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Fatal hepatic hemorrhage: an unresolved problem in the management of complex liver injuries
1University of California, Davis Medical Center, Sacramento.
Insights
Surgical techniques for severe liver injuries significantly impact survival. Hepatotomy offers high success rates for hemorrhage control, while hepatic resection has a high mortality, highlighting the need for careful technique selection in trauma care.
Area of Science:
- Trauma Surgery
- Hepatobiliary Surgery
- Surgical Hemostasis
Background:
- Severe liver injuries are associated with high mortality, primarily due to exsanguination.
- Effective surgical hemostasis is critical for managing life-threatening hemorrhage from liver trauma.
Purpose of the Study:
- To critically analyze surgical techniques for controlling hemorrhage in severe liver injuries.
- To present an algorithm for the successful surgical management of liver trauma.
Main Methods:
- Retrospective review of operative records for 683 patients undergoing exploratory laparotomy for liver trauma.
- Analysis of specific surgical techniques employed, including hepatotomy, hepatic resection, liver packing, and vascular isolation.
- Evaluation of the success rates and mortality associated with each technique.
Main Results:
- 18% of patients sustained severe liver injuries with difficult hemorrhage; 82% of deaths resulted from exsanguination.
- Hepatotomy with repair/ligation was successful in 87% of cases (44% of patients).
- Liver packing achieved an 86% survival rate in complex cases; hepatic resection had a 50% mortality.
Conclusions:
- Hepatotomy is a highly effective technique for managing severe liver injuries.
- Liver packing demonstrates significant survival benefit in complex trauma scenarios.
- An evidence-based algorithm is crucial for optimizing surgical outcomes in liver trauma.
Abstract:
The operative records of 683 patients who required an exploratory laparotomy for trauma with the findings of a liver injury were reviewed. Of the 683 patients 18% (121) sustained severe liver injuries with difficult to control hemorrhage, and 82% of the deaths, in this group of severe liver injuries, were due to exsanguination. A critical analysis of the specific surgical techniques used for hemostasis was undertaken. Hepatotomy with subsequent direct vascular and/or biliary duct repair or ligation was used in 44% of the cases and was successful 87% of the time. Hepatic resection was employed in 10% of the cases with a 50% mortality. Liver packs were used in 29% of the cases which included 14 hepatic vein and six retrohepatic vena caval injuries and five extensive bilobar parenchymal disruptions. The survival rate for this group of patients was 86%. Vascular isolation of the liver was used 8.3% of the cases and was successful 40% of the time. An algorithm for the successful surgical control of hemorrhage from severe liver injuries including indications and contra-indications of specific surgical techniques is presented.