these patients aver-
aged 12.5 days. Seven patients had either the right or the
left hepatic artery ligated and in one patient the com-
mon hepatic artery was ligated. Death in this group of 17
patients often followed the sequence of fever, increased
cardiac output, and peripheral vasodilatation character-
istic of sepsis, resulting in progressive multiorgan failure
and eventual death, or failure to control the liver hemor-
rhage in the face of refractory coagulopathy.
Group II-D (Table 5) includes 42 patients (13%) who
died intraoperatively because of failure to control the
bleeding from a severely injured liver. All had associated
major injuries requiring operative treatment. Thirty-
seven patients had 49 extra-abdominal injuries includ-
ing severe crushing chest injuries (i.e., lacerated lung,
myocardial contusion, and ruptured diaphragms in 23
 TABLE 1. Survivors Group I-S. Patients with Minor Liver Injury, TABLE 2. Survivors Group II-S: Patients with Moderate Liver Injury,
No Treatment to Liver Required (N = 120) Minimal Surgical Treatment Required (N = 60)
N Sex ratio
M:F 2:1
Sex ratio Admission vital signs
M:F 2.24:1 Stable 45
Admission vital signs Unstable 15
Stable 97 Units of blood given at admission and perioperatively
Unstable 23 Average per patient 5.92
Units of blood given at admission and perioperatively Methods of intraoperative surgical treatments used
Average per patient 2.98 Suture technique* 50
Abdominal complications with or without drains Cautery alone 3
No drains, no complications 66 Packing (removed before closing celiotomy) 2
Drained, without complications 44 Hemostatic agent alone or in combination with above 10
Drained, with complications* 8 Abdominal complications with or without drains
Not drained, with complicationst 2 No drains, no complications 37
Average stay in hospital in dayst 15.15 Drained, without complications 15
Drained, with complicationst 6
* 2 wound infections, 2 wound dehiscences, 2 left subphrenic ab- Complications without drainst 2
scesses, 2 small bowel perforations. Average stay in hospital in days§ 15.88
t 1 Staphylococcus fascitis and wound dehiscence, 1 postraumatic
pancreatitis. *
Usually simple or mattress interrupted chromic cat gut on a
t Patients with severe closed head injury and complicated orthope- swaged on liver blunt point needle.
dic injuries are not included in the average. t I wound dehiscence, 2 left subphrenic abscesses; I reoperation
bleeding, 2 wound infections.
TABLE 3. Survivors Group III-S: Patients with Severe Liver Trauma t 2 wound infections.
§ Patients with severe closed head injury and complicated orthope-
Treated with Conventional Surgical Methods (N = 42) dic injuries are not included in the average.
Sex ratio
M:F 2:1 TABLE 4. Deaths Group I-D: Late Deaths from
Admission vital signs Severe Liver Trauma (N = 17)
Stable 11

Unstable 31 Sex ratio

Units of blood given at admission and perioperatively M:F 4.25:1
(excluding 1 patient receiving 100 U) Admission vital sign
Average per patient 22 Stable 10
Dominant surgical intervention used at operation Unstable 7
Suture alone 20 Units of blood given at admission and
Resectional debridement (partial lobectomy) 15 perioperatively (excluding 1 patient
Packing alone I receiving 191 U)
Combination of methods above 6 Average per patient 37
Abdominal complications with or without drains Dominant surgical intervention used at operation
No drains, no complications 13 Suture alone 6
Drained, without complications 17 Resectional debridement 5

Drained, with complicationst 10 Packs in combination with either of above 3

Complications without drainst 2 Hepatic artery ligation with other procedures 7
Average stay in hospital in days§ 241.12 Drains*
Drained 14
*
Hepatic artery ligation was employed in three patients. Not drained 3
t 7 subphrenic abscesses. 3 wound dehiscences. Abdominal sepsis present in patients with drains 4
t 1 wound dehiscence, 1 reoperative bleeding. Abdominal sepsis present in undrained patients 3
§ Two patients with closed head injury with stays of 115 and 134 Hospitalization interval in days before deatht 12.53
days are excluded. *
Sepsis and/or multiorgan failure was present in all patients at the
time of death.
TABLE 5. Deaths Group II-D: Intraoperative Deaths t Excluding two patients with 105 and 125 days.
from Severe Liver Trauma (N = 42)
Sex ratio TABLE 6. Deaths Group III-D: Patients with Insignificant Liver
M:F 3:1 Trauma Dying As a Result ofAssociated Trauma (N = 42)
Admission vital signs
Stable 2 Sex ratio
Unstable 40 M:F 0.75:1
Units of blood infused before death Admission vital signs
Average per patient 28.5 Stable 15
Dominant surgical attempt to salvage Unstable 27
Suturing in combination with other measures 11 Ultimate cause of death
Packing (compression of injury site) 12 Closed head injury 33
Formal hepatic lobectomy 9 Severe cardiac contusion 3
Intracaval shunting 7 Pulmonary contusion 2
Resectional debridement 3 Cardiac arrest, cause unexplained 2
Common hepatic artery ligation 2 Massive exsanguination from pelvic fracture I
Right hepatic artery ligation 2 Thoracic aortic rupture I
Death before effective measures were started 6 Average hospital interval before death in days 6.8
Vol. 207 - No. 2 BLUNT TRAUMA TO THE LIVER 129
patients). In 13 patients closed head injury may have TABLE 7. Relationship Between Drainage and Incidence
been as grave as the liver injury, but it was deemed the ofAbdominal Complications
liver injury alone would likely have been fatal. Concur- Drained Infections Not Drained Infections
rent abdominal injuries were present in 17 patients in- Group (%) (%) (%) (%)
cluding spleen in 12 patients, bowel in 5, and kidney, I-S 52/120 (43) 8/52 (15)* 68/120 (57) 2/68 (3)
bladder, and gallbladder in 1 patient each. Only two of II-S 21/60 (35) 6/21 (29)t 39/60 (65) 2/39 (5)
these patients were hemodynamically stable on arrival III-S 27/42 (64) 10/27 (37)t 15/42 (36) 2/15 (13)
in the admitting area. Twelve patients (29%) arrived in I-D 14/17 (82) 4/14 (29)§ 3/17 (18) 3/3 (100)
the admitting area with no obtainable blood pressure, Total 114/239 (48) 28/114 (26)11 125/239 (52) 9/125 (4)
and 11 had systolic blood pressures < 70 mmHg. In * p < 0.02.
those 27 patients in whom prothrombin time studies t p <0.02.
were available at the time of admission, there was a t p <0.04.
marked prolongation (greater than 3 seconds over con- § NS.
trol) in 21 (75%). These injuries were described as deep IIP < 0.00002, Fisher's exact test, two-tailed.
stellate lacerations or transections, 34 (81%) primarily
involving the right hepatic lobe. In 16 patients (38%) the
injury involved the major hepatic veins or retrohepatic been to use drains in the more severely injured patients,
vena cava. Intracaval shunting of the inferior vena cava which is also reflected in this study. Of the 17 patients
was unsuccessfully attempted seven times. The com- who died late, (group I-D) all but three were drained.
mon hepatic artery was ligated twice and the right he- There was infection in four of the 14 patients drained
patic artery twice. On seven occasions formal anatomic and in one of the three not drained (NS). Of the 43
resections of the right lobe were initiated. Twelve pa- patients with severe liver injury that survived (group
tients expired while attempts were made to compress the III-S), 29 were drained and eight had complications
liver in order to achieve hemodynamic stability, and six likely associated with prolonged drainage. The 14 pa-
patients expired before any attempt at control could be tients not drained had no complications (p < 0.04). In
made. the 180 patients with minor liver injury (groups I-S and
Group III-D (Table 6) contains deaths primarily asso- II-S), 14 patients had infections attributable to drains
ciated with injuries to other organ systems. It is notewor- versus four infections in the undrained patients (p
thy that 24 of these patients were female, a sex ratio of < 0.02). The theoretical occurrence of bile peritonitis or
0.75:1 (M:F). From the data available for this study, collections of intra-abdominal bile did not occur and T
there is no clear reason for this skewed statistic. The tube drainage of the common bile duct was not used.
position of the victim in the vehicle was studied with no In this study of 323 patients with injury to the liver
significant finding between driver and passenger. These that varied from incidental and insignificant to severe
42 patients (13%) are predominantly patients with and fatal, 101 died, a 31.12% mortality rate. A more
closed head injury and an incidental liver injury, which accurate perspective of the magnitude of the problem of
was insignificant. Fatal head injury occurred in 33 of management of severe blunt liver trauma can be appre-
these patients and was a major contributing factor in an ciated if the 180 patients without significant liver injury
additional nine patients. Severe chest injury was also (groups I-S and II-S) are excluded from the study, and
prominent. Eighteen of these patients (43%) died in the the 42 patients with minor liver injury that died from
operating room or on the day of admission, and 76% the associated injury are not included (group III-D) in
died within the first week. the total of 222 patients. Among the 101 remaining pa-
Two hundred forty patients were studied regarding tients with severe liver injury there were 42 survivors
the use of intra-abdominal drainage; the 42 patients who (group III-S). There were 17 late deaths (group I-D) and
died on the operating table and 42 who died from injury 42 patients (group II-D) who died during the operation
unrelated to the abdomen were excluded. Intra-abdomi- because of failure to control the hemorrhage from liver
nal drainage was established in 1 16 (48%), and no injury. These 101 patients were the patients with liver
drainage was used in 124 (52%) (Table 7). These usually injury that were theoretically salvageable at the time of
consisted of either penrose or sump drains, or a combi- admission. Thus, the mortality rate for the liver severely
nation of both, brought out through separate wounds. injured by blunt trauma in this study is 58.4%. However,
The infection rate in the 1 16 patients who were drained the 17 late deaths (group I-D) ofthose with severe injury
was 22% versus a 4% rate in 124 patients not drained (p from blunt trauma represent a mortality rate of 5.26% of
< 0.00002, Fisher's exact test, two-tailed). The instinct the total 323. Many of the 42 intraoperative deaths and
because of traditional training of most surgeons has the 42 deaths from associated injury (groups II-D and
130r COX AND OTHERS
III-D) realistically and probably had little chance for
survival at the time they were admitted. It is the opera-
tive management of the bleeding liver in these patients
that is the real challenge to those treating severe blunt
liver trauma and provides the focus of this study.
Discussion
Myriads of measures to deal with serious liver injury
have been proposed, used, studied, and reported by re-
spected investigators from outstanding institutions
worldwide. No one surgical technique has emerged that
is clearly superior and applicable to every patient. Each
has proponents, and when expertly applied in the cor-
rect situations will have rewarding results.
Suturing
Suturing the liver has been condemned by Lim et al.,2
and according to Mays3 is based on tradition only.
Trunkey, et al.4 reporting on 81 1 patients, noted that
20.4% of their patients with extensive laceration of the
liver were treated using 0 to number 1 catgut interlock-
ing horizontal mattress sutures. During the latter part of
their study bleeding points were managed by direct su-
ture ligation. It was thought that this reduced the chance
of necrosis and hemobilia. Only 21.3% of the 81 1 pa-
tients they reported were victims of blunt trauma.
In this study suturing the liver as described above,
with variations according to the operator's perference,
was the technique most often used. All of the 60 patients
in group II-S and 26 of the 42 in group III-S were treated
using various suturing methods. In blunt trauma, where
two fragments of liver gape apart and where point liga-
tion of the bleeding vessels would require manipulative
intervention, often difficult because of poor exposure
and the technical maneuvering that adds to the trauma
already present, this simple, quick, traditional method
was effective in limiting blood loss. We experienced
none of the complications often alluded to (i.e., hemo-
bilia or liver necrosis in the survival group) when sutures
were used. Lucas and Ledgerwood5 noted that "contrary
to theoretical objections that liver sutures will cause he-
patic ischemia . . . no patient died following liver su-
ture for control of bleeding," only 9% of the patients in
that study were victims of blunt injury.
Liver Resection
Successful liver resection in 15 surviving patients in
group III-S was limited to removal of the injured frag-
ments peripheral to the fracture line of the liver. Resec-
tional debridement, completion resection, and segmen-
Ann. Surg. * February 1988
tectomy were terms used to describe these procedures.
Two patients required reoperation for bleeding and were
treated with additional ligations of the right hepatic ar-
teries. Both patients developed abscesses, presumably
related to the relative ischemia of the liver. Major liver
resection along anatomic planes advocated by many6-"
was attempted nine times and was never successfully
accomplished with a survivor (group II-D). Each of these
nine patients was stable prior to the commencement of
the attempted formal resection, and as the procedure
progressed the bleeding became uncontrollable. Mays3
in his monograph on hepatic trauma, referring to the use
of anatomic lobectomy in acute liver injury states "the
mortality rate forbids it." Pachter and Spencer12 noted a
mortality above 50% and observed "though the tech-
niques of hepatic resection have been well defined there
is declining frequency in its use." The present experi-
ence here with blunt trauma substantiates these warn-
ings.
Intracaval Shunting
Schrock et al.'3 described the use of an intracaval
shunt of the inferior vena cava in a victim of a fall with
avulsion of the hepatic veins and a lacerated retrohe-
patic inferior vena cava. Since that report Doty and
Berman'4 and Brajendranath et al.'5 among others have
added technical refinements in search of the best ap-
proach to achieving vascular control when injury to the
liver extends into the retrohepatic vena cava or the he-
patic veins. Some authors oppose intracaval shunting.
Yellin et al.'6 advocate venous isolation with occlusion
of the inflow to the liver. Balasegaram17 had eight survi-
vors in 12 patients with juxtahepatic venous injury using
venous isolation and contends that sternotomy to gain
exposure takes too much time in these desperate cir-
cumstances. Regardless, if access to the suprahepatic
vena cava is necessary, sternotomy easily allows the
quickest exposure with the least postoperative morbidity
rate.
Intracaval shunting was used in seven patients (group
II-D) without a survivor. All three approaches usually
described for the insertion of the shunt were utilized.
Patients with these injuries generally do not do well in
spite of isolated reports of successful use of either of
these methods.'8
Ligation ofArterial Inflow
In 1933 Graham and Cannell'9 postulated that opera-
tive interruption of the hepatic artery could be success-
fully done without interfering with liver viability. He-
patic artery ligation was briefly in vogue as a treatment
Vol. 207 No. 2
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BLUNT TRAUMA TO THE LIVER
for cirrhosis after being introduced by Rienhoff20 in
1951. Madding2' in 1954 suggested that hepatic artery
ligation be "used in some cases of liver injury."
Mays22'23 has recently promulgated dearterialization of
the liver in severe injury with certain limits in selected
patients. Others2426 also saw a place for its use. Still
others, Pachter and Spencer,27 see it as an unnecessary
hazard for the patient and it is without clear rationale.
In this review, two patients with right hepatic artery
ligation and one patient with ligation of the proper he-
patic artery survived (group III-S). There were also four
patients with hepatic artery ligation among those that
died intraoperatively (group II-D). Of the 17 late deaths
from liver injury (group I-D), seven had hepatic artery
ligation. Both surviving patients with right hepatic ar-
tery ligation required reoperation for continued bleed-
ing. The third survivor with ligation of the proper he-
patic artery had an uncomplicated recovery and was
discharged in 21 days. The records here show one un-
qualified success in 14 patients with hepatic artery liga-
tion.
Omental Packing
Stone and Lamb28 described the use of an isolated
omental pedicle placed into the fracture defect and held
in place by sutures. An updated report by Fabian and
Stone29 described their experience with 115 patients in
which this method of packing to obtain hemostatic con-
trol was successful 90% of the time. The experience in
this study with omental packing is limited to one patient
(group III-S) where it was successful.
Packing with Gauze
A last desperate measure to control bleeding from the
liver, packing with gauze, has recently under certain
conditions been proposed as a deliberately planned first
approach.30'3' Packing with radiopaque laparotomy
pads was used on six occasions, three times in the survi-
vors' group without complications, and three times in
the late death group. Two of the late death group devel-
oped infection and sepsis before they died.
Drains and Complications
The association between the use of intra-abdominal
drainage and infection was analyzed (Table 7). While
the traditional teaching of most surgeons is that drainage
of hepatic injuries is necessary in order to avoid bile
peritonitis and abscess formation, these data do not bear
this out. The incidence of intra-abdominal infectious
131
complications was significantly greater in those patients
who were drained compared to those who were not (p
< 0.00002). This may be related to the fact that the
mechanism of injury in this series was blunt trauma
rather than penetrating trauma, and, therefore, the oper-
ative field was less likely to be contaminated. While
there are situations encountered in these kinds of pa-
tients that may dictate the use of drainage, from this
study the evidence against routine use of drains in blunt
liver trauma would support those who believe it is not
necessary, especially in situations of insignificant liver
injury.32'33
Conclusions
Though the data presented in this study has been sub-
jected to retrospective analysis, it was accumulated in a
prospective fashion. Specific management trials were to
be scrutinized and documented. Was hepatic artery li-
gation helpful? Was major hepatic resection useful?
Could intracaval shunting be successfully used? What
about drains? Does packing have a place? When does
coagulopathy and/or hemodilution become irreversible?
These among other questions formed the basis to begin
this study; as the data were collected and analyzed on a
yearly basis other problems in the care of the liver in-
jured by blunt trauma became apparent.
Before the study began it was clear that serious injury
to the liver was a difficult condition, and both the surgi-
cal team and the patient had usually encountered a des-
perate situation. There was no concensus among the
staff as to the best approach to these problems. As the
foregoing material indicates, the entire spectrum of
known technical approaches have been utilized with
varying degrees of success and without decisive results
favoring any one approach. As each success or failure
was encountered and documented, there was a gradual
realization among the staff that the more aggressive ap-
proaches were most often futile, and there was a trend
toward less bold surgical measures. The attending sur-
geons became less inclined to attempt formal anatomic
resections. Hepatic artery ligation, at times a technical
challenge itself, did not always stop the bleeding and
there were no instances where intracaval shunting was
successful. Though these heroic measures have had per-
suasive advocates, the impression in the literature that
these are simple procedures that can simply be accom-
plished in instances of severe liver trauma is misleading
and has at times contributed to a novice, machismo
approach to major liver trauma.
The liver injured by blunt trauma and the associated
injury, both extra-abdominal and abdominal, when it
132 COX AND OTHERS
occurs creates a clinical entity requiring special consid-
erations and the best in clinical judgment and surgical
management. Severe blunt trauma must be considered a
specific disease. There are few conditions that acutely
alter the entire physiology as does blunt trauma in its
most serious forms. The mortality rate from liver
trauma bears a linear relationship to the severity of the
injury and an inverse relationship to the experience,
judgment, and skill of the team caring for the patient.
These disasters seem to occur at night and on weekends.
Since the best results reported come from institutions
where one doctor concentrates on the liver only, or a
liver team is organized, it may occasionally be well to
stay the definitive execution of care (or pack the injury)
until such a team can be assembled.34
On admission most of these patients with severe liver
injury will have gross blood return on diagnostic perito-
neal lavage. They will usually be hemodynamically un-
stable as was seen in this study. Before attempts to treat
specific organ injury are begun, effective restitution of
cellular oxygenation must be accomplished through re-
spiratory and cardiac support by whatever means are
required. In most instances severe liver injury will be-
come the priority consideration in the management of
the severely injured trauma victim.
At operation, minor injuries need little or no treat-
ment. The more severe injuries graded toward those
with retrohepatic vena caval injury or hepatic vein in-
volvement require only those measures needed to con-
trol bleeding. From these data the great majority can be
controlled with simple sutures placed 2 to 3 cm from the
edge of the fracture with an absorbable suture using a
blunt point needle with a large arc placed in whatever
fashion the operator is comfortable with. The anxiety
about intrahepatic hematoma, hemobilia, necrosis
along the suture line, bile collection, and biliary fistulae
appear to be unwarranted; they did not occur in this
series. The more peripheral these injuries are, the better.
These simple methods work, and if done with a mini-
mum of meddling, will save blood and time. Drainage of
the abdomen in these relatively minor injuries does not
appear warranted in lieu of the increased incidence of
infectious complications.
In the surgical management of fragmentation frac-
tures where the viability of distal segment of the liver is
questionable, resectional debridement is all that is nec-
essary or should be attempted. Formal or anatomic lo-
bectomy should not be attempted, and hepatic artery
ligation is rarely helpful. Bleeding points should be indi-
vidually controlled by suture ligatures in preference to
hemoclips or cautery since repeated mopping with gauze
tends to pull off the clips and abrade the eschars of the
Ann. Surg. * February 1988
cautery. These procedures can be tedious and time-con-
suming. Impatience and continuing to operate in the
face of persistent bleeding is not often rewarded by a
successful outcome. The patients must be hemodynami-
cally stable, if possible, before any attempts at technical
maneuvering are accomplished. For deeper, more cen-
tral injuries, if bleeding is arterial or is too great to ig-
nore, control at the porta hepatis using Pringle's maneu-
ver and widening the hepatotomy to control the bleeding
vessels with point ligations may be necessary. In addi-
tion, compression of the liver injury to control the
bleeding while waiting for the replacement of blood and
clotting factors seems an easy thing to do but is often
ignored. When there is a blood clot in the fracture fis-
sure, it is a good idea to dry up the area and ascertain the
degree of bleeding and if possible, in good judgment, to
leave it alone before the curiosity to probe the depth of
the wound becomes a hazard. In these kinds of lesions
packing with laparotomy pads carefully placed between
the liver and the diaphragm and then stabilized with
several packs in the subhepatic space will often be suffi-
cient treatment. No drains are used, and after several
days when the patient has been stabilized, the packs,
residual blood, and debris are removed at reoperation.
Though the experience in this study with omental pack-
ing is nil, there are some sound theoretical consider-
ations for its use.28'29 Again, even in these large injuries
(groups III-S and III-D), bile-related complications did
not occur and the incidence of infectious complications
associated with the use of drains was significantly in-
creased (p < 0.01).
Data accumulated on blood coagulation in this study
indicate that coagulation factors were depressed in the
majority of the severely injured patients. After patients
with suspected severe liver injury are admitted, and as
soon as possible during the resuscitative process, fresh
frozen plasma should be given. There comes a critical
point in the bleeding when the clotting factors become
depleted and whatever name is applied to the syndrome,
at that moment, the patient's clotting time is extended
to infinity. Though this could not always be clearly doc-
umented, this point usually comes after six to eight
transfusions of red blood cells, whether stored blood or
autotransfusion is used. When this point is recognized,
the better alternative to further frustration may well be
to pack the site and resort to replacement of red blood
cells and clotting factors in a carefully monitored inten-
sive care environment. Presently in this country the use
of component blood products is becoming standard
practice, and the luxury of fresh whole blood is becom-
ing a thing of the past. Fresh frozen plasma, cryoprecip-
itate, and platelets, as indicated, should be used early in
Vol. 207 - No.2 BLUNT TRAUMA TO THE LIVER
the care of these patients, and continued through the
postoperative period. The liver is the site of production
of these factors, and presumably has been functionally
impaired by the injury. This coagulopathy is amplified
by hypothermia, which occurs commonly after massive
transfusion of cold blood and blood products. Mainte-
nance of normothermia is essential in these patients,
and the use of efficient, high performance, simple blood
warmers is sorely needed. Such a device has recently
been described35; however, its clinical efficacy remains
unproven.
Our experience with injuries involving the retrohe-
patic vena cava previously described is similar to that of
Walt.'8 Only when these injuries can be anticipated and
suspected, and the patients' clinical condition allows
time for deliberate planning, do the shunting and inflow
bypass procedures stand a real chance of being success-
ful. At present, the best approach to juxtahepatic vascu-
lar injuries appears to be that of Pachter et al.,36 who
advocate external cooling of the liver, use of large doses
of steroids, occlusion of hepatic inflow, and a direct ap-
proach to the injury through the liver, if necessary, using
thefingerfracture technique and point ligation of bleed-
ing vessels. Until better preoperative recognition is
achieved, such as through the efforts of Federle et al.37
using computed tomography, immediately available in
the resuscitation area, or until technical advances in
surgery occur making it possible to isolate the liver easily
from its vasculature so that necessary repairs can be
made in a dry operating field, mortality rates with these
injuries will continue to be high.
There have been impressive advances in the care of
these critically injured patients especially in the area of
intensive management, in control of sepsis, pulmonary
care, nutrition, anesthesia, and technical instrumenta-
tion in monitoring. In trauma centers that care for civil
trauma, the concept of a dedicated liver team alluded to
by Spencer38 should be seriously considered. Other con-
siderations might be the use of external pump bypass set
up in advance for suspected severe liver injury or the
routine insertion of an intracaval shunt easily placed
through a groin vein before the abdomen is opened.39
Advances must continue to be made in safety standards
for the roads and highways. There must be insistence by
traumatologists that our government pass legislation to
require air bags or equivalent restraints. The people who
should be wearing seat belts just do not wear them!
Summary
This is a study of 323 patients from a major trauma
center of liver injury caused exclusively by blunt
trauma. The entire spectrum of known technical inter-
133
ventions to control liver hemorrhage were utilized by
the full-time staff of traumatologists. A mortality rate of
58.4% on 101 patients with marked hemorrhage from
the severely injured liver is noted. This is in the range
noted in other studies.'3 Overall, the mortality rate for
the 323 patients was 31% and for those who died from
liver injury if they survived the celiotomy (17 patients)
the mortality rate was 5.26%. Conservatism in the man-
agement of the more seriously injured patients is sup-
ported by the statistics collected during the study. Lib-
eral replacement of blood clotting factors is advocated.
Earlier consideration of packing to the liver might re-
duce the formidable mortality rates in those patients
with serious injury. Dedicated liver trauma teams in
institutions, where feasible, is encouraged.
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