Searching for the best operative modality for severe hepatic injuries

In the United States, there has been a trend away from hepatic resection in favor of nonresectional techniques for patients with severe hepatic injury. However, we consider that hepatic resection is more effective and safer, provided that it is performed appropriately. In 1985, we adopted a new protocol for patients undergoing hepatectomy for severe hepatic injury (class IV and V by Moore's classification). This protocol consists of criteria for hepatectomy and application of adjunctive procedures. Since 1985, we have treated 130 patients with hepatic injuries, including 24 patients (20 who underwent hepatectomy) with class IV hepatic injury and 13 patients (ten who underwent hepatectomy) with class V injury. The mortality rates of the patients with hepatic injury with class IV and V injury were 21 and 46 percent, respectively. The mortality rates for patients who underwent hepatectomy, including formal lobectomy to treat class IV and V injury, were 5 and 33 percent, respectively. The mortality rates of the patients with hepatic injury with class IV injury and the hepatectomy patients in both groups were significantly improved after introduction of the protocol. In addition, the outcome was superior to those reported by several trauma centers in the United States. Thus, we conclude that hepatectomy, including formal lobectomy, should be considered as one of the preferred treatment modalities for severe hepatic injury.