The liver is the organ most frequently injured by
abdominal trauma.1 The major cause of mortality in
patients with acute liver injuries is bleeding. Severe
liver injuries often lead to exsanguination, which is the
most common cause of death.2 However, 50% to 80%
of liver injuries stop bleeding spontaneously.2 As a
result, there's been an increase in the utilization of
nonoperative management techniques. Specific criteria
for conservative management of low-end liver trauma
have been suggested in the literature, but most
criteria are geared toward high-end injuries.
Mortality
The mortality from liver trauma decreased from 66%
during World War I to 25% during World War II and is
currently estimated between 20% and 40%. This
decrease in mortality has been attributed to the
following changes: better surgeon selection of patients
for conservative treatment, enhanced resuscitation
techniques in the acute phase, antibiotics, advanced
surgical techniques for high-end injuries, and planned
reoperations resulting in fewer infections.
Mortality for acute liver injuries has drastically
increased when the patient was associated with
injuries such as head trauma. Results from one
selected study indicated that the mortality was 69.2%
in the presence of head trauma and 7.3% without
head trauma.1 While other associated injuries don't
appear to be as significant a factor in mortality as
head injuries, they may produce other complications
such as hemorrhage and shock, which have a profound
effect on patient survival.
Shock on admission is directly proportional to the
degree of injury and is an important factor that
impacts mortality.1 Patients in shock who were
admitted had a mortality of 58%, which was
significantly higher than the 12% rate among patients
without this complication.2Additionally, patients who
were admitted in shock with an associated organ injury
had a higher mortality compared with those without
shock.
Mortality from acute liver injuries occurs in two
phases. Early deaths arise from hemorrhage and hypo
volemic shock from either the liver or associated major
vascular injuries. In comparison, late deaths are a
result of sepsis and multiple organ dysfunction
syndrome.2
Causes of injuries
It's more common to have penetrating trauma related
to what has become known as “the knife and gun
club,” a phenomenon associated with city crime. Blunt
trauma, on the other hand, often occurs from
automobile accidents or falls, and is more frequently
observed among patients in rural areas.1
Injury to the liver is more common in children due to
the flexibility of their ribs, which allows more force to
be directed to the liver. In addition, the connective
tissue in children isn't as fully developed as in adults,
which also increases the risk for liver injury.
According to Yaman et al., 56% to 76% of hepatic
injuries are caused by blunt trauma.1 The most
frequent cause of this type of abdominal injury is
related to motor vehicle, occupational, or sporting
accidents. Other causes of blunt trauma include
automobile-pedestrian accidents, falls from heights,
mountain bikes, and urban violence excluding knives
or guns.
Penetrating injuries include stab wounds caused by
sharp objects such as knives, gunshot wounds, and
shrapnel. Rib fractures that penetrate the liver are also
included in this group.
Associated injuries
Less than 50% of liver injuries occur without any other
associated injuries, indicating that the major ity of
patients experience liver injuries concomitantly with
other traumas.1 Closely associated with acute liver
injury are abdominal and retroperitoneal injuries
(59.8%), thoracic injuries (17.6%), injuries of the
extremities (11.7%), cranial, and neurological injuries
(10%).1 Head injuries are often considered to have
the most severe impact on these patients. Other
injuries associated with acute liver injury include:
pelvic fracture, long-bone fracture, nonlong bone
fractures, scalp lacerations, and soft tissue injuries.
Mortality of about 70% is cited in cases of concomitant
injury of the liver and abdomen, thorax, or brain.1
Liver anatomy
The liver is a fragile organ prone to life-threatening
injuries because of its complex vascular system and
large mass, which is prominent in the anterior portion
of the abdomen. (See Liver anatomy and physiology
facts.) Because of its proximity to the ribs, the right
lobe is more commonly injured than the left lobe. This
organ performs a wide variety of high-volume
biochemical reactions requiring highly specialized
tissues.
Injury evaluation
There're several methods to classify the level of liver
injury, including scoring systems such as the
Abdominal Trauma Index (ATI), the Injury Severity
Score (ISS), the Abbreviated Injury Scale (AIS), and
the American Association for the Surgery of Trauma
(AAST) organ injury scale. The ATI was designed to
stratify patients with penetrating injuries, and has
been used to classify patients with blunt trauma.
(SeeThe ATI.)
The ISS is an anatomical scoring system that provides
an overall score for patients with multiple injuries. The
ISS was originally designed to stratify victims of blunt
trauma, and is also used for victims of penetrating
trauma. To utilize this system, the scores for the three
most severely injured body regions are squared and
added together to obtain the ISS score. (See Example
of the ISS.)
The AIS is an anatomical scoring system first
introduced in 1969. Since then, it's been revised and
updated against survival so that it now provides a
reasonably accurate ranking of the severity of injury.
Injuries are ranked on a scale of one to six: one is
considered minor, four is severe, and six is a
nonsurvivable injury. (See The AIS .)
Table. Example of the ISS
In a hemodynamically unstable patient with severe
blunt abdominal trauma, the delayed indication for
emergency laparotomy can be life-threatening. The
need for blood transfusion correlates with the
prognosis in patients with multiple injuries, including
blunt liver trauma.1
Table. The AIS
Clinical presentation
The patient with suspected blunt or known penetrating
liver trauma usually presents with signs and symptoms
of hemorrhage, peritoneal irritation, right upper
quadrant pain, and abdominal guarding. There may be
rebound tenderness of the abdomen. In the most
critical cases, the patient may present with shock,
profound hypotension, and decreasing hemoglobin and
hematocrit. Patients with blunt liver trauma may
develop a liver abscess due to undiagnosed liver
damage.These patients will present with signs and
symptoms of acute abdominal infections and
peritonitis.
Management of acute liver injury
Management of acute liver injury is accomplished
through conservative methods or surgical
management, depending on the degree of injury.
Initially, the patient may require resuscitation before
any other treatment. Prophylactic antibiotics may be
administered. Continuous monitoring of vital signs, as
well as hemoglobin and hematocrit, are essential in
the initial period. Blood transfusions may be required if
the patient has lost a significant amount of blood
volume.
Treatment may consist of conservative or nonoperative
measures. The surgical treatments include suturing,
resection and debridement, packing of the liver, and in
the most severe cases, liver transplantation.
Nonoperative management, also known as
conservative treatment, assumes that there's no
hemodynamic instability and requires strict bed rest,
close observation, serial monitoring of hemoglobin and
hematocrit, and periodic computed tomography (CT) of
the abdomen. Inclusion criteria for nonoperative
management requires evaluation of neurologic
integrity and that excessive hepatic-related
transfusions aren't necessary. The surgeon will assess
the results of the CT of the abdomen and confirm
associated intra-abdominal injuries. Most injuries
treated nonoperatively are classified as grades I to III,
according to the AAST scoring system. Grade IV and V
injuries require operative intervention and are never
treated with a conservative or nonoperative method.
(See AAST organ injury scale.)
The main objectives in the
operative management of liver
trauma are to control the
bleeding and bile leak, remove
devitalized tissue, and control
infection in patients with
associated visceral injury as well
as to establish adequate
drainage of the abdomen.
Hemostasis may be achieved
with the use of electrocautery,
sponge gel, primary suturing,
hepatic resection, or perihepatic
packing. Utilization of any of
these techniques requires the
surgeon's careful evaluation,
and imaging results and
physical findings will help
determine the most appropriate
treatment.
Table. AAST organ injury scale
Types of procedures
Treatment of acute liver injury has come full cycle
from aggressive surgical management to extremely
conservative management. Surgeons originally packed
the liver to create a tamponade effect. Perihepatic
packing was often left in for 1 to 2 weeks, with
excessive complications. Many patients succumbed to
overwhelming infections. Infection rates and
associated morbidity were high.4 Surgeons eventually
became reluctant to utilize this therapy and
nonoperative treatment of acute liver injuries became
more prevalent.
The current trend is for surgeons to evaluate the
patient with more specific criteria to guide the
treatment. In general, hemodynamically unstable
patients with either blunt or penetrating trauma should
undergo emergency laparotomy.
Perihepatic packing for liver trauma
A 1999 report by Caruso et al.4 discouraged the use of
perihepatic packing due to increased frequency and
severity of complications related to this technique.
However, recent improvements in outcomes related to
a better understanding of the anatomy and physiology
of the liver, improved anesthetics and postoperative
care, and advances in operative techniques related to
liver transplantation, have established this technique
as the treatment of choice.
Perihepatic packing is a common surgical procedure to
control hemorrhage in traumatic or spontaneous
hepatic rupture. By placing packs around the liver, the
surgeon is able to induce tamponade and foster
hemostasis. Additional surgical intervention is required
within the following days to unpack the liver.
Perihepatic packing itself may cause serious
complications, such as hypotension and decreased
cardiac output, abdominal compartment syndrome
(ACS), and multiple organ failure because of ischemia
of the spleen and retroperitoneal organs. Other
important complications related to perihepatic packing
are thrombotic formation in the abdominal vessels,
deep vein thrombosis of the legs, and pulmonary
embolism. Perihepatic packing in patients with liver
trauma may lead to ACS and to venous thrombosis of
the lower part of the body.5 In addition, packing might
lead to elevated intra-abdominal pressure causing
cardiopulmonary dysfunction.
Failure to relieve ACS can result in multisystem organ
failure and death. Urgent decompression is the therapy
of choice, and this action is accomplished by removing
the packing. A major complication of this process is
uncontrollable bleeding, which can be life-threatening.
Perihepatic packing is accomplished using gauze
laparotomy sponges to pack the liver. Packs should be
removed when the patient is stable, which is generally
24 to 72 hours after injury. Stability is determined as
normothermic, correction of acidosis, resolution of any
coagulopathy, and a surgeon's evaluation and
recommendation for removal of the packing. The
timeframe for pack removal hasn't been proven in
research and may vary between institutions.
Timing of pack removal affects the rate of rebleeding
and the incidence of postoperative liver-related
complications such as biloma, bile leak, and intra-
abdominal abscess. Biloma is the intra-abdominal
collection of bile, which requires percutaneous or
operative drainage. A bile leak occurs when a bile
fistula is created, which may require surgical
intervention if it persists for 10 days or more. An intra-
abdominal abscess is indicated by a positive culture of
hepatic fluid. These complications usually require
operative intervention.
Anatomic resection
An anatomic resection is the removal of any of the
eight defined segments of the liver. Anatomic resection
of an acute liver injury has two primary goals: to
eradicate the source of the bleeding or to remove the
site of necrosis. This procedure is performed using
conventional anatomic planes of the liver and is
different from nonanatomic resection, which is done by
a partial resection or a resectional debridement of the
liver. One feature of the anatomic resection is that it
leaves a smooth surface on the liver with a low
propensity for septic complications.
Anatomic resection, which was widely performed
during the 1960s, was criticized because of its high
mortality. Most reports during the last decade have not
supported an anatomic resection.3
A study by Strong et al. showed that an aggressive
anatomic hepatic resection for trauma was associated
with low mortality and low liver-related morbidity rates
when performed by experienced surgeons.6 Therefore,
its role in the management of severe hepatic trauma
should be reevaluated further.3 In general, there's
little research on aggressive emergency hepatic
resection in the literature, suggesting a need for future
studies.
Partial resection surgically removes the devascularized
liver peripheral to the injured section or fracture line.
It completes the resection, which has occurred during
the traumatic injury. Removal of a partially detached
portion leaves just one surface that requires repair,
which is completed with a suture ligation of the
structure. Most liver resections require clamping of the
hepatic pedicle, called the Pringle maneuver, to avoid
excessive blood loss. Resectional debridement is
limited to removal of nonviable liver tissue adjacent to
the injured site.
Although there're other surgical therapies for liver
trauma, little research has been conducted on these
techniques to support their efficacy. Patients with
acute liver trauma may undergo laparoscopic
hepatectomy for low-grade blunt hepatic trauma. In
addition, minimally invasive surgery for hepatic
resection should increase as the method of choice for
blunt trauma. Minimally invasive surgical procedures
are increasingly being used for nonanatomic resection
to remove ischemic parts of the liver.
Preoperative considerations
Immediate treatment for liver injury includes physical
exam, abdominal ultrasound, and in some cases,
diagnostic peritoneal lavage. During the physical
exam, it's important to gain hemodynamic stability
with a modest volume of I.V. fluids or with blood and
blood products. This requires insertion of large-bore
I.V.s in the upper extremities, the right internal
jugular vein, and the subclavian vein to allow sufficient
fluid or blood product replacement with the aid of two
rapid infusion systems.
Abdominal CT scan is usually obtained to focus on the
grade of hepatic injury, the presence and quality of
hemoperitoneum, or any active bleeding. Monitoring
should include ECG, BP via an arterial line, central
venous pressure, end-tidal carbon dioxide, pulse
oximetry, and core temperature. It's imperative that
all preoperative consents and preparations are
expedited.
Intraoperative considerations
The intraoperative phase is characterized by the type
of procedure employed to create homeostasis of the
injured liver. The most frequently used techniques
include manual compression, perihepatic packing, the
Pringle maneuver, anatomic resection, nonanatomic
resection, resectional debridement, and in the most
severe cases, liver transplantation.
Warm ischemia can increase the damage to the
already existing acute liver injury and ischemic
damage, which affects other organs. To prevent
damage to the liver, the surgeon may use a perfusion
solution. This solution differs from cardioplegia, which
is used for preservation of the heart during cardiac
surgery. Cardiac cardioplegia has a high-potassium
level, which is a potent cardiac depressant and
requires cross-clamping of the aorta to prevent cardiac
arrest if leaked into the patient's circulation. Perfusion
solution administered to the patient with acute liver
trauma doesn't have this concentration of potassium
and therefore doesn't have similar complications.
Nursing responsibilities during the intraopertive phase
may involve environmental safety issues, asepsis
control, physiological monitoring, and psychological
support in the preinduction phase. Nurses can help
allay fears by providing the family with a patient
update, including information about the progress of
the surgical procedure and the condition of the patient.
Postoperative care
The postoperative phase of patient care may vary
depending on the type and severity of hepatic injury.
Nursing care may focus on replacing blood and blood
products, monitoring coagulation studies, stabilizing
vital signs, and pain management. In addition to the
management of the acute liver injury, nurses may
provide unique care to other systems affected by
trauma such as head injuries and bone fractures.
Rapid access to lab results such as arterial and venous
blood gas analysis, electrolytes, glucose, and ionized
calcium are essential for good patient management.
Reoperation
The reoperation rate for hepatic injury is
approximately 19% for various complications and
patient treatment. Surgical removal of packs,
additional procedures to promote hemostasis,
peritonitis, intra-abdominal abscess formation,
intestinal obstruction, and hematoma formation are
some of the possible conditions that would require a
surgical evaluation. It's not unusual for reexploration
after hepatic resection to be performed for repair of
splenic laceration or splenectomy, minor perforations
of the small intestine, and intra-abdominal abscess.
Morbidity
Significant factors that influence the patient's outcome
include: the mechanism of injury, delay before
surgery, shock on admission, grade of injury, presence
of an associated injury, age of the patient, injury
severity, or operative blood loss.
Morbidity rates associated with liver injury vary
significantly depending on the mechanism of injury
and can range from 5% to 24%.2 Minor complications
from acute liver injury include atelectasis and
pneumonia; urinary infection; wound infection; and
neurological deficits. Major complications include
biliary fistula, abscesses, pancreatic fistula, acute
respiratory distress syndrome, multisystem organ
failure, transfusion-related acute lung injury (TRALI),
peritonitis, and sepsis.
Liver transplantation for severe liver injury with
massive tissue destruction has been described as a
salvage therapy.7 Although surgical techniques used
for liver transplantation have improved the outcomes
for liver injured patients, the liver may be so damaged
that the only treatment choice is a transplant.
However, transplantation in unstable abdominal
trauma patients should be avoided due to high
mortality. OR
The ATI
The ATI consists of the following categories:

* none

* nonbleeding

* peripheral bleeding

* central or minor debridement

* major debridement or hepatic artery ligation

* lobectomy

* lobectomy with caval repair or extensive bilobar

debridement.