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436
E. Dulundu
59.2 Risk Factors forBiliary Injury
There are a number of risk factors that make cholecystectomy more challenging. These factors can be patient related,
disease related, or extrinsic.
Cognitive factors play an important role in bile duct injury
(BDI). An analysis examining biliary injuries during laparoscopic cholecystectomy found that 97% of injuries were
caused by visual-perceptual illusion or inadequate visualization [12].
Disease-related risk factors include severity of inammation, hemorrhage, and presence of abscess. Acute cholecystitis, impacted large gallstones, Mirizzi syndrome, or stulas
to neighboring organs can all complicate standard surgical
plans, making dissection plans questionable, difcult and
sometimes impossible [13–17].
Patient-related factors include male sex, prior operations,
obesity, skeletal deformity, advanced age, and variation in
the biliary tract anatomy [13, 18–20].
In spite of many surgeons accept the Luschka ducts as a
small bile duct which directly connected with the gallbladder
(hepaticocholecystic ducts), according to recent literature it
would be more correct to describe those structures that are
thought to cause bile leakage from the gallbladder bed after
cholecystectomy as subvesicular bile ducts which is a different entities form hepaticocholecystic ducts [21–23].
Examples of extrinsic factors increasing the risk include
equipment failure, operating room distractions, and tness or
training level of operative personnel [24]. Inadvertent thermal injury to the common bile duct may not cause immediate
injury but can result in delayed structuring [13].
59.3 Strategies toAvoid Biliary Injury
Despite their efcacy, routine preoperative MRCP, and
contrast- enhanced multislice computed tomography cholangiography are expensive tools and should be reserved for
select cases [25, 26].
Injury prevention theories have suggested that strategies
to prevent injuries would be most effective at the time of
anatomical identication and orientation, and prior to
dissection.
The Critical View of Safety (CVS) has been shown to be
a good way of getting secure anatomical identication; once
the calot triangle and the cystic plate have been exposed, it
should be conrmed that no structures other than the cystic
artery and cystic duct enter the gallbladder [27, 28]. If the
infundibular structures of the gallbladder cannot be dissected
safely operation can be stopped and patient can be referred to
a hepatobiliary specialist, another options cholecystostomy
tube can be inserted and operation postponed, or subtotal
cholecystectomy can be performed [29, 30].
If the biliary tree has been transected retrograde catheter
can be placed using for controlling the bile leak and allowing
access for cholangiography to facilitate placement of percutaneous transhepatic biliary catheters in the postoperative
period [31]. In addition, a closed-suction drain should be
placed in the gallbladder bed and patient can be referred to a
hepatobiliary specialist.
59.3.1 Classication Systems
A number of classication systems have been proposed to
describe biliary injuries. The rst reported was the Bismuth
system (Table59.1) [32]. This system categorizes strictures
based on anatomical level of injury, but not more complex
injuries often seen with laparoscopic cholecystectomies.
Strasberg proposed expansion of the Bismuth classication system (Table 59.2) [27]. This system can accurately
describe the location of leak, full or partial transection, and
complete occlusions. It has the advantage of guiding operative repair based on level of injury but does not account for
concomitant vascular injury.
In Stewart-Way classication system patients divided into
4 classes according to the mechanism and anatomy of the
injury [12].
Table 59.1 Bismuth classication system
Type Criteria
I Transection >2cm from the conuence of the hepatic ducts
II Transection <2cm from the conuence of the hepatic ducts
III Transection involving the conuence of the hepatic ducts with
continued right and left ductal communication
IV Transection resulting in the destruction of the hepatic
conuence
(disruption of the conuence ceiling)
V Aberrant right hepatic duct stricture ± Common hepatic duct
stricture
Table 59.2 Strasberg classication system
Type Criteria
A Leakage from cystic duct or minor duct in gallbladder fossa
B Occlusion of abberant hepatic duct
C Transection of aberrant hepatic duct (without concomitant
occlusion)
D Injury to the common hepatic duct or common bile duct
(CBD) lateral wall without transection
E1 Transection >2cm from the conuence of the hepatic ducts
E2 Transection <2cm from the conuence of the hepatic ducts
E3 Transection involving the conuence of the hepatic ducts with
continued right and left ductal communication
E4 Transection resulting in the destruction of the hepatic
conuence (disruption of the conuence ceiling)
E5 Aberrant right hepatic duct injury ± Common hepatic duct
injury
59 Hepato-biliary Injuries
437
The Hanover classication is extremely descriptive considering that dening the level of vascular damage and biliary injury but due to its complexity can be hard to use in a
clinical setting [33].
59.4 Diagnosis
59.4.1 Clinical Presentation
Only one-third of injuries from the ductus cysticus or small
bile ducts in the liver bed are noticed during surgery [34]. On
the other hand, partial or complete transections of CBD can
be noticed in 70–80% of cases during surgery [14, 19, 35].
Peritonitis, abdominal pain, tenderness and fever are the
most common complaints due to bile leakage in most of the
patients. In addition, cholangitis, hyperbilirubinemia, high
alkaline phosphatase and transient liver enzyme elevations
are encountered in 30–50% of patients due to CBD obstruction. Liver enzyme elevations are more pronounced in the
presence of accompanying vascular injury [34, 36, 37].
59.4.2 Imaging
Recently studies has shown no difference in CBD injury rate
with surgeons who routinely used intraoperative
cholangiography (IOC) compared with those who only
selectively used it [38, 39].
If the anatomy is not clear (i.e. severe inammation or
different biliary anatomy), or there is a suspicion of biliary
injury surgeon should not hesitate to use of IOC [15, 30].
Bile ductal blue staining or water injection test, intraoperative choledochoscopy can be used to determine the details
of BDI [40].
Intraoperative ultrasonography is used in some centers
for evaluation of choledocholithiasis with assuming to less
expense, lower failure rate, no exposure to ionizing radiation for the patient and staff and reducing the bile duct
injury [41].
One of the more contemporary techniques being investigated to reduce bile duct injury during cholecystectomy is
near infrared cholangiography, but current evidence comparing near infrared cholangiography for identication of
biliary anatomy during cholecystectomy to IOC is insufcient [30].
59.4.3 Evaluation ofBile Duct Injury
The rate of intraoperative diagnosis of BDI ranges between
15% and 80%, and manifest in a delayed fashion as a leakage or obstruction [42–44]. In the postoperative period, if
there is an extensive peritonitis and hemodynamic instability, urgent surgical exploration may be required. For patient
with stable condition initial imaging modality can be the
doppler ultrasonography which can be helpful to detect
obstructive ndings of the bile duct, abdominal uid collection, and concomitant vascular injury of the hepatic arterial
circulation [15, 19, 45]. Contrast enhanced computed
tomography (CT) is useful imaging modality to conrm
ultrasonographic ndings if any, and can show biloma, ascites, abscess, vascular injuries [15, 19, 33]. When bile duct
injury is considered with abdominal ultrasonography and
computed tomography, diagnosis can be conrmed with
MRCP and HIDA scan [46, 47].
Although ERCP is useful tool in diagnosis, it is an invasive, and should be preferred to use its therapeutic advantages [19, 36, 46].
Placement of a percutaneous transhepatic biliary drainage
catheter in a patient with signs of cholangitis and obstructive
jaundice is of great importance in terms of both therapeutic
drainage and delineation of biliary tract anatomy [37].
59.4.4 Management ofBile Duct Injuries
The success rate of bile duct injury repair in hepatobiliary
surgeon’s hands versus the primary surgeon is signicantly
higher (79% vs27%) [42]. And, many authors agree that
intraoperative recognition of BDI with immediate repair by
specialized HPB surgeons offers the best results [44, 48].
All injuries must rst be adequately characterized by the
location, the degree of injury, and presence of concomitant
vascular injury. The experience of the operating team, the
stability of the patient, the severity of acute inammation, as
well as the extent of vasculobiliary injury all play an important part in determining the success of a repair [36, 49].
If a patient is unstable, septic, or has peritonitis then the
repair should be delayed. Recent systematic review and
meta-analysis has shown that; repair delayed for 4–6weeks
is associated with substantially decreased rates of repair failure, stricture, and postoperative complication [50, 51].
Strasberg etal. generally waited for 3months from the time
of injury before performing repair [52].
The blood supply to the bile ducts is derived from the
right hepatic artery and rarely from the left at the level of the
conuence. These superior branches will travel at the 3-and
9- o’clock positions inferiorly where they form an anastomosis with a blood supply derived from the gastroduodenal
artery. Concomitant vascular injury occurs in 12% to 61% of
biliary injury cases and will involve the right hepatic artery
or its branches 90% of the time [53, 54].
Although the benet of repairing the injured hepatic
artery is controversial, some authors argue that with this
repair, potential hepatic parenchymal ischemia, necrosis and
438
atrophy can be avoided, and risk of ischemic stricture of
reconstructed bile duct can be reduced [55].
If the right hepatic artery injury does not extend to the
liver hilum, a signicant liver ischemia is rare, due to existing shunts in the hilum and preserved portal vein ow [53].
On the other hand, it is the primary blood supply to the
common hepatic bile duct and its transection may contribute
to delayed bile duct stricturing secondary to bile duct
ischemia.
Minor injury such a small leak from the cystic duct stump
or from a segmental or accessory duct less than 3mm can be
ligated. Small lateral injuries (Strasberg type D) can be
repaired over a T-tube or after inserting a thin cystic tube into
the cystic duct instead of the T tube. Small lateral injuries
can also be managed endoscopically or with a percutaneous
transhepatic biliary drainage (PTBD). If the injured segment
of the bile duct is short (<1cm), an end-to-end anastomosis
can be performed over a T-tube. However end-to-end repair
is not recommended as it is associated with a 50% failure
rate and postoperative stricture [56].
More complex injuries such as Strasberg type E4 or type
E5 injuries often require complex procedures, and attempted
repair of complex injuries by an inexperienced surgeon
should be avoided as it is associated with an 80% failure rate
[30, 57].
Other than this, patients with severe concomitant vascular injury, or in the setting of severe inammation, a
delayed repair is often advisable. Nearly one third of
patients undergoing early repair of Strasberg type E injuries (Fig. 59.1) will develop an anastomotic stricture
requiring intervention [58].
In patients who are planned to undergo surgery, it is very
important to perform the Roux-en-Y anastomosis in a tension free fashion in the form of mucosa to-mucosa. Since the
area with the richest blood supply is at biliary conuence,
E. Dulundu
partial SIVB & SV
liver resection
Roux-en-Y
anastomosis
(stricture)
Fig. 59.2 Stricture of Roux-en-Y anastomosis after biliary injury
anastomosis should be attempted to be made proximally as
possible.
Bilioenteric stenting following reconstruction is controversial. In current practice, stents are preferred in cases
where the duct is small, the tissues are inamed or when
there is a concern about the viability of anastomosis. Potential
risks of stents include pressure necrosis, scar formation, or
bleeding via arteriobiliary stula [59]. If patient has PTBD
this can be aid in visualization of the duct, allow more secure
anastomosis and help to obtain a cholangiography postoperatively to evaluate the integrity of the anastomosis. For some
Strasberg type E4 and E5 injury or main hepatic duct is
injured within the parenchyma of the liver, it may be necessary to perform a limited 4B/5 liver resection to gain enough
length of bile duct and have adequate room for creating the
bilioenteric anastomosis (Fig.59.2).
If the injury is so high that an anastomosis to third order
biliary radicles is required for repair, then an anatomical liver
resection may be preferable because the stricture rate with
these small anastomoses is very high. Resection may also be
required in patients with severe concomitant vascular injury
leading to parenchymal necrosis, delayed stricture, or recurrent abscesses in the injured liver [60]. In rare cases patients
may need transplantation especially due to severe vasculobiliary injury, subsequent acute fulminant liver failure or secondary biliary cirrhosis [61].
Fig. 59.1 MRI imaging of Strasberg E bile duct injury
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Surgical Treatment forSevere Liver
Injuries
FlorinBotea, AlexandruBarcu, andIrinelPopescu
60
Abstract
Traumatic injuries represent the third cause of death
world-wide, with over ve million deaths each year.
Because of its anterior location in the abdomen and its
fragility, the liver is one of the most frequently injured
organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the approach of
liver injury towards a non-operative management (NOM).
In high-grade liver injuries, surgical treatment remains
the main option; surgical approach is mandatory in hemodynamically unstable patients, while debatable in stable
ones: some authors support the surgical approach, others
advocate the NOM.As in any trauma, for optimal results,
the emergency centers, emergency medical services transport and the tertiary centers must effectively cooperate in
order to maximize the therapeutic efciency.
60.1 Background
Traumatic injuries represent the third cause of death worldwide, with over ve million deaths each year [1]. Blunt abdominal trauma accounts for 13% of all emergencies and 80% of
abdominal injuries [2], 75% being related to motor vehicle collision or auto versus pedestrian accidents [3], while blows and
falls are responsible for 15% and 6–9%, respectively [4]; occult
trauma may occur with domestic violence and child abuse.
The liver and spleen are the most commonly injured solid
organs [3, 4]. Other organs are often injured in patients with
liver injury (LI). LI usually occur after blunt trauma of the
A. Barcu
“Dan Setlacec” Center of General Surgery and Liver
Transplantation, Fundeni Clinical Institute, Bucharest, Romania
F. Botea (
“Dan Setlacec” Center of General Surgery and Liver
Transplantation, Fundeni Clinical Institute, Bucharest, Romania
“Titu Maiorescu” University, Bucharest, Romania
*) · I. Popescu
upper abdomen and lower thorax, but also in penetrating
trauma (the second most injured organ) [5, 6]. LI is more com-
mon in young men, with a male/female ratio of 3:1 [1]. In
blunt LI, organs like spleen, pancreas, kidney, lung, heart, ribs,
pelvic bones, vertebras and spinal cord are injured in approximately 80% of cases [7, 8]. Blunt LI is usually caused by
motor vehicle collision [6], the right posterior section (segments 6 and 7) being the most common site of trauma [9]. In
penetrating LI, structures like inferior vena cava, liver hilum
(main bile duct, portal vein, hepatic artery), mesentery, colon,
diaphragm, right lung, duodenum, right kidney and abdominal
aorta may be injured. Also, association between various potential lesions are to be always considered.
The advancements in diagnosis and interventional therapy shifted the approach of LI towards a non-operative management (NOM). Indeed, many studies reported better
outcome after conservative management [10, 11].
Nevertheless, in high-grade LI, surgical treatment remains
the main option; surgical approach is mandatory in hemodynamically unstable patients, while debatable in stable ones:
some authors support the surgical approach [12], others
advocate the NOM [13]. As in any trauma, for optimal
results, the emergency centers, emergency medical services
transport and the tertiary centers must effectively cooperate
in order to maximize the therapeutic efciency.
60.2 Diagnostics
The evaluation of the trauma patient is based on historical data
(trauma to the right and middle upper quadrant, right rib cage,
or right ank), mechanism of injury, prehospital vital signs
and its uctuations, examination ndings (pain in the right
upper abdomen, right chest wall, or right shoulder due to diaphragmatic irritation, associated with abdominal tenderness
and peritoneal signs), emergency lab tests (hematocrit, base
decit and lactate, and liver enzymes), imaging (ultrasound
+/− CT scan), and underlying medical conditions [14]. A neg-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_60
441
442
F. Botea et al.
ative history and exam do not reliably exclude LI.Moreover,
the consciousness is often altered by associated neurologic
injury and/or intoxication, or due to sedation and intubation,
and therefore medical history, symptoms and sign are impossible to be assessed in these cases [8].
High values of liver transaminase increase the likelihood of
LI and may be an indicator of severity of the injury [15].
However, patients with comorbidities such as alcohol- induced
liver disease or hepatitis may have elevated transaminase concentrations at baseline. A FAST ultrasound exam (Focused
Assessment with Sonography for Trauma) is mandatory in all
trauma patients. CT scan is the primary method for identifying
all intra-abdominal injury [16], with high sensitivity and specicity (97–98% and 97–99%, respectively) [9]; in case of a
negative CT scan, the rate of missed injury is extremely low
(<0.06%) [9]. CT scan (multidetector helical computed
tomography) is performed only in stabilized and cooperative
(otherwise sedated) patients, (with particular care to potential
spinal cord injuries), guiding the trauma management.
Magnetic resonance imaging (MRI) may be useful in a subset
of hemodynamically stable patients who cannot undergo CT
scan (allergy to radiological contrast) or necessitate MRI cholangiography for extrahepatic biliary injury.
The American Association for the Surgery of Trauma
(AAST) classication system is the most widely accepted
injury grading scale based on CT scan (Table60.1) [6, 17].
To correlate between AAST grade and patient’s physiologic
status, the World Society of Emergency Surgery (WSES)
seems to be more useful, reecting both the hemodynamic
status and the anatomic grade of the LI [7, 18] (Table60.2).
Most LIs are of low-grade according to AAST classication,
as 67% of LIs are AAST low grade I–III LI [6], when the
success of NOM is most likely to occur. Higher grade LI
(IV–V) may be managed by NOM or surgery, depending on
the dynamics of the clinical status. Grade VI LI are always
severely hemodynamically unstable (hemorrhagic shock)
and therefore surgery is mandatory in this situation; however, due to the cataclysmic event, the patient often does not
arrive in time for surgery [8]. However, there is no correlation between AAST grade and patient physiologic status, so
AAST classication should be supplemented by hemodynamic status and associated injuries. Therefore, the LI grading system proposed by the World Society of Emergency
Surgery (WSES) seems to be more useful, reecting both the
hemodynamic status and the anatomic grade of the LI [7,
18]. In our experience, World Society of Emergency Surgery
(WSES) classication had more upfront relevancy, the
hemodynamical instability being the main criteria for choosing surgery over NOM, LIs grade being of secondary
importance.
Improved availability, rapidity and sensitivity of diagnostic imaging, most notably CT scan, alongside with the development of critical care monitoring, determined a shift from
surgery to NOM for most hemodynamically stable patients
with LI, leading to a signicant decrease of both morbidity
and mortality [19–21].
Table 60.1 The American Association for the Surgery of Trauma (AAST) classication system for liver injury (LI)
Grade Type of Injury Description of injury
I Hematoma Subcapsular hematoma <10% of the liver surface area;
Laceration <1cm in depth
II Hematoma Subcapsular hematoma 10-50% of the liver surface area; intraparenchymal hematoma <10cm in diameter;
Laceration
III Hematoma >50% surface area of ruptured subcapsular/parenchymal hematoma; intraparenchymal hematoma >10cm/
Laceration >3cm in depth and >10cm in length; liver vascular injury; active bleeding contained within the parenchyma.
IV Laceration Parenchymal disruption involving 25–75% of a hemiliver/1–3 Couinaud segments; active liver bleeding into
V Laceration Parenchymal disruption involving >75% of a hemiliver/>3 Couinaud segments.
Vascular Juxtahepatic venous injury involving the retro hepatic vena cava/central major hepatic veins.
VI Vascular Hepatic avulsion
aAdvance one grade for multiple injuries up to grade III
Table 60.2 World Society of Emergency Surgery (WSES) classication and guidelines for blunt/penetrating (stab/gun) liver injury
Severity of LI WSES grade AAST grade Hemodynamic CT-scan Treatment
Minor I I–II Stable Yes/No NOM
Moderate II III Stable Yes + local exploration in penetrating LI NOM
Severe III IV–V Stable Yes + local exploration in penetrating LI NOM
IV I–VI Unstable No Surgery
LI liver injury, NOM nonoperative management, AAST The American Association for the Surgery of Trauma
1–3cm in depth and≤10cm in length.
expanding
the peritoneum.
60 Surgical Treatment forSevere Liver Injuries
443
60.3 Treatment
Liver trauma had always represented a difcult challenge.
Since the rst documented liver resection performed in the
XVII century by Hildanus for liver trauma, the signicant
developments in the last two decades in diagnosis, patient
monitoring and interventional therapies, and the optimal
results of non-operative approach in spleen trauma favor the
Liver trauma (blunt / penetrating)
Hemodynamically Stable
N
o
n
o
p
e
r
a
t
i
v
e
m
a
n
a
g
e
m
e
n
t
Constrast-enhanced CT
AAST I-V
Peritonitis
No
Active bleeding
(contrast blush at CT)
No
Serial clinical & lab
assessment
Yes
Effective
non-operative management of liver trauma [22]. The current
nonoperative and operative decisional algorithm in the management of liver trauma is depicted in Fig.60.1.
Independently of the grade of LI, the management is
determined by the hemodynamical status: surgery is mandatory in emergency in unstable patients, while non-operative
approach, although still controversial in high-grade LI, may
be used in stable cases. Even though surgery in high-grade
Hemodynamically Unstable
AAST I-VI
Yes
Surgery
Embolization
Uneffective
No
Hemodinamical &
clinical stability
O
p
e
r
a
t
i
v
e
m
a
n
a
g
e
m
e
n
t
Fig. 60.1 Current nonoperative and operative management of liver trauma
Yes
444
F. Botea et al.
injuries may result in high mortality as well [23, 24], there
are no randomized studies to compare surgery versus NOM
in stable patients [25].
Initial management of LI is aimed at rapid stabilization
and identication of life-threatening injuries, as described in
Advanced Trauma Life Support (ATLS) protocols. Primary
assessment is carried out according to the ABCDE pattern:
Airway, Breathing, Circulation, Disability (neurologic injuries), and Exposure.
Hemodynamic instability, not the grading of the injury,
represents the main indication for operative approach
(Fig.60.2). Unstable patients are managed as follows:
• in case of positive FAST ultrasound exam—the patient
goes directly to the operating room for emergency lapa-
rotomy. When available, resuscitative endovascular bal-
loon occlusion of the aorta may provide hemodynamic
support until denitive treatment with angioembolization
or laparotomy.
• in case of unclear FAST exam, diagnostic peritoneal
lavage with aspiration of 10mL of gross blood indicates a
signicant bleeding, warranting the emergent
laparotomy.
• subsequent hemodynamically instability after failed
NOM warrants emergent surgery.
• if no evidence of intra-abdominal injury (negative FAST
exam, and abdominal CT), other sites of bleeding or other
non-hemorrhagic causes of shock are to be considered.
In hemodynamically stable patient, the following scenarios
are to be considered:
• regular vital signs and lab tests (low risk)—clinical obser-
vation of <12hours is usually enough to rule out occult
intra-abdominal injury [5, 26, 27].
• regular vital signs but modied lab tests (hematocrit <30
percent, AST/ALT >130units/L, microscopic hematuria
>25 red blood cells per high power eld) and/or high-risk
examination ndings (e.g. peritoneal signs, abdominal
distension, seat belt sign)—CT scan is recommended,
with the following scenario:
– no LI at CT—clinical observation of <12 hours is
recommended;
– LI at CT, without active bleeding—NOM is
recommended.
– LI at CT with active bleeding—either NOM or imme-
diate surgery is recommended, depending on hemodynamically stability:
NOM is recommended in blunt or stab (but not gunshot) penetrating LI in hemodynamically stable
patients, in I–V AAST grade injuries, in absence of
other intra-abdominal injuries. Even though extraabdominal lesions requiring surgery could be pres-
ent (except severe head trauma), NOM of LI is still
recommended.
emergent abdominal surgery must be offered to:
• hemodynamically unstable patient with a positive FAST ultrasound exam, independently of
the AAST grade injury (I–VI).
• hemodynamically stable patients with associated intra-abdominal injuries leading to peritonitis (e.g. signs of peritoneal irritation, evidence of
pneumoperitoneum) and/or diaphragmatic rupture, persistent and severe digestive bleeding.
• failure of NOM—patient becoming unstable
despite aggressive conservative treatment,
including blood transfusion +/− liver arterial
embolization.
• persistent systemic inammatory response
(SIRS—ileus, fever, tachycardia, oliguria).
• unexplained signs of bleeding in an unstable
patient with strongly suspected intra-abdominal
trauma.
Fortunately, LI is usually minor and successfully treated
by clinical observation, supportive treatment, and sometime
arterial embolization [19] (NOM). Surgery is needed in
<15% of cases, generally for unstable patients or in case of
failed NOM [6].
60.3.1 Nonoperative Management
NOM is the treatment of choice for blunt and stab penetrating LI in hemodynamically stable patients, independently of
injury grade. Failure of NOM leads to immediate surgical
treatment. NOM comprises clinical observation, supportive
care and, in selected cases, of liver arterial embolization
[28], requiring optimal patient selection, availability of
resources (intensive care unit beds, blood bank support,
immediate operating room availability, and experienced
interventional angiographers and surgeons).
NOM is deployed in over 80% of blunt LI with a success
rate of over 90% [19, 21, 29, 30] (Fig.60.3). NOM seems to
be associated with improved overall survival in comparison
with surgical treatment, while reducing the overall costs
[31]. The improvements in intensive care management and
use of interventional radiology appear to signicantly contribute to the high successful rate of NOM [32].
NOM is contraindicated in case of [33]:
• hemodynamically unstable patient despite initial
resuscitation.
• hemodynamically stable patients with:
– other indication for abdominal surgery (e.g.,
peritonitis);
60 Surgical Treatment forSevere Liver Injuries
445
Fig. 60.2 Case presentation of an AAST IV grade liver injury (LI).
34-year old male with polytrauma by car accident, hemodynamically
unstable; at CT-scan—rupture of segments 4, 5, and 8—parenchymal
disruption involving 3 Couinaud’s segments; previous surgery in other
hospital (hepatorrhaphy and perihepatic packing); at admittance in our
Fig. 60.3 Hemodynamically stable patient with AAST IV grade liver injury, with successful nonoperative management
center: stable, ileus, fever, tachycardia, oliguria, high transaminase levels, leukocytosis (22.000 el/mm
sound guided nonanatomic liver resection of segments 4, 5 and 8), with
no major complications (minor biliary stula treated conservatively)
3
); relaparotomy after 36hours (ultra-
– gunshot injury—relative contraindication because of
high probability of NOM failure (up to 30% of cases)
[34] and undetected associated intra-abdominal injuries;
– concomitant severe head injuries;
– absence of facilities and personnel for intensive care
monitoring and treatment, for arterial embolization,
and for urgent abdominal exploration in case of NOM
failure.
Disadvantages of NOM are [35]:
• increased risk for biliary complications (biloma and/or
persistent bile leak), occurring in up to 21% of cases,
manifested as abdominal pain and/or a persistent SIRS
(fever, tachycardia, and leukocytosis) [36];
• increased risk of missed intra-abdominal injury, particularly hollow organ injury;