Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 71


Home  | About Us | Editors | Search | Ahead Of Print | Current Issue | Archives | Submit Article | Instructions | Subscribe | Contacts | Login 

Table of Contents
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 118-123

Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia

1 Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Radiology, Zagazig Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Department of Radiology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Web Publication29-Jun-2013

Correspondence Address:
Wagih Mommtaz Ghnnam
14 Gawad Hosney Street, Sherbin, Dakahlia
Login to access the Email id

Source of Support: This research is approved by our hospital (Khamis Mushayt General Hospital research committee) no external funds used, Conflict of Interest: None

DOI: 10.4103/2229-5151.114271

Rights and Permissions

Background: To evaluate our experience with non-operative management of blunt liver trauma at a level II trauma hospital in the Kingdom of Saudi Arabia.
Materials and Methods: We prospectively evaluated 56 patients treated for blunt liver trauma at our hospital over a 4-year period (April 2008 to April 2012). Patients who were hemodynamically stable [non-operative group I (NOP)] were treated conservatively in the intensive or intermediate care unit (ICU or IMCU). Patients who were hemodynamically unstable or needed laparotomy for other injuries were treated by urgent laparotomy [operative group II (OP)]. All NOP group patients had computed tomography (CT) of the abdomen with oral and intravenous contrast. Injuries grades were classified according to the American Association for the Surgery of Trauma (AAST). Follow-up CT of the abdomen was performed after 2 weeks in some cases.
Results: A total of 56 patients were treated over a 4-year period. Twenty patients (35.7%) were treated by immediate surgery. NOP group of 36 patients (64.3%) were managed in the ICU by close monitoring. Surgically treated group had more patients with complex liver injury (90% versus 58.3%), required more units of blood (6.05 versus 1.5), but had a longer hospital stay (16.6 days versus 15.1 days). None of the patients from the non-operated group developed complications nor did they need operation. The only mortality (in two patients) was in the operated group.
Conclusion: The NOP treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The NOP treatment should be the treatment of choice in such patients whenever CT and ICU facilities are available.

Keywords: Blunt abdominal trauma, hepatic trauma, hepatoraphy, non-operative management

How to cite this article:
Ghnnam WM, Almasry HN, Ghanem MA. Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia. Int J Crit Illn Inj Sci 2013;3:118-23

How to cite this URL:
Ghnnam WM, Almasry HN, Ghanem MA. Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia. Int J Crit Illn Inj Sci [serial online] 2013 [cited 2022 Dec 4];3:118-23. Available from: https://www.ijciis.org/text.asp?2013/3/2/118/114271

   Introduction Top

The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury. The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle crashes (MVC), and associated injuries contribute significantly to mortality and morbidity and may masks the liver injury, leading to a delay in diagnosis. [1],[2],[3]

Management of hepatic injuries has evolved over the past 30 years. Prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of concern about ongoing hemorrhage and/or missed intra-abdominal injuries needing repair. [4] The recognition that between 50% and 80% of liver injuries stop bleeding spontaneously, coupled with better imaging of the injured liver by computed tomography (CT) has led progressively to the acceptance of non-operative (NOP) management with a resultant decrease in mortality rates. [5] Modern treatment of liver trauma is increasingly NOP. Advantages of NOP management include avoidance of non-therapeutic celiotomies and the associated cost and morbidity, fewer intra-abdominal complications compared to operative repair, and reduced transfusion risks. It is associated with a low overall morbidity and mortality and does not result in increases in length of the hospital stay, need for blood transfusions, bleeding complications, or associated hollow viscus injuries as compared with operative management. Improvement in resuscitation and careful monitoring in high dependency unit, coupled with advances in diagnostic tools has helped to make a NOP policy possible and acceptable. [6],[7],[8] Neither the grade of injury nor the amount of hemoperitoneum on CT predicts the outcome of NOP management and mandates laparotomy. [9]

Surgeons should have a clear understanding of the indications for operative intervention. [10] Patients with hepatic trauma associated with hemodynamic instability and other organ injuries require surgery, because they continue to have significantly higher mortality. [11],[12]

This study evaluated the outcome of NOP management of liver injury in a level II trauma hospital in Saudi Arabia.

   Materials and Methods Top

During a 48-month study period, starting April 2008, we prospectively included all patients who were admitted to our level II trauma hospital with blunt liver trauma diagnosed by abdominal ultrasonography (US) and CT in hemodynamically stable patients and operative findings in hemodynamically unstable patients. Ethical approval to conduct the study was obtained from our hospital ethics' review committee before the commencement of the study.

Our protocol for treating patients with suspected blunt abdominal trauma was immediate resuscitation and Focused Abdominal Ultrasonography for Trauma (FAST) done (while resuscitation going on) in the emergency department (ER); once free intra-peritoneal fluid was detected in hemodynamically unstable patient, they were shifted immediately to the operative room (OR) for exploratory laparotomy and, if liver injury was found, they were included in the operative group (group II).

In hemodynamically stable patients found to have intra peritoneal fluid by abdominal US, abdominal CT with intravenous contrast was done immediately or within 24 hours in all cases and liver injury graded by CT were included in group I (NOP group) [Figure 1], [Figure 2], [Figure 3]; all patients were admitted in the intensive or intermediate care unit (ICU or IMCU) and kept under close observation. All the patients were monitored for serial complete blood count (CBC) assessment every 8-12 hours. All patients were advised to restrict their activity quietly in the bed for 48-72 hours. When three serial CBC assessments were stable and the follow-up abdominal US findings had not worsened, the patients were shifted to the ward and allowed quiet activity. On the 7 th day, if there was no significant alteration in the hematology and US findings and the patient continued to be stable, the patient was discharged home with instructions to restrict activity at home for 2-4 weeks from the time of injury. Moreover, these patients were regularly followed-up bi-weekly at a outpatient clinic.
Figure 1: Axial post-contrast CT shows small hepatic contusion

Click here to view
Figure 2: Axial post-contrast CT shows capsular tear, stellate hepatic laceration with injury close to the hilum, no hematoma, grade III

Click here to view
Figure 3: Axial post-contrast CT shows capsular tear, large stellate hepatic laceration involving segments 7 and 8, active hemorrhage, and subcapsular hematoma, grade IV

Click here to view

Data on demographic characteristics, injury type and severity, associated injuries, blood transfusions, interventions, failure of NOP management, hospital stay, and death were presented. Patients were grouped into those who underwent an immediate operation (OP) and those who were managed without operation (NOP).

Assessment of hemodynamic stability was based on routine vital signs. Patients with systolic blood pressure >90 mmHg, either at admission or after 2 l crystalloid infusion, were generally regarded as hemodynamic stable. NOP management was applied to all hemodynamic stable patients with hepatic injury, regardless of the grade of liver injury.

Injury severity was determined from CT and operative observations and classified by means of the Liver Injury Scale (LIS) [Table 1]. [13] Patients who underwent laparotomy for hemodynamic instability or any other indication, either with or without a CT scan, were classified as being treated operatively. Other patients admitted to the ICU or surgical ward for observation were classified as being treated non-operatively.
Table 1: The liver injury scale classification[13]

Click here to view

Any patient who was initially observed in the ICU and subsequently required surgery was considered a failure of NOP management. NOP management was discontinued in patients with hemodynamic instability, who were unresponsive to moderate amounts of crystalloid infusion, who had a significant fall in hematocrit and hemoglobin concentration, or if any intra-abdominal hollow viscus injury was suspected. There were no other specifically defined criteria for abandonment of NOP management.

Statistical analysis was performed with SPSS version 19 using the Chi-square test for discrete variables and the unpaired t test for continuous variables. Level of significance was set at P < 0.05.

   Results Top

A total number of 4382 trauma patients were referred to our hospital and 846 (19.3%) patients had abdominal trauma; 56 patients (6.6%) had hepatic injury, 52 (92.9%) were male, and 4 (7.1%) were female. The mean age was 36.7 ± 15.3 years (range 17-81 years) [Table 2]. Most hepatic trauma were due to motor vehicle crashes (MVCs) including car drivers and pedestrians, 50 cases (89.2%) while non-traffic causes including falls were the etiology in 5 patients (8.9%) of blunt hepatic trauma [Table 3]. Associated traumas (85.7%) included both intra and extra-abdominal injuries. Spleen trauma was the most common associated intra-abdominal injured organ seen in 4 (7.1%) patients. Other associated injuries were thorax (26.8%), intracranial injury (25%), and lower extremity (12.5%). Isolated hepatic injuries were in 8 (14.3%) cases [Table 3]. Duration of hospital stay was 0-36 days with a mean of 15.6 ± 7.6 days and a median of 14.5 days. There was insignificant difference in hospital stay between the patients operated and those managed non-operatively [Table 2]. Patients with operative management had significantly worse admission hemodynamic parameters, higher ISS, and higher grade of liver trauma. ISS mean and median were 26.3 ± 12.8 and 25 years, respectively. One patient was explored because of renal injury [Figure 4]. Grading of injury showed significant difference with the management (P < 0.001). A significantly higher death rate was in the patients with higher ISS (P < 0.0001). Dead patients had higher grade of injury. In group II patients, bleeding was controlled via techniques of suturing, packing, resection, and debridement [Table 4] and [Figure 5]. Two patients with grade V and VI of injury needed immediate surgery and died due to severity of injury and hemorrhage.
Figure 4: Coronal post-contrast CT shows combined liver and right kidney injury and the patient was explored, liver tear sutured, and kidney repaired

Click here to view
Figure 5: Intraoperative liver tear stopped bleeding spontaneously

Click here to view
Table 2: Characteristics of patients groups

Click here to view
Table 3: Grades, causes of liver injury, and associated injuries

Click here to view
Table 4: Operative methods for controlling bleeding in patients (n=20) with liver trauma

Click here to view

   Discussion Top

The size of the liver and its solid (non-compressible) consistency when combined, renders it vulnerable to blunt forces, applied either to the upper abdominal or lower thoracic regions, especially on the right. It is the most frequently damaged abdominal organ and is second only to the brain in overall visceral susceptibility to this modality of violence. [14] Because the liver is predominantly perfused with low-pressure venous blood, hepatic parenchymal injuries can often be treated non-operatively in stable patients. In the absence of definable active arterial extravasation, even extensive lacerations may be treated conservatively. [15] Non-surgical treatment has become the standard of care in hemodynamically stable patients with blunt liver trauma. The use of helical CT in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to non-surgical management of blunt liver injuries. [12]

In the literature, the most common cause of liver injury is blunt abdominal trauma, which is secondary to MVC; in most instances, blunt liver trauma is associated with spleen injury in 45% of patients. Rib fractures are associated with injury to the right superior aspect of the liver in 33% of patients. Isolated liver injury occurs in <50% of patients. Both blunt and penetrating liver injuries are more common in males, which are similar to our results mentioned above. [16],[17],[18] Konig et al., reviewed their liver trauma to assess their experience with these injuries, and the success of NOP management protocols and concluded liver trauma managed in a trauma centre has low morbidity and mortality. Mortality is governed mainly by poly trauma and, in the case of the liver, by the severity of grade of injury. [3] In our study, success rate of NOP was 100%, none of the case needed laparotomy; this coincide with the reported success rate in literatures. Initially, NOP management was applied to only lower-grade hepatic injuries and to patients with only mild to moderate amounts of hemoperitoneum. [11] As experience accumulated, more patients with blunt hepatic injury were managed non-operatively. In the current study, hemodynamically stable patients with no other injuries requiring operative intervention formed 64% of the total cases, and all these patients were successfully managed none surgically. In the initial reports of NOP management, there was concern that it would lead to higher transfusion requirements and to prolonged ICU and hospital lengths of stay. Although there have been reports about excessive blood being transfused in the hope that bleeding will stop, in recent studies, NOP management did not carry with it a greater need for transfusion than did operative management. Most reports agree with our study, that transfusion requirements are less with NOP management. [15],[19],[20]

Complication such as "biloma" and abscess formation has been reported. Their incidence varies from 2.8% for biloma and 0.7% for abscess. [21] We had no case of such complications.

Our patients who were non-operatively managed, showed no significant difference in the hospital lengths of stay. The death rate of all patients with liver injury was 3.6%, very similar to the rate in other reports. [4],[15] Patients with significant liver injury leading to death usually have early indications for surgery. All patients managed non-operatively were alive with no death reported [Table 5].
Table 5: Literature review of outcome of NOP management of liver injury

Click here to view

Limitation of study

In this study, all hemodynamically stable patients, irrespective of the grade of hepatic injury, underwent NOP management. We could not try to shorten the hospital stay for NOP group and will be considered in the future study.Sup>[23]

   Conclusion Top

We concluded that hemodynamically stable patients with liver injuries can be managed safely non-operatively, while urgent surgery continues to be the standard for hemodynamically compromised patients. NOP management does not lead to longer hospital stay or increased blood transfusion rates and it had excellent outcome.

   References Top

1.Brasel KJ, DeLisle CM, Olson CJ, Borgstrom DC. Trends in the management of hepatic injury. Am J Surg 1997;174:674-7.  Back to cited text no. 1
2.Coughlin PA, Stringer MD, Lodge JP, Pollard SG, Prasad KR, Toogood GJ. Management of blunt liver trauma in a tertiary referral centre. Br J Surg 2004;91:317-21.  Back to cited text no. 2
3.Konig T, Aylwin C, Walsh M, Hutchins R. Modern management of liver trauma. Inj Extra 2007;38:117.  Back to cited text no. 3
4.Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, et al. Blunt hepatic Injury: A paradigm shift from operative to non-operative management in the 1990s. Ann Surg 2000;231:804-13.  Back to cited text no. 4
5.Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, et al. Status of non-operative management of blunt hepatic injuries in 1995: A multicenter experience with 404 patients. J Trauma 1996;40:31-8.  Back to cited text no. 5
6.Lyuboslavsky Y, Pattillo MM. Stable patients with blunt liver injury: Observe, do not operate. Crit Care Nurs Q 2009;32:14-8.  Back to cited text no. 6
7.Gibson D, Canfield CM, Levy PD. Selective non-operative management of blunt abdominal trauma. J Emerg Med 2006;31:215-21.  Back to cited text no. 7
8.Al-Gari MA, Hussein SR. Trends in the management of blunt liver trauma. Saudi Med J 2002;23:513-6.  Back to cited text no. 8
9.Fang JF, Chen RJ, Wong YC, Lin BC, Hsu YB, Kao JL, et al. Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury. Am J Surg 1998;176:315-9.  Back to cited text no. 9
10.Bismar HA, Alam MK, Al-Keely MH, Alsalamah SM, Mohammed AA. Outcome of non operative management of blunt liver trauma. Saudi Med J 2004;25:294-8.  Back to cited text no. 10
11.Somasundar PS, Mucha P, McFadden DW. The evolving management of blunt hepatic trauma. Am Surg 2004;70:45-8.  Back to cited text no. 11
12.Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, et al. CT in blunt liver trauma. Radiographics 2005;25:87-104.  Back to cited text no. 12
13.Moore EE, Cogbill TH, Gregory JJ, Shackford SR, Malangoni MA, Howard CR. Organ injury scaling: Spleen and liver. J Trauma 1995;38:323-4.  Back to cited text no. 13
14.Tanaka T, Kawashita Y, Kawahara D, Kuba S, Kawahara Y, Fujisawa H, et al. Complete dissection of a hepatic segment after blunt abdominal injury successfully treated by anatomical hepatic lobectomy: Report of a case. Case Rep Gastroenterol 2011;5:125-31.  Back to cited text no. 14
15.Croce MA, Fabian TC, Menke PG, Waddle-Smith L, Minard G, Kudsk KA, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg 1995;221:744-55.  Back to cited text no. 15
16.Zangana AM. Penetrating liver War injury: A report on 676 cases, After Baghdad invasion and Iraqi Civilian War April 2003. Adv Med Dent Sci 2007;1:10-4.  Back to cited text no. 16
17.Christmas AB, Wilson AK, Manning B, Franklin GA, Miller FB, Richardson JD, et al. Selective management of blunt hepatic injuries including non operative management is a safe and effective strategy. Surgery 2005;138:606-10.  Back to cited text no. 17
18.Velmahos GC, Toutouzas K, Radin R, Chan L, Rhee P, Tillou A, et al. High success with nonoperative management of blunt hepatic trauma: The liver is a sturdy organ. Arch Surg 2003;138:475-81.  Back to cited text no. 18
19.Kozar RA, Moore FA, Cothren CC, Moore EE, Sena M, Bulger EM, et al. Risk factors for hepatic morbidity following nonoperative management. Arch Surg 2006;141:451-9.  Back to cited text no. 19
20.Sharma OP, Oswanski MF, Singer D, Raj SS, Daoud YA. Assessment of non operative management of blunt spleen and liver trauma. Am Surg 2005;71:379-86.  Back to cited text no. 20
21.Carrillo EH, Wohltmann C, Richardson JD, Polk HC Jr. Evolution in the treatment of complex blunt liver injuries. Curr Probl Surg 2001;38:1-60.  Back to cited text no. 21
22.Kirshtein B, Roy-Shapira A, Lantsberg L, Laufer L, Shaked G, Mizrahi S. Non operative management of blunt splenic and liver injuries in adult polytrauma. Indian J Surg 2007;69:9-13.  Back to cited text no. 22
23.Norrman G, Tingstedt B, Ekelund M, Andersson R. Nonoperative management of blunt liver trauma: Feasible and safe also in centres with a low trauma incidence. HPB (Oxford) 2009;11:50-6.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

This article has been cited by
1 Operation After Radiologic Embolization for Blunt Liver Trauma
Rebecca L. John,Mustafa H. Kabeer,Yigit S. Guner,David L. Gibbs
Journal of Pediatric Surgical Nursing. 2020; 9(3): 107
[Pubmed] | [DOI]
2 Non-operative management of blunt hepatic and splenic injury: a time-trend and outcome analysis over a period of 17 years
Margot Fodor,Florian Primavesi,Dagmar Morell-Hofert,Veronika Kranebitter,Anna Palaver,Eva Braunwarth,Matthias Haselbacher,Ulrich Nitsche,Stefan Schmid,Michael Blauth,Eva Gassner,Dietmar Öfner,Stefan Stättner
World Journal of Emergency Surgery. 2019; 14(1)
[Pubmed] | [DOI]
3 A systematic review of the safety and efficacy of non-operative management in patients with high grade liver injury
Yosuf Saqib
The Surgeon. 2019;
[Pubmed] | [DOI]
4 Blunt liver trauma: a descriptive analysis from a level I trauma center
Ibrahim Afifi,Sheraz Abayazeed,Ayman El-Menyar,Husham Abdelrahman,Ruben Peralta,Hassan Al-Thani
BMC Surgery. 2018; 18(1)
[Pubmed] | [DOI]
Dova Subba Rao,Mallapraggada Rama Chandra Mohan,Erabatti Santosh
Journal of Evidence Based Medicine and Healthcare. 2016; 3(33): 1551
[Pubmed] | [DOI]
Mallikarjun P,Vinay Sagar Cheeti,Ravi Shankar Karupothula
Journal of Evidence Based Medicine and Healthcare. 2015; 2(39): 6203
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded115    
    Comments [Add]    
    Cited by others 6    

Recommend this journal