Hepatic injuries are common following blunt abdominal trauma and penetrating trauma to the right upper quadrant of the abdomen.  Fortunately, minor liver injuries are much more common and frequently stop bleeding without any intervention.  There is essentially no mortality from this group of patients.  As the injuries get more serious, particularly Grade IV injuries with ruptured intraparenchymal hematoma and parenchymal disruption involving one to three segments of the liver, the mortality increases sharply.  Injuries to the juxtahepatic veins are extraordinarily severe.  Their mortality exceeds 85%.   

It is very important to have a sound understanding of the vasculature of the liver.  The hepatic veins define the anatomy of the liver.  The three main hepatic veins are the right, middle, and left veins.  The middle hepatic vein usually joins the left hepatic vein and drains directly into the vena cava.  The caudate lobe also drains directly into the vena cava.  There are a number of variations in the arterial anatomy of the liver and it is essential to be aware of this since occasionally application of compression of the portohepatic vasculature known as the Pringle maneuver, may not control hepatic inflow and bleeding.  This is true in a replaced left hepatic artery.

There are a number of operative techniques for controlling hepatic injuries.  At exploratory laparotomy, upon opening the peritoneal cavity, the liver is inspected.  If there is any injury, it is wise to take down the falciform ligament and fully inspect the right lobe and the juxtahepatic areas at the dome of the liver.  This rapidly allows the surgeon to understand the anatomic location and the severity of the injury.  If there is significant hemorrhage, a number of packs should be placed directly on the dome of the liver and a number of packs placed on the inferior border of the liver.  Bimanual compression is then performed.  One of the limitations of packing injuries of the liver is that excessive pressure can be transmitted to the vena cava and decrease venous return and a cardiac inflow.  This can have a significant hypotensive effect.  Similarly, placing too many packs above the dome of the liver and against the diaphragm can decrease excursion of the diaphragm and result in hypoventilation.  This is also a consideration in closing the abdomen as excess packs can result in abdominal compartment syndrome.  Hepatic inflow occlusion is obtained by placing a vascular clamp on the portahepatis.  A full exploratory laparotomy is then carried out to determine other injuries.  Once other injuries are excluded, attention is then focused on the liver.   

An important judgment is whether this is a relatively minor injury which can be controlled with digital pressure, or if it is necessary to use a direct operative technique to control bleeding from the liver.  The second judgment is whether this can be done with the current exposure especially if there is juxtahepatic venous bleeding.  If, the exposure is not adequate, an immediate sternotomy needs to be performed. 

The reason that this is an important decision is that it is imperative to control major hepatic bleeding before multiple whole body transfusions have taken place and the patient is anticoagulated and no autologous clot is being formed at the site of the hepatic injury.  If this is a severe liver injury, an immediate sternotomy allows for excellent visualization of the superior aspect of the liver.  Massive venous hemorrhage can then be controlled early on in the course of the operation.   

Total hepatic inflow occlusion decreases the bleeding from the liver injury to allow for identification of specific hepatic arteries and veins that have been injured.  They should be controlled with either clips or with specific ligation.  If there is a severe burst injury to the right lobe of the liver, it may be necessary to perform debridement of devitalized liver tissue.  This debridement should be minimal, as a formal right lobe resection will result in a substantial mortality.  Various hemostatic agents can be applied directly to the wound to aid in hemostasis.   

Management of the Inferior Vena Cava 

Lacerations to the inferior vena cava represent a significant challenge.  It is essential to get proximal and distal control with direct digital compression of the vena cave on the vertebrae.  Sponge sticks can also be used to gain proximal and distal control of the inferior vena cava.  Once control is gained, the extent and severity of the injury to the vena cava is determined.  There are a number of methods for gaining definitive control of the laceration and performing an adequate repair.  A method which has been very useful is to place a small basket Satinsky clamp on the laceration of the inferior vena cava.  A second larger clamp is placed deep to the first which completely includes the entire laceration.  The first clamp is then removed.   The laceration is within the jaws of the large Satinsky clamp and can be repaired with a running nonabsorbable suture.  It is essential to realize that this method significantly decreases venous return and, therefore, aggressive resuscitation through a suprahepatic venous line must be conducted.  Once the laceration is repaired, it needs to be inspected to be sure that there is adequate blood flow through the vena cava and that it is not narrowed.  If the vena cava is narrowed, it may be necessary to place an autologous vein patch to avoid narrowing of the vena cava.  This is usually not necessary. 

Ligation of the inferior vena cava is possible in the event that it is impossible to repair the laceration.  In this event, the legs should be elevated postoperatively and the lower extremities carefully observed for edema.   

Occasionally, there may be an anterior and posterior vena cava laceration.  There are two methods to deal with this injury.  The first is to repair the anterior laceration.  The lumbar veins are then ligated and transected and the vena cava rolled laterally to expose the posterior laceration.  It is then repaired.  

Another method is to extend the anterior laceration and repair the posterior laceration through the lumen of the vena cava.  Once the posterior laceration is repaired, the anterior laceration is then closed.    

Summary 

Injury to the liver and vena cava frequently represent a major challenge to the surgeon.  It is essential to have a sound understanding of the anatomy, especially the venous drainage of the liver.  Adequate exposure of the entire liver is important to determine the full extent of the injury.  Control of hemorrhage can be performed with a number of maneuvers which include packing, digital control, direct suture ligation, and debridement.  Injuries to the vena cava require distal and proximal control and then careful repair of the laceration.  These injuries require a sound understanding of the anatomy and a carefully thought out therapeutic plan.  

Selected Reading 

Advanced Trauma Operative Management: Surgical Strategies for Penetrating Trauma. Textbook.  Eds. LM Jacobs, RI Gross, SS Luk. Chapter Three. Liver. Pp 107-135.