ECMO-/ECLS

of these injuries have been reported. Successful management requires an
understanding of the segmental anatomy of the liver. Peitzman and Marsh
published an excellent review of the operative management of complex liver
injuries in 2012 [19].^ Their report highlights the components of operative
control of hepatic parenchymal injury, which includes adequate exposure, an
experienced co-surgeon, good anesthesia support, and supradiaphragmatic
intravenous access. They recommend initial management of deep
parenchymal fractures with compression, followed by suture ligation of bleeding
vessels, and the avoidance of deep liver sutures. The Pringle maneuver can
help differentiate between hepatic arterial bleeding (bleeding decreases when
the clamp is engaged) and hepatic venous bleeding. Ideally, intermittent
clamping of the porta hepatis (<30 minutes at a time) should be performed to
decrease the degree of hepatic ischemia. When large fractures are present
and not able to be controlled with finger fracture and tying of vessels, an
anatomic resection should be considered. The definitive operation should
control bleeding and any potential bile leak, debride non-viable tissue, and
adequately drain the resected margin if the patient is stable. However, in cases
where there is uncontrolled hemorrhage, coagulopathy, and coldness, a
massive liver resection should not be undertaken. Control of the hemorrhage
by packing and placement of a temporary abdominal closure can buy valuable
time for ongoing resuscitation and stabilization of the patient. Definitive
treatment may be deferred until the patient is stable.