title: A comprehensive five-step surgical management approach to penetrating liver injuries that require complex repair.
abstract: BACKGROUND
  The objective of this study was to describe a comprehensive five-step surgical management approach for patients with penetrating liver trauma based on our collective institutional experience.
  
  
  METHODS
  A prospective consecutive study of all penetrating liver traumas from January 2003 to December 2011 at a regional Level I trauma center in Cali, Colombia, was conducted.
  
  
  RESULTS
  A total of 538 patients with penetrating thoracoabdominal trauma were operated on at our institution. Of these, 146 had penetrating liver injuries that satisfied the inclusion criteria for surgical intervention to manage their hepatic and/or associated injuries. Eighty-eight patients (60%) had an American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) of Grade III (54 patients, 37%), Grade IV (24 patients, 16%), and Grade V (10 patients, 7%). This group of patients required advanced "complex" techniques of hemostasis such as the Pringle maneuver (PM), perihepatic liver packing (PHLP), and/or hepatotomy with selective vessel ligation (SVL). The focus of our study was this subgroup of patients, which we further divided into two as follows: those who required only PM + PHLP (55 patients, 63%) to obtain control of their liver hemorrhage and those who required PM + PHLP + SVL (33 patients, 37%). Of the patients who required PM + PHLP + SVL, 10 (27%) required ligation of major intrahepatic branches, which included suprahepatic veins (n = 4), portal vein (n = 4), retrohepatic vena cava (n = 1), and hepatic artery (n = 1). The remaining 23 patients (73%) required direct vessel ligation of smaller intraparenchymal vessels. The overall mortality was 15.9% (14 of 88), with 71.4% (10 of 14) related to coagulopathy. Mortality rates for Grade III was 3.7% (2 of 54), for Grade IV was 20.8% (5 of 24), and for Grade V was 70% (7 of 10). The mortality in the PM + PHLP + SVL group was higher compared with the PM + PHLP group (12 [36.4%] vs. 2 [3.6%], p = 0.001].
  
  
  CONCLUSIONS
  For those patients who fail to respond to PM + PHLP and/or those who have AAST-OIS penetrating liver injuries, Grades IV and V would benefit from immediate intraparenchymal exploration and SVL.
authors.affiliation: Departamento de Cirugía, Fundación Valle del Lili, Cali, Colombia. ordonezcarlosa@gmail.com
authors.forename: Carlos Alberto
authors.initials: CA
authors.lastname: Ordoñez
authors.forename: Michael W
authors.initials: MW
authors.lastname: Parra
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Salamea
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Puyana
authors.forename: Mauricio
authors.initials: M
authors.lastname: Millán
authors.forename: Marisol
authors.initials: M
authors.lastname: Badiel
authors.forename: Juán
authors.initials: J
authors.lastname: Sanjuán
authors.forename: Luis F
authors.initials: LF
authors.lastname: Pino
authors.forename: David
authors.initials: D
authors.lastname: Scavo
authors.forename: Wilmer
authors.initials: W
authors.lastname: Botache
authors.forename: Ricardo
authors.initials: R
authors.lastname: Ferrada
mesh_terms: D000293:Adolescent; D000328:Adult; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008099:Liver / Q000293:injuries* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014193:Trauma Centers; D014951:Wounds, Stab / Q000601:surgery*; D055815:Young Adult