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The Authors present a case of thoracoabdominal trauma from a road accident in a young woman who received care initially in a level II hospital. She was then transferred to a level I Trauma Centre with the onset of haemorrhagic shock due to haemopericardium and haemoperitoneum from liver injuries. A chest CT scan led to the suspicion of aortic dissection, hence a cardiopulmonary bypass (CPB) for life support was instituted just before laparotomy through the femoral vessels. Exploration of the peritoneal cavity was performed as a first step because haemoperitoneum was deemed to be the main cause of shock. One litre of blood was aspirated and hepatosplenic tears were sutured to obtain haemostasis. Subsequently, aortic dissection was ruled out by median sternotomy, while a right atrial disruption was identified and repaired by stitches and a pericardial homologous patch. Nevertheless, the ascending aorta was explored by transverse arteriotomy. The postoperative course was uneventful and the woman has never presented cardiac or abdominal symptoms as a result of trauma or surgery.

The treatment of liver traumas has evolved considerably over recent decades with the possibility of non-operative management and arteriographic embolisation for selected patients in haemodynamically stable conditions. The aim of the study was to compare two periods with different approaches to the management of blunt or penetrating liver injuries. From January 1989 to October 2004, 252 patients were admitted to the emergency surgery department of Niguarda Hospital in Milan for liver traumas. Hepatic lesions accounted for 66% of abdominal lesions due to trauma and were classified according to the Organ Injury Scaling system. Abdominal ultrasound and CT scans were used to investigate the injuries. The study consisted of two periods: during the first period (1989-1993) surgery was the only treatment for trauma-induced hepatic lesions of any grade. Damage control surgery was employed for unstable patients undergoing laparotomy. From 1994 on, grade 1-2 injuries in patients with haemodynamically stable conditions were treated by non-operative management and grade 3 injuries by embolisation. In this second period only unstable patients with active bleeding or haemoperitoneum >500 ml with grade 3-5 injuries underwent laparotomy. The overall mortality for liver traumas was 27% (68/252) and was intraoperative in 97% of cases (66/68). Deaths were due to liver haemorrhage in 30 cases and to bleeding from extrahepatic or extra-abdominal injuries in the other 38 cases. Liver trauma was therefore directly responsible for mortality in as many as 12% of cases (30/252). The present study analysed two periods characterised by different approaches to the management of liver trauma. In the first period, laparotomy was the only choice, whereas subsequently non-operative management came to play an important role in haemodynamically stable patients and proved to be a safe method in selected cases. Major liver resections are seldom indicated in liver injuries. Damage control surgery has been practised since the first period and, before any surgical manoeuvres are performed, still represents a valuable tool to guarantee haemodynamic stability, which is the crucial factor for the outcome of liver resections for trauma.