Operative Management of Adult Blunt Hepatic Trauma

The concept of damage control was introduced by Stone et al.²¹ in the 1980s and promulgated by the group at Ben Taub in 1992.²² This came after the report by Denver General that in patients sustaining fatal hepatic hemorrhage after trauma, hemostasis was not possible as patients were hypothermic, acidotic, and receiving large volumes of packed red cells before blood component or fresh blood.¹⁹ This led to the concept of the “bloody vicious cycle.”²⁰ The term “damage control” was popularized by the group at the University of Pennsylvania in the 1993.²⁷ They described initial control of hemorrhage and contamination followed by packing and temporary abdominal closure, ICU restoration of normal physiology, and delayed definitive repair of intra-abdominal injuries. The decision for damage control should be made very early in the operation before the onset of severe coagulopathy, acidosis, and hypothermia. Early institution of packing as a damage control technique has been shown to lessen mortality.^28–30 Close observation in the ICU for continued bleeding is warranted as is monitoring for abdominal compartment syndrome. A recent prospective study has demonstrated that the early use of open abdomens in patients at risk for intra-abdominal hypertension/ abdominal compartment syndrome enhanced survival.³¹ Frequent monitoring of bladder pressures is warranted.^31,32

Postoperative angiography has been recommended by some authors after damage control laparotomy.^33,34 Badellino and coworkers³³ reported that 52% of patients demonstrated bleeding on postoperative hepatic angiography. Similarly, in a study by Schwab and coworkers,³⁴ half of patients with perihepatic packing and damage control underwent angiography and 62% of these demonstrated active bleeding. However, not all studies have reported such high therapeutic rates for embolization.³⁵  At the current time, the specific subset of patients who would benefit most from hepatic angiography is not well defined. Prospective studies are needed before definitive recommendations. Complications have been reported in more than 40% of patients after angioembolization and include parenchymal necrosis, bile leak, abscess, and liver failure.^35,36