A recent 10-year experience with major liver trauma at the Maine Medical Center was reviewed in order to examine treatment options involving interhospital transfer in the management of major liver trauma in rural areas. Liver injuries of at least Grade III by the systems of Moore or Mirvis were included, except for patients admitted without vital signs. We found 98 cases of major hepatic trauma, of which 54 had been referred by 21 smaller hospitals. Of 15 patients received after laparotomy elsewhere, nine underwent reoperation for control of bleeding or removal of packs, and three died of associated injury or multiple organ failure (MOF). Of the other 39 transferred patients, 23 diagnosed by computed tomography (CT) were selected for nonoperative management with success, 11 survived after operation, one died of hemorrhage, and four died of associated injuries or MOF. For the entire group of 98 cases, adjuncts perceived as useful included perihepatic gauze packing (11 cases) and angiographic embolization (6 cases). Mortality increased with increasing magnitude of injury. Even with major hepatic trauma on CT, stable patients are unlikely to require surgery. Active hemorrhage in unstable patients may be controlled temporarily by expeditious operative techniques including gauze packing. These findings usually allow cooperation between rural hospital and referral center in the management of these potentially serious cases.