Damage Control Surgery for Severe Liver Trauma

Primary Approach

The primary surgical approach for hemodynamically unstable patients with severe liver injury is immediate hemorrhage control through perihepatic packing and damage control resuscitation, while avoiding major hepatic resections during the initial operation, as recommended by the World Journal of Emergency Surgery 1, 2

Control of hemorrhage is the immediate priority that determines survival in patients with severe liver trauma 1, 3
Control of bile leakage is secondary but essential to prevent later complications in patients with severe liver trauma 1, 2
Initiation of damage control resuscitation, including early activation of massive transfusion protocols, is crucial in patients with severe liver trauma 3, 4

For minor to moderate bleeding, manual compression alone may suffice, or techniques such as electrocautery, bipolar devices, or argon beam coagulation may be used in patients with severe liver trauma 3
For major hemorrhage, perihepatic packing is the cornerstone technique and should be employed early, as recommended by the World Journal of Emergency Surgery 3, 5

Major hepatic resections must be avoided during the initial damage control operation for severe liver trauma, as this is a Grade 2B recommendation that significantly impacts mortality, according to the World Journal of Emergency Surgery 1, 2, 5

Hepatic artery injuries should be managed with primary repair if possible, or selective hepatic artery ligation if repair fails, and mandatory cholecystectomy if right or common hepatic artery requires ligation, as recommended by the World Journal of Emergency Surgery 3, 4
Portal vein injuries should be managed with primary repair whenever possible, and portal vein ligation should be avoided due to high risk of liver necrosis, according to the World Journal of Emergency Surgery 3, 4
Retrohepatic caval/hepatic vein injuries should be managed with perihepatic packing as the safest initial approach, as recommended by the World Journal of Emergency Surgery 3, 4

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may be used as a temporizing bridge to definitive hemorrhage control in hemodynamically unstable patients with severe liver trauma, as a Grade 2B recommendation, according to the World Journal of Emergency Surgery 1, 2
Post-operative angioembolization is an essential tool for persistent arterial bleeding after damage control procedures for severe liver trauma, and should be immediately available, as recommended by the World Journal of Emergency Surgery 1, 2, 3

Temporary abdominal closure should be utilized when there is a high risk of abdominal compartment syndrome, planned second-look operation is needed, or patient remains physiologically deranged despite initial hemorrhage control, as recommended by the World Journal of Emergency Surgery 5

The "lethal triad" of hypothermia, acidosis, and coagulopathy must be aggressively reversed in patients with severe liver trauma, as this drives mortality, according to the World Journal of Emergency Surgery 3, 5
Failure to activate massive transfusion protocols early can lead to increased mortality in patients with severe liver trauma, and simultaneous intraoperative intensive resuscitation is of paramount importance, as recommended by the World Journal of Emergency Surgery 3, 4