Early diagnosis and management of liver trauma with hemorrhagic shock occasionally necessitates a multidisciplinary approach, involving emergency services, radiology, and the operating room, to control significant hemorrhage. In recent years, the use of all-in-one resuscitation rooms in Japan, known as hybrid emergency rooms (ER), has been expanding for trauma care. We present a case of a 50-year-old man with penetrating liver trauma that was rapidly treated in the hybrid ER from diagnosis to definitive care from surgery to angioembolization without transferring the patient (240 minutes). The use of the hybrid ER system may improve survival rates in cases of penetrating torso trauma due to a shortened duration from patient arrival to diagnosis.

In abdominal trauma, the liver is the most injured organ and treatment is usually determined by hemodynamics. Severe liver injury with extensive parenchymal injury and uncontrollable bleeding may rapidly evolve into the lethal triad of death (acidosis, hypothermia, and coagulopathy), requiring damage control surgery (DCS). Damage control resuscitation for trauma treatment reduces the need for DCS by enabling rapid control of massive bleeding. Thus, definitive surgery can be completed in one operation. Despite the systematic application of damage control resuscitation, definitive surgery cannot be achieved in severe, and extensive liver injuries. Therefore, understanding, and acquiring damage control surgical techniques is necessary to achieve DCS for severe liver injury. The Western Trauma Association and the World Society of Emergency Surgery have proposed algorithms for the nonoperative and operative management of blunt hepatic trauma. The algorithms list several surgical skills, including electrocautery or argon beam, manual compression, perihepatic packing, the Pringle maneuver, liver suture, omental packing, selective hepatic artery ligation, balloon tamponade, hepatic vascular isolation, and the shunt operation. These techniques require a multidisciplinary approach and individual honing of skills by the surgeon. Trauma surgeons, even hepatobiliary surgeons, must practice damage control techniques in severe liver injury models (animals or cadavers).

A male pedestrian in his 30’s was hit by a car and immediately taken to hospital by ambulance. On arrival, his blood pressure was 83/64 mmHg and his heart rate was 140 beats/min. Computed tomography showed extravasation of contrast medium from the lateral segment of the liver. Given the exacerbation caused by hypotension, an emergency laparotomy was performed. Temporary hemostasis was achieved by packing with gauze and a subsequent transcatheter arterial embolization. At the 2^nd laparotomy, a small amount of active bleeding from the injury site was noted; therefore, an emergency lateral segmentectomy was performed. The postoperative course was uneventful and he was discharged home 8 days later. The pathology of the liver specimen revealed that a 2.5 cm hepatic hemangioma was the cause of bleeding. Traumatic rupture of hepatic hemangiomas is rare, and most reported cases are of giant hemangiomas. Our case demonstrated that even a small hemangioma can elicit life-threatening bleeding in blunt abdominal trauma.

Citations

• Rupture of a Hepatic Hemangioma in the Remnant Liver Following Hybrid Extended Left Hemihepatectomy in a Living Liver Donor: A Case Report
  Rei Tsunoda, Hajime Matsushima, Akihiko Soyama, Ayaka Kinoshita, Kazushige Migita, Ayaka Satoh, Shun Nakamura, Fumika Kamehama, Takashi Hamada, Hajime Imamura, Tomohiko Adachi, Susumu Eguchi
  Surgical Case Reports.2026; 12(1): n/a.     CrossRef

Non-operative management of blunt liver injury has been demonstrated as a safe and effective treatment for most grades of injury. As the severity of liver injury increases, so does the risk of complications. A 21-year-old male was brought to the trauma center following a high speed motorbike accident. He underwent a laparotomy and angioembolization for a Grade 4 liver injury. A biloma was diagnosed on Day 18 post injury, and he underwent Endoscopic Retrograde Cholangiopancreatography and biliary stenting which were unsuccessful. There were 2 re-admissions for infected perihepatic collections. In this case, an Endoscopic Retrograde Cholangiopancreatography was not a helpful procedure due to a disconnected liver segment, and morbidity occurred due to instrumentation of the biliary tree (the likely cause of infected biloma). Hepatic resection should be considered for patients who fail non-operative management. Further assessment of efficacy using a larger dataset for analysis is required.

Purpose
Liver injuries constitute an important cause of hospital admissions, pediatric morbidity, and sometimes mortality. This study was undertaken to assess the spectrum of pediatric liver injuries with special emphasis on the management of acute complications.
Methods
This retrospective study used data from the Department of Pediatric Surgery, Bangalore Medical College, Bengaluru, India, between March 2013 and March 2019. All children between 1-18 years were included in the study (n = 33). Children were assessed with relevance to age, sex, mode of injury, hemodynamic stability at admission, need for blood transfusions, surgery, radiological investigations, complications, total number of days of stay in hospital, and mortality.
Results
There were 27 (81.8%) males and 6 (18.18%) were females. The most common cause for injury was a road traffic accident (60.6%). The majority (nearly 65%) of pediatric liver injuries were Grade II and III. There were 4 children who had post traumatic complications including 2 pseudoaneurysms, 1 inferior vena cava thrombus, and 1 bile leak with a biloma formation which were managed appropriately.
Conclusion
Timely and appropriate radiological evaluation is required for assessments of complications. The majority of complications can be managed conservatively, and minimally invasive techniques like endoscopic retrograde cholangiopancreatography is helpful in the management of complications.