The management of hepatic and splenic injuries on the “home front” has changed dramatically over the last two decades. The impetus for this change has been driven largely by improvements in diagnostic and interventional capabilities facilitating nonoperative therapeutic strategies for blunt abdominal trauma. Management of these same injury patterns on the battlefield presents unique challenges unlike those experienced in civilian trauma care. The deployed surgeon is frequently faced with managing these injuries in the context of severely poly-traumatized casualties or multiple casualties, all of which must be evaluated using sound clinical judgment and only a modicum of diagnostic information. In the civilian setting, most trauma surgeons identify solid organ injury with high tech multi-detector CT scans. Management of all but the most severe of these solid organ injuries is relegated to the interventional radiologist to control arterial hemorrhage by virtue of angioembolization. Having limited medical care resources in the austere combat environment , the military surgeon must expect and prepare to operate on splenic and hepatic injury . The basic premise for the management of these injuries is simple. In general “do not let the skin stand between you and the diagnosis,” particularly in the unstable patient with the potential for abdominal injury. Have a “battle plan” in mind before the scalpel is placed to the skin: control bleeding, control contamination, and get out.

Although each patient and injury is unique, the application of a standard and conservative approach will optimize management, minimize the risk of missed injury, and improve outcomes. “Conservative” in this circumstance means “surgery.” All penetrating injuries to the peritoneum require exploration. In contrast to the civilian trauma setting, there is a limited role for nonoperative management of blunt splenic injury on the battlefield with the exception of low-grade injuries. Several studies derived from the data from military operations in Iraq and Afghanistan demonstrated that blunt splenic injury, particularly AIS grades 1–3, could be successfully managed nonoperatively with appropriate selection of stable patients without other indications for laparotomy. These management decisions were predicated on a low op-tempo environment, whereby combat casualties could spend as much time as necessary in the hospital at the strategic evacuation platform to ensure they remained hemodynamically stable with stable hemoglobin concentrations. The failure of nonoperative management was low with no deaths attributable to the requirement for subsequent surgery. Splenic injury in the context of hemodynamic instability, falling hemoglobin, or any sign of clinical deterioration is basically an “old school” surgical disease. Blunt hepatic injury can be managed nonoperatively, particularly if the hematoma is intraparenchymal and there is no gross extravasation of contrast. Just as in blunt splenic injury management, in the mature theater with strategic air evacuation, do not evacuate the liver injury casualty to level IV until you are comfortable with their clinical status.

Before delving any deeper into the specifics of the surgical management of the liver and spleen injury, it is important to be familiar with a few of the broad overarching concepts with respect to abdominal injury. The battlefield trauma surgeon must have a keen understanding of tactical combat casualty care (TCCC ), damage control resuscitation , and damage control surgery, including being facile with exposure techniques. After injury in a combat zone, casualties are attended to by self, combat life savers, medics, and corpsmen in austere environments with limited resources. These prehospital providers have been provided the tools and training for airway management, compressible junctional hemorrhage control, and peripheral hemorrhage control. However, no current capability exists to control noncompressible truncal hemorrhage . The most common cause of potentially survivable injury leading to death on the battlefield is hemorrhage, and the majority of the hemorrhage is noncompressible bleeding within the chest, abdomen , and/or pelvis. Medical evacuation and operational contingencies may further protract casualty arrival to the military medical treatment facility such that many casualties with abdominal injury will arrive in shock with attendant hypothermia, acidosis, and coagulopathy. The surgeon needs to act quickly to counteract the further evolution of the “lethal triad ” of trauma. Metabolic acidosis is a consequence of inadequate tissue perfusion often from hemorrhage in the combat casualty. Hypothermia is due to the lack of intrinsic thermoregulatory capacity, also secondary to the decreased availability of oxygen to develop cellular energy. This hypothermia can also be exacerbated by cold climate. Coagulopathy results from consumption, dilution, ongoing blood loss, interrelationships with intrinsic thermoregulatory mechanisms, and acid/base balance. If not corrected, this lethal triad will be uniformly fatal. Consequently, it is vitally important to have substantial resuscitative resources in addition to surgical resources at facilities that provide damage control surgical capability.

Contemporary military data suggests that the requirement for a massive resuscitation can be predicted by simple parameters available clinically or with point of care testing in the resuscitation area of the medical treatment facility (MTF):

In circumstances that warrant massive transfusion, the damage control resuscitation concept, which is a combination of permissive hypotension and hemostatic resuscitation, should be utilized. With this paradigm, crystalloid infusion should be minimized and the ongoing resuscitation conducted with a balanced ratio of plasma to red blood cells to platelets (if available). The availability of component therapy will usually be adequate at level III facilities depending on the stage of the conflict, but supply may be taxed in mass casualty scenarios. In contrast, level II facilities are frequently not well resourced with blood and blood products. In situations where the demand exceeds the limited supply of blood component resources, the surgeon should liberally call for fresh warm whole blood when utilizing the damage control resuscitation concept. See Chap. 4 for a detailed discussion of these concepts and practices.

Penetrating abdominal trauma does not require an extensive diagnostic evaluation, and the patient almost exclusively belongs in the operating room for an exploratory laparotomy. If the mechanism is single or with several projectiles (gunshot wounds), then plain x-ray of the chest and pelvis is helpful to identify locations of the missiles or fragments. Don’t forget to do a pericardial ultrasound unless you have already decided to do a pericardial window in the OR. In the “unstable” patient, just go to the OR and figure it out there. A more common scenario in modern conflicts will be the patient presenting with multiple small wounds from an explosive device, many of which may be superficial, as well as a blunt component from the blast or vehicle crash. Evaluate these patients with a good physical exam and a trauma ultrasound (FAST) to triage them to CT scan or the OR. The FAST has proven very effective for the assessment of abdominal injury in guiding further diagnostics and surgical management after battlefield injury. Patients with unstable vital signs or peritonitis should go right to the OR; otherwise, a CT scan is very helpful for delineating the number, location, and depth of penetration of the projectiles as well as any intra-abdominal injury.

Once you have diagnosed an injury to the liver and/or spleen, now comes decision time. The number one factor is always patient stability, followed by your physical exam and imaging findings. In the combat setting, these clinical decisions will be influenced by the availability of interventional capabilities (usually none), blood bank capability, the ability to closely and serially observe the patient (usually limited, particularly in forward environments), bed and ICU capacity, and evacuation chain status. All of these factors usually weigh much more heavily in favor of operative management rather than observation only. You can consider nonoperative management for low to moderate grade injuries (grades 1–3) with no evidence of bleeding and no other injuries requiring operation, and in a patient you can observe for at least 48–72 h. Otherwise the best option is usually to “heal with steel” in the operating room.

Though many alternatives are available, the midline incision is the most expedient and versatile incision for opening the abdomen . This incision can easily be extended into a median sternotomy for exposure and control of the intrapericardial inferior vena cava which may be necessary, particularly in patients with retrohepatic vena cava injury. Remember that once the peritoneal cavity is entered, the exploration should proceed in a methodical fashion by order of priority: hemorrhage control, contamination control, and definitive repair if possible/warranted. Subcostal extension of the incision may be useful for optimum exposure, particularly for management of hepatic injury .

Do not skimp on your exposure! Exposure and expedience are the two critical factors to improve damage control surgical outcomes. Attempting a limited incision laparotomy approach is usually a waste of time and effort – in patients who often don’t have extra time to spare. To adequately mobilize, pack, and potentially definitively manage liver and spleen injuries, the upper extent of the incision must be at level of the xiphoid, so make a full laparotomy incision from the start. As a side note, if you get called to assist on a difficult laparotomy, the most effective contribution you can usually make right away is to extend the incision and thereby improve exposure.

Should you begin your laparotomy by doing a full four quadrant packing, or just suction out the blood to identify the bleeding area and get to work? The dogmatic factions that adhere steadfastly to their particular technique will never completely agree on the best approach to the trauma laparotomy with hemoperitoneum, but each has its applications and advantages. Many very experienced trauma surgeons have discarded the mantra of trauma to “pack all 4 quadrants” and either do focused packing in the area of injury or do no packing and simply evacuate the clot in order to identify the injury that is bleeding the most significantly. This approach has merit for injuries to a single area or vessel that you can quickly identify and control and, likewise, avoids wasting time and supplies. It is a less effective and inappropriate technique for injuries to multiple areas with large-volume hemorrhage and patient instability. What is clear is that haphazardly pushing a handful of laparotomy sponges into a large pool of blood does nothing for exposure or hemorrhage control. Packing is an art, so be an artist.