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Hepatic resection: The logical approach to surgical management of major trauma to the liver
Hepatic Resection: The Logical Approach to Surgical Management of Major Trauma to the Liver
M. Balasegaram, MB, FRCS, FRCS (Ed), FACS, FRACS,” Kuala Lumpur, Malaysia Suresh K. Joishy, MD,7 Kuala Lumpur, Malaysia
Trauma to the liver carries a high mortality. The leading cause of death is hemorrhage from the injured liver. We showed 11 years ago and repeatedly since then that the quickest, safest and most definitive form of treatment of control hemorrhage in the extensively injured liver is resection, and thai it gives the best hope for survival [l--3]. The surgical literature in the West has hundreds of reports of hepatic trauma [4-61; we fail to see why, even in the best medical centers [ 7],2 percent of patients or less undergo hepatic resection. Hepatic surgeons are passing judgments that there is no good indication for hepatic resection in emergency cases and that it carries a very high mortality [7-91. A dangerous trend is being established to stop using resection and to use instead inferior methods of controlling bleeding such as packing, hepatostomy and drainage, hepatic artery ligation and so-called resectional debridement. The persistence of hemorrhage as the prime cause of death should clearly indicate the ineffectiveness of these numerous methods. The mortality rates for hepatic resection reported in large series is confusing because they do not differentiate whether the mortality is related to associated injuries or liver resection per se, breakdown figures are not given according to the type or extent of resection, and all patients are lumped together in one “lobectomy” group. Finally, many reports contain too few resections to generalize about global mortality. Attempts have been made recently to clear the myths surrounding hepatic trauma [ 71. The purpose of this report is to give precise indications and morFrom the Department of Surgery, General Hospital.’ Kuala Lumpur, Malaysia, and the University of California ICMR Institute for Medical Research,+ Kuala Lumpur. Malaysia. This work was supported in part by Research Grant Al 10051 (UC ICMR) to the Department of International Health, School of Medicine, University of California, San Francisco, from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Public Health Service, Bethesda. Maryland. Requests for reprints should be addressed to Professor M. Salasegaram, Department of Surgery, General Hospital, Kuala Lumpur, Malaysia.
580
tality rates for hepatic trauma and to match these with the type of resection. We shall try to point out several misguided principles in the treatment of hepatic trauma and establish the superiority of resection. Material
and Methods
Three hundred seventy-nine patients were treated for hepatic trauma at the General Hospitals in Kuala Lumpur and Seremban by the senior author (MB) since 1961. The liver injuries were divided into three major groups: blunt trauma, high velocity missile injuries, and stab wounds. Our diagnostic procedures, surgical technique and specially designed instruments for hepatic surgery have been fully described and are beyond the scope of this report [IO]. We generally adhere to the following guidelines. Aggressive resuscitative methods are extremely important, and no time should be lost; surgery and resuscitation should go hand in hand. When the time factor is critical, modern diagnostic methods are useless and immediate laparotomy for diagnosis is mandatory. Extensive wounds with bleeding and devitalized liver tissue will require resection irrespective of the type of injury. Subcapsular hematomas with intralobar rupture due to blunt injury should be resected. Patients with high velocity missile wound tracts may appear deceptively healthy, only to undergo delayed necrosis and bleeding; hence resection should be performed. Stab wounds may be amenable to nonresectional methods, but if the internal damage is extensive, resection is indicated. Postoperatively all patients should receive broad-spectrum antibiotics intravenously. Results Blunt trauma: In 206 patients, a majority of the injuries were incurred in automobile or heavy vehicle accidents. Extensive lacerations, tears and subcapsular hematomas with intralobar rupture of the liver were common and required major resection. Most of the resections were right-sided with hemi- or extended hemiresections. Despite the extensive resections, all but 6 of the 51 patients survived.
The American Journal of Surgery
Hepatic Resection
High velocity missile injuries: Most of these were due to high velocity injuries in civil violence. Twenty-six of 81 patients underwent resection, and only 3 died. Stab with internal shatter: These were not simple linear stab wounds. Stabbing and churning motion by an unusual weapon used locally caused extensive internal damage to the liver. Seven of 31 patients underwent resection, and all survived. The type of resections performed matched with mortality rates and type of trauma are summarized in Table I. Comments Hepatic resection in the West has very few indications: trauma, tumor and cysts [ll], whereas in Malaysia, with a high incidence of primary hepatic tumors, amoebic and pyogenic abscess, intrahepatic calculi and ever-increasing trauma, there is a much broader range of indications for resection. Since hepatic tumors and cysts are not common in the West, the surgeon is left with trauma alone as a definite indication for resection. Even then, hepatic resections appear to be limited to the domain of surgical giants. The surgeons who earlier advocated resection for trauma have come up with contradictory statements [4,8,12-141. Reports on hundreds and even thousands of cases of hepatic trauma and the presentation of voluminous data on clinical picture, diagnostic tests, treatment of shock and sepsis, along with mortality rates for a small number of resections, tend to confuse the issue of whether high mortality is related to actual resection or to complications in traumatized patients [44]. All resections are lumped together as “lobectomies,” and high mortality rates are presented without relating them to the type of resection or type of trauma. This point is well illus-
TABLE II
TABLE I
Surgical Management of Hepatic Trauma: Type of Resection, Type of Trauma and Mortality
Type of Resection
Type of Trauma” Stab High With Velocity Internal Blunt Missile Shatter
Right hemihepatectomy Left hemihepatectomy Right extended hemihepatectomy Left extended hemihepatectomy Left lateral segmental resection Middle wedge resection Right lobectomy Combined right lobectomy and left lateral segmental resection
10 (2)
5 (1)
12 (1) 18 (2)
i(1)
Total resections Mortality (%)
51 (6) 11.76
1 3 1 6(l) 0
1 2 0 1 l(1)
26 (3) 11.53
7 (0) 0
’ Numbers in parentheses indicate postoperative deaths.
trated by comparing our own series with recently reported American and British series (Table II). Despite the large number of cases reported from the United States, an extremely small number of patients have undergone resection, and yet the mortality rate for emergency resection is 50 percent compared with only 10.5 percent in our series. The British series are too small to draw conclusions. Neither the American nor the British series classify the types of resection or relate mortality to the type of resection. We have classified major resections performed for hepatic trauma and matched the mortality rates with the type of trauma (Table I). It is gratifying to note a mortality rate of only 11.76
Hepatic Surgery for Trauma to the Liver: Comparison in the United States, the United Kingdom and Malaysia* United States 1978 [ 71
Hepatic Trauma Total cases Hospital mortality of all admitted cases Blunt trauma High velocity missile Stab wounds Hemihepatectomy/“lobectomy”
(%)
Debridement/“resectional debridement” Hepatic artery ligation Packing Resections for blunt trauma and mortality Resections for high velocity missile wounds and mortality Stab wounds with internal shatter Mortalitv for emeraencv “lobectomv”
968 12.1 40 186 91 25 (2.6%) 46 (4.8%) 14 (1.4%) 3 (0.3%) Not classified Not categorized 0 50%
United Kingdom, 1979 [9] 15 20
;2’(80% of small total) 2 (13.8%) 0 but advocated 0 but advocated Not classified Not categorized 0
* Numbers in parentheses indicate percentages of total cases. + Packing in 12 patients in our series was performed as a definitive treatment in the earlier years (1961-1964) hepatic resection.
Volume 142, November 1981
Malaysia, 1979 (Current Report) 379 15.8 206 81 35 84 (22.2%) 62 (16.3%) 4(1%) 12 (3.2%)+ 51 26 7 10.5% before we started performing
581
Balasegaram
TABLE III
and Joishy
Value of Hepatic Resection in Trauma to the Liver: Comparison With Nonresectional Methods
Onset of hemostasis Method of hemostasis Anatomic principles Devitalized liver tissue Recurrent bleeding from raw surface of liver Postoperative infection and abscess formation Repair of biliary system and venous systems
Packing
Hepatic Artery Ligation
“Resectional Debridement”
Hepatic Resection
Delayed Indirect local None Left behind Frequent
Delayed Indirect distant Anomalies encountered Left behind Frequent
Delayed’ Indirect local Nonanatomic Partly left behind Frequent
Immediate Direct local Sound anatomic principles None left Rare
Common
Common
Common
Not common
Not done
Not done
Partial anatomic
Complete anatomic
percent in cases of blunt trauma, which is the most dreaded condition in hepatic trauma. Mortality does not increase despite extended resections. Mortality rates for resection in patients with high velocity missile injuries are remarkably similar (11.53 percent), and no mortality was noted after a small number of resections for stab injuries. What are the reasons for the extremely high mortality rates for emergency hepatic resections in the West? We believe the resections presented as “emergency lobectomy” are probably conducted in a less-than-emergency fashion. The time-honored “finger fracture technique” to “tease out and chisel out” blood vessels and ducts will never achieve speedy resection [8]. We, however, achieve immediate hemostasis by a specially designed hepatic hemostatic clamp that can be applied across the entire mass of the liver. We believe the bleeding liver is like a bleeding blood vessel that needs to be clamped immediately. The idea of applying the clamp is not new [15], but we have improved the design and efficacy of the clamps. It has been claimed that hepatic resection is a formidable procedure that should not be undertaken in an acutely traumatized patient [7,8]. One glance at the high mortality rates observed even for elective resection will prove them formidable only to the surgeon [16]. In fact, the sequence of procedures recommended in the management of liver trauma in some centers lists them in the order of technical difficulty rather than effectiveness: multiple ligations, resectional debridement, hepatic artery ligation, hepatostomy and drainage, and lastly resection [17]. It is recommended that hepatic resection be considered a few days after bleeding has been controlled by other methods. Careful scrutiny of nonresectional methods shows that the mortality related to them could have been avoided if resection had been carried out in the first place. Hepatic artery ligation, the so-called resectional debridement and even packing have gained undue importance in the treatment of liver trauma [7-91. Before we establish the superiority of resection over these methods, it may be worthwhile to review the
582
basic features of hepatic trauma. Hemorrhage is the main cause of death; sepsis is the main complication and second most common cause of death. Retention of devitalized liver tissue is the most deleterious factor in perpetuating hemorrhage, sepsis and shock [18]. We believe that resection is the only means to achieve the goals of treatment: (1) immediate control of hemorrhage, (2) removal of all devitalized tissue, and (3) reduction of postoperative complications such as sepsis, abscess formation or leakage. Finally, resection is the only procedure that takes into account the complex anatomy of the vascular and ductal system of the liver. We have compared the relative values of packing, hepatic artery ligation and “resectional debridement,” and established the superiority of resection (Table III). We believe packing should not be performed except before transporting the patient to a center where resection can be performed. Packing has no place in a well-equipped medical center. The most important drawback of hepatic artery ligation is leaving the devitalized liver tissue behind, leading to sepsis, leakage and recurrent hemorrhage. It has been suggested that hepatic artery ligation be carried out along with “resectional debridement.” We caution that two indefinite procedures are worse than one. We still do not understand the term “resectional debridement.” In hepatic surgery one can either resect or debride. It has been explained that after debridement one resects along the plane caused by the gap in the liver by injury. The liver is a complex organ. It is dangerous to carry out such a nonanatomic resection. With our technique we can probably perform major resection faster than “resectional debridement.” Similarly, no one should be so desperate as to carry out such procedures as hepatostomy and catheter drainage of central hepatic hematomas [19]. Liver wounds should not be drained like fistulas, nor are they -dry or weeping wounds to be controlled by sprinkling collagen powders [ 71. Hepatic venous injuries pose a special problem due to their inaccessibility. Some centers advocate split sternal incisions and cannulation of the inferior vena cava with balloon catheters and tamponade [7,8].
The American Journal of Surgery
Hepatic Resection
These procedures are time-consuming in these patients in whom the time factor is so critical. It is no wonder that the mortality rate is close to 100 percent. It is best to gain direct access to the veins after extending the abdominal incision to the chest. Summary Recent reports on the management of hepatic trauma have discouraged hepatic resection and supported hepatic artery ligation, “resectional debridement” and even packing. These nonresectional procedures are based on misguided principles and should never replace resection. Traditional methods of conducting hepatic resection in an emergency as used in the West probably cause delay in achieving immediate hemostasis, thus contributing to mortality. Compared with Western reports, our mortality for major hepatic resections is considerably low. This is probably due to faster resection and achievement of hemostasis by our clamping techniques. We conclude that it is quite logical to perform resection as the first line of treatment in major hepatic trauma. References 1. Balasegaram M. Blunt injuries to the liver: problems and management. Ann Surg 1969;169:544-50. 2. Balasegaram M. Hepatic surgery: present and future. Ann R Coil Surg Engl 1970;47:139-56. 3. Balasegaram M. Hepatic surgery: review of a personal series
Volume 142, November 1981
of 95 major resections. Aust NZ J Surg 1972;42:1-10. 4. Trunkey DD, Shirest GT, McClelland R. Management of liver trauma in 811 consecutive patients. Ann Surg 1974;179: 722-8. 5. DeFore WW Jr, Mattox KL, Jordan GL Jr, Beak AC Jr. Management of 1,590 consecutive cases of liver trauma. Arch Surg 1976;111:493-7. 6. Lim RC Jr, Lau G, Steele M. Prevention of complications after liver trauma. Am J Surg 1976;132:156-62. 7. Walt AJ. The mythology of hepatic trauma-or Babel revisited. Am J Surg 1978;135:12-8. 8. Mays ET. Hepatic trauma. Curr Probl Surg 1976;13:5-73. 9. Blumgart LH, Drury JK, Wood CB. Hepatic resection for trauma, tumor and biliary obstruction. Br J Surg 1979;66:762-9. 10. Joishy SK, Balasegaram M. Hepatic resection for malignant tumors of the liver: essentials for a unified surgical approach. Am J Surg 1980;139:360-9. 11. Longmire WP Jr. Hepatic surgery: trauma, tumors and cysts. Ann Surg 1965;161:1-14. 12. Mays ET. Lobectomy, sublobar resection and resectional debridement for severe liver injuries. J Trauma 1972;12: 309-14. 13. McClelland R, Shires T, Poulos E. Hepatic resections for massive trauma. J Trauma 1964;4:282-9 1. 14. Walt AJ, Freeark RJ, Lucas CE, Mays ET. Symposium on hepatic trauma. Contemp Surg 1975;6:74-101. 15. Nakayama K. Simplified hepatectomy. Br J Surg 1958;45: 645-9. 16. Foster JH, Berman MM. Solid liver tumors. Major Probl Clin Surg 1977;22:1-342. 17. Lucas CE. Liver injury: a modern day surgical challenge. S Afr J Surg 1976;14:163-74. 18. Atik M, Grossman R, Dekernian J. Hepatectomy for severe liver injury. Arch Surg 1966;92:636-42. 19. Gewertz BL, William WR. Hepatostomy for central hepatic hematomas. J Trauma 1975;15:271-4.
583
M. Balasegaram, MB, FRCS, FRCS (Ed), FACS, FRACS,” Kuala Lumpur, Malaysia Suresh K. Joishy, MD,7 Kuala Lumpur, Malaysia
Trauma to the liver carries a high mortality. The leading cause of death is hemorrhage from the injured liver. We showed 11 years ago and repeatedly since then that the quickest, safest and most definitive form of treatment of control hemorrhage in the extensively injured liver is resection, and thai it gives the best hope for survival [l--3]. The surgical literature in the West has hundreds of reports of hepatic trauma [4-61; we fail to see why, even in the best medical centers [ 7],2 percent of patients or less undergo hepatic resection. Hepatic surgeons are passing judgments that there is no good indication for hepatic resection in emergency cases and that it carries a very high mortality [7-91. A dangerous trend is being established to stop using resection and to use instead inferior methods of controlling bleeding such as packing, hepatostomy and drainage, hepatic artery ligation and so-called resectional debridement. The persistence of hemorrhage as the prime cause of death should clearly indicate the ineffectiveness of these numerous methods. The mortality rates for hepatic resection reported in large series is confusing because they do not differentiate whether the mortality is related to associated injuries or liver resection per se, breakdown figures are not given according to the type or extent of resection, and all patients are lumped together in one “lobectomy” group. Finally, many reports contain too few resections to generalize about global mortality. Attempts have been made recently to clear the myths surrounding hepatic trauma [ 71. The purpose of this report is to give precise indications and morFrom the Department of Surgery, General Hospital.’ Kuala Lumpur, Malaysia, and the University of California ICMR Institute for Medical Research,+ Kuala Lumpur. Malaysia. This work was supported in part by Research Grant Al 10051 (UC ICMR) to the Department of International Health, School of Medicine, University of California, San Francisco, from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Public Health Service, Bethesda. Maryland. Requests for reprints should be addressed to Professor M. Salasegaram, Department of Surgery, General Hospital, Kuala Lumpur, Malaysia.
580
tality rates for hepatic trauma and to match these with the type of resection. We shall try to point out several misguided principles in the treatment of hepatic trauma and establish the superiority of resection. Material
and Methods
Three hundred seventy-nine patients were treated for hepatic trauma at the General Hospitals in Kuala Lumpur and Seremban by the senior author (MB) since 1961. The liver injuries were divided into three major groups: blunt trauma, high velocity missile injuries, and stab wounds. Our diagnostic procedures, surgical technique and specially designed instruments for hepatic surgery have been fully described and are beyond the scope of this report [IO]. We generally adhere to the following guidelines. Aggressive resuscitative methods are extremely important, and no time should be lost; surgery and resuscitation should go hand in hand. When the time factor is critical, modern diagnostic methods are useless and immediate laparotomy for diagnosis is mandatory. Extensive wounds with bleeding and devitalized liver tissue will require resection irrespective of the type of injury. Subcapsular hematomas with intralobar rupture due to blunt injury should be resected. Patients with high velocity missile wound tracts may appear deceptively healthy, only to undergo delayed necrosis and bleeding; hence resection should be performed. Stab wounds may be amenable to nonresectional methods, but if the internal damage is extensive, resection is indicated. Postoperatively all patients should receive broad-spectrum antibiotics intravenously. Results Blunt trauma: In 206 patients, a majority of the injuries were incurred in automobile or heavy vehicle accidents. Extensive lacerations, tears and subcapsular hematomas with intralobar rupture of the liver were common and required major resection. Most of the resections were right-sided with hemi- or extended hemiresections. Despite the extensive resections, all but 6 of the 51 patients survived.
The American Journal of Surgery
Hepatic Resection
High velocity missile injuries: Most of these were due to high velocity injuries in civil violence. Twenty-six of 81 patients underwent resection, and only 3 died. Stab with internal shatter: These were not simple linear stab wounds. Stabbing and churning motion by an unusual weapon used locally caused extensive internal damage to the liver. Seven of 31 patients underwent resection, and all survived. The type of resections performed matched with mortality rates and type of trauma are summarized in Table I. Comments Hepatic resection in the West has very few indications: trauma, tumor and cysts [ll], whereas in Malaysia, with a high incidence of primary hepatic tumors, amoebic and pyogenic abscess, intrahepatic calculi and ever-increasing trauma, there is a much broader range of indications for resection. Since hepatic tumors and cysts are not common in the West, the surgeon is left with trauma alone as a definite indication for resection. Even then, hepatic resections appear to be limited to the domain of surgical giants. The surgeons who earlier advocated resection for trauma have come up with contradictory statements [4,8,12-141. Reports on hundreds and even thousands of cases of hepatic trauma and the presentation of voluminous data on clinical picture, diagnostic tests, treatment of shock and sepsis, along with mortality rates for a small number of resections, tend to confuse the issue of whether high mortality is related to actual resection or to complications in traumatized patients [44]. All resections are lumped together as “lobectomies,” and high mortality rates are presented without relating them to the type of resection or type of trauma. This point is well illus-
TABLE II
TABLE I
Surgical Management of Hepatic Trauma: Type of Resection, Type of Trauma and Mortality
Type of Resection
Type of Trauma” Stab High With Velocity Internal Blunt Missile Shatter
Right hemihepatectomy Left hemihepatectomy Right extended hemihepatectomy Left extended hemihepatectomy Left lateral segmental resection Middle wedge resection Right lobectomy Combined right lobectomy and left lateral segmental resection
10 (2)
5 (1)
12 (1) 18 (2)
i(1)
Total resections Mortality (%)
51 (6) 11.76
1 3 1 6(l) 0
1 2 0 1 l(1)
26 (3) 11.53
7 (0) 0
’ Numbers in parentheses indicate postoperative deaths.
trated by comparing our own series with recently reported American and British series (Table II). Despite the large number of cases reported from the United States, an extremely small number of patients have undergone resection, and yet the mortality rate for emergency resection is 50 percent compared with only 10.5 percent in our series. The British series are too small to draw conclusions. Neither the American nor the British series classify the types of resection or relate mortality to the type of resection. We have classified major resections performed for hepatic trauma and matched the mortality rates with the type of trauma (Table I). It is gratifying to note a mortality rate of only 11.76
Hepatic Surgery for Trauma to the Liver: Comparison in the United States, the United Kingdom and Malaysia* United States 1978 [ 71
Hepatic Trauma Total cases Hospital mortality of all admitted cases Blunt trauma High velocity missile Stab wounds Hemihepatectomy/“lobectomy”
(%)
Debridement/“resectional debridement” Hepatic artery ligation Packing Resections for blunt trauma and mortality Resections for high velocity missile wounds and mortality Stab wounds with internal shatter Mortalitv for emeraencv “lobectomv”
968 12.1 40 186 91 25 (2.6%) 46 (4.8%) 14 (1.4%) 3 (0.3%) Not classified Not categorized 0 50%
United Kingdom, 1979 [9] 15 20
;2’(80% of small total) 2 (13.8%) 0 but advocated 0 but advocated Not classified Not categorized 0
* Numbers in parentheses indicate percentages of total cases. + Packing in 12 patients in our series was performed as a definitive treatment in the earlier years (1961-1964) hepatic resection.
Volume 142, November 1981
Malaysia, 1979 (Current Report) 379 15.8 206 81 35 84 (22.2%) 62 (16.3%) 4(1%) 12 (3.2%)+ 51 26 7 10.5% before we started performing
581
Balasegaram
TABLE III
and Joishy
Value of Hepatic Resection in Trauma to the Liver: Comparison With Nonresectional Methods
Onset of hemostasis Method of hemostasis Anatomic principles Devitalized liver tissue Recurrent bleeding from raw surface of liver Postoperative infection and abscess formation Repair of biliary system and venous systems
Packing
Hepatic Artery Ligation
“Resectional Debridement”
Hepatic Resection
Delayed Indirect local None Left behind Frequent
Delayed Indirect distant Anomalies encountered Left behind Frequent
Delayed’ Indirect local Nonanatomic Partly left behind Frequent
Immediate Direct local Sound anatomic principles None left Rare
Common
Common
Common
Not common
Not done
Not done
Partial anatomic
Complete anatomic
percent in cases of blunt trauma, which is the most dreaded condition in hepatic trauma. Mortality does not increase despite extended resections. Mortality rates for resection in patients with high velocity missile injuries are remarkably similar (11.53 percent), and no mortality was noted after a small number of resections for stab injuries. What are the reasons for the extremely high mortality rates for emergency hepatic resections in the West? We believe the resections presented as “emergency lobectomy” are probably conducted in a less-than-emergency fashion. The time-honored “finger fracture technique” to “tease out and chisel out” blood vessels and ducts will never achieve speedy resection [8]. We, however, achieve immediate hemostasis by a specially designed hepatic hemostatic clamp that can be applied across the entire mass of the liver. We believe the bleeding liver is like a bleeding blood vessel that needs to be clamped immediately. The idea of applying the clamp is not new [15], but we have improved the design and efficacy of the clamps. It has been claimed that hepatic resection is a formidable procedure that should not be undertaken in an acutely traumatized patient [7,8]. One glance at the high mortality rates observed even for elective resection will prove them formidable only to the surgeon [16]. In fact, the sequence of procedures recommended in the management of liver trauma in some centers lists them in the order of technical difficulty rather than effectiveness: multiple ligations, resectional debridement, hepatic artery ligation, hepatostomy and drainage, and lastly resection [17]. It is recommended that hepatic resection be considered a few days after bleeding has been controlled by other methods. Careful scrutiny of nonresectional methods shows that the mortality related to them could have been avoided if resection had been carried out in the first place. Hepatic artery ligation, the so-called resectional debridement and even packing have gained undue importance in the treatment of liver trauma [7-91. Before we establish the superiority of resection over these methods, it may be worthwhile to review the
582
basic features of hepatic trauma. Hemorrhage is the main cause of death; sepsis is the main complication and second most common cause of death. Retention of devitalized liver tissue is the most deleterious factor in perpetuating hemorrhage, sepsis and shock [18]. We believe that resection is the only means to achieve the goals of treatment: (1) immediate control of hemorrhage, (2) removal of all devitalized tissue, and (3) reduction of postoperative complications such as sepsis, abscess formation or leakage. Finally, resection is the only procedure that takes into account the complex anatomy of the vascular and ductal system of the liver. We have compared the relative values of packing, hepatic artery ligation and “resectional debridement,” and established the superiority of resection (Table III). We believe packing should not be performed except before transporting the patient to a center where resection can be performed. Packing has no place in a well-equipped medical center. The most important drawback of hepatic artery ligation is leaving the devitalized liver tissue behind, leading to sepsis, leakage and recurrent hemorrhage. It has been suggested that hepatic artery ligation be carried out along with “resectional debridement.” We caution that two indefinite procedures are worse than one. We still do not understand the term “resectional debridement.” In hepatic surgery one can either resect or debride. It has been explained that after debridement one resects along the plane caused by the gap in the liver by injury. The liver is a complex organ. It is dangerous to carry out such a nonanatomic resection. With our technique we can probably perform major resection faster than “resectional debridement.” Similarly, no one should be so desperate as to carry out such procedures as hepatostomy and catheter drainage of central hepatic hematomas [19]. Liver wounds should not be drained like fistulas, nor are they -dry or weeping wounds to be controlled by sprinkling collagen powders [ 71. Hepatic venous injuries pose a special problem due to their inaccessibility. Some centers advocate split sternal incisions and cannulation of the inferior vena cava with balloon catheters and tamponade [7,8].
The American Journal of Surgery
Hepatic Resection
These procedures are time-consuming in these patients in whom the time factor is so critical. It is no wonder that the mortality rate is close to 100 percent. It is best to gain direct access to the veins after extending the abdominal incision to the chest. Summary Recent reports on the management of hepatic trauma have discouraged hepatic resection and supported hepatic artery ligation, “resectional debridement” and even packing. These nonresectional procedures are based on misguided principles and should never replace resection. Traditional methods of conducting hepatic resection in an emergency as used in the West probably cause delay in achieving immediate hemostasis, thus contributing to mortality. Compared with Western reports, our mortality for major hepatic resections is considerably low. This is probably due to faster resection and achievement of hemostasis by our clamping techniques. We conclude that it is quite logical to perform resection as the first line of treatment in major hepatic trauma. References 1. Balasegaram M. Blunt injuries to the liver: problems and management. Ann Surg 1969;169:544-50. 2. Balasegaram M. Hepatic surgery: present and future. Ann R Coil Surg Engl 1970;47:139-56. 3. Balasegaram M. Hepatic surgery: review of a personal series
Volume 142, November 1981
of 95 major resections. Aust NZ J Surg 1972;42:1-10. 4. Trunkey DD, Shirest GT, McClelland R. Management of liver trauma in 811 consecutive patients. Ann Surg 1974;179: 722-8. 5. DeFore WW Jr, Mattox KL, Jordan GL Jr, Beak AC Jr. Management of 1,590 consecutive cases of liver trauma. Arch Surg 1976;111:493-7. 6. Lim RC Jr, Lau G, Steele M. Prevention of complications after liver trauma. Am J Surg 1976;132:156-62. 7. Walt AJ. The mythology of hepatic trauma-or Babel revisited. Am J Surg 1978;135:12-8. 8. Mays ET. Hepatic trauma. Curr Probl Surg 1976;13:5-73. 9. Blumgart LH, Drury JK, Wood CB. Hepatic resection for trauma, tumor and biliary obstruction. Br J Surg 1979;66:762-9. 10. Joishy SK, Balasegaram M. Hepatic resection for malignant tumors of the liver: essentials for a unified surgical approach. Am J Surg 1980;139:360-9. 11. Longmire WP Jr. Hepatic surgery: trauma, tumors and cysts. Ann Surg 1965;161:1-14. 12. Mays ET. Lobectomy, sublobar resection and resectional debridement for severe liver injuries. J Trauma 1972;12: 309-14. 13. McClelland R, Shires T, Poulos E. Hepatic resections for massive trauma. J Trauma 1964;4:282-9 1. 14. Walt AJ, Freeark RJ, Lucas CE, Mays ET. Symposium on hepatic trauma. Contemp Surg 1975;6:74-101. 15. Nakayama K. Simplified hepatectomy. Br J Surg 1958;45: 645-9. 16. Foster JH, Berman MM. Solid liver tumors. Major Probl Clin Surg 1977;22:1-342. 17. Lucas CE. Liver injury: a modern day surgical challenge. S Afr J Surg 1976;14:163-74. 18. Atik M, Grossman R, Dekernian J. Hepatectomy for severe liver injury. Arch Surg 1966;92:636-42. 19. Gewertz BL, William WR. Hepatostomy for central hepatic hematomas. J Trauma 1975;15:271-4.
583