Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:342   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   

 Table of Contents    
Year : 2011  |  Volume : 4  |  Issue : 1  |  Page : 114-119
Management of liver trauma in adults

Department of Surgery & Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center 1945 State Rt. 33, Neptune, USA

Click here for correspondence address and email

Date of Submission17-Feb-2010
Date of Acceptance22-Jul-2010
Date of Web Publication18-Feb-2011


The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.

Keywords: Liver, injury, damage control surgery

How to cite this article:
Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock 2011;4:114-9

How to cite this URL:
Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock [serial online] 2011 [cited 2022 Oct 7];4:114-9. Available from:

   Introduction Top

The liver is one of the most frequently injured organs in abdominal trauma. [1],[2] The anterior location in the abdominal cavity and fragile parenchyma with easily disrupted Glisson's capsule make this organ vulnerable to injury.

There is a paradigm shift in the management of liver trauma due to advancements of diagnostic and therapeutic modalities. About a century ago, Pringle conducted an animal experiment, occluding the porta hepatis in liver trauma while repairing the injuries. [3] However, application of the same principle in trauma victims led to high mortality. [4] Since 1965, the introduction of diagnostic peritoneal lavage (DPL) has led to many nontherapeutic laparotomies in previously unsuspected low-grade injuries. [5] Operative intervention in high-grade injuries may result in high mortality as well. [4],[6] Introduction of computed tomography (CT) scan, use of ultrasonography in trauma, availability of angiography, enhanced critical care monitoring and damage control surgery have revolutionized the management of liver trauma. Numerous studies have shown better outcome with conservative management. [7],[8] Though there is a broader consensus regarding the nonoperative approach even in high-grade injuries, however, some controversies still exist. [8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18]

This review discusses the diagnostic modality and therapeutic approach to liver trauma.

   Classification of the Liver Injuries Top

Liver injury is classified based on severity of the injury [Table 1].[19]
Table 1: Grading of liver injury based on American Association of Surgery for trauma (AAST)[19]

Click here to view

   Diagnosis Top

Imaging studies are the main diagnostic modality of evaluation of presence or absence of liver trauma.


Ultrasonography is a noninvasive procedure and highly operator-dependent. Focused assessment by ultrasound for trauma (FAST) has been advocated in initial trauma evaluation. [20] The purpose of this exam is to provide a quick bedside assessment for hemoperitoneum and hemopericardium. A FAST exam consists of sonographic evaluation of pericardium, right upper quadrant, including Morrison's pouch, left upper quadrant and the pelvis. This evaluation is not designed to identify the degree of organ injuries, but rather the presence of blood. The sensitivity and specificity of this examination are 63-100% and 95-100%, respectively. [20],[21],[22] Negative FAST examination does not exclude intra-abdominal injuries or hemoperitonium. Retroperitonial injuries and hollow viscus injuries can also be missed by ultrasound evaluation.

Recent advancement of contrast-enhanced sonography improved the diagnostic accuracy in terms of conspicuity, size and completeness of the injury, as compared to non-contrast sonography. It is also similar to CT scan in terms of identification of ongoing hemorrhage in the liver. [23]

Computed tomography scan

CT scan is the first imaging study which gives relatively detailed delineation of solid organ injuries and retroperitoneal injuries as well. CT scan is the standard imaging study for hemodynamically stable patients following blunt trauma. [24],[25] Severity of injuries is also graded based on CT scan examination. [19] Extravasation of contrast demonstrated on CT scan (35-40 HU) indicates active bleeding from the injury site and further intervention is needed. [26],[27]

The sensitivity and specificity of the CT scan for liver injuries are 92-97% and 98.7%, respectively. [28]

CT scan plays an integral role in the nonoperative management of liver injuries. Follow-up CT scan is recommended for high-grade injuries (grades IV-V) in 7-10 days to determine the injury status and complications as well. [8],[29] CT scan-guided percutaneous drainage may also be performed when complications such as biloma and intra-abdominal collections occur.

Angiogram and angioembolization

Angiography plays a vital role in the conservative management of the liver injury. Extravasation of contrast seen on CT scan requires emergency angiography and angioembolization in hemodynamically stable patients. Post-operative angioembolization is also reported in damage control surgery prior to removal of packing, if rebleeding is suspected. [30],[31] The sensitivity and specificity of angiogram identifying active bleeding in liver injuries is 75% and the success rate of controlling the hemorrhage is 68-93%. [11],[30],[32] The multidisciplinary approach to conservative management of high-grade liver injuries shows better outcome with less blood transfusion, early recovery time and less intensive care days. The mortality is low as well. [33]

Diagnostic peritoneal lavage

DPL was one of the most common modalities used in the diagnostic evaluation for blunt abdominal trauma in the mid-20th century. [29] This procedure is very sensitive for hemoperitoneum. Positive DPL led to a rate of almost 30% non-therapeutic, unnecessary laparotomies. [5],[34] Widely available CT scans and the introduction of FAST have generally replaced the invasive DPL. However, the Advanced Trauma Life Support course (ATLS) still includes this modality and it remains one of the skills that physicians need to learn for ATLS certification.

   Management Top

Management of liver injury has evolved in the last 25 years. Advancement of imaging studies plays a key role in the conservative approach. In early 1970, more than 80% of the liver injuries were managed operatively. In late 1990, 80-90% of these injuries were successfully managed by nonoperative means.

Nonoperative management

Penetrating injury

Nonoperative management is now recommended for stab wound as well as low-velocity gunshot wound to right upper quadrant in stable patients, if other injuries have been excluded which require laparotomy. [35],[36] Most of the injuries which fall in this category are grade I and grade II injuries.

Blunt injury

In blunt liver trauma, nonoperative management is a standard of care in hemodynamically stable patients. It is not the grade of the injury, but rather the hemodynamic parameters of the patient which dictate the conservative versus operative management decision. The patient's positive response to an initial fluid bolus or maintenance of a stable hemodynamic state allows for a CT scan of abdomen and pelvis. If extravasation is identified, angiogram and angioembolization should be considered. Failures of these steps then mandate operative intervention.

The most common reasons for failure are advanced age, delayed bleeding, hypotension and active extravasation of contrast not controlled by angioembolization. [33],[37],[38],[39]

There is an overall survival benefit and 23% reduction of mortality for conservative approach in blunt liver injury. [40],[41],[42]

Operative management

Penetrating injury

Recent literature supports operative intervention only in hemodynamically unstable patients, usually as a result of a high-velocity gunshot wound. Other indication for operative intervention is an associated hollow viscus injury. [43]

Trunkey has described the operative procedure for unstable gunshot wounds to the liver. [29] If the patient is unstable or deteriorating in the emergency room, patients should be taken to the operating room within 15 minutes. Activation of massive blood transfusion protocol, four quadrant packing, direct compression and rapid control of fecal contamination are the initial steps. Debridement, ligation of the bleeding vessel, lobectomy and repair of venous injury under total vascular isolation are the best strategies with good outcome. If the triad of coagulopathy, acidosis and hypothermia are encountered during this phase of the repair, perihepatic packing and temporary closure of the abdominal incision with transfer to intensive care unit (ICU) should be the priority. The patient should be taken back to operating room as soon as the metabolic derangement is corrected and rewarming has occurred.

Blunt injury

The main indication of the operative approach to the blunt liver injury is hemodynamic instability, not the grading of the injury. Although a higher grade injury has higher potential for failure of nonoperative management, hemodynamic instability remains the most important branch of the decision tree indicating operative intervention.

Rebleeding, constant decline of hemoglobin and increased transfusion requirement, as well as the failure of angioembolization of actively bleeding vessels are a few factors which indicate the need forlaparotomy. [33],[37],[38],[39]

The operative approach has also evolved over the last two decades. Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods, compared to anatomical resection of the liver and use of the atriocaval shunt. [9],[44],[45],[46],[47],[48],[49],[50],[51]

Operative procedure for liver injuries

The first and the most important step in operative management of blunt liver injury is to pack all four quadrants with laparotomy pads and manually compress the liver using both hands for 15-20 minutes. This allows the anesthesiologist to catch up with the resuscitation. Then remove the lower quadrant packing first, followed by left upper quadrant and finally right upper quadrant. If the spleen is actively bleeding, splenectomy should be performed. Assess the liver laceration and identify the bleeding vessel. Direct suture ligation should be performed using 3-0 or 4-0 absorbable suture. A patch of omentum can be used to fill the gap created by the laceration. If bleeding continues, then perform the Pringle maneuver (apply a noncrushing clamp through the foramen of Winslow). [3] The clamp can be safely applied up to 1 hour.

Operative approach for hepatic vein and/or retrohepatic caval injuries

If bleeding continues despite the Pringle maneuver, then retrohepatic, caval or hepatic vein injury should be suspected.

The preferred method for caval and hepatic vein injury is total vascular isolation. [47] The procedure consists of performing a Pringle maneuver, and clamping of the inferior vena cava above and below the injury. Superiorly, the inferior vena cava can be isolated just below the diaphragm or through the pericardium by extending the incision to a median sternotomy and inferiorly, just above the renal veins. This approach allows direct repair of the vascular injury. Aortic clamping is not recommended for the vena caval or hepatic vein injury. [29] The vascular isolation technique has reported a better survival rate compared to atriocaval shunt. [47],[52] Anatomical lobectomy is rarely performed; however, in the hands of an expert, the outcome is very good. [53],[54]

During the operative repair, if the patient develops coagulopathy, acidosis, or hypothermia, damage control surgery should be considered.

Damage control surgery

Damage control surgery includes perihepatic packing and closure of the abdominal incision either using a Bogata bag or partial closure of proximal abdominal incision. Kreig et al. recommend six folded laparatomy pads to be placed between the liver and the abdominal wall to obtain tamponade. [44] The patient should be transferred to the ICU as soon as possible for continued resuscitation and warming. As soon as the metabolic derangement is corrected, the patient should be taken back to operating room for re-exploration. The timing of re-exploration depends upon the correction of acidosis, coagulopathy and hypothermia. Usually, 12-24 hours is the safe period for re-exploration and formal completion of the surgery.

Role of hemostatic agents in liver trauma

A number of commercial hemostatic agents are readily available and can be used as an adjunct after repair of liver injuries. The most commonly used agents are gelatin gelfoams, oxidized cellulose, microfibrillar collagen, thrombin, thrombin with gelatin (floseal) and fibrin sealant (tisseel). [55]

Application of extracorporeal circulation in the massive liver and/or retrohepatic caval injury

The use of extracorporeal circulation devices during the repair of the juxtahepatic caval injuries has been noted in the past with variable success. The concept behind this device is to bypass the flow from the injured area using an extracorporeal circuit, with or without an active pump. Therefore, repair can be performed in a bloodless field. These devices increase the complexity of the operation, and the physician must be familiar with the technique and concept as well. Successful use of venovenous bypass following clamping of the inferior vena cava during anhepatic phase of liver transplant provided the idea in the management of retrohepatic caval injuries. [56] This technique allows blood to be diverted from the inferior vena cava, with or without portal vein decompression, and drain it into the right atrium either directly or through internal jugular vein or superior vena cava. [57],[58],[59],[60]

Liver transplantation in massive liver and hepatic venous and retrohepatic caval injury

Orthotopic liver transplantation has been reported as an extreme measure in massive hepatic venous and retrohepatic caval injuries.[61],[62],[63],[64],[65] Since the mortality rate associated with these injuries is extremely high and there is a shortage of organs available for procurement as well, the indication for liver transplantation is very restricted. Most of the indications described in the literature are uncontrolled bleeding despite repeated previous surgery and acute or progressive liver failure following repair of injury. In the last two decades, less than 20 liver transplantations have been performed for liver trauma with variable success, however, the biggest series was reported by Delis and colleagues, in which three out of four patients survived after liver transplantation.[66] A case of extracorporeal repair and "autotransplantation" has also been reported in the case of total avulsion of hepatic veins and a retrohepatic caval injury. [67] This patient's first operation consisted of the ligation of hepatic veins and inferior retrohepatic vena cava, and then transfer to another facility where the second operation was performed. Immediately upon arrival, extracorporeal bypass was established between left femoral vein and left axillary vein, using a centrifugal pump. Additional cannula was inserted into the inferior mesenteric vein threaded back to the portal vein and connected to the bypass circulation. After cross-clamping the hepatoduodenal ligament, the liver was removed en bloc with the retrohepatic vena cava. After ex vivo repair of the massive liver injury was completed, the liver was re-transplanted. Revascularization was done just over 3 hours without using any extension grafts for the portal vein or hepatic artery. After establishing adequate bleeding control, the procedure was completed with an end-to-end choledochocholedochostomy over a T-tube.

Role of interventional radiology in liver injury

The interventional radiologist plays an integral role in the nonoperative management of liver injuries. Angiography and angioembolization has become the gold standard in the management of liver injuries for hemodynamically stable patients, if a contrast extravasation is seen on CT scan. Furthermore, conservative management may cause vascular/or biliary complications, particularly in high-grade injuries which require imaging intervention. Post-traumatic pseudoaneurysm, intrahepatic arteriovenous fistula and hemobilia are a few vascular complications which may appear following liver injuries and angioembolization is the first step in the management of these complications. [68] Symptomatic biloma, liver and intra-abdominal abscesses can also be successfully managed by CT-guided percutaneous drainage. [69]

   Conclusion Top

Management of liver injury has evolved over the last two decades. Hemodynamic status, not the grade of the injury, should dictate the management. CT scan of the abdomen and pelvis is a standard diagnostic modality in hemodynamically stable patients. Extravasation of contrast during CT scans requires further intervention. Unstable patients should mandate emergency laparotomy. Direct control of bleeding vessels, vascular isolation and damage control surgery are preferred and the most popular approaches compare to anatomical resection of liver and the use of an aortocaval shunt.

   References Top

1.Clancy TV, Gary Maxwell J, Covington DL, Brinker CC, Blackman D. A statewide analysis of level I and II trauma centers for patients with major injuries. J Trauma 2001;51:346-51.  Back to cited text no. 1
2.Matthes G, Stengel D, Seifert J, Rademacher G, Mutze S, Ekkernkamp A. Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole body helical computed tomography. World J Surg 2003;27:1124-30.  Back to cited text no. 2
3.Pringle JH. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg, 1908; 48:541-549  Back to cited text no. 3
4.Lamb CA. Rupture of the liver. N Engl J Med 1939;221:855-9.  Back to cited text no. 4
5.Olson WR, Redman HC, Hildreth DC. Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 1972;104:536-43.  Back to cited text no. 5
6.Gourgiotis S, Vougas V, Germanos S, Dimopoulos N, Bolanis I, Drakopoulos S, et al. Operative and nonoperative management of blunt hepatic trauma in adults: A single-center report. J Hepatobiliary Pancreat Surg 2007;14:387-91.   Back to cited text no. 6
7.Pachter HL, Hofstetter SR. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995;169:442-54.   Back to cited text no. 7
8.Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, et al. Status of nonoperative management of blunt hepatic injuries in 1995: A multicenter experience with 404 patients. J Trauma 1996;40:31-8.   Back to cited text no. 8
9.Pachter HL, Spencer FC, Hofstetter SR, Liang HG, Coppa GF. Significant trends in the treatment of hepatic trauma: experience with 411 injuries. Ann Surg 1992;215:492.  Back to cited text no. 9
10.Cogbill TH, Moore EE, Jurkovich GJ. Severe hepatic trauma: a multi-center experience with 1335 liver injuries. J Trauma 1988;48:1433-8.   Back to cited text no. 10
11.Asensio JA, Demetriades D, Chahwan S, Gomez H, Hanpeter D, Velmahos G, et al. Approach to the management of complex hepatic injuries. J Trauma 2000;48:66-9.   Back to cited text no. 11
12.Feliciano DV, Mattox KL, Jordan GL Jr, Burch JM, Bitondo CG, Cruse PA. Management of 1000 consecutive cases of hepatic trauma (1979-1984). Ann Surg 1986;204:438-45.  Back to cited text no. 12
13.Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619-22.   Back to cited text no. 13
14.Croce MA, Fabian TC, Menke PG, Waddle-Smith L, Minard G, Kudsk KA, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. results of a prospective trial. Ann Surg 1995;221:744-53.   Back to cited text no. 14
15.Carrillo EH, Platz A, Miller FB, Richardson JD, Polk HC Jr. Non-operative treatment of blunt hepatic trauma. Br J Surg 1998;85:461-8.   Back to cited text no. 15
16.Carrillo EH, Richardson JD. Delayed surgery and Interventional procedures in complex liver injuries. J Trauma 1999;46:978.  Back to cited text no. 16
17.Knudson MN, Maull KI. Non-operative management of solid organ injuries: past, present and future. Surg Clin North Am 1999;79:1357-71.  Back to cited text no. 17
18.Farnell MB, Spencer MP, Thompson E, Williams HJ Jr, Mucha P Jr, Ilstrup DM. Non-operative management of blunt hepatic trauma in adults. Surgery 1988;104:748-56.  Back to cited text no. 18
19.Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling, Spleen, liver. (1994 rev) J Trauma 1995;38:323.   Back to cited text no. 19
20.Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma 1999;46:466-72.  Back to cited text no. 20
21.Hsu JM, Joseph AP, Tarlinton LJ, Macken L, Blome S. The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: Experience of an Australian major trauma service. Injury 2006;38:71-75.  Back to cited text no. 21
22.Richards JR, Schleper NH, Woo BD, Bohnen PA, McGahan JP. Sonographic assessment of blunt abdominal trauma: a 4 -year prospective Study. J Clin Ultrasound 2002;30:59-67.  Back to cited text no. 22
23.Catalano O, Lobianco R, Raso MM, Siani A. Blunt hepatic trauma: Evaluation with contrast-enhanced sonography. J Ultrasound Med 2005;24:299-310.  Back to cited text no. 23
24.Poletti PA, Mirvis SE, Shanmuganathan K, Killeen KL, Coldwell D. CT criteria for management of blunt liver trauma: Correlation with angiographic and surgical findings. Radiology 2000;216:418-27.   Back to cited text no. 24
25.Becker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Eur Radiol 1998;8:553-62.  Back to cited text no. 25
26.Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, et al. CT in blunt liver trauma. Radiographics 2005;25:87-104.  Back to cited text no. 26
27.Taourel P, Vernhet H, Suau A, Granier C, Lopez FM, Aufort S. et al. Vascular emergencies in liver trauma. Eur J Radiol 2007;64:73-82.  Back to cited text no. 27
28.Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, et al. Practice management guidelines for the evalluation of blunt abdominal trauma. The EAST practice guidelines work group. J Trauma 2002;53:602-15.  Back to cited text no. 28
29.Trunkey DD. Hepatic trauma: Contemporary management. Surg Clin North Am 2004;84:437-50.   Back to cited text no. 29
30.Sclafani SJ, Shaftan GW, McAuley J, Nayaranaswamy T, Mitchell WG, Gordon DH, et al. Interventional radiology in the management of hepatic trauma. J Trauma 1984;24:256.  Back to cited text no. 30
31.Johnston JW, Gracias VH, Reilly PM. Hepatic angiography in the damage control population. J Trauma 2001;50:176.  Back to cited text no. 31
32.Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB, et al. Interventional techniques are useful adjuncts in nonoperativemanagement of hepatic injuries. J Trauma 2000;46:619-24.  Back to cited text no. 32
33.Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, et al. Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s. Ann Surg. 2000;231:804-13.   Back to cited text no. 33
34.Nagy KK, Roberts RR, Joseph KT, Smith RF, An GC, Bokhari F, et al. Experience with over 2500 diagnostic peritoneal lavage for suspected intra-abdominal injury following blunt trauma. Injury 2000;31:479-82.  Back to cited text no. 34
35.Demetriades D, Gomez H, Chahwan S, Charalambides K, Velmahos G, Murray J, et al. Gunshot injuries to the liver: The role of selective nonoperative management. J Am Coll Surg 1999;188:343-8.   Back to cited text no. 35
36.Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006;244:620-8.   Back to cited text no. 36
37.Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: A prospective study. Arch Surg 2003;138:844-51.   Back to cited text no. 37
38.David Richardson J, Franklin GA, Lukan JK, Carrillo EH, Spain DA, Miller FB, et al. Evolution in the management of hepatic trauma: a 25-year perspective. Ann Surg 2000;232:324-30.  Back to cited text no. 38
39.Meredith JW, Young JS, Bowling J. Nonoperative management of blunt hepatic trauma: the exception or the rule? J Trauma 1994;36:529-35.  Back to cited text no. 39
40.Goan YG, Huang MS, Lin JM. Nonoperative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults. J Trauma 1998;45:360-4.   Back to cited text no. 40
41.Sherman HF, Savage BA, Jones LM, Barrette RR, Latenser BA, Varcelotti JR, et al. Nonoperative management of blunt hepatic injuries: Safe at any grade? J Trauma 1994;37:616-21.   Back to cited text no. 41
42.Coimbra R, Hoyt DB, Engelhart S, Fortlage D. Nonoperative management reduces the overall mortality of grades 3 and 4 blunt liver injuries. Int Surg 2006;91:251-7.   Back to cited text no. 42
43.Marr JDF, Krige JEJ, Terblanche J. Analysis of 153 gunshot wounds of the liver. Br J Surg 2000;87:1030-4.  Back to cited text no. 43
44.Krige JE, Bornman PC, Terblanche J. Liver trauma in 446 patients. S Afr J Surg 1997;35:10-5.   Back to cited text no. 44
45.Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Blunt hepatic injury: Minimal intervention is the policy of treatment. J Trauma 2000;49:722-8.   Back to cited text no. 45
46.Duane TM, Como JJ, Bochicchio GV, Scalea TM. Re-evaluating the management and outcomes of severe blunt liver injury. J Trauma 2004;57:494-500.  Back to cited text no. 46
47.Khaneja SC, Pizzi WF, Barie PS, Ahmed N. Management of penetrating juxtahepatic inferior vena cava injuries under total vascular occlusion. J Am Coll Surg 1997;184:469-74.   Back to cited text no. 47
48.Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin N Am 1996;76:763-82.  Back to cited text no. 48
49.Beal SL. Fatal hepatic haemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma 1990;30:163-9.  Back to cited text no. 49
50.Buechter KJ, Sereda D, Gomez G, Zeppa R. Retrohepatic vein injuries: Experience with 20 cases. J Trauma 1989;29:1698-704.  Back to cited text no. 50
51.Rovito PF. Atrial caval shunting in blunt hepatic vascular injury. Ann Surg 1987;205:318-21.  Back to cited text no. 51
52.Burch M J, Feliciano V D, Mattox L K. The Atriocaval shunt: Facts and Fiction. Ann surg 1998;207:555-66.  Back to cited text no. 52
53.Strong RW, Lynch SV, Wall DR, Liu CL. Anatomic resection for severe liver trauma. Surgery 1998;123:251-7.   Back to cited text no. 53
54.Trunkey DD. Mastery of Surgery. In: Baker RJ, Fischer JE, editors. Lippincott Williams and Wilkins; 2001. p. 1128-47. USA  Back to cited text no. 54
55.Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Shapiro ML, Lawson JH. A comprehensive review of topical hemostatic agents: efficacy and recommendations of use. Ann of surg 2010;251:217-28.  Back to cited text no. 55
56.Shaw BW Jr, Martin DJ, Marquez JM, Kang YG, Bugbee AC Jr, Iwatsuki S, et al. Venous bypass in clinical liver transplantation. Ann surg 1984;200:524-34.  Back to cited text no. 56
57.Horwitz JR, Black T, Lally KP, Andrassy RJ. Venous bypass as an adjunt for the management of a retrohepatic venous injury in a child. J Trauma 1995;39:584-5.  Back to cited text no. 57
58.Baumgartner F, Scudamore C, Nair C, Karusseit O, Hemming A. Venovenous bypass for major hepatic and caval trauma. J Trauma 1995;39:671-3.  Back to cited text no. 58
59.Rogers FB, Reese J, Shackford SR, Osler TM. The use of venovenous bypass and total vascular isolation of the liver in the surgical management of juxtahepatic venous injuries in blunt hepatic trauma. J Trauma 1997;43:530-3.  Back to cited text no. 59
60.Biffl WL, Moore EE, Franciose RJ. Venovenous bypass and hepatic vascular isolation as adjunts in the repair of destructive wounds to the retrohepatic inferior vena cava. J Trauma 1998;45:400-03.  Back to cited text no. 60
61.Ringe B, Pichlmayr R, Ziegler H, Grosse H, Kuse E, Oldhafer K, et al. Management of severe hepatic trauma by two- stage total hepatectomy and subsequently liver transplantation. Surg 1991;109:792-5.   Back to cited text no. 61
62.Ringe B, Pichlmayr R. Total hepatectomy and liver transplantation: a life saving procedure in patients with severe hepatic trauma. Br J Surg 1995;82:837-9.  Back to cited text no. 62
63.Ringe B, Lübbe N, Kuse E, Frei U, Pichlmayr R. Total hepatectomy and liver transplantation as two-staged procedure. Ann Surg 1993;218:3-9  Back to cited text no. 63
64.Jeng LB, Hsu CH, Wang CS, Chen RJ, Chen SC, Chen MF. Emergent liver transplantation to salvage a hepatic avulsion injury with disrupted suprahepatic vena cava. Arch Surg 1993;128:1075-77.  Back to cited text no. 64
65.Chiumello D, Gatti S, Caspani ML, Savioli M, Fassati R, Gattinoni L. A blunt complex abdominal trauma: total hepatectomy and liver transplantation. Intensive Care Med 2002;28:89-91.  Back to cited text no. 65
66.Delis SG, Bakoyiannis A, Selvaggi G, Weppler D, Levi D, Tzakis AG. Liver transplantation for severe hepatic trauma: Experience from a single center. World J Gastroenterol 2009;15:1641-4.  Back to cited text no. 66
67.Boggi U, Vistoli F, Del Chiaro M, Signori S, Sgambelluri F, Roncella M, et al. Extracorporeal repair and liver autotransplantation after total avulsion of hepatic veins and retrohepatic inferior vena cava injury secondary to blunt abdominal trauma. J Trauma 2006;60:405-06.  Back to cited text no. 67
68.Goffette P Pierre, Laterre Pierrre-Franciscois. Traumatic injuries: Imaging and intervention in post-traumatic complication (delayed intervention). Eur Radiol 2002;12:994-1021.  Back to cited text no. 68
69.Owings JT, Lengle SJ. Combined hepatic abscess and arterial pseudoaneurysms from blunt trauma: a case report and management strategy. J Trauma 1995;38:634-8.  Back to cited text no. 69

Correspondence Address:
Nasim Ahmed
Department of Surgery & Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center 1945 State Rt. 33, Neptune
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2700.76846

Rights and Permissions


  [Table 1]

This article has been cited by
1 Woman with Blunt Abdominal Trauma
Siou-Ting Lee, Sheng-Der Hsu, Yu-Chin An, Ya-Che Chen, Yu-Chun Lin
Annals of Emergency Medicine. 2022; 79(4): e29
[Pubmed] | [DOI]
2 Trauma laparotomy and damage control surgery
William Maclean, Bruce Levy, Timothy Rockall
Surgery (Oxford). 2022;
[Pubmed] | [DOI]
3 Liver trauma in the intensive care unit
Alexandra Hetherington, Filipe S. Cardoso, Erica L.W. Lester, Constantine J. Karvellas
Current Opinion in Critical Care. 2022; 28(2): 184
[Pubmed] | [DOI]
4 A deep learning framework for automated detection and quantitative assessment of liver trauma
Negar Farzaneh, Erica B. Stein, Reza Soroushmehr, Jonathan Gryak, Kayvan Najarian
BMC Medical Imaging. 2022; 22(1)
[Pubmed] | [DOI]
5 Emerging Applications of Contrast-enhanced Ultrasound in Trauma
E. Tester, BS, MS Brenda, Liu, MD Ji-Bin, R. Eisenbrey, PhD John, Koenig, MD George
[Pubmed] | [DOI]
6 Biological compatibility of oxidized cellulose vs. porcine gelatin to control bleeding in liver lesions in rats
Maria de Lourdes Pessole Biondo-Simões, Jaqueline Alves Zwierzikowski, Juliane Castro Duarte Antoria, Sérgio Ossamu Ioshii, Rogério Ribeiro Robes
Acta Cirúrgica Brasileira. 2021; 36(11)
[Pubmed] | [DOI]
7 Ultra-low-dose computed tomography and its utility in wrist trauma in the emergency department
Erdal Tekin, Kutsi Tuncer, Ibrahim Ozlu, Recep Sade, Rustem Berhan Pirimoglu, Gokhan Polat
Acta Radiologica. 2021; : 0284185121
[Pubmed] | [DOI]
8 The value of systematic follow-up imaging for assessing pseudoaneurysm formation after blunt and penetrating liver injury: A level 1 trauma centre experience
Neeral R Patel, Aia S Mehdi, Amandeep Sandhu, Dermot Mallon, Elizabeth Dick, Nicola Batrick, Elika Kashef
Trauma. 2021; : 1460408621
[Pubmed] | [DOI]
9 Multiple liver perforations: complication of an outpatient liposuction procedure
Julian Pohlan, Hannah Miller, Markus H. Lerchbaumer, Felix Krenzien, Christian Benzing, Martina T. Mogl, Torsten Diekhoff
Radiology Case Reports. 2021; 16(4): 906
[Pubmed] | [DOI]
10 A novel inflatable device for perihepatic packing and hepatic hemorrhage control: A proof-of-concept study
Joao Rezende-Neto, Sachin Doshi, David Gomez, Bruna Camilotti, Dan Marcuzzi, Andrew Beckett
Injury. 2021;
[Pubmed] | [DOI]
11 Loss of Claudin-3 Impairs Hepatic Metabolism, Biliary Barrier Function, and Cell Proliferation in the Murine Liver
Felix Alexander Baier, Daniel Sánchez-Taltavull, Tural Yarahmadov, Cristina Gómez Castellà, Fadi Jebbawi, Adrian Keogh, Riccardo Tombolini, Adolfo Odriozola, Mariana Castro Dias, Urban Deutsch, Mikio Furuse, Britta Engelhardt, Benoît Zuber, Alex Odermatt, Daniel Candinas, Deborah Stroka
Cellular and Molecular Gastroenterology and Hepatology. 2021; 12(2): 745
[Pubmed] | [DOI]
12 Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored
Dominik A. Jakob, Panagiotis Liasidis, Morgan Schellenberg, Kazuhide Matsushima, Lydia Lam, Demetrios Demetriades, Kenji Inaba
World Journal of Surgery. 2021; 45(4): 1014
[Pubmed] | [DOI]
13 Endoscopic Diagnosis and Management of Gastrointestinal Trauma
Robert J. Sealock, Mohamed Othman, Koushik Das
Clinical Gastroenterology and Hepatology. 2021; 19(1): 14
[Pubmed] | [DOI]
14 Imaging in traumatic injury to the inferior vena cava
S. Eleti, M. Roshen, M. Griffiths, S. Cross
Clinical Radiology. 2021; 76(10): 787.e15
[Pubmed] | [DOI]
15 Penetrating thoracoabdominal injuries from multiple-spiked spear stabbing: Case report and literature review
David Muchuweti, Edwin Muguti
Clinical Case Reports. 2020; 8(6): 1002
[Pubmed] | [DOI]
16 Recent Trends in Management of Liver Trauma
Rajan Chaudhry, Arunima Verma
Indian Journal of Surgery. 2020;
[Pubmed] | [DOI]
17 Increasing age is associated with worse outcomes in elderly patients with severe liver injury
Elizabeth Gorman, Marko Bukur, Spiros Frangos, Charles DiMaggio, Rosemary Kozar, Michael Klein, H. Leon Pachter, Cherisse Berry
The American Journal of Surgery. 2020; 220(5): 1308
[Pubmed] | [DOI]
18 Intrahepatic pseudoaneurysm following penetrating abdominal injury: Surgical and endovascular management of 2 complicated cases
Laila H. AbuAleid, Khaled Elshaar, Almoaiad A. Alhazmi, Mohammed Al Sherbini, Khalid Albohiri
International Journal of Surgery Case Reports. 2020; 71: 250
[Pubmed] | [DOI]
19 Bicycle handlebar injury in a child resulting in complex liver laceration with massive bleeding and bile leakage: A case report
Jan Grosek, Žan Cebron, Jurij Janež, Aleš Tomažic
International Journal of Surgery Case Reports. 2020; 72: 386
[Pubmed] | [DOI]
20 Intrinsically Bioactive Cryogels Based on Platelet Lysate Nanocomposites for Hemostasis Applications
Bárbara B. Mendes, Manuel Gómez-Florit, Ana C. Araújo, Justina Prada, Pedro S. Babo, Rui M. A. Domingues, Rui L. Reis, Manuela E. Gomes
Biomacromolecules. 2020; 21(9): 3678
[Pubmed] | [DOI]
21 Surgical pulmonary embolectomy in a multi-trauma patient: One-center experience in the resource-limited setting
Phung Duy Hong Son, Nguyen Huu Uoc, Pham Huu Lu, Doan Quoc Hung, Hoang-Long Vo
SAGE Open Medical Case Reports. 2020; 8: 2050313X20
[Pubmed] | [DOI]
22 Hepatic autotransplant for hepatic vein avulsion after blunt abdominal trauma
Lisa A. Bevilacqua, Devon J. Pace, Allison A. Aka, Jessica Latona, George J. Koenig, Joshua A. Marks, Murray J. Cohen, Warren R. Maley
Journal of Trauma and Acute Care Surgery. 2020; 89(3): e55
[Pubmed] | [DOI]
23 A New Viscous Potential Function for Developing the Viscohyperelastic Constitutive Model for Bovine Liver Tissue: Continuum Formulation and Finite Element Implementation
Zahra Matin Ghahfarokhi, Mehdi Salmani-Tehrani, Mahdi Moghimi Zand, Sara Esmaeilian
International Journal of Applied Mechanics. 2020; 12(03): 2050029
[Pubmed] | [DOI]
24 A case report of blunt liver trauma in times of COVID-19 pandemic
Vlad Braga, Iulian Slavu, Adrian Tulin, Bogdan Socea, Lucian Alecu
Romanian Journal of Orthopaedic Surgery and Traumatology. 2020; 3(2): 90
[Pubmed] | [DOI]
25 Results of blunt hepatic trauma surgery at Nghe An General Friendship Hospital
Huy Toàn Nguy?n
Vietnam Journal of Endolaparoscopic Surgey. 2020; 10(5)
[Pubmed] | [DOI]
26 Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Aaron J. Thomas, Christine O. Menias, Perry J. Pickhardt, Akram M. Shaaban, Ayman H. Gaballah, Sireesha Yedururi, Khaled M. Elsayes
American Journal of Roentgenology. 2019; 213(1): 8
[Pubmed] | [DOI]
27 FGF21 functions as a sensitive biomarker of APAP-treated patients and mice
Rong Li, Chao Guo, Xinmou Wu, Zhaoquan Huang, Jian Chen
Oncotarget. 2017; 8(27): 44440
[Pubmed] | [DOI]
28 Survival Fight of a Teen With Polytrauma, Severe Head Injury, Gr-V Liver Injury Followed By ARDS, Managed in a Rural Hospital of Andaman, India
Sidharth Bhasin, Anil Kumar Narayan, Janardhan AL
International Journal of User-Driven Healthcare. 2017; 7(2): 42
[Pubmed] | [DOI]
Dova Subba Rao, Mallapraggada Rama Chandra Mohan, Erabatti Santosh
Journal of Evidence Based Medicine and Healthcare. 2016; 3(33): 1551
[Pubmed] | [DOI]
Ye. V. Semichev, A. N. Baikov, P. S. Bushlanov, Ye. A. Gereng, G. Ts. Dambayev
Bulletin of Siberian Medicine. 2015; 14(1): 92
[Pubmed] | [DOI]
Ye. V. Semichev, A. N. Baikov, P. S. Bushlanov, G. Ts. Dambayev
Bulletin of Siberian Medicine. 2015; 14(2): 91
[Pubmed] | [DOI]
Mallikarjun P, Vinay Sagar Cheeti, Ravi Shankar Karupothula
Journal of Evidence Based Medicine and Healthcare. 2015; 2(39): 6203
[Pubmed] | [DOI]
33 Non-operative management versus operative management in high-grade blunt hepatic injury
Roberto Cirocchi, Stefano Trastulli, Eleonora Pressi, Eriberto Farinella, Stefano Avenia, Carlos Hernando Morales Uribe, Ana Maria Botero, Luis M Barrera
Cochrane Database of Systematic Reviews. 2015; 2015(8)
[Pubmed] | [DOI]
34 Ischemic versus pharmacologic hepatic preconditioning
Silvio Marcio Pegoraro Balzan,Vinicius Grando Gava,Alexandre Rieger,Daniel Pra,Luciano Trombini,Fernanda Fleig Zenkner,Jorge André Horta,Guaraci Azambuja,Luciano Schopf,Pedro Lucio de Souza
Journal of Surgical Research. 2014;
[Pubmed] | [DOI]
35 Presentation and outcome of surgically managed liver trauma: Experience at a tertiary care teaching hospital
Saaiq, M. and Niaz-ud-Din and Zubair, M. and Shah, S.A.
Journal of the Pakistan Medical Association. 2013; 63(4): 436-439
36 Case report: Management of pediatric blunt abdominal trauma following an ATV accident leading to liver hilum injury
Noah J. Switzer,David L. Bigam,Bryan Dicken
Journal of Pediatric Surgery Case Reports. 2013; 1(5): 102
[Pubmed] | [DOI]
37 Conservative Management of Major Liver Necrosis after Angioembolization in a Patient with Blunt Trauma
Husham Abdelrahman,Ahmad Ajaj,Sajid Atique,Ayman El-Menyar,Hassan Al-Thani
Case Reports in Surgery. 2013; 2013: 1
[Pubmed] | [DOI]
38 Protective Effect of Tropisetron on Rodent Hepatic Injury after Trauma-Hemorrhagic Shock through P38 MAPK-Dependent Hemeoxygenase-1 Expression
Liu, F.-C. and Yu, H.-P. and Hwang, T.-L. and Tsai, Y.-F.
PLoS ONE. 2012; 7(12)


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Classification o...
    Article Tables

 Article Access Statistics
    PDF Downloaded251    
    Comments [Add]    
    Cited by others 38    

Recommend this journal