The use of segmental anatomy for an operative classification of liver injuries

There is no universally accepted standard classification for liver injuries, and thus accurate comparison of reports on the subject is impossible. Most published reports on liver trauma suggest that both morbidity and mortality have a linear correlation with not only the amount of liver parenchyma injured but also with the magnitude of the surgical intervention. The exceptions are retrohepatic vein injuries, which have a mortality independent of associated parenchymal injury but should be integrated in any classification of liver injury. The classification proposed is based on the segmental anatomy of the liver (as defined by Couinaud): Grade I--Injuries requiring no operative intervention, or any injury that requires operative intervention limited to a segment or less. Grade II--Any injury that requires operative intervention involving two or more segments. Grade III--Any injury with an associated juxta- or retrohepatic vein injury. We reviewed all patients with isolated liver injuries during the past 5 years and prospectively reviewed all patients for the 6-month period from January to June 1988 and applied this classification. Sixty-nine patients had grade I injuries, with one death (1%); thirteen patients had grade II injuries, with six deaths (46%); and 13 patients had grade III injuries with nine deaths (69%). Postoperative morbidity was 7% for grade I, 57% for grade II, and 50% for grade III. This study supports the conclusion that morbidity and mortality from liver injury are directly related to the volume of parenchyma involved, and that segmental anatomy can be applied to define this volume. Mortality from retrohepatic vein injuries is independent of associated parenchymal injury. We believe that this proposed classification will provide a simple, reproducible, and accurate means for reporting and comparing liver injuries.