Liver injury: What you need to know.

The liver is the most commonly injured abdominal solid organ regardless of mechanism. The majority of liver injuries are grades I to III, with 12% to 20% as grades IV and V. In the hemodynamically stable patient or prompt responder to resuscitation, 85% to 90% of blunt liver injuries can be managed nonoperatively, regardless of the grade of injury. The promulgation of nonoperative management has resulted in decreased overall mortality for blunt liver injury. On the other hand, over the past 30 years, major advances in resuscitation science, intensive care, damage-control surgery, and nonoperative adjuncts have done little to reduce the operative morbidity and mortality of grades IV and V liver injuries. Angiography with embolization is often effective in stopping bleeding. However, angioembolization confers additional risk of complications (i.e., major hepatic necrosis and sepsis). This review will briefly present critical surgical anatomy and grading systems for liver trauma, followed by organ-specific diagnostic, resuscitation, and triage considerations. It will review importantlimitations, risk factors for failure, and complications associated with nonoperative management and angioembolization. This article presents operative techniques and pearls for surgical treatment of the most severe injuries, including adjuncts for hemorrhage control. Finally, we suggest the 6 Ps as an operative strategy for liver injury: Push-Pack-Pringle-Put Back-Phone-Pivot.