CHAPTER XXI
Wounds of the Liver and of the Extrahepatic Biliary Tract
(829 Casualties)
Gordon F. Madding, M. D., Knowles B. Lawrence, M. D., and Paul A. Kennedy, M. D.
The 829 wounds of the liver which are discussed in this chapter occurred in3,0661 of the 3,154 abdominal injuries observed by the 2d AuxiliarySurgical Group during 1944 and 1945 (table 73). Four hundred and forty-six (53.8percent) were thoracoabdominal. The case fatality rate in this group was 24.0percent (107), against 27.0 percent (224) for the whole group. In 51 of the 829wounds of the liver, the gallbladder was injured, and the extrahepatic biliaryducts were injured in 2 others. There were 16 deaths in these 53 cases.
TABLE 73.-Essential data in 829 wounds of liver
Type of wound | Cases | Frequency | Deaths | Case fatality rate | |
In 3,066 abdominal injuries | In 829 liver injuries | ||||
|
| Percent | Percent |
|
|
Univisceral | 339 | 11.1 | 40.9 | 33 | 9.7 |
Multivisceral | 490 | 16.0 | 59.1 | 191 | 39.0 |
| 829 | 27.0 | 100.0 | 224 | 27.0 |
NATURE OF INJURY
The majority of these injuries occurred in the right lobe of the liver, as might have been expected because of its greater size. In the 538 cases observed in 1944 in which these data were accurately stated, the right lobe was involved 446 times (82.9 percent), the left lobe 73 times, and both lobes 19 times. In-
1Calculationsfor injuries of the liver are made on a total of 3,066 abdominal injuries,instead of on 3,154, the base figure for all other calculations. When the 88histories which represent the difference between the two totals becameavailable, the medical officers who had done the work on wounds of the liver hadbeen transferred from the command, and it was thought wiser not to change theirtabulations.
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volvement of adjacent viscera could usually be explained bythe location of the hepatic injury. Wounds about the hilum were seldom seen,possibly because its protected location kept it from injury but more probablybecause most such injuries were immediately fatal. Injuries in this areainvolved such structures as the extrahepatic biliary ducts, the retroperitonealportion of the duodenum, the pancreas, the stomach, the colon, and the venacava.
Most wounds of the liver were lacerating, penetrating, or perforating.Penetrating wounds were usually less serious than those which involved largermasses of tissue, though they were sometimes followed by graver complications,such as bile leakage or hemorrhage. Twenty-four percent of all hepatic injurieswere severe, sometimes severe enough to require resection of a part of a lobe.The remaining wounds were described as of slight or moderate severity.
Bleeding from the liver, which was only occasionally described as severe, hadceased at the time of exploration in 91.1 percent of all cases. The significanceof this observation will be discussed later (p. 278).
Some bile leakage had occurred in practically every case, butthe presence of blood and exudate in the peritoneal cavity, and sometimes ofintestinal content also, made an estimate of the amount of bile spillimpossible.
EVOLUTION OF METHODS OF MANAGEMENT
The management of wounds of the liver by surgeons of the 2d AuxiliarySurgical Group was a matter of evolution and the result of their own clinicalobservations. They had no decisive principles of therapy to guide them. Observations of military surgeons in World War I were brief and frequentlycontradictory. Bailey2 advocated expectant treatment if it werepossible to be certain that the wound affected only the liver. Lee3and Wallace4 also favored nonintervention inmost cases. The Committee on Surgery of the National Research Council5apparently felt that, in World War II, operative therapywould be necessary more often than it had been in the past.
All of these observers recognized the possibility that spontaneous hemostasismight occur in injuries of the liver, but they placed different degrees ofreliance upon it. Bailey felt that physiologic changes incidental to anesthesiaand surgery might cause renewed bleeding. On the contrary, Wallace's6 experience that spontaneous hemostasis usually occurred within 6 to 10 hours of wounding is inclose agreement with theexperience of the 2d Auxiliary Surgical Group.
The observers cited were in general agreement about the possibility ofsecondary hemorrhage from the liver, although there was some variance of
2Bailey, Hamilton: Surgery ofModern Warfare. Edinburgh: E. & S. Livingstone, 1941-42.
3The Medical Department of the United States Army in the World War.Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1.
4Wallace, Cuthbert: WarSurgery of the Abdomen. London: J. & A. Churchill, 1918.
5Abdominaland Genito-Urinary Injuries. Military Surgical Manuals. Prepared under theauspices of the Committee on Surgery of the Division of Medical Sciences of theNational Research Council. Philadelphia and London: W. B. Saunders Co., 1942.
6See footnote 4.
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opinion about its frequency and danger. Makins7 stated that secondaryhemorrhage did not occur in the absence of sepsis.
Lee8 advised suture of the liver in preference topacking. Wallace9 gave diametrically opposite advice.Bailey,10while admitting the theoretic superiority of suture, nevertheless concluded thatpacking was "infinitely better" because of the technical difficultiesattending suture of the liver. Packing, suture, and free muscle grafts were allmentioned by the Committee on Surgery of the National Research Council aspermissible methods for the accomplishment of hemostasis and repair of hepaticwounds.11 Comments on the use of simple drainage and on the risk of bileperitonitis were notably lacking in these discussions of hepatic injuries.
The greatest measure of agreement among surgeons prior toWorld War II was their advocacy of expectant or conservative treatment, or notreatment at all, for most wounds of the liver. Many of these men were surgeonswho had carried over the idea from their experience in World War I. This policy,however, was incompatible with the surgical philosophy of World War II, in whichoperative intervention was held to be in the best interests of practically everycasualty with an abdominal wound if he lived to reach a forward hospital. Sincethe liver was frequently wounded, both alone and in combination with otherorgans, the problem of management of hepatic injuries became important early inthe war.
During the initial activities of the 2d Auxiliary SurgicalGroup in 1942-43 (a period not covered by these data), wounds of the liver werevariously managed by packing, suture, free muscle grafts, and expectanttreatment. Suture and muscle grafts proved impractical in the hands of mostsurgeons, and expectant treatment was not thought to be reliable. During thisperiod, therefore, gauze packing was the most frequently used of all methods. Astime passed, however, serious complications were observed following thistechnique. The removal of gauze packs in field hospitals was more than onceattended by disastrous hemorrhage. Abscesses occurred within the liver or theperihepatic space, and necrosis of hepatic tissue occurred in areas which hadbeen packed. Hepatitis and biliary peritonitis were other complications. Theseand other undesirable results of gauze packs were emphasized in Burford's12report of hepatic injuries observed in a general hospital.
Early removal of the pack was practiced in some cases in an attempt toprevent these complications, but this plan was not successful. As soon as thepack was removed, the external wound tended to close prematurely. Attempts tosubstitute Penrose drains for packs were also unsuccessful. Adequate
7Makins. Cited by Bailey. See footnote 2, p. 276.
8See footnote 3, p. 276.
9See footnote 4, p. 276.
10See footnote 2, p. 276.
11See footnote 5, p. 276.
12Review of 1,000 ThoracicCases. Bull. U. S. Army. M. Dept. 89: 70-72, June 1945.
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drainage by this means proved impossible except under direct vision, when theabdomen was open.
By early 1944, many surgeons of the group had concluded thatthe use of packs in wounds of the liver was associated with too many risks tojustify their employment if it could possibly be avoided. They had become awareof the frequency with which spontaneous hemostasis was observed in fresh wounds,and it seemed to them that the only justification for the use of a pack was theprevention of secondary hemorrhage. Since this was not a frequent complication,a trend began away from the use of gauze packs and toward simple drainage of thesubhepatic space (Morison's pouch). At first there was some disagreementconcerning the necessity for drainage, but the presence of bile in discharges ina substantial proportion of cases when both drains and gauze packs were used, aswell as the frequent observation of bile in the peritoneal cavity in wounds ofthe liver, convinced most surgeons of the necessity for external drainage as aprotection against bile peritonitis.
Some surgeons continued to close the abdomen without drainage when theinjuries of the liver were limited to lacerations or penetrations which requiredno special treatment. The majority, however, took the position that all injuriesrequired drainage, on the ground that it was impossible to predict, in a givencase, whether bile leakage would or would not occur. In a few patients withthoracoabdominal wounds, troublesome bile empyema resulted from failure todrain the subphrenic space after operation had been performed through the rightthorax. It was the consensus that this complication would probably not haveoccurred in these cases if drainage had been instituted through a subcostalincision.
These clinical observations led to almost completeabandonment of packing as a method of treatment in hepatic injuries and to itsalmost universal replacement by drainage of Morison's pouch. The data recordedin this chapter substantiate the soundness of this change of policy. The almosttotal absence of postoperative hemorrhage in the cases which were drainedindicates that this risk had been overemphasized early in the war. Similarly,the efficacy of drainage as a means of preventing bile peritonitis is attestedby the absence of this complication in the cases treated by this method.
TREATMENT
The location of the incision in injuries of the liver (table 74) naturallydepended, in any given case, upon the extent of the injury or injuries, and, inparticular, upon whether the wound was abdominal or thoracoabdominal. Thepopularity of the transdiaphragmatic approach increased as the war progressed.In an occasional case, thoracolaparotomy was employed; the incision was extendedover the chest wall onto the abdomen, the costal arch being cut or the incisionpassing through the 10th or 11th intercostal space.
In many wounds of the liver, there was sufficient fragmentation of the organto necessitate actual resection of the damaged tissue instead of debride-
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ment. Often a substantial amount of tissue had to be removed.In this sort of case, it was not unusual to find completely detached pieces ofliver lying free in the peritoneal cavity as a result of the original trauma.
TABLE 74.-Distribution ofsurgical approaches in 432 wounds of liver
Approach | 1944 | 1945 | Total | |||
Cases | Proportion | Cases | Proportion | Cases | Proportion | |
|
| Percent |
| Percent |
| Percent |
Laparotomy | 172 | 53.0 | 42 | 39.3 | 214 | 49.6 |
Thoracotomy | 107 | 32.9 | 50 | 46.7 | 157 | 36.3 |
Combined laparotomy and thoracotomy | 40 | 12.3 | 14 | 13.1 | 54 | 12.5 |
Thoracolaparotomy1 | 6 | 1.8 | 1 | .9 | 7 | 1.6 |
| 325 | 100.0 | 107 | 100.0 | 432 | 100.0 |
1In this technique, thethoracic incision was extended across the costal arch onto the abdominal wall.
In a sample of 695 casesobserved in 1944 and 1945 inwhich full data concerning treatment were available (table 75), the changing proportions of casestreated by drainage and by packing are a significant reflection of increasingsurgical experience. Though originally some wounds of the liver were regarded astoo small to require drainage, this attitude became less and less frequent asthe war progressed. In some cases in which drainage was instituted, there was nobile in the discharge after operation, but, as already noted, it was impossible,either preoperatively or at operation, to identify the cases in which this couldbe expected to happen. The size of the missile was not the determiningconsideration. A wound caused by a small foreign body which cut a main bilechannel was likely to be followed by more profuse drainage than a superficialhepatic injury of greater extent. The principle that all suspected wounds of theliver should be explored and the additional principle that all should be treatedby adequate drainage were eventually established as the only sound policy inthis type of injury.
TABLE 75.-Percentagedistribution of operations in 695 wounds of liver
Operation | 1944 | 1945 | Total |
Drainage only | 48.50 | 87.4 | 57.8 |
Suture and drainage | 6.50 | 1.8 | 5.3 |
Suture and pack | .95 | 0 | .8 |
Pack only | 34.10 | 9.6 | 28.2 |
Muscle graft | .15 | 0 | .1 |
No treatment | 9.80 | 1.2 | 7.8 |
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Drainage was instituted with Penrose or cigarette drains. Two were employedif the wound was large or if there was more than one injury. The acceptedpractice was to place a Penrose drain lateral to the postero-inferior margin ofthe liver, to prevent collections of bile or pus in this region, and to use thesame technique for drainage of the subhepatic space. To guard against woundinfections and disruptions, the drains were not brought to the exterior throughthe original laparotomy or thoracolaparotomy incision. Instead, they weredelivered through a dependent incision placed subcostally in the anterior ormidaxillary line and preferably at least 1.5 inches long. It was found essentialto extend this incision through all layers of the abdominal wall. If they werenot widely opened, the drains were likely to become strangulated and their wholepurpose would be defeated. In the occasional case, a debrided wound trackcoincided with the site of the usual subcostal incision for drainage and couldbe used satisfactorily for this purpose.
It was imperative to keep the drains in situ until bile drainage had ceasedcompletely. This was usually by the 10th or 12th day, though it was sometimesconsiderably later. Drains were always shortened gradually, beginning on the 4th or 5th day. They were never removed abruptly in toto.
Although packing became less and less popular as a definitivemethod of treatment as the war progressed, the temporary use of a dry pack wasoccasionally extremely helpful. Active oozing from large superficial wounds ofthe liver could be controlled by this means while more urgent injuries werebeing cared for. It was unusual, when the pack was removed, not to find thatbleeding had ceased and that no other measures were necessary to control it.
Relatively few wounds of the liver were sutured by surgeonsof the group in the course of the war. By 1945, most of them had abandoned thepractice completely, chiefly because it had been repeatedly observed that moreserious bleeding might follow this procedure than had existed before it.
POSTOPERATIVE COMPLICATIONS
Not very many complications of wounds of the liver wereobserved in forward hospitals as compared with the number observed in hospitalsfarther to the rear. A report by Burford13 from a general hospitalshowed that 25, chiefly resulting from inadequate drainage, had occurred in 98wounds of the liver. They included subphrenic abscess in 14 cases, intrahepaticabscess in 6 cases, and bile empyema in 5 cases.
The complications observed in field hospitals were what mighthave been expected in view of the nature of the wounds. They were chieflypresented as bile empyema or a biliary thoracic fistula. The diaphragm wasobviously perforated in all thoracoabdominal wounds, which comprised 53.8percent of the wounds of the liver. Bile and exuded fluids, if they could notdrain externally because a pack had been used or for other reasons, sometimesforced their way through the sutured diaphragmatic wound, with the results just
13See footnote 12, p. 277.
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stated. The technique by which the diaphragm was closedseemed to have nothing to do with their occurrence. In one such case, the lungwas adherent to the diaphragmatic suture line, and the erosion of a bronchus bybile created an extremely serious problem. Occasionally the bile, after it haderoded the diaphragmatic suture line and reached the pleura, caused a breakdownof the thoracotomy incision, with a resulting subphrenic pleurocutaneousfistula.
Although there was no instance in a forward hospital of afatal secondary hemorrhage, a surgeon of the group witnessed such an accident ina general hospital after removal of a pack from the liver on the 18thpostoperative day. The single instance of serious postoperative bleeding whichoccurred while these patients were under observation in forward hospitals isrecorded in detail because of the lessons implicit in the case:
Case report-An American soldierwas admitted to a field hospital after being wounded in the right costophrenicsulcus and the hilar region of the liver by high-explosive shell fragments. Thewound was extended and debrided under nitrous oxide-oxygen-ether anesthesia, anda shell fragment and several bits of clothing were removed from the liver. Therewas some oozing of dark blood, but the bleeding was not thought sufficient tojustify any special hemostatic measures. Penrose drains were introduced andbrought out through a separate drainage incision.
For 36 hours after operation, there was copious drainage of bile, but thepostoperative course was otherwise uneventful until the eighth postoperativeday. Then a severe hemorrhage occurred through the drainage incision. It ceasedspontaneously, and there was no further bleeding until the ninth day, when a second severe hemorrhageoccurred. Like the preceding hemorrhage, it was massive and obviously arterialin origin. It was checked by the insertion of a gauze pack deeply into the liverwound, through the enlarged drainage incision. A third hemorrhage 36 hours laterwas checked by the insertion of a fresh pack after the removal of the originalpack.
Chills and fever occurred on the 16th postoperative day, while the secondpack was still in situ. On the 17th day, the temperature rose to 105.8? F., and another severe hemorrhage occurred about the pack. The external woundwas then opened under Pentothal anesthesia, and the wound in the liver wasexposed by excision with the actual cautery for a depth of 7 cm. A large artery was found to have beenpartially severed by the original injury. It was clamped and ligated, andPenrose drains were inserted into the depth of the wound.
Convalescence was stormy. Severe distention developed on the 18th day(counting from the day of the first operation). On the 22d day, there wasprofuse biliary drainage. On the 32d day, a liver abscess was drained. On the41st day, a pelvic abscess was drained, and on the 51st day a subhepatic abscesswas drained. Thereafter recovery was satisfactory, and when the patient wasevacuated on the 75th day, he was in good condition.
The hemorrhages in this case were probably all caused by repeated reopeningof the partially severed artery as the surrounding clot retracted. The insertionof the first pack, on the ninth day after operation, was perhaps justified, inan attempt to control bleeding by conservative means. In retrospect, however, itclearly would have been wiser to explore the bleeding area without delay whenhemorrhage recurred; it was known that the wound was in the hilum, and thehemorrhage was so massive that extensive packing was necessary to check it.There was no local or systemic evidence of infection when this pack was applied. It seems certain, however,that the compli-
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cations which followed-infection, secondary venous bleeding,hepatic abscess, subhepatic abscess, and pelvic abscess-all arose because a packwas used and drainage was thus impeded. Any one of these complications couldreadily have been fatal, and all might have been prevented had the secondaryhemorrhage been attacked at its source when it first occurred on the eighthpostoperative day.
CASE FATALITY RATES AND FACTORS OF MORTALITY
The case fatality rate in these 829 wounds of the liver, 27.0 percent (224deaths), is to be compared with the rate of 66.3 percent reported for similarwounds in American Expeditionary Forces in World War I.14 These 829 woundsrepresented 27.0 percent of 3,066 abdominal injuries, in contrast to the 13.3percent represented by comparable wounds among American soldiers in World War I(table 8, p. 93). The British proportion of wounds of the liver in that war was16.8 percent (table 8).
Shock was responsible for 115 of the 224 fatalities in woundsof the liver, 51.3 percent of the total number of deaths. All deaths from thiscause occurred before the end of the second postoperative day. When thesepatients were first seen, they were all in serious circulatory collapse, whichpersisted in spite of vigorous efforts at resuscitation. Blood loss was only oneof several contributory factors; others included disturbances of cardiorespiratory physiology, overwhelming contamination of the peritoneal andpleural cavities, actual destruction of tissue, and widespread retroperitonealcellulitis.
Pulmonary complications were the cause of 38 deaths, 17.0 percent of thetotal number. Trauma to the diaphragm, which occurred in over half of all woundsof the liver; trauma to the lung; contamination of the pleural cavities by bile;and the necessary prolongation of anesthesia and operation provided an amplebackground for this cause of death.
Peritonitis was primarily responsible for 28 deaths, 12.5 percent of thetotal number. It was present to some degree in all fatal cases, but it was notconsidered the primary cause of death unless it was widespread or took the formof a localized process, such as a subphrenic abscess.
Oliguria and renal failure were the chief causes of death in 19 cases (8.5percent). The so-called transfusion kidney and pigment nephropathy could not beexcluded as the principal lesion in these cases, but interesting possibilitiesobviously suggest themselves concerning the relationship between the liverdamage and the renal failure.
In the remaining 24 cases, the causes of death included such conditions asgas gangrene, head injuries, and wounds of the spinal cord with paraplegia. Thehepatic injury in this group usually played only a minor role in the fataloutcome.
It should be emphasized again that in no case in this series could deathduring the postoperative period in a forward hospital be ascribed to bleeding
14See footnote 3, p. 276.
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from the liver. In World War I, hemorrhage was the chiefsource of both morbidity and mortality in wounds of the liver, while in WorldWar II, at least in the cases handled by the 2d Auxiliary Surgical Group, bileleakage and damage of the hepatic parenchyma (after shock) were the chieffactors of mortality.
The source of bleeding in wounds of the liver is the hepaticartery, the hepatic vein, or the portal vein. Unless, therefore, a hilar injuryhas been sustained or a missile has penetrated deeply into the liver tissue,serious bleeding should not be common. The larger branches of the portal veinlie nearer the surface than the branches of the arterial system, but thepressure in the venous system is low (8 to10 mm. Hg), and hemorrhage from them, as is clear from this series of wounds ofthe liver, is not difficult to control.
The change in therapeutic methods reflects this change of emphasis. In WorldWar I, packs to control hemorrhage furnished the chief method of treatment whenactive treatment was undertaken at all. In World War II, active therapy wasundertaken in all cases, and drainage eventually became the most popular methodof treatment.
The death rate in this series undoubtedly was influenced by certain factorssuch as the wounding agent (p. 97), the timelag from injury to operation (p.103), the availability of adequate shock therapy (p. 124), and the use of the sulfonamides and later of penicillin(p. 197). It is difficult, however, to reduce their influence to statisticalterms. The case fatality rate was higher during the winter than the summer,probably, as in other injuries, because of the higher winter incidence ofrespiratory infections.
The case fatality rate was directly proportional to thenumber of viscera injured (table 10, fig. 22). It was 9.7 percent when only theliver was injured, but it rose to 84.6 percentwhen four or more other viscera were injured also.
Associated extra-abdominal injuries were chiefly compoundfractures of the long bones, traumatic amputations, injuries of the head andspinal cord, and injuries of the lungs and other thoracic structures, including,occasionally, the heart. They added greatly to the morbidity of this series andundoubtedly contributed to the death rate, though it is impossible to evaluatetheir individual influence.
WOUNDS OF THE EXTRAHEPATIC BILIARY TRACT
The degree of damage to the gallbladder varied widely in the51 wounds of the liver in which this organ was implicated. In oneinstance, the fundus was partially avulsed from its bed; but the gallbladderwall was not damaged, and simple suture was the only treatment necessary. Infive cases, the wounds of the fundus were small and could be closed bypurse-string suture. In the remaining cases, the damage was almost evenlydivided between severe lacerations which required cholecystectomy and lesssevere injuries which could be treated by cholecystostomy.
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One of the two patients with an injury of the common duct suffered aperforation of the hepaticoduodenal ligament; simple suture, without drainage,was followed by prompt recovery. The other had a wound of the duct near theampulla of Vater. It was overlooked at operation, and, while the patient hadother severe injuries, this error unquestionably contributed to the fataloutcome.
Because of the presence of wounds of the liver in all wounds of theextrahepatic biliary tract, it is clearly impossible to determine the influenceexerted by the latter type of injury upon the case fatality rate. It wasprobably not very important. The rate for all wounds of the liver was 27.0 percent. For the 53 cases inwhich wounds of the liver were associated with injuries of theextrahepatic biliary tract, it was 30.2 percent, which is not materiallydifferent.
