Liver injury occurs in approximately 5% of all trauma admissions.¹ The sheer size of the organ, along with its position under the right costal margin, make the liver exceedingly susceptible to traumatic injury. The management of liver injuries continues to evolve with improved modes of diagnosis and management, both operatively and nonoperatively. However, the most severe liver parenchymal and retrohepatic venous injuries as well as those involving the portal triad continue remain a challenge and despite technological advances, still often lead to death. Therefore, despite our progress in liver injury management, many avenues for improvement remain to be explored.

Comprehensive knowledge of hepatic anatomy is essential to the proper management of traumatic liver injuries. The understanding of the ligamentous attachments, parenchyma, and intraparenchymal and extraparenchymal vascularity of the liver is key to the effective application of methods for control and repair in liver injuries (Fig. 29-1).

Lobes

Cantlie first described the lobar anatomy in 1898. The liver is divided into two lobes by a 75° angle traversing from the gallbladder fossa posteriorly to the left side of the inferior vena cava. This is the so-called line of Cantlie. Therefore, the left lobe includes the hepatic tissue to the left of the falciform ligament along with the quadrate and caudate lobes. Whereas, the right lobe consists of the remaining parenchyma.

Functional Anatomy

The functional anatomy of the liver separates the liver into segments pertinent to resection. In 1953, Couinaud provided the basis of modern resection planes by dividing the liver based on the distribution of the hepatic veins and glissonian pedicles.² The right hepatic vein traverses between the right posterolateral (VI and VII) and right anteromedial (V and VIII) segments. On the left, the left hepatic vein delineates the anterior (III and IV) and posterior (II) segments. The caudate lobe (I) drains directly into the inferior vena cava (Fig. 29-2).

Hepatic Artery

The common hepatic artery branches from the celiac artery. This provides about 25% of the hepatic blood flow and 50% of hepatic oxygenation. The artery then branches into the gastroduodenal, right gastric, and proper hepatic arteries. The proper hepatic is found in the porta hepatis usually to the left of the common bile duct and anterior to the portal vein. It is found by transversely incising the peritoneum overlying the hepatoduodenal ligament, a maneuver facilitated by mobilization of the hepatic flexure of the colon toward the midline. At the hilum of the liver, the artery bifurcates into a right (the longer branch) and a left hepatic artery. There are a number of anatomic variances. The most frequent (11%) is the aberrant superior mesenteric origin of the right hepatic artery traversing behind the duodenum. Other variants include a left hepatic artery origin from the left gastric artery (8%) and the left and right hepatic arteries arising from a superior mesenteric artery origin (9%). With these multiple variants, great care must be taken when controlling traumatic hemorrhage.

Hepatic Veins

The hepatic veins develop from within the hepatocytes’ central lobar veins. The superior, middle, and inferior vein branches originating from the right lobe form the right hepatic vein. The middle hepatic vein derives from the two veins arising from segments IV and V and frequently includes a branch from the posterior portion of segment VIII. In 90% of patients, the middle hepatic vein joins the left hepatic vein just before draining into the inferior vena cava. The left hepatic vein is more variable in its segmental origin. Most important is the posterior positioning of the vein when dissecting the left coronary ligament; great caution must be used in this area to avoid inadvertent injury. The hepatic veins are notoriously fragile and can be easily torn if great care is not taken when mobilizing the liver. In order to surgically access these veins, the liver must be fully mobilized. The retrohepatic vena cava is about 8–10 cm in length. It receives the blood of the hepatic veins and also multiple small direct hepatic vessels. Exposure of this area can be very difficult, especially when an injury and accompanying hemorrhage make visualization very difficult. Surgical exposure can be facilitated by extending a midline laparotomy into a right thoracoabdominal incision with division of the costochondral cartilage and continuation onto the right chest. The diaphragm is radially taken down with cautery, taking care to leave enough of a rim of diaphragm for reapproximation, and control of the inferior vena cava can be obtained in the chest.

Portal Vein

The portal vein is formed from the confluence of the splenic and superior mesenteric veins directly behind the pancreatic head. It provides about 75% of hepatic blood flow and 50% of hepatic oxygen. The portal vein lies posterior to the hepatic artery and bile ducts as it ascends toward the liver. At the parenchyma, the portal vein divides into a short right and a longer left extrahepatic branch. Surgically, the portal vein can be approached by division of the pancreas at its neck or with a generous Kocher maneuver of the duodenum toward the midline.

Ligaments

When operating on the liver, it is crucial to understand the ligamentous attachments. The coronary ligaments attach the diaphragm to the parietal surface of the liver. The triangular ligaments are at the lateral extensions of the right and left coronary ligaments. The falciform ligament with the underlying ligamentum teres attaches to the anterior peritoneal cavity. The medial portion of the coronary ligaments is where the hepatic veins traverse and therefore dissection in this area must be done with caution. In order to effectively visualize the liver during operative therapy, these ligaments must be divided and the liver fully mobilized into the field of view.

Since the liver is the largest intra-abdominal organ, it is not surprising that the liver is one of the most commonly injured solid organ in blunt and penetrating injury. Out of 26,392 total trauma encounters at the Shock Trauma Center from 2010 to 2013, 796 patients (3%) had liver injuries (252 penetrating and 542 blunt).

Uniform classification of liver injury is essential to compare the efficacy of management techniques (Fig. 29-3). The American Association for the Surgery of Trauma established a detailed classification system that has been widely utilized (Table 29-1).³ This classification provides for uniform comparisons of both nonoperative and operatively managed hepatic injury.

Care for the patient with possible liver injury should proceed by the tenants of Advanced Trauma Life Support (ATLS). Of utmost importance is the initial evaluation, including attention to airway, breathing, and circulation. Other life-threatening injuries may take precedence over possible internal injury in the primary survey. However, liver injury may indeed be a cause of hemorrhagic shock and should not be overlooked. Resuscitation strategies continue to evolve in the care of trauma patients, with focus on early transfusion of blood products and the establishment of a ratio of packed red cells to plasma that is more similar to whole blood.

Plain radiographs and ultrasound obtained in the trauma resuscitation unit may give clues to possible liver injury in the presence of right-sided rib fractures, hemothorax, or hemoperitoneum. Although nonoperative management of liver injuries has become routine, a patient exhibiting clear peritoneal signs and/or hemodynamic instability requires immediate operative exploration. Important but often overlooked points in the patient with a significant liver injury is the detrimental effect that hypothermia can have on coagulation, particularly for the patient with a liver injury. Appropriate laboratory data should be collected and include type and cross, hemoglobin level, coagulation profile, and base deficit.

Hemodynamically Unstable Patient

If after primary survey and initial resuscitation the patient remains hemodynamically unstable, it is necessary to immediately determine the possible causes of the continued shock state. This can be difficult in patients with multiple injuries involving multiple organ systems, but the correct body cavity that harbors the ongoing hemorrhage must be identified. Intra-abdominal injury can be an obvious cause of instability if the physical examination reveals peritoneal signs, penetrating injury, or hemoperitoneum on focused abdominal sonography for trauma (FAST). Similarly, an expeditious chest x-ray and pelvic radiograph is imperative to ensure the ongoing blood loss is not from a hemothorax or a rapidly expanding zone III hematoma.

Focused Abdominal Sonography for Trauma

The focused abdominal sonography for trauma (FAST) exam is the primary modality for the determination of hemoperitoneum in the unstable patient. Surgeons have become very adept and familiar with this diagnostic modality. Richards et al reported a 98% sensitivity of ultrasound for hemoperitoneum in grades III and higher liver injury.⁴ However, they were not able to identify the anatomic location of the hepatic parenchymal injury in 67% of these severely damaged livers. A multi-institutional study by Rozycki et al concluded that the RUQ area is the most common site of hemoperitoneum accumulation in blunt abdominal trauma.⁵ Diagnostic peritoneal lavage (DPL) is a very accurate method for determining the presence of intraperitoneal blood, though it has been largely replaced by ultrasound for the diagnosis of hemoperitoneum. It should remain a component of the trauma surgeon’s skill-set as ultrasound is not universally available, excessive subcutaneous air or morbid obesity can render ultrasound difficult to interpret, and the sensitivity of FAST after penetrating injuries is less than that for blunt. FAST has a reported sensitivity of 46% and specificity of 94% in penetrating injury.^6,7 It can be used to triage patients to surgery if positive, but is not a reliable tool to exclude injury if negative. Two interesting studies have demonstrated that fascial penetration can be verified by ultrasound examination.⁸ Again, the sensitivity of this modality is low but the specificity is high. Ultrasound may be a good screening tool for fascial penetration and a positive result could alleviate the need for bedside wound exploration and also contribute to operative decision making.⁹ Future study in this area may develop greater uses for ultrasound in select penetrating injuries.

Hemodynamically Stable Patient

FAST examination has proven to be a very good diagnostic tool in the diagnosis of hemoperitoneum in the blunt trauma patient, but a negative FAST does not preclude the presence of a liver injury.¹⁰

Contrast-enhanced sonography shows some promise in the detection of liver injury. Contrast-enhanced ultrasound uses intravenously injected microbubbles containing gases other than air to produce the “contrasted” images. Valentino et al reported a 100% sensitivity and specificity in seven liver injury patients with grade II–IV injuries.¹¹ Similarly McGahan et al reported 90% detection in liver injuries of the same grades.¹² Another study described the ability of this modality to detect active extravasation from solid organs.¹³ With these advancements, patients may be subject to less risk from radiation or CT contrast. However, technology is not yet at the point where this technique can replace CT scanning.

CT Scanning

The advent of CT scanning and advances in technology has resulted in tremendous changes in the management of liver injury. Since the first use of CT to diagnose intra-abdominal injury in the early 1980s, CT has become a routine part of the management of trauma patients.^14,15 The advent of the helical CT scan has improved resolution and speed of scanning. Being able to grade the extent of injury and to follow the evolution of an existing injury can determine if nonoperative management is possible and successful (Fig. 29-4). A contrast-enhanced helical CT scan provides information on injury grade, amount of hemoperitoneum, active extravasation of contrast (Fig. 29-5), and the presence of pseudoaneurysm.

CT scanning is also being used in penetrating injury. Triple-contrast CT in back and flank wounds has been shown to have good sensitivity; however, the sensitivity for diaphragmatic and small bowel injury is less.¹⁶ Therefore, a minor hepatic laceration can be evaluated and nonoperatively managed with CT guidance, but continued frequent abdominal exam must also accompany this algorithm.

Laparoscopy

Laparoscopy has been successfully used to diagnose peritoneal penetration of penetrating trauma, thus saving the patient from a nontherapeutic exploratory laparotomy.¹⁷ Repair of hepatic injury found at laparoscopy has also been reported in hemodynamically stable patients.^18,19

Anatomic relationships are key to understanding the management of liver trauma. Blunt hepatic injury traverses almost exclusively along the segments of the liver. This most likely occurs due to the strength of the fibrous covering around the portal triad preventing injury from transecting these structures. However, the hepatic veins do not have a similar fibrous structure and therefore, having less resistance, are the primary structures injured in blunt trauma. Penetrating trauma, on the other hand, involves both venous and arterial injury with direct transection of any structure in the trajectory. These anatomic principles are key to understanding the rationale for making decisions in the management of liver trauma.

Hemodynamically Normal Patient With Blunt Injury

Nonoperative treatment of the hemodynamically normal patient with blunt injury has become the standard of care in most trauma centers (see Fig. 29-4). In 1995, Croce et al published a prospective trial of nonoperative management of liver injury.¹ In this study, patients with all grades and volumes of hemoperitoneum were evaluated against operative controls. The investigators found that successful nonoperative management was possible in 89% of hemodynamically normal patients. Most blunt liver injuries produce hepatic venous injuries that are low pressure (3–5 cm H₂O). Hence, hemorrhage usually stops once a clot forms on the area of disruption. Successful nonoperative therapy resulted in lower transfusion requirements, abdominal infections, and hospital lengths of stay. Hurtuk et al found that in the past 10 years there has been no effect on mortality in solid organ injury with the increased prevalence of nonoperative management.²⁰ Coimbra et al reiterated these data by examining their experience in nonoperative treatment of grade III and IV hepatic injury.²¹ They reported no mortality in their nonoperatively managed patients. Richardson et al have recommended that hemodynamically stable patients who have received less than 4 units of blood can be safely managed nonoperatively.²² Unlike the spleen, liver-related bleeding can be made worse by operative intervention. Manipulation of venous injuries can result in massive hemorrhage and death.²³

A study by Tinkoff et al showed that the need for operative intervention increases with liver grade, but grade alone is not an indication for operation. These data from the National Trauma Data Bank demonstrated that 73% of grade IV and 63% of grade V liver injuries could be successfully managed nonoperatively.²⁴ A more recent retrospective study by the research consortium of New England Centers for Trauma examined nonoperative management of only grade IV and V injuries and reported an 8.8% failure rate for nonoperative management. Risk factors for failure were a presenting blood pressure of less than 100 mm Hg and the presence of associated abdominal injuries. Importantly, they found no increase in mortality in patients that failed initial nonoperative management.²⁵ However, Polanco et al, using National Trauma Data Bank data from patients with liver AIS scores of greater than or equal to 4, asked the question, “has the pendulum swung too far?”²⁶ In the study, they showed a rather alarming trend in the percentage of hypotensive patients that underwent attempted nonoperative management. Although only seven percent of the patients failed, those patients had a statistically significant increase in mortality. Age, sex, injury severity score (ISS), Glasgow Coma Score (GCS), and (not surprisingly) hypotension were predictors of unsuccessful nonoperative management. This paper highlights the importance of the initial management decision in patients with high-grade liver injuries. An additional factor favoring successful nonoperative management of high-grade liver injuries is the type of resuscitation strategy that is implemented. As recently shown by Shrestha et al, damage control resuscitation strategies increased successful nonoperative management and decreased mortality in a retrospective review of over 200 patients with grade IV and V hepatic injuries who received blood products.²⁷ Importantly, there was no increase in liver-related complications.

The extent of hemoperitoneum, presence of contrast extravasation, or pseudoaneurysm are not contraindications for nonoperative management; however, these patients are at higher risk for nonoperative failure. A patient with a CT finding of contrast blush or extravasation may benefit from catheter-directed intravascular therapy and angioembolization, though the precise indications for angiography have not been well defined. Misselbeck et al reviewed their 8-year experience with hepatic angioembolization and found that hemodynamically stable patients with contrast extravasation on CT scan were 20 times more likely to require embolization than those without extravasation.²⁸ Sivrikoz and colleagues have shown that angiography in severe blunt hepatic injury is associated with improved survival in both operatively and nonoperatively managed patients; however, patients managed with angiography did have more complications.²⁹ Finally, Letoublon et al employed angioembolization for either active contrast extravasation seen on CT scanning in hemodynamically stable patients managed nonoperatively or as an adjunctive technique to control arterial bleeding despite laparotomy. They report a complication rate of 70% in their retrospective review.³⁰

Complications of Nonoperative Blunt Hepatic Injury Management

Most, but not all, patients with blunt nonoperative liver injuries heal without complication.³¹ A retrospective multi-institutional study included 553 patients with grade III–V injury.³² Of these patients, 12.6% developed hepatic complications that included bleeding, biliary pathologies, abdominal compartment syndrome, and infection. Significant coagulopathy and grade V injury were found to be predictors of complication. Therefore, with current nonoperative management strategies, complications must be expeditiously recognized and dealt with appropriately.

Bile Leaks

One of the more frequent complications is bile leakage. Bilomas or bile leak can occur in 3–36% of nonoperatively managed patients.³³ Hepatobiliary hydroxy iminodiacetic acid (HIDA) scan and MRCP have been used to localized bile leaks.³⁴ Evidence of bile leak by HIDA scan does not mandate intervention. Hyperbilirubinemia, abdominal distention, and intolerance to feeding may all indicate a bile leak. CT scan or ultrasound evaluation with percutaneous drainage is the treatment for symptomatic leaks. Importantly, the majority of bile leaks occur after operative management. Anand et al found that only 8% of patients developed bile leak with high-grade liver injuries managed nonoperatively.³⁵ For patients presenting with bile peritonitis and/or with large leaks not responsive to percutaneous drainage alone, the addition of endoscopic retrograde cholangiography (ERC) (Fig. 29-6) and biliary stent placement is effective.³⁶ Sphincterotomy can also decrease the biliary pressure and allow healing of the bile leak.³⁷ In some instances, actual stenting of a large ductal injury can be accomplished.³⁸ Griffen et al have reported success with a combined laparoscopic and ERC approach. They described patients with biliary ascites taken to operating room for laparoscopic bile drainage and drain placement near the site of injury with postoperative ERC and bile duct stenting. They reported no septic complications and healing of the substantial biliary leaks.³⁹ Hommes et al, in their prospective observational study, classified bile leaks as minor or major, with major defined as greater than 400 mL/d or leaks lasting greater than 14 days. Patients with major leaks underwent ERC and stenting while minor bile leaks nearly always resolved without ERC or other decompressive maneuvers.⁴⁰

Abscess

Perihepatic abscesses have also been uncommonly encountered with nonoperative management (Fig. 29-7). The patient may exhibit signs of sepsis, abnormal liver function tests, abdominal pain, or food intolerance. Abscesses, like biliary collections, can often be managed by CT-guided drainage catheters. However, if the patient fails to improve with drainage and antibiotics, wide surgical drainage should be performed. This may involve merely incision and adequate drainage of the cavity or it may involve extensive debridement of the hepatic parenchyma.

Hemorrhage

Delayed hemorrhage after nonoperative management is fairly rare. Kozar et al reported a 13% overall incidence of liver-related complications in patients presenting with high-grade (grades III–V) injuries managed nonoperatively, with bleeding accounting for 8% of the complications.⁴¹ Bleeds occurred almost equally between early (<24 hours) and late (>24 hours) time periods post-injury. Late bleeds occurred only in patients with grade IV and V injuries, the majority of which were managed with angioembolization.

Devascularization and Hepatic Necrosis

Disruption of vascular inflow to a hepatic segment following trauma or post-angioembolization can lead to necrosis of that segment of liver. The consequences of necrosis may include elevation of liver transaminases, coagulopathy, bile leaks, abdominal pain, feeding intolerance, respiratory compromise, renal failure, and sepsis. Devascularization can be identified by CT scan. It can be differentiated from intraparenchymal hemorrhage when follow-up CT scans reveal segments of liver that remain devascularized or have foci of air within the devascularized area.⁴² Hepatic necrosis requiring operative debridement occurs much less frequently in patients managed nonoperatively.

Hemobilia

Hemobilia can occur after blunt hepatic injury. In 1871, Quincke described the triad of right upper quadrant pain, jaundice, and upper GI bleeding that indicated hemobilia. This triad may not be evident in the trauma patients with hemobilia.⁴³ In a 1994 study, three patients developed hemobilia with massive upper gastrointestinal hemorrhage following blunt hepatic injury.⁴⁴ The authors concluded that hepatic artery pseudoaneurysm with hemobilia is predisposed by bile leak and that angiographic embolization was appropriate for patients without sepsis and with small cavities. However, formal hepatic resection or drainage, after angiographic vascular control, may be necessary for septic patients or those with large cavities. Hemobilia is much less common with the prevalence of nonoperative management.

Systemic Inflammatory Response

Nonoperatively treated patients with inadequately drained bile or blood collections may be susceptible to the development of systemic inflammatory responses syndrome. Franklin et al and Letoublon et al advocate laparoscopic evacuation of undrained bile or hemoperitoneum at post-injury days 3–5.^45,46 They report a marked decrease in the inflammatory response in many of these patients.

Unusual Complications

Large subcapsular hematomas have been described to elevate intraparenchymal pressures high enough to cause segmental portal hypertension and hepatofugal flow.⁴⁷ This “compartment syndrome of the liver” was described in a patient managed nonoperatively whose decreasing hematocrit and increasing liver function tests promoted angiographic examination revealing the hepatofugal flow in the right portal vein. After operative drainage of the tense hematoma, the patient did well with reversal of flow and viability of the right lobe liver tissue. This type of compressive complication has also been described causing Budd–Chiari syndrome when hematoma results in intrahepatic vena cava compression or hepatic venous obstruction.⁴⁸ With the frequent use of CT scanning, previously unidentified complications of liver injury may be seen. Figure 29-8 shows a series of CT scan images of a patient that underwent operative control of liver bleeding with packing followed immediately by CT scanning. Thrombosis of the retrohepatic cava was seen, with clot extending up to the right atrium. Approximately 24 hours after packs were removed and therapeutic anticoagulation was started.

Follow-Up CT Scanning of Blunt Hepatic Injury

Definitive data on the value of follow-up CT scanning of blunt hepatic injury are not available. Some published reports suggest postobservation CT scans on those with more severe (grade III–V) injuries. Cuff et al reported that of the 31 patients who received follow-up CT scans 3–8 days post-injury, only 3 patients’ scans affected future management.⁴⁹ Additionally, the three scans that affected management were obtained due to a change in clinical picture and not merely routine. Cox et al concluded from their follow-up of 530 patients, including 89 grade IV or V, that follow-up CT scans are not indicated as part of the nonoperative management of blunt liver injuries.⁵⁰ There are certain patterns of injury that may be at higher risk of biliary complications, such as a cleft injuries, suggesting that routine follow scans may aid in diagnosis.⁵¹ Unfortunately, the time to onset of biliary complications can range from days to weeks, making a recommendation difficult.⁴¹ Currently, follow-up CT scans are generally indicated only for those patients who develop signs or symptoms suggestive of hepatic abnormality.

Length of Observation, Venous Thromboembolic Prophylaxis, and Resumption of Activity

Bed rest and prolonged periods of in-hospital observation are no longer advocated. Parks et al concluded in their retrospective study of 591 patients with blunt liver injuries that the length of in-hospital observation should be based solely on clinical criteria and they recommended discharge in patients with a normal abdominal examination and stable hemoglobin.⁵² Though data is retrospective and studies are small, existing data suggest that early (defined as ≤48 hours) institution of chemical thromboembolic prophylaxis is safe.^53,54 Resumption of normal activity also seems safe, but the period of time needed to refrain from high-risk activities, such as contact sports, remains unclear. Most hepatic injuries seem to have resolved by CT in 4 months, but whether this period of time is optimal, is unknown. A contrary approach to this practice can be based on some interesting animal studies. Dulchavsky et al found in animal studies that hepatic wound burst strength at 3 weeks was as great or greater than uninjured hepatic parenchyma.⁵⁵ This is most likely a result of fibrosis throughout the injured parenchyma and Glisson’s capsule. This study suggests that activity can be resumed about 1 month after injury, though human studies have not been performed.

Hemodynamically Normal Patient With Penetrating Injury

Nonoperative Management of Penetrating Injury

Peritoneal penetration has mandated operative exploration for many years. However, many trauma centers have adopted selective nonoperative management of knife stab wounds to the right upper quadrant. The work of Nance and Cohn in 1969 supported this nonoperative care in patients with stab wounds who were hemodynamically normal and had no evidence of peritoneal irritation.⁵⁶ Since then, reports of successful nonoperative management of gunshot wounds (GSW) have been published. Renz and Feliciano prospectively treated 13 patients with right thoracoabdominal GSW nonoperatively.⁵⁷ The rationale behind this management is that the wounds caused by small caliber weapons may produce injury to diaphragm and liver only, sparing any intestinal injury. The authors stressed the importance of serial abdominal exams and contrast CT scanning in their successful nonoperative management of penetrating injury. Other centers concur with this selective nonoperative management.^58,59 Demetriades et al even reported successful nonoperative management of penetrating grade III and IV liver injuries that required angioembolization.⁶⁰ The criteria for nonoperative management include those patients who are hemodynamically normal, have no peritoneal signs, and are not mentally impaired. These patients then undergo contrast-enhanced CT scan to rule out other abdominal visceral injury. Serial abdominal exams as well as close hemodynamic monitoring are also implemented. Triple-contrast CT of 86 abdominal GSW, as reported by Shanmuganathan et al, had a sensitivity and specificity of 97% and 98%, respectively.⁶¹ Velmahos et al do not use triple-contrast CT and report a sensitivity and specificity of 90.5% and 96%, respectively, in diagnosing intra-abdominal organ injuries requiring surgical intervention.⁶²

Missed or deliberate nonrepair of small diaphragmatic lesions may lead to long-term adverse sequelae, not only of diaphragmatic herniation, but also of possible bilio-pleural fistula.⁶³ Late intervention for other missed injury (eg, duodenal injury) may also lead to substantial morbidity. Nonoperative management of right upper quadrant penetrating trauma must be performed at a center with sufficient resources that has not only the capability of close continuous monitoring, but also CT radiology accessibility and immediate operating room availability.

Operative Management of Patients With Minor Liver Injury

The decision for operative intervention of incidental liver injury may develop due to laparotomy for penetrating injury, patient instability, or concomitant internal injury. The incision of choice remains the midline incision from the xiphoid to the pubis with full surgical prep of the chest, abdomen, and groins, thus the ability to rapidly access all cavities. Not only will the operating surgeon be able to gain access to the hepatic region, but the entire peritoneal cavity will also be able to be inspected and manipulated. On opening the peritoneal cavity, attention should first be focused on the rapid evacuation of old blood and stopping ongoing hemorrhage. Laparotomy pads should be used to clear the peritoneal cavity of clot. In minor liver injury, the bleeding from the liver can initially be managed with packing of the hemorrhagic area. While packs are in place, the remainder of the peritoneal cavity should be inspected for bowel and other solid organ injury. Many minor liver injuries do not require operative fixation and nonbleeding wounds should not be probed or otherwise manipulated, as this may exacerbate the situation and cause dislodgement of clot. Small wounds of the liver parenchyma with minimal bleeding may be able to be controlled with electrocautery, argon beam coagulation, or topical hemostatics. Small to moderate bleeding cavities may first be inspected for any obvious bleeding vessels that can be ligated. Next, packing a tongue of omentum, with its vascular supply intact, into the wound halts most moderate bleeding. Stone and Lamb first described this technique in 1975.⁶⁴ Wrapping a column of absorbable gelatin sponge with oxidized regenerated cellulose makes another beneficial device. This is then inserted like a plug into deeper bleeding cavities. Omentum is often then brought up into the wound and secured to increase hemostasis. These maneuvers are very successful in the management of minor liver injury.