WSES classification and guidelines for liver trauma

Recommendations for operative management (OM) in liver trauma (blunt and penetrating)

Patients should undergo OM in liver trauma (blunt and penetrating) in case of hemodynamic instability, concomitant internal organs injury requiring surgery, evisceration, impalement (GoR 2 A).

Primary surgical intention should be to control the hemorrhage, to control bile leak and to institute an intensive resuscitation as soon as possible (GoR 2 B).

Major hepatic resections should be avoided at first, and considered subsequently (delayed fashion) only in case of large devitalized liver portions and in centers with the necessary expertise (GoR 3 B).

Angioembolisation is a useful tool in case of persistent arterial bleeding (GoR 2 A).

As exsanguination represents the leading cause of death in liver injuries OM decision mainly depends on hemodynamic status and associated injuries [6].

In those cases where no major bleeding are present at the laparotomy, the bleeding may be controlled by compression alone or with electrocautery, bipolar devices, argon beam coagulation, topical hemostatic agents, or omental packing [6, 8, 24, 40, 41].

In presence of major haemorrhage more aggressive procedures can be necessary. These include first of all hepatic manual compression and hepatic packing, ligation of vessels in the wound, hepatic debridement, balloon tamponade, shunting procedures, or hepatic vascular isolation. It is important to provide concomitant intraoperative intensive resuscitation aiming to reverse the lethal triad [6, 8, 41].

Temporary abdominal closure can be safely considered in all those patients when the risk of developing abdominal compartment syndrome is high and when a second look after patient’s hemodynamic stabilization is needed [8, 40, 41].

Anatomic hepatic resection can be considered as a surgical option [2, 42, 43]. In unstable patients and during damage control surgery a non-anatomic resection is safer and easier [6, 8, 24, 44]. For staged liver resection, either anatomic either non-anatomic ones can be safely made with stapling device in experienced hands [44].

If despite the fundamental initial maneuvers (hepatic packing, Pringle maneuver) the bleeding persists and evident lesion to a hepatic artery is found, an attempt to control it should be made. If repair is not possible a selective hepatic artery ligation can be considered as a viable option. In case of right or common hepatic artery ligation, cholecystectomy should be performed to avoid gallbladder necrosis [44, 45]. Post-operative angio-embolization is a viable option, when possible, allowing hemorrhage control while reducing the complications [6, 8, 24, 46]. After artery ligation, in fact, the risk of hepatic necrosis, biloma and abscesses increases [6].

Portal vein injuries should be repaired primarily. The portal vein ligation should be avoided because liver necrosis or massive bowel edema may occur. Liver Packing and a second look or liver resection are preferable to portal ligation [6, 44].

In those cases where Pringle maneuver or arterial control fails, and the bleeding persists from behind the liver, a retro-hepatic caval or hepatic vein injury could be present [6, 46]. Three therapeutic options exist: 1) tamponade with hepatic packing, 2) direct repair (with or without vascular isolation), and 3) lobar resection [7]. Liver packing is the most successful method of managing severe venous injuries [6, 24, 47–49]. Direct venous repair is problematic in non-experienced hands, with a high mortality rate [6, 24].

When hepatic vascular exclusion is necessary, different types of shunting procedures have been described, most of them anecdotally. The veno-veno bypass (femoral vein to axillary or jugular vein by pass) or the use of fenestrated stent grafts are the most frequent type of shunt used by surgeons familiar with their use [8, 24, 44, 50]. The atrio-caval shunt bypasses the retro-hepatic cava blood through the right atrium using a chest tube put into the inferior cava vein. Mortality rates in such a complicated situations are high [8]. Liver exclusion is generally poorly tolerated in the unstable patient with major blood loss [6].

In the emergency, in cases of liver avulsion or total crush injury, when a total hepatic resection must be done, hepatic transplantation has been described [44].

The exact role of post-operative angio-embolization is still not well defined [51–55]. Two principal indications have been proposed: 1) after primary operative hemostasis in stable or stabilized patients, with an evidence at contrast enhanced CT-scan of active bleeding, and 2) as adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency laparotomy [6, 56].