Fatal hepatic hemorrhage: an unresolved problem in the management of complex liver injuries.

The operative records of 683 patients who required an exploratory laparotomy for trauma with the findings of a liver injury were reviewed. Of the 683 patients 18% (121) sustained severe liver injuries with difficult to control hemorrhage, and 82% of the deaths, in this group of severe liver injuries, were due to exsanguination. A critical analysis of the specific surgical techniques used for hemostasis was undertaken. Hepatotomy with subsequent direct vascular and/or biliary duct repair or ligation was used in 44% of the cases and was successful 87% of the time. Hepatic resection was employed in 10% of the cases with a 50% mortality. Liver packs were used in 29% of the cases which included 14 hepatic vein and six retrohepatic vena caval injuries and five extensive bilobar parenchymal disruptions. The survival rate for this group of patients was 86%. Vascular isolation of the liver was used 8.3% of the cases and was successful 40% of the time. An algorithm for the successful surgical control of hemorrhage from severe liver injuries including indications and contra-indications of specific surgical techniques is presented.