Hemostatic Methods for the Management of Spleen and Liver Injuries

World J. Surg. 20, 1107–1112, 1996 WORLD Journal of SURGERY © 1996 by the Société Internationale de Chirurgie Hemostatic Methods for the Management of Spleen and Liver Injuries Selman Uranüs, M.D., F.A.C.S., Hans-Jörg Mischinger, M.D., Johann Pfeifer, M.D., Leo Kronberger, Jr., M.D., Hans Rabl, M.D., Georg Werkgartner, M.D., Peter Steindorfer, M.D., Julius Kraft-Kirz, M.D. Department of Surgery, University Surgical Clinic, Karl-Franzens University, Auenbruggerplatz 29, A-8036 Graz, Austria Abstract. The spleen and liver are the most frequently injured organs during blunt and penetrating abdominal trauma. Emergency laparotomy is crucial for early control of bleeding and to prevent “secondary” injury as a result of physiologic splanchnic vasoconstriction and free oxygen radicals. Altogether 98 patients with spleen and liver injuries were treated over an 8-year period. Primary orthotopic spleen preservation could be achieved in 46 of 63 patients. In 58 patients with hepatic trauma, hemostatic treatment was chosen based on the severity of the injury. Nonoperative management was used for four splenic and seven hepatic trauma patients. The most commonly used techniques were fibrin sealing, suturing, and débridement for hepatic injury and mesh splenorrhaphy, fibrin glue, and partial resection with a TA stapler for splenic injury. The death of patients with complex injuries was mainly due to preclinical massive blood loss and multiple organ failure. Blunt or penetrating abdominal trauma is often associated with injuries to the spleen and liver. The spleen, with an involvement rate of more than 60%, is the intraabdominal organ most often injured during blunt trauma, followed by the liver [1]. After head injury, hemorrhage (30.5%) is the second major cause of death after an injury [2]. The first aim of successful operative management is to control the active hemorrhage, and the second is to achieve surgical repair that preserves as much of the damaged organs as possible. Every effort always has been and still is made to conserve the liver in trauma cases, whereas splenectomy was the usual treatment for splenic injury. Immunologic studies on the increased susceptibility to infection after total splenectomy led to the current practice of organ preservation. This report describes our techniques and clinical experience with hemostasis and organ preservation after spleen and liver injuries. Patients and Methods Patients Over an 8-year period, we treated 98 patients with spleen and liver injuries. Our classification of splenic trauma (Table 1), which we have used since 1987, has five grades (0 to IV) and generally conforms to the standards of the Organ Injury Scaling (O.I.S) Correspondence to: S. Uranüs, M.D. Committee published in 1989 (Table 2) [3]. Classification of liver injuries was according to the O.I.S. scale (Table 3). Of the 63 patients with splenic injuries (Table 4), primary orthotopic organ conservation was achieved in 46. Four patients with 0 degree injuries were treated nonoperatively. For first and second degree injuries, suturing, coagulation, or fibrin sealing (or a combination of treatments) sufficed for hemostasis. All third degree injuries were treated by splenorrhaphy using an absorbable compressive mesh. Seventeen patients required total splenectomy for fourth degree injuries. Partial resection was carried out for deep injuries of one pole or one-half of the spleen. In 58 patients with hepatic trauma (Table 5), hemostatic treatment was chosen based on the severity of the injury diagnosed by ultrasonography or computed tomography (CT). Eight of fifty-eight patients (14%) (seven with first degree injuries and one with a second degree injury) were managed nonoperatively. A Pringle maneuver with a maximum duration of 60 minutes was applied to all patients with injuries of grade IV or above. For deep parenchymal lacerations, the parenchyma was sutured, coagulated, or sealed with fibrin glue and collagen fleece (or a combination thereof). Débridement and resection were carried out to remove devascularized necrotic tissue. When definitive hemostasis could not be achieved during the primary operation on grade V and VI injuries, perihepatic packing was followed by a programmed reoperation 24 to 48 hours later; the abdominal wound was closed temporarily with a zipper. The most commonly used techniques were fibrin sealing, suturing, and débridement. Techniques Nonoperative Management. Treatment without surgery was first applied for splenic trauma and only much later for hepatic trauma. Nonoperative management is feasible for grade 0 splenic injury and for some grade I and II liver and spleen injuries. It is not possible to define precisely all the criteria on which to base the decision to manage a splenic or liver injury nonoperatively. In any case, the patient selected for nonoperative treatment must be hemodynamically stable. Patients with an altered state of consciousness due to injury, medication, alcohol, or drugs are particularly poor candidates for nonoperative management [4]. 1108 World J. Surg. Vol. 20, No. 8, October 1996 Table 1. Classification of splenic rupture. Table 3. Liver injury. Degree Criteria Scale 0 1 2 Subcapsular hematoma Capsular tear Superficial ruptures of the parenchyma without involvement of the hilus Deep ruptures of the parenchyma, partly involving the hilus and segmental arteries; massive fragmentation of one pole Massive fragmentation of the whole organ and/or total hilar tear I 3 4 Hematoma Laceration Subcapsular, nonexpanding, , 10% surface area Capsular tear, nonbleeding, , 1 cm parenchymal depth Hematoma Subcapsular, nonexpanding, 10 –50% surface area Intraparenchymal, nonexpanding, , 2 cm in diameter Capsular tear, active bleeding 1–3 cm parenchymal depth, , 10 cm in length II Laceration III Hematoma Table 2. Splenic injury scale. Gradea Descriptionb Laceration I Hematoma Laceration Subcapsular, nonexpanding, , 10% surface area Capsular tear, nonbleeding, , 1 cm parenchymal depth Hematoma Subcapsular, nonexpanding, 10 –50% surface area; intraparenchymal nonexpanding, , 2 cm in diameter Capsular tear, active bleeding, 1–3 cm parenchymal depth that does not involve a trabecular vessel IV Hematoma Laceration II Laceration III Hematoma Description Subcapsular, . 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding Intraparenchymal hematoma . 2 cm or expanding Parenchymal depth . 3 cm Ruptured intraparenchymal hematoma with active bleeding Parenchymal disruption involving 25–50% of hepatic lobe V Laceration Vascular Parenchymal disruption involving . 50% of hepatic lobe Juxtahepatic venous injuries (i.e., retrohepatic vena cava major hepatic veins) Subcapsular, . 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma . 2 cm or expanding Parenchymal depth . 3 cm or involving trabecular vessels VI Vascular No. Surgical method (%) Laceration Ruptured intraparenchymal hematoma with active bleeding Laceration involving segmental or hilar vessels producing major devascularization (. 25% of spleen) Laceration Vascular Completely shattered spleen Hilar vascular injury that devascularizes spleen Laceration IV Hematoma V a Advance one grade for multiple injuries to the same organ. Based on most accurate assessment at autopsy, laparotomy, or radiologic study. b Patients in whom a concomitant injury to other abdominal organs cannot definitively be ruled out and those with a deteriorating abdominal situation after initial resuscitation should be treated operatively. In these cases emergent laparoscopy can be of high diagnostic value. It can help reduce the negative laparotomy rate and can provide information on the location and intensity of bleeding. Another important advantage of laparoscopy is salvage of intraperitoneal blood with autotransfusion [5–7]. Nonoperative management requires careful clinical and laboratory observation, preferably in the surgical intensive care unit (ICU), including strict bed rest for 48 to 72 hours. Close monitoring during the first days should include bedside ultrasonography, CT scanning, or scintigraphy. It is preferable that the patient be examined by the same surgeon, who should be experienced in nonoperative management. In our unit, the average hospital stay Hepatic avulsion Table 4. Treatment of traumatic splenic rupture. Nonoperative 4 (6) Fibrin glue 7 (11) Coagulation 2 (3) Mesh28 (45) splenorrhaphy Stapler-resection 5 (8) Primary 17 (27) splenectomy Secondary 2 (3) splenectomy Total 63 Degree of injury 0 I II III IV 4 0 0 0 0 5 0 0 0 2 2 4 0 0 0 24 0 0 0 0 0 0 0 0 5 0 0 0 0 17 0 0 0 2 0 4(6%) 5(8%) 13(20%) 26(40%) 17(26%) is 14 to 20 days. We also perform follow-up CT scanning or ultrasonography 6 to 8 weeks after discharge. Use of Adhesives. Of the adhesives currently available, fibrin glue is the most suitable for treating spleen and liver lacerations. Fibrin sealing is based on the conversion of fibrinogen to fibrin; and the reaction is the same as during the final phase of blood clotting. The fibrin glue we use (Tissucol; Immuno, Vienna, Austria) is a biologic two-component adhesive. Fibrin promotes clotting, tissue adhesion, and wound healing through interaction with the fibroblasts. Fibrin glue can be applied most precisely with a sprayer (Tissomat; Immuno). Collagen fleece (Tissofleece; Immuno) is a suitable hemostyptic substance for covering bleeding surfaces. It is composed of Uranüs et al.: Spleen/Liver Injuries 1109 Table 5. Trauma to the liver: treatment methods (58 patients), 01/01/1990 –12/31/1994. Surgical method No. times useda Conservative Vicryl suture Fibrin adhesive Debridement Segmentectomy Perihepatic packing Atypical resection Hemihepatectomy Total 8 50 36 42 6 12 7 5 166a No. by degree of injury I II III IV V VI 7 0 0 0 0 0 0 0 7 1 4 2 0 0 0 0 0 5 0 23 17 20 0 0 0 0 23 0 8 6 8 6 0 0 0 8 0 10 7 10 0 7 5 2 10 0 5 4 5 0 5 2 3 5 a Because of combined use of methods this number is not equal to the number of patients. heterologous collagen fibrils obtained from devitalized connective tissue and is fully resorbable. Fibrin glue and collagen fleece are used mainly for treatment of first and second degree injuries or in combination with other modalities in higher degree lesions. With severe bleeding, a warm laparotomy pad should be used as a parenchymal tamponade to temporarily free the injured surface of blood; otherwise the adhesives do not adhere. Fibrin is applied, and the collagen fleece is pressed on it for a few minutes. A major advantage of these hemostatic agents is that they can be combined with any other repair techniques. Coagulation Techniques. Among the various coagulation techniques, infrared, hot air, argon beam, and laser coagulation have proved to be most useful during surgery on the spleen and liver. An advantage of these methods, in contrast to adhesive procedures, is that the parenchymal surface need not be completely free of blood. Coagulation is suitable for controlling the bleeding of first and second degree injuries. Coagulation is not as suitable for extensive, deep lacerations, because too much valuable time is lost before adequate hemostasis is achieved. The ratio of coagulation necroses to healthy residual parenchyma is also unfavorable in these cases. The infrared contact coagulator (IRC) consists of a tungsten halogen lamp whose infrared beam is applied to a rigid quartz fiberoptic via a gold-plated reflector. The interchangeable probes are straight or angled; application can be continuous or in short bursts lasting a few seconds. The thermocoagulator (Leister Hot-Jet-Coagulator; Leister Austria, Schönberg, Tirol, Austria) uses a hot-air jet that after 3 minutes of warm-up produces a temperature of about 5008C 3 mm from the tip of the jet. The intensity is regulated simply by adjusting the distance of the jet to the exposed tissue. A laser emits nonvisible light with various wavelengths, depending on the preferred system. Laser coagulation works well for slight bleeding from superficial lesions. It does not work with severe bleeding, as the stream of blood absorbs the laser beam. The high cost of the equipment has limited the use of this method. The argon beam coagulator (ABC) is a noncontact monopolar electrocoagulator. It emits argon gas, which blows away blood and clears the injured field. The device transfers radiofrequency electrical energy through the stream, causing coagulation. Parenchymal Suture. Suturing by hand is the oldest and most flexible method. Slowly absorbable atraumatic sutures are the most suitable. The sutures most commonly used are crossed and uncrossed single button stitches, mattress sutures, and U sutures. Pledget-armed sutures can also be used to reinforce the edges after resections or for deep ruptures. A piece of the omentum is sometimes useful as a patch. During splenic surgery the new adhesive and coagulation techniques have increasingly encroached on the position of the hand suture. During liver surgery it is still a worthwhile technique for hemostasis and for arresting intrahepatic bile ducts. Partial Resection. When deep injuries involve only a pole or half of the spleen, partial resection is the most effective strategy for both hemostasis and organ preservation. A valuable alternative to the sutured partial splenectomy is resection with the TA stapler. Prior to resection the spleen should be mobilized all around and placed on the abdominal wall. The splenic parenchyma is then compressed digitally adjacent to the injured area and the staples applied. We usually use the TA-55 device and absorbable staples (Auto Suture Instruments, Norwalk, CT, USA) [8]. The greatest advantages of this technique are its simplicity of use, the practicality of the instrument itself, and the reduction in time and blood transfusion required for surgery. For hepatic injury resectional débridement is indicated in the presence of severe trauma (grade III and above). The feeding portal arterial vessels and bile ducts should be clipped, ligated, or sutured selectively as completely as possible. Resection is indicated only when there is no other way to control life-threatening hemorrhage with a totally segmental or local disruption. Selective hepatic artery ligation is still considered controversial, and it should be performed only in exceptional cases. Unstable patients with multiple severe injuries and continuous hypovolemia set up a vicious cycle of hypothermia, coagulopathy, acidosis, and further blood loss. In these cases perihepatic packing may be the only time-bridging technique to stabilize the patient. We leave the packing in the abdomen for 24 to 48 hours; a zipper provides temporary closure. Use of Compressive Mesh. Orthotopic conservation of the spleen in cases of first and second degree injury can usually be accomplished without difficulty with the techniques described above, but they often do not suffice for more severe trauma. When deep, extensive tears involve both the hilar and diaphragmatic surfaces, it is too time-consuming to attempt to achieve hemostasis with sutures, coagulation, and fibrin sealing. The best approach in these cases is splenorrhaphy with an absorbable mesh. An appropriately sized piece of mesh with an absorbable thread is wrapped around the spleen, and the thread is pulled together on the hilar face to produce hemostasis without compromising intraparenchymal circulation [1]. During liver surgery a perihepatic mesh may also be used [9]. Absorbable meshes made of polyglactine 910 (Vicryl; Ethicon, Neuilly, France) and presized for each hepatic lobe are available. The main problem is that there is a risk that a compartment syndrome can develop, which would then necessitate removal of the mesh after a day or two. This method should be applied only when there is no other alternative. 1110 Results In our series the overall splenic preservation rate after trauma was 69.8% (44 of 63 patients). A primary splenectomy was performed in 17 cases with fourth degree injury. In two other cases, primary conservation was followed by secondary splenectomy after 8 hours and 7 days, respectively. In the first of these two cases, a repeat laparotomy was required 8 hours after the first operation due to after-bleeding; the spleen had not been completely mobilized, and the mesh had slipped off. The second case involved not only third degree splenic rupture, treated with a compressive mesh, but also a ruptured liver, pancreatic hematoma, lacerations of the terminal mesenteric and transverse mesocolon, multiple fractures of the extremities, and bilateral thoracic contusion. The patient developed multiple organ failure and persistent ileus. A repeat laparotomy and subsequent splenectomy were performed because we assumed that the patient’s deterioration could have been due to total necrosis of the spleen after splenorrhaphy. Histology disproved this assumption; and retrospectively we have to admit that the splenectomy—which was one of our early trials with this method—was not necessary. Other than these two cases, splenic conservation never led to a second laparotomy. Two patients succumbed to other injuries 4 hours and 5 days, respectively, after successful conservation of the spleen. Autopsy showed no postoperative bleeding. Of the 58 liver trauma patients, 5 died immediately after surgery owing to the severity of their injuries. Three other patients died within a week of multiple organ failure. In only 3 of 12 patients with perihepatic packing were relaparotomy and further surgical intervention required after the definitive wound closure. In two of them the source of the bleeding was found in the liver; in the third the source could not be identified, and this patient succumbed after a week to his severe multiple injuries. Seven patients with grade V and VI injuries underwent atypical resection, and five had a hemihepatectomy. Perihepatic packing was required in 12 cases. A bilioma developed in four cases with débridement and wide-suture hepatorrhaphy; two of them required relaparotomy, and percutaneous transhepatic drainage sufficed for the other two. Discussion Emergency laparotomy is crucial for early control of bleeding in the presence of severe hepatic and splenic injuries. “Secondary” injury after trauma as a result of physiologic splanchnic vasoconstriction with gut ischemia has become increasingly important for determining the outcome [2]. Because prolonged hemostasis may potentiate the stress of injury, rapid laparotomy and damage control have been advocated for severely injured patients [10]. An orthotopically preserved spleen with its natural vascular supply and an adequate residual parenchymal mass of at least 25% are prerequisites for normal hematologic and immunologic function [11]. Upon admission, patients with severe bursting ruptures generally have other injuries, have lost a lot of blood, and are usually in shock; thus reconstruction and conservation of the spleen should not take significantly more time than would a splenectomy. The best course with these injuries is splenorrhaphy with an absorbable compressive mesh, which quickly and effectively stops the bleeding [1]. With this method the first step is identical to World J. Surg. Vol. 20, No. 8, October 1996 splenectomy (i.e., complete mobilization of the spleen and rotation onto the abdominal wall). If it appears at this point that the organ cannot be saved, a splenectomy can be performed immediately without loss of time. Fast, complete mobilization of the spleen with avoidance of any further damage is of vital importance with regard to the decision as to whether the organ can be preserved. If the decision is to preserve the spleen, it is already in the correct position for further measures. Second or third degree injuries involving only one pole of the spleen can be treated with partial resection. Resection using a stapler makes organ conservation possible in many cases, and it represents a valuable alternative to the sutured partial splenectomy or splenorrhaphy. Its greatest advantages are simplicity of use, the practicality of the instrument itself, and the reduction in time and blood transfusion. For splenic preservation the choice of procedure depends not only on the clinical findings but also on the surgeon’s experience in splenic surgery and the equipment available at the particular hospital. Complications after orthotopic spleen conservation are slight and are usually avoidable when the procedure is chosen and performed correctly. The incidence and the effects of these complications are not greater or more severe, respectively, than for splenectomy [1, 12]. In elderly patients the concept of splenic salvage should be used with judgment and care. Splenectomized patients should be informed of the defect in their immune system and be encouraged to keep their pneumococcal immunizations current. The main cause of the high primary mortality with complex liver trauma is hemorrhage. As a rule, morbidity and mortality increase with preadmission blood loss and the time required during surgery to achieve hemostasis [13]. For accurate diagnosis and effective further treatment, the liver must be completely mobilized by severing of the falciform, triangular, and coronary ligaments. Only then is it possible to lift the liver onto the abdominal wall and explore the dorsal surface and the vena cava. With grade I and II injuries, suture, adhesives, and coagulation suffice for hemostasis; but with deep tears involving multiple segments, débridement and atypical resection are required. If bleeding cannot be stopped, perihepatic packing can be applied for 24 to 48 hours as a drastic measure to win time and to stabilize the patient. The disadvantages are that relatively heavy bleeding resumes when the packing is removed, and that a systemic sepsis syndrome can be expected in about one-fourth of the patients [14]. The second operation should bring about ultimate and lasting hemostasis. Fibrin sealing and collagen fleece are effective for less severe liver and spleen injuries as either the primary agent or as an adjuvant for obtaining hemostasis [15]. Nonoperative management is limited to patients who are hemodynamically stable upon admission or after initial resuscitation and who are not in an altered state of consciousness due to injury, medication, alcohol, or drugs [1, 16]. Laparoscopy is an efficient diagnostic tool and can make nonoperative therapy for blunt injury easier and safer [17]. When nonoperative management fails, more patients require splenectomy as well as more blood, and the hospital stay is longer [18]. Determination of the source, site, and degree of organ injury and the presence of ongoing bleeding are the main points to be determined by laparoscopy. Exclusion of injury to other organs is an important basic criterion for nonoperative management. Lapa- Uranüs et al.: Spleen/Liver Injuries roscopy also offers the advantage of blood salvage and autotransfusion during abdominal exploration. A limitation for laparoscopy, especially in patients with penetrating trauma, could be detection of hollow viscus injuries. Laparoscopy is absolutely contraindicated in patients with hemodynamic instability or severe diffuse peritonitis [19]. Résumé La rate et le foie sont les organes les plus fréquemment blessés lors des traumatismes fermés et pénétrants de l’abdomen. Une laparotomie est essentielle pour contrôler de façon efficace l’hémorragie et pour prévenir les lésions « secondaires » en rapport avec la vasoconstriction splanchnique et la libération de radicaux libres. Quatre-vingt dix-huit blessés présentant des lésions spléniques et hépatiques ont été vus pendant ces huit dernières années. Une conservation splénique a été possible chez 46 de 63 patients avec lésion splénique. Chez 58 patients avec une lésion hépatique, la technique d’hémostase a été choisie en fonction de la sévérité de la lésion. Un traitement non - chirurgical a pu ètre mené à terme chez quatre patients ayant une lésion splénique et chez sept ayant une lésion hépatique. Les techniques les plus utilisées pour le foie ont été l’encollage par la fibrine et le débridement suivi de suture, alors que pour les lésions spléniques, on a employé la mise en place d’un filet, la colle de fibrine et la splénectomie partielle avec la pince TA. La mortalité chez les patients ayant une lésion hépatique complexe a été essentiellement en rapport avec des hémorragie massives préopératoires et la défaillance multi-viscérale. Resumen El bazo y el hı́gado son los órganos que con más frecuencia resultan lesionados en el trauma abdominal cerrado o penetrante. La laparotomı́a de urgencia es crucial para el control precoz del sangrado y para prevenir lesión “secundaria” como resultado de la vasoconstricción esplácnica fisiológica y de los radicales libres de oxı́geno. Noventa y ocho pacientes con lesiones del bazo y el hı́gado fueron tratados en los últimos ocho años. Se logró la conservación ortotópica primaria del bazo en 46 de 63 pacientes. En 58 con trauma hepático, se escogió el tratamiento hemostásico con base en la gravedad de la lesión. El manejo no operatorio fue utilizado en cuatro casos de trauma esplénico y en siete de trauma hepático. Las técnicas más frecuentemente empleadas fueron el sellamiento con fibrina, la sutura y desbridamiento de la lesión hepática y esplenorrafia con malla, el pegante de fibrina y la resección parcial con el suturador automático TA en la lesión esplénica. La muerte en pacientes con lesiones complejas se debi Invited Commentary M. Gage Ochsner, M.D. Department of Trauma Surgery and Surgical Critical Care, Memorial Medical Center, Savannah, Georgia, U.S.A. Uranus et al. have provided us with their experience over an 8-year period of managing liver and splenic injuries in 98 patients. 1111 ó principalmente a pérdida preclı́nica masiva de sangre y a falla orgánica múltiple. References 1. Uranüs, S.: Organ conservation with traumatic rupture of the spleen. In Current Spleen Surgery, S. Uranüs, editor. Munich, Zuckschwerdt, 1995, pp. 47–75 2. Shackford, S.R.: The evolution of modern trauma care. Surg. Clin. North Am. 75:147, 1995 3. Moore, E.E., Shackford, S.R., Pachter, H.L., McAnnich, J.W., Browner, B.D.: Organ injury scaling: spleen, liver, and kidney. J. Trauma 29:1664, 1989 4. McConnel, D.B., Trunkey, D.D.: Nonoperative management of abdominal trauma. Surg. Clin. North Am. 70:677, 1990 5. Fingerhut, A., Aubert, J.D.: Is there a place for diagnostic and therapeutic laparoscopy in trauma of abdomen? In Surgical Research, S. Uranüs, editor. Munich, Zuckschwerdt, 1994, pp. 29 –31 6. Livingstone, D.H., Tortella, B.J., Blackwood, J., Machiedo, G.W., Rush, B.F.: The role of laparoscopy in abdominal trauma. J. Trauma 33:471, 1992 7. Smith, R.S., Meister, R.K., Tsoi, E.K.M., Bohman, H.R.: Laparoscopically guided blood salvage and autotransfusion in splenic trauma: a case report. J. Trauma 34:313, 1993 8. Uranüs, S., Kronberger, L., Kraft-Kinz, J.: Partial splenic resection using the TA-stapler. Am. J. Surg. 168:49, 1994 9. Jacobson, L.E., Kirton, O.C., Gomez, G.A.: The use of an absorbable mesh wrap in the management of major liver injuries. Surgery 111:455, 1992 10. Rotondo, M.F., Schwab, C.W., McGonigal, M.D.: Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury. J. Trauma 35:375, 1993 11. Van Wyck, D.A., Witte, M.H., Witte, C.L., Thies, A.C.: Critical splenic mass for survival from experimental pneumococcemia. J. Surg. Res. 28:14, 1980 12. Morgenstern, L.: The avoidable complications of splenectomy. Surg. Gynecol. Obstet. 145:525, 1977 13. Buechter, K.J., Zeppa, R., Gomez, G.: The use of segmental anatomy for an operative classification of liver injuries. Ann. Surg. 211:669, 1990 14. Pachter, H.L., Liang, H.G., Hofstetter, S.R.: Injury to the liver and biliary tract. In Trauma, K.L. Mattox, E.E. Moore, D.V. Feliciano, editors, Norwalk, CT, Appleton & Lange, 1988, pp. 429 – 442 15. Ochsner, M.G., Maniscalco-Theberge, M.E., Champion, H.R.: Fibrin glue as a hemostatic agent in hepatic and splenic trauma. J. Trauma 30:884, 1990 16. Andersson, R., Bengmark, S.: Conservative treatment of liver trauma. World J. Surg. 14:483, 1990 17. Uranüs, S.: Diagnostic and emergent laparoscopy. In Current Spleen Surgery, S. Uranüs, editor. Munich, Zuckschwerdt, 1995, pp. 79 – 80 18. Fingerhut, A., Cayol, V., Aubert, J.D.: Nonoperative management of the spleen. In Surgical Research, S. Uranüs, editor. Munich, Zuckschwerdt, 1994, pp. 29 –31 19. Simon, R.J., Ivatury, R.R.: Current concepts in the use of cavitary endoscopy in the evaluation and treatment of blunt and penetrating truncal injuries. Surg. Clin. North Am. 75:157, 1995 The severity of injury for each organ was compared to the method, or combination of methods, used to achieve hemostasis. Among 63 patients with splenic injury, 4 were managed nonoperatively, 17 required primary splenectomy, and 42 were salvaged operatively. Fibrin glue and argon beam coagulation were used for the minor injuries, except for five cases in which a stapled resection was employed. All of the more serious injuries (n 5 26) were treated with an absorbable mesh wrap. Interestingly, only 4 of 63 (6%) of patients with splenic injury were managed nonoperatively, which is much lower than most reported series from the United States. 1112 Fifty-eight patients sustained hepatic injury, eight of whom were managed nonoperatively. Of the remaining 50 patients, various techniques were used for hemostasis including débridement and suture ligature, fibrin glue, argon beam coagulation, resection, packing, and mesh wrap. The more severe liver injuries were often treated with more than one technique: Débridement, suture ligature, and fibrin glue were utilized most frequently. The authors results are excellent, and their approach to injuries of these solid organs is similar to other published reviews on the management of these injuries [1, 2]. One technique employed widely by Uranus et al. is the use of fibrin glue as a primary or adjunctive hemostatic agent. In this series fibrin glue was utilized in 62% and 11% of patients with hepatic and splenic injury, respectively. The authors utilized a commercially available product that has yet to be approved for use in the United States, although effectiveness has been reported in cases of “compassionate use” [3]. In those countries where the commercial fibrin glue is not available, a “homemade” product is used that combines cryoprecipitate and bovine thrombin. Although effective for hemostasis, untoward effects of precipitous hypotension associated with the “homemade” glue have been reported, most likely related to the bovine thrombin utilized [4, 5]. This complication has not been reported with the commercially available product. The major concern regarding use of the commercial fibrin glue is a perceived risk of viral transmission associated with a product obtained from pooled human plasma. The “homemade” glue often involves the use of single donor plasma that has been screened for human immunodeficiency virus and hepatitis but has not been treated. Conversely, the commer- World J. Surg. Vol. 20, No. 8, October 1996 cial product utilizes screened plasma that undergoes processing designed to achieve logarithmic killing of viral particles. In addition, the new commercial fibrin glues utilize human thrombin, rather than bovine thrombin, which has likewise been processed to eliminate viruses and may eliminate the risk of hypotension attributed to bovine thrombin. This process begs the question: Is it safer to allow exposure to screened, but not treated, single donor plasma or to screened and treated pooled plasma? The authors are to be commended on their excellent results achieved using their treatment protocols for these challenging injuries. Their success with the commercially available fibrin glue will hopefully stimulate and accelerate final approval for use of this product in the United States. It will provide another option to U.S. surgeons for achieving hemostasis of the injured liver and spleen. References 1. Feliciano, D.V.: Surgery for liver trauma. Surg. Clin. North Am. 69:273, 1989 2. Pachter, H.L., Spencer, F.C., Hofstetter, S.R.: Significant trends in the treatment of hepatic trauma: experience with 411 injuries. Ann. Surg. 215:492, 1992 3. Kram, H.B., Nathan, R.C.: Fibrin glue achieves hemostasis in patients with coagulation disorders. Arch. Surg. 124:385, 1989 4. Ochsner, M.G., Maniscalco-Theberge, M.E., Champion, H.R.: Fibrin glue as a hemostatic agent in hepatic and splenic trauma. J. Trauma 30:884, 1990 5. Berguer, R., Staerkel, R.L., Moore, E.E.: Warning: fatal reaction to the use of fibrin glue in deep hepatic wounds; case reports. J. Trauma 31:408, 1991