The liver is the largest solid organ in the body occupying almost the whole of the upper abdomen and is thus very vulnerable to any injury inflicted on the abdomen or the lower part of the right chest.

Liver is a vital organ, very important for the maintenance of life. It is involved in a large number of functions like the production of essential serum proteins, digestion, metabolism, blood-clotting mechanism, detoxification and excretion of many drugs and waste products. One cannot dispense with the liver as is possible in the case of one lung or one kidney, the stomach or a segment of the intestine, uterus or testis, etc. But, then, liver also has a great regeneration power. If even a four-fifth of the liver is removed the remaining part quickly grows in size and compensates for the loss, and maintains the life without much problem.

It has now been conclusively proved that all liver injuries, including bullet injuries, do not require surgical intervention. The natural physiological process of the human body can stop bleeding and, therefore, a select group of patients can be successfully managed with non-operative supportive management. But, then, this should be attempted only in good hospitals and that also by experienced surgeons.

The majority of liver injury cases require emergency surgical management, and the patients who seem to be bleeding profusely (they remain in a state of shock in spite of blood transfusions) should be directly wheeled to the operation theatre without any prior investigation or elaborate preparation, as speed is of the essence. An experienced surgeon with expertise in the management of abdominal trauma, good operation theatre facilities, plenty of blood (preferably fresh blood and not the stored blood) along with plasma and other blood components, a good anesthetic team with ICU facilities are the prerequisites for a good outcome.

The availability of a cardio-vascular surgeon inside the operation theatre is helpful not only for the control of the superior part of the IVC in the chest but also for the repair of the traumatized veins.

In case there is uncontrollable bleeding from the liver or the veins (as seen in grade III to V injuries) more advanced techniques have to be used. Vascular isolation of the liver may be required.

The bottom line in handling liver injury cases is the extent of injury sustained by the patient, the time gap between the incident leading to the injury and the operation and the expertise available in the hospital. In complex liver injury cases, the results have been very poor all over the world.