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Massive liver trauma involving the suprarenal vena cava
Massive Liver Trauma Involving the Suprarenal Vena Cava DOMINIC ALBO, Jr., M.D., Salt Lake City, Utah CHRIS CHRISTENSEN, M.D., Salt Lake City, Utah BRIAN L. RASMUSSEN, M.D., Salt Lake City, Utah THOMAS C. KING, M.D., Salt Lake City, Utah
During the past decade there has been increasing interest in major hepatic resections for extensive liver trauma, primarily because of the high mortality associated with the treatment of these injuries by other methods [1-z]. Other factors responsible for this trend are a better understanding of the detailed anatomy of the liver especially with respect to its blood supply [.4,5] and the demonstrations by Quattlebaum [S], Pack and Baker [71, Longmire [S], and others of the feasibility of successfully resecting large portions of human liver. Massive trauma to the liver is often the result of motor vehicle accidents so that consequently emergency exploration must be performed in outlying community hospitals where facilities do not allow major hepatic resections. Improved resuscitative technics in these community centers and better transportation of the injured patient present us with increasing numbers of critically injured patients who can be saved by definitive therapy. We have reviewed a two year experience with major hepatic resections for trauma at the University of Utah College of Medicine; this limited series illustrates several important points in the management of these patients. 1. Major hepatic injury can be safely treated by temporary packing while the patient is prepared for moving and then transported to a medical facility where definitive treatment can be given. 2. An excellent blood banking facility, ca-
From the Department of Surgery, of Medicine, Salt Lake City, Utah. Presented at the Twenty-First Southwestern Surgical Congress, 2-5.1969.
960
University Annual Stateline.
of Utah Meeting Nevada,
College of
the June
pable of providing large amounts of blood, is mandatory. 3. An internal shunt should be considered when dealing with injuries to the hepatic veins or the suprarenal vena cava if exanguinating hemorrhage is to be avoided. During the two year period from 1966 to 1968, we had five patients with injuries requiring right hepatic lobectomies. All five patients were male and their ages ranged from nine to thirty-two years of age. Three had suprarenal caval lacerations. One died on the operating table from uncontrollable hemorrhage; four survived and are now fully rehabilitated. Two of these cases are briefly described to emphasize these points. Case Reports CASE I. The patient, a thirty-one year old white man, was admitted to the University Hospital after having struck a parked car while travelling at approximately 35 mph. On admission the patient’s blood pressure was 60/O mm. Hg. He required immediate tracheostomy and positive pressure respiratory assistance to stabilize a flail chest. An initial peritoneal tap was negative. Deterioration in the clinical course and signs of intra-abdominal bleeding led to exploratory laparotomy four hours after admission. He had a large stellate laceration of the right lobe of the liver with ends of jagged ribs protruding through lacerations in the diaphragm. The peritoneal cavity was full of blood and the patient was bleeding heavily from the liver laceration. Packs were used to control the bleeding and the midline incision was extended to the right subcostal area. The packing allowed careful dissection of the porta hepatis and right hepatic artery and duct. Each time the packs were removed from the lacerated liver, severe venous bleeding from a tear in the vena cava occurred. The
American
Journal
of
Surgery
Suprarenal
The vena cava was intermittently occluded above the .renal veins in an attempt to isolate the source of hemorrhage, and during one period of occlusion, the patient had a cardiac arrest. An exclusion clamp was finally placed on the tear in the vena cava and the laceration sutured. After the patient’s condition was stabilized with whole blood and fluids, right hepatic lobectomy was completed in the usual manner. During the operation this patient required forty-six units of blood. His postoperative course was complicated by a dehiscence but otherwise he did remarkably well and was discharged four weeks after admission. Comment: This case illustrates the need for access to large quantities of blood. It also points out the difficulty in managing suprarenal vena caval injuries which in the past have been believed to be uniformly fatal, especially when the tear was due to a blunt injury. Schrock, Blaisdell, and Mathewson [9], in an excellent review of this problem, were unable to find a report of a survivor from this type of lblunt injury to the hepatic veins or suprarenal vena cava [lo,1 11, although patients have survived after penetrating injuries to this area [14,13]. Aronsen et al. [14], in a series of nine resections for blunt injuries to the liver, had 100 per cent mortality in four patients who had vena cava involvement. In a recent article by Foster et al. [15] six of fifty patients undergoing major hepatic resection for trauma had avulsions of one or more hepatic veins from the vena cava with resultant lacerations of this vessel. Two of these died of exanguinating hemorrhage and two had cardiac arrest in the operating room but were successfully resuscitated and are long-term survivors. The next case demonstrates the value of packing the wounds to establish initial hemastasis in preparation for transferring the patient to a major medical facility. CASE II. The patient, a twenty year old white man, was flown to the University Hospital after having been initially explored in a small community hospital for suspected intra-abdominal inHe had sustained the injury in a jeep juries. accident on a mountain trail 200 miles from Salt Lake City and at the initial operation was found to have a large stellate laceration of the right lobe of the liver. The wound was packed with four Mayo packs to control bleeding and the abdomen was closed in preparation for transfer to our hospital. On arrival at the University Hospital he was alert and vital signs were stable. He was taken Vol. 118, December 1969
Vena Cava and
Liver Trauma
to the operating room where the incision was reopened and extended to the right subcostal area. On removing the packs, massive hemorrhage began from a tear in the suprarenal vena cava. He was managed in much the same way as the previous case and received thirty-six units of blood. Postoperatively his course was complicated by a wound infection and a subphrenic abscess but he recovered and is now doing well.
Comments Methods to control hemorrhage from hepatic vein avulsion injuries and tears in the suprarenal vena cava have not been definitely established [16,17], and these two cases are examples of the problems one has with uncontrollable hemorrhage in these situations. Placement of gauze packs in liver wounds as definitive treatment in controlling hemorrhage is almost universally condemned. Packing acts as a tampon rather than a drain, pressure necrosis of the already injured portion of the liver may be followed by profuse hemorrhage, and the infection rate is increased [1,15,18]. However, packing the liver as a temporary measure while preparations are being made to transport the patient to a major medical center may be life-saving, as it undoubtedly was in the patient in case II, and we advocate its use in this situation. Several approaches to this problem have been recently advocated. Heaney et al. [19] suggest clamping the aorta below the diaphragm to prevent loss of blood volume into the lower torso and extremities while return flow through the vena cava is prevented, and they advise tape encirclement of the porta hepatis and the inferior vena cava above and below the liver. Schrock et al. [9], after investigating the anatomy of the suprarenal vena cava in adult cadavers, described a technic for exposure and repair of blunt hepatic vein avulsion. They use an internal shunt and insert the catheter into the inferior vena cava through the right atria1 appendage. We have modified this approach and insert the catheter through a venotomy below the renal veins. (Fig. 1.) The procedure is as follows : A right thoracoabdominal incision is made with division of the diaphragm down to the vena cava. The pericardium is incised just above the diaphragm, taking care not to injure the phrenic nerve, and an umbilical tape is then placed around the vena cava at this point. A tape is 961
Albo et al.
Midd vein
lepatic Cava
Fig. 1.
Vascular isolation of the liver. Catheter is in place within the intrahepatic vena cava. Tapes are placed around the soprarenal and suprahkpatic vena cava. then placed around the inferior vena cava just above the renal veins. If the porta hepatis has not been previously dissected with individual ligation of the vessels and ducts, it can be temporarily occluded with a vascular clamp on the hepatic duodenal ligament [S] . The vena cava is then temporarily clamped below the renal veins and a venotomy is made just above the occluded clamp. A No. 36 or 38 caval catheter or 3,‘s inch polyvinyl tubing with a long silk suture on its distal end is then introduced through the venotomy and made to lie just above the renal veins and in the right atrium. The suture is brought out through the venotomy to allow removal at the end of the procedure. The previously placed snares around the vena cava above and below the liver are 962
now secured and the venotomy is closed with an exclusion vascular clamp. This completes the vascular isolation of the liver and allows repair of the damage to the suprarenal vena cava. These injuries are best approached through the interlobar fissure especially if the laceration is in this area, but they can also be approached from the right lateral gutter, reflecting the liver anteriorly and medially. Care must be taken to avoid the middle hepatic vein which lies in the interlobar fissure and drains portions of both the right and the left lobes of the liver. This technic greatly simplifies the establishment of a field dry enough for careful dissection of the critical structure in this area. Hepatic inflow occlusion bears comment. The American
Journal of Surgery
Suprarenal
Normothermic porta hepatis occlusion for thirty minutes and occlusion of the right hepatic artery in the same patient for fifty-nine minutes with only minimal evidence of hepatic dysfunction have been reported [ZO]. Longmire [s] reported liver resection utilizing hypothermia and afferent vascular occlusion for fifty-seven minutes with a successful outcome. Williams occluded the afferent circulation to the liver continuously for one hour and fifteen minutes without hypothermia with only temporary impairment in some liver function studies postoperatively [I 81. The maximal safe ischemic period generally quoted is fifteen minutes in normothermic patients and thirty minutes in hypothermic patients [I 81. Massive transfusion of cold blood usually required in severe liver trauma should permit at least thirty minutes of inflow occlusion [9]. Summary Experience with major hepatic resections is discussed with particular emphasis on those cases with injury to the suprarenal vena cava. The feasibility of transporting persons with massive liver trauma from small community hospitals to major medical centers using packs to obtain temporary control of hemorrhage is emphasized. The role of major hepatic resections for extensive liver trauma, especially in blunt injuries involving the suprarenal vena cava is discussed. The importance of having blood banking facilities capable of providing massive amounts of blood is stressed. A modification of Schrock’s technic for vascular isolation of the liver in injuries to the hepatic veins and suprarenal vena cava is presented. References 1. 2. 3.
MCCLELLAND,R. N. and SHIRES, T. Management of liver trauma in 259 consecutive patients. Ann. Surg., 161: 248, 1965. ATIK, M., GROSSMAN,R., and DEKERNIAN,J. Hepatectomy for severe liver injury. Arch. Surg., 92 : 636,1966. MIKESKY, W. E., HOWARD, J. M., and DE
Vol. 118, December 1969
Vena
Cava
and
Liver
Trauma
BAKEY, M. D. Injuries of the liver in 300 consecutive patients. Internat. Obst. Surg., 103 : 323,1956. 4. GOLDSMITH,N. A. and WOODBURNE,R. T. The surgical anatomy pertaining to liver resection. Surg. Gynec. & Obst. 105: 310, 1957. 5. HEANEY, J. E., JR. Clinical anatomic aspects of radica1 hepatic surgery. J. Znternat. Coil. Surgeons, 22 : 542,1954. 6. QUATTLEBAUM, J. K. Massive resection of the liver. Ann. Sura.. 13’7: 787. 1952. 7. PACK, G. T. and-BAKER, H. ‘W. Total right hepatic lobe&my. Ann. Surg., 138: 253, 1953. 8. LONGMIRE,W. P. J. Hepatic surgery: trauma, tumors and cvsts. Ann. Surer.. 161: 1.1965. 9. SCHROCK,T., B&SDELL, W. F:, and MATHEWSON, C., JR., Management of blunt trauma to the liver and hepatic veins. Arch. Surg., 96: 698, 1968, 10. OCHSNER,J. L., CRAWFORD,E. S., and DEBAKEY, M. E. Injuries of the vena cava caused by external trauma. Surgery, 49: 397,196l. 11. WILSON, D. H. Incidence, aetiology, diagnosis and prognosis of closed abdominal injuries: a study of 265 consecutive cases. h-it. J. Surg., 50: 381,1963. 12. STARZL, T. E. et al. The treatment of penetrating wounds of the inferior vena cava. Surgery, 51: 195,1962. 13. FELDMAN, E. A. Injury to the hepatic vein. Am. J. Surg., 111: 244,1966. 14. ARONSEN, K. F., BENGMARK,S., DAHLGREN, S., ENGEVIK,L., ERICSSON,B., and THOREN, L. Liver resection in the treatment of blunt injuries to the liver. Surgery, 63: 236,1968. 15. FOSTER, J. H., LAWLER, M. R., WELBORN, M. B., HALCOMB,G. W., and SAWYER,J. L. Recent experience with major hepatic resection. Ann. Surg., 167 : 651,1968, 16. DONOVAN,A. J., TURRILL,F. L., and FACEY, F. L. Hepatic trauma. S. Cl&. North America, 48: 1313,1968. 17. NOER,R. J. Acute injuries of the liver (Scudder Oration of Trauma). Am. Coil. Surgeons Bull., January-February, 1969. 18. MADDING,G. F. and KENNEDY,P. A. Trauma to the liver. Philadelphia, 1965. W. B. Saunders Co. 19. HEANEY, J. P., STANTON, W. K., HALBERT, D. S., SEIDEL, J., and VICE, T. An improved technique for vascular isolation of the liver: experimental study and case reports. Ann. Surg., 163: 237, 1966. 20. ANASTESIA, L. F., WILLIAMS, L. F., and BYRNE, J. J. One hour hepatic ischemia without serious damage. J.A.M.A., 201: 1051, 1967.
963
During the past decade there has been increasing interest in major hepatic resections for extensive liver trauma, primarily because of the high mortality associated with the treatment of these injuries by other methods [1-z]. Other factors responsible for this trend are a better understanding of the detailed anatomy of the liver especially with respect to its blood supply [.4,5] and the demonstrations by Quattlebaum [S], Pack and Baker [71, Longmire [S], and others of the feasibility of successfully resecting large portions of human liver. Massive trauma to the liver is often the result of motor vehicle accidents so that consequently emergency exploration must be performed in outlying community hospitals where facilities do not allow major hepatic resections. Improved resuscitative technics in these community centers and better transportation of the injured patient present us with increasing numbers of critically injured patients who can be saved by definitive therapy. We have reviewed a two year experience with major hepatic resections for trauma at the University of Utah College of Medicine; this limited series illustrates several important points in the management of these patients. 1. Major hepatic injury can be safely treated by temporary packing while the patient is prepared for moving and then transported to a medical facility where definitive treatment can be given. 2. An excellent blood banking facility, ca-
From the Department of Surgery, of Medicine, Salt Lake City, Utah. Presented at the Twenty-First Southwestern Surgical Congress, 2-5.1969.
960
University Annual Stateline.
of Utah Meeting Nevada,
College of
the June
pable of providing large amounts of blood, is mandatory. 3. An internal shunt should be considered when dealing with injuries to the hepatic veins or the suprarenal vena cava if exanguinating hemorrhage is to be avoided. During the two year period from 1966 to 1968, we had five patients with injuries requiring right hepatic lobectomies. All five patients were male and their ages ranged from nine to thirty-two years of age. Three had suprarenal caval lacerations. One died on the operating table from uncontrollable hemorrhage; four survived and are now fully rehabilitated. Two of these cases are briefly described to emphasize these points. Case Reports CASE I. The patient, a thirty-one year old white man, was admitted to the University Hospital after having struck a parked car while travelling at approximately 35 mph. On admission the patient’s blood pressure was 60/O mm. Hg. He required immediate tracheostomy and positive pressure respiratory assistance to stabilize a flail chest. An initial peritoneal tap was negative. Deterioration in the clinical course and signs of intra-abdominal bleeding led to exploratory laparotomy four hours after admission. He had a large stellate laceration of the right lobe of the liver with ends of jagged ribs protruding through lacerations in the diaphragm. The peritoneal cavity was full of blood and the patient was bleeding heavily from the liver laceration. Packs were used to control the bleeding and the midline incision was extended to the right subcostal area. The packing allowed careful dissection of the porta hepatis and right hepatic artery and duct. Each time the packs were removed from the lacerated liver, severe venous bleeding from a tear in the vena cava occurred. The
American
Journal
of
Surgery
Suprarenal
The vena cava was intermittently occluded above the .renal veins in an attempt to isolate the source of hemorrhage, and during one period of occlusion, the patient had a cardiac arrest. An exclusion clamp was finally placed on the tear in the vena cava and the laceration sutured. After the patient’s condition was stabilized with whole blood and fluids, right hepatic lobectomy was completed in the usual manner. During the operation this patient required forty-six units of blood. His postoperative course was complicated by a dehiscence but otherwise he did remarkably well and was discharged four weeks after admission. Comment: This case illustrates the need for access to large quantities of blood. It also points out the difficulty in managing suprarenal vena caval injuries which in the past have been believed to be uniformly fatal, especially when the tear was due to a blunt injury. Schrock, Blaisdell, and Mathewson [9], in an excellent review of this problem, were unable to find a report of a survivor from this type of lblunt injury to the hepatic veins or suprarenal vena cava [lo,1 11, although patients have survived after penetrating injuries to this area [14,13]. Aronsen et al. [14], in a series of nine resections for blunt injuries to the liver, had 100 per cent mortality in four patients who had vena cava involvement. In a recent article by Foster et al. [15] six of fifty patients undergoing major hepatic resection for trauma had avulsions of one or more hepatic veins from the vena cava with resultant lacerations of this vessel. Two of these died of exanguinating hemorrhage and two had cardiac arrest in the operating room but were successfully resuscitated and are long-term survivors. The next case demonstrates the value of packing the wounds to establish initial hemastasis in preparation for transferring the patient to a major medical facility. CASE II. The patient, a twenty year old white man, was flown to the University Hospital after having been initially explored in a small community hospital for suspected intra-abdominal inHe had sustained the injury in a jeep juries. accident on a mountain trail 200 miles from Salt Lake City and at the initial operation was found to have a large stellate laceration of the right lobe of the liver. The wound was packed with four Mayo packs to control bleeding and the abdomen was closed in preparation for transfer to our hospital. On arrival at the University Hospital he was alert and vital signs were stable. He was taken Vol. 118, December 1969
Vena Cava and
Liver Trauma
to the operating room where the incision was reopened and extended to the right subcostal area. On removing the packs, massive hemorrhage began from a tear in the suprarenal vena cava. He was managed in much the same way as the previous case and received thirty-six units of blood. Postoperatively his course was complicated by a wound infection and a subphrenic abscess but he recovered and is now doing well.
Comments Methods to control hemorrhage from hepatic vein avulsion injuries and tears in the suprarenal vena cava have not been definitely established [16,17], and these two cases are examples of the problems one has with uncontrollable hemorrhage in these situations. Placement of gauze packs in liver wounds as definitive treatment in controlling hemorrhage is almost universally condemned. Packing acts as a tampon rather than a drain, pressure necrosis of the already injured portion of the liver may be followed by profuse hemorrhage, and the infection rate is increased [1,15,18]. However, packing the liver as a temporary measure while preparations are being made to transport the patient to a major medical center may be life-saving, as it undoubtedly was in the patient in case II, and we advocate its use in this situation. Several approaches to this problem have been recently advocated. Heaney et al. [19] suggest clamping the aorta below the diaphragm to prevent loss of blood volume into the lower torso and extremities while return flow through the vena cava is prevented, and they advise tape encirclement of the porta hepatis and the inferior vena cava above and below the liver. Schrock et al. [9], after investigating the anatomy of the suprarenal vena cava in adult cadavers, described a technic for exposure and repair of blunt hepatic vein avulsion. They use an internal shunt and insert the catheter into the inferior vena cava through the right atria1 appendage. We have modified this approach and insert the catheter through a venotomy below the renal veins. (Fig. 1.) The procedure is as follows : A right thoracoabdominal incision is made with division of the diaphragm down to the vena cava. The pericardium is incised just above the diaphragm, taking care not to injure the phrenic nerve, and an umbilical tape is then placed around the vena cava at this point. A tape is 961
Albo et al.
Midd vein
lepatic Cava
Fig. 1.
Vascular isolation of the liver. Catheter is in place within the intrahepatic vena cava. Tapes are placed around the soprarenal and suprahkpatic vena cava. then placed around the inferior vena cava just above the renal veins. If the porta hepatis has not been previously dissected with individual ligation of the vessels and ducts, it can be temporarily occluded with a vascular clamp on the hepatic duodenal ligament [S] . The vena cava is then temporarily clamped below the renal veins and a venotomy is made just above the occluded clamp. A No. 36 or 38 caval catheter or 3,‘s inch polyvinyl tubing with a long silk suture on its distal end is then introduced through the venotomy and made to lie just above the renal veins and in the right atrium. The suture is brought out through the venotomy to allow removal at the end of the procedure. The previously placed snares around the vena cava above and below the liver are 962
now secured and the venotomy is closed with an exclusion vascular clamp. This completes the vascular isolation of the liver and allows repair of the damage to the suprarenal vena cava. These injuries are best approached through the interlobar fissure especially if the laceration is in this area, but they can also be approached from the right lateral gutter, reflecting the liver anteriorly and medially. Care must be taken to avoid the middle hepatic vein which lies in the interlobar fissure and drains portions of both the right and the left lobes of the liver. This technic greatly simplifies the establishment of a field dry enough for careful dissection of the critical structure in this area. Hepatic inflow occlusion bears comment. The American
Journal of Surgery
Suprarenal
Normothermic porta hepatis occlusion for thirty minutes and occlusion of the right hepatic artery in the same patient for fifty-nine minutes with only minimal evidence of hepatic dysfunction have been reported [ZO]. Longmire [s] reported liver resection utilizing hypothermia and afferent vascular occlusion for fifty-seven minutes with a successful outcome. Williams occluded the afferent circulation to the liver continuously for one hour and fifteen minutes without hypothermia with only temporary impairment in some liver function studies postoperatively [I 81. The maximal safe ischemic period generally quoted is fifteen minutes in normothermic patients and thirty minutes in hypothermic patients [I 81. Massive transfusion of cold blood usually required in severe liver trauma should permit at least thirty minutes of inflow occlusion [9]. Summary Experience with major hepatic resections is discussed with particular emphasis on those cases with injury to the suprarenal vena cava. The feasibility of transporting persons with massive liver trauma from small community hospitals to major medical centers using packs to obtain temporary control of hemorrhage is emphasized. The role of major hepatic resections for extensive liver trauma, especially in blunt injuries involving the suprarenal vena cava is discussed. The importance of having blood banking facilities capable of providing massive amounts of blood is stressed. A modification of Schrock’s technic for vascular isolation of the liver in injuries to the hepatic veins and suprarenal vena cava is presented. References 1. 2. 3.
MCCLELLAND,R. N. and SHIRES, T. Management of liver trauma in 259 consecutive patients. Ann. Surg., 161: 248, 1965. ATIK, M., GROSSMAN,R., and DEKERNIAN,J. Hepatectomy for severe liver injury. Arch. Surg., 92 : 636,1966. MIKESKY, W. E., HOWARD, J. M., and DE
Vol. 118, December 1969
Vena
Cava
and
Liver
Trauma
BAKEY, M. D. Injuries of the liver in 300 consecutive patients. Internat. Obst. Surg., 103 : 323,1956. 4. GOLDSMITH,N. A. and WOODBURNE,R. T. The surgical anatomy pertaining to liver resection. Surg. Gynec. & Obst. 105: 310, 1957. 5. HEANEY, J. E., JR. Clinical anatomic aspects of radica1 hepatic surgery. J. Znternat. Coil. Surgeons, 22 : 542,1954. 6. QUATTLEBAUM, J. K. Massive resection of the liver. Ann. Sura.. 13’7: 787. 1952. 7. PACK, G. T. and-BAKER, H. ‘W. Total right hepatic lobe&my. Ann. Surg., 138: 253, 1953. 8. LONGMIRE,W. P. J. Hepatic surgery: trauma, tumors and cvsts. Ann. Surer.. 161: 1.1965. 9. SCHROCK,T., B&SDELL, W. F:, and MATHEWSON, C., JR., Management of blunt trauma to the liver and hepatic veins. Arch. Surg., 96: 698, 1968, 10. OCHSNER,J. L., CRAWFORD,E. S., and DEBAKEY, M. E. Injuries of the vena cava caused by external trauma. Surgery, 49: 397,196l. 11. WILSON, D. H. Incidence, aetiology, diagnosis and prognosis of closed abdominal injuries: a study of 265 consecutive cases. h-it. J. Surg., 50: 381,1963. 12. STARZL, T. E. et al. The treatment of penetrating wounds of the inferior vena cava. Surgery, 51: 195,1962. 13. FELDMAN, E. A. Injury to the hepatic vein. Am. J. Surg., 111: 244,1966. 14. ARONSEN, K. F., BENGMARK,S., DAHLGREN, S., ENGEVIK,L., ERICSSON,B., and THOREN, L. Liver resection in the treatment of blunt injuries to the liver. Surgery, 63: 236,1968. 15. FOSTER, J. H., LAWLER, M. R., WELBORN, M. B., HALCOMB,G. W., and SAWYER,J. L. Recent experience with major hepatic resection. Ann. Surg., 167 : 651,1968, 16. DONOVAN,A. J., TURRILL,F. L., and FACEY, F. L. Hepatic trauma. S. Cl&. North America, 48: 1313,1968. 17. NOER,R. J. Acute injuries of the liver (Scudder Oration of Trauma). Am. Coil. Surgeons Bull., January-February, 1969. 18. MADDING,G. F. and KENNEDY,P. A. Trauma to the liver. Philadelphia, 1965. W. B. Saunders Co. 19. HEANEY, J. P., STANTON, W. K., HALBERT, D. S., SEIDEL, J., and VICE, T. An improved technique for vascular isolation of the liver: experimental study and case reports. Ann. Surg., 163: 237, 1966. 20. ANASTESIA, L. F., WILLIAMS, L. F., and BYRNE, J. J. One hour hepatic ischemia without serious damage. J.A.M.A., 201: 1051, 1967.
963