Hepatic resection in the management of complex injury to the liver

Nonoperative management has become the standard for >80% of the blunt liver injuries. In the cases where operation is required, current operative management emphasizes packing, damage control, and early utilization of interventional radiology for angiography and embolization. Liver resection is thought to have minimal role in the management of hepatic injury because of the high morbidity and mortality in many reports. The objective of this study was to show that the management of complex liver injuries with anatomic or nonanatomic resection can be accomplished by experienced trauma surgeons, in conjunction with liver surgeons in some cases, with low morbidity and mortality related to the procedure. Delayed, planned anatomic resection was also applied.

This is a retrospective, observational study, on patients admitted to the University of Pittsburgh Medical Center (UPMC)-Presbyterian from December 1986 through March 2001. The patients included in this report underwent hepatic resection for complex liver injuries (grade 3, 4, and 5) according to the American for Association the Surgery of Trauma-Organ Injury Scale. Age, sex, mechanism of trauma, type of resection (nonanatomic, segmentectomy, lobectomy, and hepatectomy), surgical complications, hospital length of stay, and mortality were the variables analyzed.

Two hundred sixteen adult patients were admitted with complex liver injury, during the period of December 1986 to March 2001. Fifty-six patients of this series underwent liver resection: 21 anatomic segmentectomies, 23 nonanatomic resections, 3 left lobectomies, 8 right lobectomies, and 1 hepatectomy with orthotopic liver transplant. The median age was 31 years (range, 15-83 years). The Injury severity Score average was 34 +/- 10 (range, 16-59). Mechanism was blunt in 62.5% and penetrating in 37.5%. The grades of hepatic injury were 9 grade III, 32 grade IV, and 15 grade V. A total of 28.5% (16 of 56) of patients had concomitant hepatic venous injury. The overall morbidity was 62.5%. The morbidity related to liver resection was 30%. The overall mortality of the series was 17.8%. Mortality from liver injury was 9% in this series of patients undergoing liver resection for complex hepatic injury.

This study demonstrates that liver resection should be considered as a surgical option in patients with complex injury, as initial or delayed management, and can be accomplished with low mortality and liver related morbidity.