Selective vascular isolation of the liver as part of initial damage control for grade 5 liver injuries: Shouldn’t we use it more frequently?

•Patients with severe liver injury may as part of the initial damage control operation, concurrently with intermittent Pringle maneuver, and intra- and perihepatic packing.•For patient unstable to undergo embolization in the intervention radiology suite, or if there is no such service in the hospital, selective vascular isolation of various liver vessels performed by the trauma surgeon should be an option.•Trauma surgeons should be able and trained to perform selective vascular isolation for liver injuries.

BackgroundSevere liver trauma (grade 4 and 5) carries mortality greater than 40%. It represents a major surgical challenge in patients with hemodynamic instability who require an immediate exploratory laparotomy. Perihepatic packing and damage control can sometimes work, but for severe liver injuries, adjunct maneuvers might be needed (such as early embolization or hepatic artery ligation). During a patient’s first operation for severe liver trauma, anatomic resection is rarely tolerated.Materials and methodsWe managed a 31 year-old male with a blunt grade 5 right-lobe liver injury in severe hypovolemic shock.ResultsAs part of the initial damage control operation, concurrently with intermittent Pringle maneuver, he underwent intra- and perihepatic packing; selective isolation and ligation of the right portal vein, right hepatic artery, and right hepatic vein; and repair of the retrohepatic inferior vena cava. Then, 36 h later, the patient underwent a right hepatectomy.ConclusionFor patients with severe liver injuries, selective vascular isolation and ligation may be considered as part of damage control (in addition to intermittent Pringle maneuver) and might enable anatomic resection at a later stage.