The incidence of abdominal trauma, and thus that of liver trauma, has been increasing in the past few years. Improvements in the understanding of the anatomy of the liver and improvements in diagnostic techniques have resulted in shorter and better operations with less delay between injury and surgery. Improvements in transportation to adequate hospital facilities and vigorous resuscitative measures have also contributed to lowering the mortality rate for this type of injury. Suggestions are made for the surgical management of liver injuries, together with illustrative case reports

Brush, B. E.

Fox, T. A., Jr.

Grodsinsky, C.

English

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Henry Ford Hospital Medical JournalVolume 21 | Number 4 Article 512-1973Surgical Treatment of Liver Trauma: TechnicalConsiderations and Case ReportsC. GrodsinskyT. A. Fox Jr.B. E. BrushFollow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public HealthCommonsThis Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.Recommended CitationGrodsinsky, C.; Fox, T. A. Jr.; and Brush, B. E. (1973) "Surgical Treatment of Liver Trauma: Technical Considerations and CaseReports," Henry Ford Hospital Medical Journal : Vol. 21 : No. 4 , 187-190.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol21/iss4/5H e n r y Ford H o s p . M e d . Journa l V o l . 2 1 , N o . 4 , 1973 Surgical Treatment of Liver Trauma Technical Considerations and Case Reports C. G r o d s i n s k y , M D , T. A . Fox, Jr., M D a n d B. E. B r u s h , M D * The incidence of abdominal trauma, and thus that of liver trauma, has been increasing in the past few years. Improvements in the un-derstanding of the anatomy of the liver and improvements in diagnostic techniques have resulted in shorter and better operations with less delay between injury and surgery. Im-provements in transportation to adequate hospital facilities and vigorous resuscitative measures have also conthbuted to lowering the mortality rate for this type of injury. Sug-gestions are made for the surgical manage-ment of liver injuries, together with illustrative case reports. 'Department of Surgery Address reprint requests to Dr. Grodsinsky at Henry Ford Hospital, 2799 W. Grand Blvd, De-troit, Ml 48202 /ADVANCES in recent years have con-t r ibuted to the more successful manage-ment of the patient undergoing surgical operat ion of the liver. The incidence of liver trauma has increased along wi th the increase in the number of abdominal traumas. DiagnosticaUy, peritoneal lav-age has al lowed more accurate interpre-tations in b lunt abdominal trauma. In penetrat ing t rauma, improvements in transportat ion to hospital facilit ies, vig-orous resuscitative measures and prompt surgical intervent ion have definitely low-ered the mortal i ty rate. We believe that all penetrat ing wounds of the abdomen should be surgically explored. Wi th im-proved liver scanning and bacteriological studies, morb id i ty and mortal i ty f rom liver abscesses have been reduced sig-nificantly. Liver operations are most commonly indicated for: 1. Trauma 2. Abscess 3. a. Benign tumors or cysts b. Primary or secondary cancers 4. Transplantation M o r e accura te k n o w l e d g e of the anatomy of the liver has shortened the length o f t h e surgical procedures and re-duced the incidence of postoperat ive h e m o r r h a g e , b i l i a ry f i s tu las and hematobi l ia. Ant ib io t ics , a l though im-portant in the contro l of sepsis, have not helped reduce the incidence of post-operative intra-abdominal purulent col-lections. 187 Grodsinsky, Fox and Brush We encountered 44 liver injuries in 190 patients operated for abdominal trauma dur ing the past five years. This experi-ence has given us an oppo r t un i t y to evaluate the technical management of these problems. From this experience we wi l l review three case reports and make the fo l lowing recommendat ions: 1. Pay careful attention to the post-operative needs of the patient. 2. Supe r f i c i a l l iver w o u n d s and through-and-through non-bleeding perforations made by small caliber, low velocity bullets may be treated by drainage only. 3. Larger wounds, usually bleeding at the t ime of exp lo ra t i on , requ i re suturing as well as drainage. 4. Patients wi th severe burst ing, crush-ing, high velocity bullet wounds and shotgun wounds at close range re-quire resectional debr idement and possible lobectomy. Retrohepatic caval and major hepatic vein injuries near the cava are the chief indica-tions for formal lobectomy. 5. Use of packing either wi th gauze or "abso rbab le " hemostat ics should be avoided except for temporary purposes. 6. In extensive drainage, Penrose and, when requi red, sump drains should be inst i tuted. 7. Biliary decompress ion is recom-mended only w i th injuries to the biliary tract, duodenum or head of t he pancreas . It is no t r e c o m -mended in injuries conf ined to the liver. Discussion Sutur ing is usually used to con t ro l hemorrhage at the t ime of surgery. Its usefulness is greatest in the care of stab-bing or incised wounds of the liver. Oc-casionally, sutures used to approximate the liver edges produce more bleeding and bile extravasation than they cont ro l . Excisional debr idement involves the removal of all devitalized liver tissue and the contro l of bleeding and bile extrava-sation by means of sutur ing. An attempt should be made to individually ligate all major vessels and bile ducts on the cut surface o f t h e liver wi th interrupted black silk. To suture the liver parenchyma, we prefer through-and-through overlapping chromic catgut. No attempt should be made to reconstruct the liver profi le by approximating sutures and we prefer to leave the raw surface open for better drainage. The introduct ion of an absorb-able hemostatic between two raw sur-faces shou ld be c o n d e m n e d . These hemostat ics serve as t ampons , delay healing and may eventually lead to innu-merable compl icat ions. Several drains should be used and should be brought out of the abdomen by the shortest route. Hepatic lobectomy is rarely required and the early enthusiasm of some for this radical treatment is no longer present. There are, however, l imited indications for formal lobectomy. One of these is in patients wi th either blunt or penetrat ing injuries who have extensive devitaliza-t ion of a major por t ion of the tissues of one lobe of the liver. The second major indication wou ld be damage to the hepa-tic veins or vena cava to the extent that right lobectomy wou ld be required to visualize and contro l this injury. A left lobectomy can be performed f rom the abdomen, but the thoraco-abdominal in-cision offers the best exposure for a right lobectomy. In per forming any lobectomy there should be individual l igation o f t h e b lood vessels and bile ducts in the porta hepatis. We prefer the f inger fracture method of div iding the liver parenchyma and advocate individual ligation of the major vessels and bile ducts in the liver substance. Several Penrose drains are used as well as one or two sump drains. We do not employ a T-tube in the com-mon bile duct unless it has been injured or there is some injury to the duodenum or pancreas. 188 Surgical Treatment of Liver Trauma Table 1 Associated Visceral Injuries In 44 Patients with Liver Trauma Number Number Extent of of of Injury Cases Deaths Liver only 2 0 One associated injury 14 l i Two associated injuries b 1 Three associated injuries 3 2 Four associated injuries 4 0 Five or more associated injuries 3 0 Table 2 Treatment of Liver Injuries in 44 Patients Number Type of of Treatment Cases Drainage only 25 Suturing and drainage 8 Debridement, partial resection and drainage e Hepatic lobectomy and drainage 3 Clinical Data In our series of 44 patients, there were 37 males and 7 females wi th an age range f rom 16 to 62 years wi th a median of 28 years. Five (5) were blunt injuries and 39 were penet ra t ing in ju r ies , i nc lud ing 6 stab wounds and 2 shotgun wounds. The re-maining 31 were pistol or rifle wounds. It is stated that the number of viscera involved in association w i th the liver wound is the most important single factor in predict ing p r o g n o s i s . O u r experi-ence is given in Table 1. Two of our three deaths occurred in pa-tients who had serious medical problems in addi t ion to their trauma. One of our deaths o c c u r r e d in a pa t i en t w i t h rheumatic heart disease who had under-gone aortic valve replacement. The sec-ond occurred in a massively obese male w h o exh ib i t ed a " P i c k w i c k i a n " syn-drome. All three deaths occurred in patients who also had massive peritoneal con-tamination f rom colon injuries. Al though def in i te conclusions cannot be drawn f rom such a small series, it appears that the degree of contaminat ion at the t ime of in jury is more impor tan t than the number of associated visceral injuries. None of our deaths occurred in patients undergoing hepatic lobectomy. The types of treatment employed are given in Table 2. It can be seen that almost 60% of liver injuries can be managed successfully by drainage alone. We have had no mortality and minimal morbid i ty in cases treated by drainage alone. illustrative Case Reports Case Report # 1 A 34-year-old policeman sustained a gun-shot wound ofthe chest and abdomen. After a thoracotomy tube was inserted to relieve an expanding hemo-pneumothorax, the patient underwent an exploratory laparotomy. Multi-ple injuries included: (1) A five centimeter stellate laceration of the right lobe of the liver; (2) Laceration of the second portion of the duodenum and head of the pancreas; (3) Laceration o f the right colon, and (4) Transection of the spleen. The bleeding from the liver was controlled by means of suturing. The lacerations of the duodenum and pancreas were sutured and a T-tube inserted into the common duct. A splenectomy and a right transverse colostomy were performed. After a stormy post-operative course including massive pulmonary em-bolism, intra-abdominal infection and wound dehiscence, the patient was discharged from the hospital three months later. Comments Hemorrhage f rom smaller liver lacera-tions can usually be control led by sutur-ing. We believe that T-tube drainage of the common bile duct is necessary in the 189 Grodsinsky, Fox and Brush presence of d u o d e n o - p a n c r e a t i c i n -juries; but is unnecessary and even harm-ful in liver resection a lone. ' Adequate drainage of the hepatic and subhepatic area is most impor tant . This removes blood and bile which form an excellent cu l t u re m e d i u m fo r the bac ter ia l l y -contaminated tissues. We prefer to drain wi th mult ip le Penrose drains and some type of sump dra in. These drains are brought out through a dependent drain-age incision placed subcostally at the midaxi l lary or poster io r axi l lary l ine . When extensive liver resections are re-q u i r e d , McCle l l and and Shires'* have suggested that in addi t ion to anterior drainage, posterior drainage should be provided by excising a por t ion of the twe l f th r ib to establ ish t h rough -and -through drainage of the resected liver bed. The drains are al lowed to remain until there is no fur ther drainage except for a serous type of f luid f rom the tissues. They are gradual ly shor tened over a period of three to four days. Case Report # 2 An 18-year-old male was brought into the Emergency Room after sustaining a stab wound in the right upper quadrant. He was hypotensive, but had no other significant find-ings. At laparotomy, 2000 ml of partially clotted blood was presented in the peritoneal cavity. A small puncture wound was found in the liver, but it had ceased bleeding. Nothing was done to the puncture wound and the abdomen was closed with drainage to the damaged area. Comments This case represents a common f ind ing after explorat ion for a single stab wound of the abdomen with injury to the liver. Similar f indings are seen wi th some small caliber, low velocity gunshot wounds of the liver. Most of the t ime the only treat-ment consists of drainage o f t h e area. We believe that any hemostatic packing of the w o u n d should be avoided as these agents serve as tampons to prevent the drainage of b lood , bi le, and devitalized l ivert issue. Likewise, c losureof small de-fects in the surface of the liver can pro-duce the same effect. For these reasons, we believe in leaving the wound open unless it is bleeding massively. Case Report # 3 A 20-year-old male sustained a gunshot wound of the right upper abdomen. At laparotomy a large stellate fracture ofthe right lobe ofthe liver and a complete transection of the upper right ureter were found. The ureter was repaired by an end-to-end anastomosis and a right hepatic lobectomy was performed. The area ofthe hepatic lobectomy was drained by three Penrose drains. No T-tube was used. Two weeks post-operatively the patient un-derwent drainage of a large right subphrenic abscess. His condition slowly improved and he was discharged from the hospital three weeks later. Comments Hepatic lobectomy was performed in this patient because it was the best, if not only, way to control hemorrhage and re-move dev i ta l i zed t issue. The p rope r management of hypovolemia and a bet-ter understanding o f t h e anatomy o f t h e liver are factors contr ibut ing to the lower mortal i ty rate in hepatic resections for trauma. In spite of apparently adequate drainage in right hepatic lobectomies, we cont inued to have the subphrenic ab-scess as a common compl icat ion. We are considering the use of posterior drainage through the bed of the twel f th r ib. References 1. Madding GF, Lawrence KB and Kennedy PA: Forward surgery of the severely wounded. Second Aux Surgical Group 1: 307, 1942-1945 2. Mikesky WE, Howard JMand DeBakeyME: Injuries of the liver in 300 consecutive pa-tients. Int Abst Surgery 103:232, 1956 Lucas CE and Walt AJ: Critical decisions in liver trauma. Arch Surg 101:277, 1970 McClelland R and Shires T: Hepatic resec-tion for massive trauma. Trauma 4:282,1963 190 

Surgical Treatment of Liver Trauma: Technical Considerations and Case Reports

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Surgical Treatment of Liver Trauma: Technical Considerations and Case Reports

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