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Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 53-59

Diagnosis and treatment of traumatic liver injuries

Department of Surgery, College of Medicine and Medical Sciences, Taif University, PO Box 888, Taif 21947, Kingdom of Saudi Arabia

Date of Web Publication26-Jul-2017

Correspondence Address:
Bilal O Al-Jiffry
Department of Surgery, College of Medicine and Medical Sciences, Taif University, PO Box 888, Taif 21947
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_38_17

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Following abdominal trauma, especially the blunt one, the liver is considered the second abdominal organ liable to injury and the first leading cause of death. The most common cause of liver injury is blunt abdominal trauma secondary to motor vehicle accidents and it carries a higher mortality rate than open one. With the recent trends of nonoperative management of the majority of liver trauma patients, the introduction of damage control surgery (DCS) and other therapies such as hepatic artery embolization and liver transplantation is still having a growing role in severe hepatic injuries with hemodynamic instability. The better understanding of hepatic anatomy and pathophysiology, in addition to the advance in diagnostic imaging, resuscitation, intensive care, and the introduction of DCS, has led to marked improvement in the mortality rate following liver injury.

Keywords: Blunt abdominal injury, damage control surgery, liver trauma, nonoperative management

How to cite this article:
Al-Jiffry BO. Diagnosis and treatment of traumatic liver injuries. Saudi Surg J 2017;5:53-9

How to cite this URL:
Al-Jiffry BO. Diagnosis and treatment of traumatic liver injuries. Saudi Surg J [serial online] 2017 [cited 2023 Mar 29];5:53-9. Available from: https://www.saudisurgj.org/text.asp?2017/5/2/53/211610

  Introduction Top

The liver is the largest intra-abdominal solid organ with a thin capsule and a relatively fixed position in relation to the spine, making it particularly prone to injury and it is the second most commonly injured organ in abdominal trauma, but damage to the liver is the most common cause of death after abdominal injury.[1],[2],[3] The right hemi liver is injured more commonly than the left due to its large size and proximity to ribs.[1] In Europe, blunt trauma accounts for 80%–90% of all liver injuries, while in South Africa and North America, penetrating injuries account for 66% and 88% of liver trauma, respectively.[1] The mortality rate is higher with blunt abdominal trauma than with penetrating injuries.[4]

The initial clinical assessment of patients with blunt abdominal trauma is often inaccurate as the associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult; however, the diagnostic accuracy has been improved due to the advancement in imaging modalities.[1],[2],[3],[4],[5]

Management of liver trauma may vary widely from nonoperative management (NOM) with or without angioembolization to damage control surgery (DCS) which is mainly centered on stopping the bleeding by packing, Pringle's maneuver, and vascular exclusion to totally replacing the liver by a liver transplant.[4],[5],[6] In this article, the different options of diagnosis and treatment of liver trauma will be discussed.

  Diagnosis Top

Clinical manifestations of hepatic injuries are related to the type of trauma, amount of blood loss, and peritoneal irritation.[7],[8],[9] There would be a history of blunt or penetrating trauma with pain in the right upper abdominal quadrant which may be referred to the right shoulder due to irritation of the inferior surface of the diaphragm in addition to nausea and vomiting.[1],[2],[3] Examination of the patient will show variable degrees of shock which may predominate the picture.[9] Signs of peritoneal irritation such as tenderness, rebound tenderness, and guarding are usually found and these signs would be prominent in case of bile leak.[8] The initial clinical assessment of patients with blunt abdominal trauma is often inaccurate as the associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult.[1] Studies showed that the accuracy rate of clinical evaluation alone does not exceed 65% for detecting intraperitoneal bleeding.[8] Occasionally, patients with blunt abdominal trauma do well initially, but they subsequently develop a liver abscess, presumably due to unrecognized liver damage and these patients present with signs and symptoms of deep-seated infection.[9] The mechanism of injury is critically important in assessing patients with abdominal injury and this information may be obtained from the patient, relatives, police, or emergency care personnel.[10] Following initial assessment, a conscious patient, who is hemodynamically unstable following blunt trauma and has generalized peritonism, or those with sustained penetrating injury, should undergo immediate laparotomy without further investigation.[10],[11],[12],[13]

Hemodynamically stable patients with suspected liver injury can be investigated at this stage to define the nature of the injury.[10] Focused assessment with sonography for trauma (FAST) has gained increased acceptance, particularly in the emergency department, for the rapid evaluation of patients with blunt or penetrating abdominal trauma.[14],[15],[16],[17],[18],[19] It is cheap, portable, and noninvasive, compared to peritoneal lavage, and it does not use radiation or iodinated contrast media.[20],[21],[22] The sensitivity of FAST for the presence of intra-abdominal fluid in patients with trauma ranges from 75% to 93.8% and the specificity from 97% to 100%.[14],[15] However, some pitfalls remain in abdominal ultrasonography such as missing injuries at the dome or lateral segments of the liver and difficulty in distinguishing hepatic lacerations or hematomas because they are isoechoic to the normal liver.[23],[24] Contrast-enhanced ultrasonography has been proved to be useful in penetrating liver trauma without prolongation of examination time and it increases the sensitivity and the specificity of ultrasound in the evaluation of abdominal trauma not only in the detection of free peritoneal fluid but also in the visualization of the parenchymal lacerations.[25] However, US is operator dependent, where you may not find an expert ultrasonographer in the midnight; in addition, US contrast is not widely available in every casualty.[1]

Contrast-enhanced computed tomography (CT) is the gold standard diagnostic tool as it has high sensitivity and specificity for detecting liver injuries which increase as the time between injury and scanning increases, evidently because hematomas and lacerations become better defined.[9],[26],[27],[28],[29] CT without intravenous contrast enhancement is of limited value in hepatic trauma, but it can be useful in identifying or following up a hemoperitoneum.[18],[30],[31] The advantages of CT scanning in hepatic injury include the following; accurate grading of liver injuries, crude quantitation of the degree of hemoperitoneum, mandatory for patients with blunt trauma whose liver injury is to be managed nonoperatively, and detection of missile tracts in penetrating trauma patients which is imperative for surgeons who want to attempt nonoperative management of penetrating wounds.[32],[33],[34],[35] Although CT is very useful in the evaluation of stable patients with abdominal trauma, most authors agree that unstable patients, with either blunt or penetrating trauma, are unlikely to benefit from this investigation because of the valuable time that it requires.[32] False-positive errors are recorded with CT scans where the adjacent ribs may mimic contusion or hematoma, especially in the presence of air contrast level within the stomach in a patient with a nasogastric tube.[36],[37] False-negative findings may occur if contrast enhancement is used in patients with fatty liver where the enhanced fatty liver may become iso-attenuating relative to the laceration or hematoma; in this situation, a nonenhanced CT scan may provide useful information regarding hepatic injury.[37] Branching hepatic lacerations can mimic unopacified portal or hepatic veins or dilated intrahepatic bile ducts, so careful evaluation of serial images has to be done.[36],[37]

Magnetic resonance imaging (MRI) has a limited role in the evaluation of blunt abdominal trauma, it has no advantage over CT scanning, and there is no sufficient experience to establish its false-positive and false-negative findings.[6] However, MRI may be useful in pregnant women in whom the radiation dose is a concern, in patients with renal failure, and in allergic patients to radiographic contrast medium, in addition, magnetic resonance cholangiopancreatography (MRCP) can be used in the assessment of biliary injury including that of pancreatic duct trauma.[38]

Angiography can be used in stable patients where cross-sectional imaging may provide sufficient detail to treat the patient conservatively; however, it has no role in unstable patients.[39] A dynamic angiographic study may demonstrate the site of active bleeding; in addition, it can be combined with angiographic embolization, especially in high-grade liver injury.[40]

Endoscopic retrograde cholangiopancreatography (ERCP) may help in the delineation of the biliary tree in patients with liver trauma, and stents may be used to treat biliary leaks.[41],[42]

Laparoscopy in patients with abdominal trauma can reduce negative and nontherapeutic laparotomy rates, patient morbidity rates, hospital treatment costs, and can be used as therapeutic tool in selected patients; however, its use in this context requires further study.[43],[44],[45],[46],[47],[48],[49],[50]

  Classification of Liver Injury Top

Liver trauma ranges from a minor capsular tear, with or without parenchymal injury, to extensive disruption involving both hemi liver with associated hepatic vein or vena caval injury.[1] In 1989, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma produced a Hepatic Injury Scale and it was revised and modified in 1994[51] by which hepatic injuries are described in most major trauma centers [Table 1]. Grade I or II injuries are considered minor; they represent 80%–90% of all cases and usually require minimal or no operative treatment.[1],[52] Grade III–V injuries are generally considered severe and often require surgical intervention, while Grade VI injuries are regarded as incompatible with survival.[1]
Table 1: American Association for the Surgery of Trauma Hepatic Injury Scale

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  Management Top


Three observations prompted the move toward nonoperative treatment. First, the practice of nonoperative treatment was initially advocated for splenic injuries and then extended to the liver. The success of treatment in children led to attempts of nonoperative treatment in adults.[52],[53],[54] Second, the high rate of nontherapeutic operations in many patients with blunt hepatic injuries was not in patients' best interest.[1] Third, the advent of CT scanning greatly facilitated both diagnosis and grading of injuries and gave some reassurance that the intestinal injuries had not occurred.[1],[54]

There has been several reports started since 1985, where Trunkey [55] defined the criteria for NOM: the patient must be hemodynamically stable, absence of peritoneal signs, availability of CT, monitoring in intensive care unit, facility of immediate surgery, and absence of other organ injuries. These criteria have become less strict, where multiple reports are trending more to NOM.[3] Other reports even went to the extreme suggesting that all patients should be treated first by NOM regardless of their trauma, provided the addition of angiography and embolization that made the NOM more feasible and more successful.[56],[57],[58] The success rate of nonoperative treatment has been remarkably high, and the necessity for operations for ongoing hemorrhage has been reported to be from 5% to 15%, but there remains a concern over missed bowel injuries that have been reported from 1% to 3%.[59],[60],[61],[62],[63] Nonoperative treatment of abdominal stab wounds has been practiced successfully in numerous centers and is on the rise.[1] NOM of gunshot wounds has been more controversial; however, many reports are calling to add these group of patients to the NOM group.[64],[65],[66],[67] Demetriades et al.[68] reported 152 patients with penetrating solid organ injuries recording that 28.4% of all liver injuries were successfully managed nonoperatively. Appropriately selected patients with liver gunshot injuries deemed feasible, safe, and effective, regardless of the liver injury severity in centers with suitable facilities.[67]

The failure rate of NOM ranges from 6% to 10% and it correlates with the grade of liver injury and this may arise from injuries that have not been recognized at the time of initial presentation and/or become apparent after initial delay.[1]

  Operative Management Top

Damage control surgery

This usually implies saving the patient's life and stopping the bleeding which will make the patient more stable and in a better physiological and hemodynamical state to be able to have the definitive treatment.[1] Skin preparation should allow for extension of a midline abdominal incision to a median sternotomy or right thoracotomy, if necessary, for adequate exposure of posterior liver injuries.[69],[70] If the indication for surgery is an obvious penetrating through-and-through liver injury, or the patient failed the NOM and has clear liver injury, only a bilateral subcostal incision is a useful alternative which has been adopted by many investigators to have better liver exposure.[1] DCS includes perihepatic packing and partial abdominal closure or Bogota bag.[69] Usually, an average of six laparotomy pads can be packed to get the tamponade effect between the liver and the abdominal wall.[70] The timing of re-exploration is controversial, but usually 12–24 h is the safe time for re-exploration if the patient's condition permits. As many hospitals have a general surgeon on call with limited liver or trauma experience, if a major liver injury is encountered, initial control of bleeding can be achieved with temporary tamponade of the right upper quadrant using packs, portal triad occlusion (Pringle maneuver), bimanual compression of the liver, or even manual compression of the abdominal aorta above the celiac trunk.[71],[72] Digital compression of the portal triad (Pringle maneuver) can be used diagnostically and compression can be maintained with an atraumatic vascular clamp if hemorrhage decreases and the clamp should be occluded only to the degree necessary to compress the blood vessels in order not to injure the common bile duct.[73] If hemorrhage is unaffected by portal triad occlusion, major vena cava injury or atypical vascular anatomy should be suspected.[74],[75] Although the permitted occlusion time of the portal triad is controversial, most authors now agree that clamping of the hepatic pedicle for up to 1 h is well tolerated with no adverse effects on liver function.[33],[69]

After initial intraoperative resuscitation, the liver must be mobilized adequately to allow a thorough examination of the damaged area and to decide on the necessary surgical technique, unless the injury is already accessible through the incision.[69],[72],[76] Mobilization is achieved by dividing the falciform, triangular and coronary ligaments, and by placing abdominal packs posteriorly to maintain this position.[50] Care should be taken to avoid impairing venous return, by either excessive lifting and/or rotation of the mobilized liver, or excessive packing causing caval compression.[1],[50] There are several tricks to stop the bleeding other than the one mentioned before, however we advise that most of these should be done by experienced surgeons in a stable patient or if the patient is still bleeding after trying the previous methods mentioned.[1] Several specific modalities began to be used more often to treat arterial bleeding as hepatorrhaphy has been used with increased frequency.[77] When the arterial bleeding occurred deep within the hepatic parenchyma, a tractotomy was advocated to expose and suture ligate the arterial flow, but control of deep arterial bleeding was often technically difficult to accomplish.[77],[78],[79] A high rate of infection following suture ligation of the deep arterial bleeding has led to reconsideration of its use, although it remained an operation that could occasionally be lifesaving.[80],[81],[82],[83],[84]

Major venous bleeding was recognized as a major source of mortality, particularly in patients who had been in high-speed motor vehicle crashes.[1] The nearly uniform lethality of retrohepatic vena caval injuries with an attempt at direct repair led to the development of the atriocaval shunt which was developed by Schrock et al.;[85] however, the operation required opening the chest to expose the atria which was associated with accelerated hypothermia and coagulopathy and the mortality rate remained high. Diffuse bleeding from damaged or devitalized liver increasingly required surgical treatment; however, resection debridement has been increasingly used in addition to the use of absorbable gauze packing and drainage or omental pedicle.[86],[87],[88]

  Definitive Surgery Top

This should be carried out in a stable patient by an experienced surgeon at a second stage to deal with a certain problem.[1] One of the most common problems is bile leak and collection with an incidence of 6%–20%.[89] Intra-abdominal collection is best treated by a radiological-guided drain and it can be investigated by MRCP or ERCP.[41],[89] ERCP is advocated by some to be much better where the leak is identified and can be treated by sphincterotomy and a stent with very high success rate; however, some patients still require surgical ligation.[41] Another reason to go to the operating room is liver necrosis and abscess formation which might increase with attempts to stop the bleeding with angioembolization in NOM or by arterial ligation and packing in DCS.[1] The best option for treating this problem is to drain the abscess radiologically; however, if drainage is not sufficient, operative drainage is advised.[1] Liver resection might be necessary with reported frequency of 2%–5% in most series, with an overall mortality of 17.8% and morbidity around 30%.[90],[91],[92]

Rebleeding in the postoperative period is a challenging problem and it may be related to coagulopathy, inadequate initial surgical repair, and missed retrohepatic venous injury.[1] Confirmed coagulation defects should be corrected as rapidly as possible with fresh frozen plasma and platelet transfusions. Some authors recommend reoperation after transfusion of 10 units of blood in 24 h;[93] however, the limit of 6 units in the first 12 h [94],[95] seems to be more reasonable. In cases with slow rebleeding when the limit of 6 units has not been exceeded, embolization of the bleeding vessels may be helpful.[95]

Intra-abdominal sepsis in the postoperative period occurs in approximately 7%–12% of patients and can be treated through radiological or surgical drainage.[96] Arteriovenous fistula is not an uncommon complication with an incidence of <3% and is usually treated by embolization.[97]

Liver transplantation has been reported as an extreme intervention in cases of severe and complicated hepatic trauma with twenty cases described in literature.[98] Esquivel et al. first reported the use of liver transplantation in two patients with progressive hepatic failure and uncontrollable bleeding.[99] The transplant decision is difficult because usual criteria are not validated, liver's potential recovery is difficult to evaluate, and associated sepsis and head injuries which may interfere with the proper decision.[100]

  Outcome Top

The mortality rate from liver trauma has fallen from 66% in the World War I, to 27% in the World War II, to current levels of 10%–15%.[101],[102] The mechanism of injury has an important bearing on mortality rate, with blunt trauma carrying a higher mortality rate (10%–30%) than penetrating liver trauma (0%–10%).[103]

  Conclusion Top

The better understanding of hepatic anatomy and pathophysiology, in addition to the advance in diagnostic imaging, resuscitation, intensive care, and the introduction of DCS, has led to marked improvement in the mortality rate following liver injury.

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Conflicts of interest

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  References Top

Al-Jiffry BO, AlMalki O. Hepatic Trauma, Hepatic Surgery, Prof. Hesham Abdeldayem (Ed.), InTech. 2013. Available from: https://www.intechopen.com/books/hepatic-surgery/hepatic-trauma. DOI: 10.5772/52793.  Back to cited text no. 1
Feliciano DV. Surgery for liver trauma. Surg Clin North Am 1989;69:273-84.  Back to cited text no. 2
Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg 1984;199:467-74.  Back to cited text no. 3
Clemente N, Di Saverio S, Giorgini E, Biscardi A, Villani S, Senatore G, et al. Management and outcome of 308 cases of liver trauma in Bologna Trauma Center in 10 years. Ann Ital Chir 2011;82:351-9.  Back to cited text no. 4
Li Petri S, Gruttadauria S, Pagano D, Echeverri GJ, Di Francesco F, Cintorino D, et al. Surgical management of complex liver trauma: A single liver transplant center experience. Am Surg 2012;78:20-5.  Back to cited text no. 5
Schweizer W, Tanner S, Baer HU, Lerut J, Huber A, Gertsch P, et al. Management of traumatic liver injuries. Br J Surg 1993;80:86-8.  Back to cited text no. 6
Krige JE, Bornman PC, Terblanche J. Liver trauma in 446 patients. S Afr J Surg 1997;35:10-5.  Back to cited text no. 7
Legome EL. Liver Trauma; 2016. Available from: http://www.emedicine.medscape.com/article/370508.  Back to cited text no. 8
Carrillo EH, Wohltmann C, Richardson JD, Polk HC Jr. Evolution in the treatment of complex blunt liver injuries. Curr Probl Surg 2001;38:1-60.  Back to cited text no. 9
Paterson-Brown S. Core Topics in General and Emergency Surgery. 3rd ed.: Elsevier; 2005. p. 239-57.  Back to cited text no. 10
Sherlock DJ, Bismuth H. Secondary surgery for liver trauma. Br J Surg 1991;78:1313-7.  Back to cited text no. 11
Garden J. Hepatobiliary and Pancreatic Surgery. 3rd ed.: Elsevier; 2003. p. 331-47.  Back to cited text no. 12
Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, et al. Liver trauma: WSES position paper. World J Emerg Surg 2015;10:39.  Back to cited text no. 13
Bode PJ, Edwards MJ, Kruit MC, van Vugt AB. Sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma. AJR Am J Roentgenol 1999;172:905-11.  Back to cited text no. 14
Kimura A, Otsuka T. Emergency center ultrasonography in the evaluation of hemoperitoneum: A prospective study. J Trauma 1991;31:20-3.  Back to cited text no. 15
Hoffmann R, Nerlich M, Muggia-Sullam M, Pohlemann T, Wippermann B, Regel G, et al. Blunt abdominal trauma in cases of multiple trauma evaluated by ultrasonography: A prospective analysis of 291 patients. J Trauma 1992;32:452-8.  Back to cited text no. 16
Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin North Am 1996;76:763-82.  Back to cited text no. 17
Casillas VJ, Amendola MA, Gascue A, Pinnar N, Levi JU, Perez JM. Imaging of nontraumatic hemorrhagic hepatic lesions. Radiographics 2000;20:367-78.  Back to cited text no. 18
Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, et al. WSES classification and guidelines for liver trauma. World J Emerg Surg 2016;11:50.  Back to cited text no. 19
Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma 1995;39:492-8.  Back to cited text no. 20
McKenney MG, Martin L, Lentz K, Lopez C, Sleeman D, Aristide G, et al. 1,000 consecutive ultrasounds for blunt abdominal trauma. J Trauma 1996;40:607-10.  Back to cited text no. 21
Richards JR, McGahan JP, Pali MJ, Bohnen PA. Sonographic detection of blunt hepatic trauma: Hemoperitoneum and parenchymal patterns of injury. J Trauma 1999;47:1092-7.  Back to cited text no. 22
Soto JA, Morales C, Múnera F, Sanabria A, Guevara JM, Suárez T. Penetrating stab wounds to the abdomen: Use of serial US and contrast-enhanced CT in stable patients. Radiology 2001;220:365-71.  Back to cited text no. 23
Hochmuth A, Fleck M, Hauff P, Reinhardt M, Kosmehl H, Hilger I, et al. First experience in using a new ultrasound mode and ultrasound contrast agent in the diagnosis of blunt renal trauma: A feasibility study in an animal model. [Preliminary report]. Invest Radiol 2000;35:205-11.  Back to cited text no. 24
Adam A, Roddie ME. CT of the liver and biliary tract. In: Blumgart LH, editor. Surgery of the Liver and the Biliary Tract. 2nd ed. Edinburgh: Churchill Livingstone; 1994. p. 243-70.  Back to cited text no. 25
Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, et al. Liver trauma: WSES position paper. World J Emerg Surg 2015;10:39-49.  Back to cited text no. 26
Cachecho R, Clas D, Gersin K, Grindlinger GA. Evolution in the management of the complex liver injury at a level I trauma center. J Trauma 1998;45:79-82.  Back to cited text no. 27
Timofte D, Hutanu I, Livadariu RM, Soroceanu RP, Munteanu I, Diaconu C, et al. Management of traumatic liver lesions. Rev Med Chir Soc Med Nat Iasi 2015;119:431-6.  Back to cited text no. 28
Kutcher ME, Weis JJ, Siada SS, Kaups KL, Kozar RA, Wawrose RA, et al. The role of computed tomographic scan in ongoing triage of operative hepatic trauma: A Western Trauma Association multicenter retrospective study. J Trauma Acute Care Surg 2015;79:951-6.  Back to cited text no. 29
Fang JF, Chen RJ, Wong YC, Lin BC, Hsu YB, Kao JL, et al. Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma. J Trauma 2000;49:1083-8.  Back to cited text no. 30
Khan AN. Liver Trauma Imaging; 2017. Available from: http://www.emedicine.medscape.com/article/370508.  Back to cited text no. 31
Federle MP, Jeffrey RB Jr. Hemoperitoneum studied by computed tomography. Radiology 1983;148:187-92.  Back to cited text no. 32
Shuman WP. CT of blunt abdominal trauma in adults. Radiology 1997;205:297-306.  Back to cited text no. 33
Ingram MC, Siddharthan RV, Morris AD, Hill SJ, Travers CD, McKracken CE, et al. Hepatic and splenic blush on computed tomography in children following blunt abdominal trauma: Is intervention necessary? J Trauma Acute Care Surg 2016;81:266-70.  Back to cited text no. 34
Toombs BD, Lester RG, Ben-Menachem Y, Sandler CM. Computed tomography in blunt trauma. Radiol Clin North Am 1981;19:17-35.  Back to cited text no. 35
McGehee M, Kier R, Cohn SM, McCarthy SM. Comparison of MRI with postcontrast CT for the evaluation of acute abdominal trauma. J Comput Assist Tomogr 1993;17:410-3.  Back to cited text no. 36
Fulcher AS, Turner MA, Yelon JA, McClain LC, Broderick T, Ivatury RR, et al. Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: Preliminary findings. J Trauma 2000;48:1001-7.  Back to cited text no. 37
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. 38
Hagiwara A, Yukioka T, Ohta S, Tokunaga T, Ohta S, Matsuda H, et al. Nonsurgical management of patients with blunt hepatic injury: Efficacy of transcatheter arterial embolization. AJR Am J Roentgenol 1997;169:1151-6.  Back to cited text no. 39
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. 40
Sugimoto K, Asari Y, Sakaguchi T. ERCP in the non-surgical management of blunt liver trauma. J Trauma 1993;35:192-9.  Back to cited text no. 41
Sosa JL, Markley M, Sleeman D, Puente I, Carrillo E. Laparoscopy in abdominal gunshot wounds. Surg Laparosc Endosc 1993;3:417-9.  Back to cited text no. 42
Sosa JL, Arrillaga A, Puente I, Sleeman D, Ginzburg E, Martin L. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds. J Trauma 1995;39:501-4.  Back to cited text no. 43
Ditmars ML, Bongard F. Laparoscopy for triage of penetrating trauma: The decision to explore. J Laparoendosc Surg 1996;6:285-91.  Back to cited text no. 44
Hallfeldt KK, Trupka AW, Erhard J, Waldner H, Schweiberer L. Emergency laparoscopy for abdominal stab wounds. Surg Endosc 1998;12:907-10.  Back to cited text no. 45
Chen RJ, Fang JF, Lin BC, Hsu YB, Kao JL, Kao YC, et al. Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma. J Trauma 1998;44:691-5.  Back to cited text no. 46
Pilcher CJ, Wesolowski MS, Jawad MA. Laparoscopic applications for abdominal trauma injuries. AORN J 1996;64:366-75.  Back to cited text no. 47
Villavicencio RT, Aucar JA. Analysis of laparoscopy in trauma. J Am Coll Surg 1999;189:11-20.  Back to cited text no. 48
Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, et al. Organ injury scaling: Spleen, liver, and kidney. J Trauma 1989;29:1664-6.  Back to cited text no. 49
Ochsner MG, Jaffin JH, Golocovsky M, Jones RC. Major hepatic trauma. Surg Clin North Am 1993;73:337-52.  Back to cited text no. 50
Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, et al. American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, liver, and kidney, validation based on the national trauma data bank. J Am Coll Surg 2008;207:646-55.  Back to cited text no. 51
Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg 2005;200:648-69.  Back to cited text no. 52
Richie JP, Fonkalsrud EW. Subcapsular hematoma of the liver. Nonoperative management. Arch Surg 1972;104:781-4.  Back to cited text no. 53
van As AB, Millar AJ. Management of paediatric liver trauma. Pediatr Surg Int 2017;33:445-53.  Back to cited text no. 54
Trunkey DD. Hepatic trauma: Contemporary management. Surg Clin North Am 2004;84:437-50.  Back to cited text no. 55
Meyer AA, Crass RA, Lim RC Jr., Jeffrey RB, Federle MP, Trunkey DD. Selective nonoperative management of blunt liver injury using computed tomography. Arch Surg 1985;120:550-4.  Back to cited text no. 56
Parks NA, Davis JW, Forman D, Lemaster D. Observation for nonoperative management of blunt liver injuries: How long is long enough? J Trauma 2011;70:626-9.  Back to cited text no. 57
Norrman G, Tingstedt B, Ekelund M, Andersson R. Non-operative management of blunt liver trauma: Feasible and safe also in centres with a low trauma incidence. HPB (Oxford) 2009;11:50-6.  Back to cited text no. 58
Letoublon C, Chen Y, Arvieux C, Voirin D, Morra I, Broux C, et al. Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma. World J Surg 2008;32:1189-93.  Back to cited text no. 59
Marx JA, Moore EE, Jordan RC. Limitations of computed tomography in the evaluation of acute abdominal trauma-prospective randomized study. J Trauma 1985;25:933-8.  Back to cited text no. 60
Buckman RF Jr., Piano G, Dunham CM, Soutter I, Ramzy A, Militello PR. Major bowel and diaphragmatic injuries associated with blunt spleen or liver rupture. J Trauma 1988;28:1317-21.  Back to cited text no. 61
Fischer RP, Miller-Crotchet P, Reed RL. The hazards of non-operative management of adults with blunt abdominal injury. J Trauma 1988;28:1445-9.  Back to cited text no. 62
Kemmeter PR, Hoedema RE, Foote JA, Scholten DJ. Concomitant blunt enteric injuries with injuries of the liver and spleen: A dilemma for trauma surgeons. Am Surg 2001;67:221-5.  Back to cited text no. 63
Sherck JP, Oakes DD. Intestinal injuries missed by computed tomography. J Trauma 1990;30:1-5.  Back to cited text no. 64
Schnüriger B, Talving P, Barbarino R, Barmparas G, Inaba K, Demetriades D. Current practice and the role of the CT in the management of penetrating liver injuries at a Level I trauma center. J Emerg Trauma Shock 2011;4:53-7.  Back to cited text no. 65
Navsaria PH, Nicol AJ, Krige JE, Edu S. Selective nonoperative management of liver gunshot injuries. Ann Surg 2009;249:653-6.  Back to cited text no. 66
Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D. Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. J Trauma 2005;59:1155-60.  Back to cited text no. 67
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. 68
Wilson RH, Moorehead RJ. Hepatic trauma and its management. Injury 1991;22:439-45.  Back to cited text no. 69
Stain SC, Yellin AE, Donovan AJ. Hepatic trauma. Arch Surg 1988;123:1251-5.  Back to cited text no. 70
Feliciano DV, Pachter HL. Hepatic trauma revisited. Curr Probl Surg 1989;26:453-524.  Back to cited text no. 71
Canizaro PC, Pessa ME. Management of massive hemorrhage associated with abdominal trauma. Surg Clin North Am 1990;70:621-34.  Back to cited text no. 72
Pringle JH. V. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg 1908;48:541-9.  Back to cited text no. 73
Moore EE. Edgar J. Poth Lecture. Critical decisions in the management of hepatic trauma. Am J Surg 1984;148:712-6.  Back to cited text no. 74
Walt AJ, Bender JS. Injuries of the liver. In: Schwartz SI, Ellis H, editors. Maingot's Abdominal Operations. Vol. 2. Norwalk, Connecticut: Appleton-Century-Crofts; 1985. p. 1577-90.  Back to cited text no. 75
Smadja C, Traynor O, Blumgart LH. Delayed hepatic resection for major liver injury. Br J Surg 1982;69:361-4.  Back to cited text no. 76
Lucas CE, Ledgerwood AM. Prospective evaluation of hemostatic techniques for liver injuries. J Trauma 1976;16:442-51.  Back to cited text no. 77
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. 78
Trunkey DD, Shires GT, Mc Clelland R. Management of liver trauma in 811 consecutive patients. Ann Surg 1974;179:722-8.  Back to cited text no. 79
Morris JA Jr., Eddy VA, Blinman TA, Rutherford EJ, Sharp KW. The staged celiotomy for trauma. Issues in unpacking and reconstruction. Ann Surg 1993;217:576-84.  Back to cited text no. 80
Aaron S, Fulton RL, Mays ET. Selective ligation of the hepatic artery for trauma of the liver. Surg Gynecol Obstet 1975;141:187-9.  Back to cited text no. 81
Mays ET, Conti S, Fallahzadeh H, Rosenblatt M. Hepatic artery ligation. Surgery 1979;86:536-43.  Back to cited text no. 82
Mays ET. Hepatic trauma. Curr Probl Surg 1976;13:5-73.  Back to cited text no. 83
Flint LM Jr., Polk HC Jr. Selective hepatic artery ligation: Limitations and failures. J Trauma 1979;19:319-23.  Back to cited text no. 84
Schrock T, Blaisdell FW, Mathewson C Jr. Management of blunt trauma to the liver and hepatic veins. Arch Surg 1968;96:698-704.  Back to cited text no. 85
Moore EE, Seagraves A. Non-resectional management of major hepatic trauma. Am J Surg 1985;150:725-9.  Back to cited text no. 86
Walt AJ. Founder's lecture: The mythology of hepatic trauma – Or Babel revisited. Am J Surg 1978;135:12-8.  Back to cited text no. 87
Stone HH, Lamb JM. Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver. Surg Gynecol Obstet 1975;141:92-4.  Back to cited text no. 88
Wahl WL, Brandt MM, Hemmila MR, Arbabi S. Diagnosis and management of bile leaks after blunt liver injury. Surgery 2005;138:742-7.  Back to cited text no. 89
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;215:492-500.  Back to cited text no. 90
Polanco P, Leon S, Pineda J, Puyana JC, Ochoa JB, Alarcon L, et al. Hepatic resection in the management of complex injury to the liver. J Trauma 2008;65:1264-9.  Back to cited text no. 91
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. 92
Cué JI, Cryer HG, Miller FB, Richardson JD, Polk HC Jr. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: Critical refinements of a useful technique. J Trauma 1990;30:1007-11.  Back to cited text no. 93
Beal SL. Fatal hepatic hemorrhage: An unresolved problem in the management of complex liver injuries. J Trauma 1990;30:163-9.  Back to cited text no. 94
De Toma G, Mingoli A, Modini C, Cavallaro A, Stipa S. The value of angiography and selective hepatic artery embolization for continuous bleeding after surgery in liver trauma: Case reports. J Trauma 1994;37:508-11.  Back to cited text no. 95
Brick SH, Taylor GA, Potter BM, Eichelberger MR. Hepatic and splenic injury in children: Role of CT in the decision for laparotomy. Radiology 1987;165:643-6.  Back to cited text no. 96
Krige JE, Bornman PC, Terblanche J. Therapeutic perihepatic packing in complex liver trauma. Br J Surg 1992;79:43-6.  Back to cited text no. 97
Honoré C, Deroover A, Gilson N, Detry O. Liver transplantation for hepatic trauma: Discussion about a case and its management. J Emerg Trauma Shock 2011;4:137-9.  Back to cited text no. 98
Esquivel CO, Bernardos A, Makowka L, Iwatsuki S, Gordon RD, Starzl TE. Liver replacement after massive hepatic trauma. J Trauma 1987;27:800-2.  Back to cited text no. 99
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. 100
Pachter HL, Liang HG, Hofstetter SR. Liver and biliary tract trauma. In: Moore EE, Mattox KL, Feliciano DV, editors. Trauma. 2nd ed. Norwalk, Connecticut: Appleton and Lange; 1991. p. 441-63.  Back to cited text no. 101
Helling TS, Morse G, McNabney WK, Beggs CW, Behrends SH, Hutton-Rotert K, et al. Treatment of liver injuries at level I and level II centers in a multi-institutional metropolitan trauma system. The Midwest Trauma Society Liver Trauma Study Group. J Trauma 1997;42:1091-6.  Back to cited text no. 102
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. 103


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