The changes that have occurred over the last several decades regarding the management of liver injuries have been described in several recent publications [1–3]. The number of liver injuries being identified has increased over time associated with improvements in techniques for diagnosis and the widespread use of computed tomography (CT) in injured patients [1, 2]. However, the incidence of major, high-grade hepatic injuries has remained largely unchanged in 12–15 % of all liver injuries [1–4]. Most liver injuries in patients with satisfactory hemodynamics are now managed nonoperatively [3, 5, 6]. While some have reported that this shift in management has not changed resident operative experience [5], others have noted a significant decline in the resident operative experience in the management of liver trauma [6, 7]. Lucas reported that recent graduating chief surgical residents performed a mean of 1.2 operations for hemostasis with liver injuries with most having no experience with complex techniques of liver injury management such as tractotomy or hepatic resection [7]. Given the preponderance of nonoperative management, it may take years for a surgeon to accrue substantial personal experience in the operative management of patients with complex, high-grade liver injuries. Currently, patients with liver injuries undergoing operative treatment are frequently the subset of patients with the most severe liver injuries, unstable hemodynamics, and the most severe physiologic derangements. The relatively infrequent presentation of patients with complex liver injuries requiring operative treatment combined with their typically unstable hemodynamics has created a challenging scenario for the training of future trauma surgeons. What is the best way to train surgeons to manage an injury that occurs infrequently in even the busiest trauma centers but when present, requires rapid decision making, challenging surgical exposure of the site of bleeding, and potentially complex operative techniques for hemostasis?

The pitfalls of dealing with complex liver injuries are different compared than those of severe injuries of the spleen and kidney even though these injuries are often combined into outcome studies on “solid organ injuries.” For the spleen and kidney, mobilization and excision are often an expeditious way to deal with the actively bleeding and extensively damaged organ. However with the liver, especially when major venous injuries are present, mobilization for exposure can increase hemorrhage and potentially complicate operative management [8]. Perihepatic packing can help achieve hemostasis with selected severe liver injuries even when major venous injuries are present as long as the retroperitoneal tissues have not been significantly violated and can be used to help tamponade bleeding [3, 8, 9]. Unfortunately, some injuries will not respond to perihepatic packing, will continue to bleed even when packed, and require direct repair. Deciding when to abandon packing and proceed with direct repair requires experience, judgment, and then familiarity with techniques to expose and repair this challenging injury.

In order to optimize outcome from major hepatic injuries, the surgeon needs to be fully prepared to rapidly execute several operative steps and have a variety of techniques in their armamentarium. The maneuvers and techniques that can be applied are discussed in recent publications [3, 10] and in previous chapters of this work. How to become facile in these techniques when the injury is uncommon is an ongoing challenge since residency, fellowship, and even years of practice may expose the surgeon to few severe hepatic injuries. A combination, though, of structured training and self-directed learning can familiarize the surgeon or trainee with the relevant anatomy and techniques for surgical exposure that prove useful in managing these injuries.