COMPLEX HEPATIC INJURIES

The most significant contribution to the management of hepatic injurie s over the past 5 years has been the nonoperative management of blunt injuries in the adult patient. Recent data suggest that as many as 80% of all blunt hepatic injuries may be treated in this fashion, with a success rate exceeding 95%. The fear of missing hollow viscus injuries , as well as the risk of sudden hemorrhage in the observational period , leading to an increase in hepatic-related deaths, seems exaggerated. The intraoperative management of complex hepatic injuries revolves ar ound strict adherence to resuscitation prior to addressing the lesion itself. At times, ''damage control'' with termination of surgery and ' 'packing'' the patient with planned re-exploration are critical, as th ese maneuvers are often lifesaving. The Pringle maneuver and intrahepa tic hemostasis for grades III to IV injuries have resulted in a mortal ity rate under 10%. Juxtahepatic venous injuries continue to carry an inordinately high mortality rate. lntracaval shunts, when used, should be inserted early in the course of the operation before excess transf usions are given and acidosis and hypothermia develop.