Surgical restraint in the management of liver trauma

There is controversy over best treatment for liver injury. In England blunt injury to the liver is more common than penetrating injury (the reverse is true in the United States). Blunt injury has a worse prognosis than penetrating injury. A review is presented of 20 years' experience in treating patients with liver injury at one general hospital in England. A protocol for surgical treatment aimed at controlling bleeding from the liver is described. Eighty patients were treated between 1971 and 1990; 12 patients had computed tomographic evidence of liver injury and were initially observed (three patients eventually required surgery). Blunt abdominal injury was the cause of liver injury in 75 of the 80 patients treated. Motor vehicle accidents accounted for the majority of the injuries (57 of 75 blunt abdominal injuries). Possible treatment options included in the protocol were direct suture, liver artery ligation (tying off), or resection (removal of liver tissue); often the use of well-placed packing is enough to stop liver bleeding. Using this protocol 29 patients who had severe injuries were initially treated by placement of packing; this was later removed and surgery performed if required. Six of these patients later required surgery (hemihepatectomy, or removal of a portion of the liver). There were 39 patients who required immediate surgical exploration and definitive surgery; 11 of these patients died (28 percent). Of those treated by packing only, three patients died (10 percent). One death occurred in a patient who had been treated elsewhere using packing and died after being transferred to the university hospital. It is recommended that when patients are in stable condition, they should be assessed using computed tomographic scanning. (Consumer Summary produced by Reliance Medical Information, Inc.)