kanker

1. Extrahepatic Biliary and
Vascular Injuries
Niqui Kiffin, MD
16 March 2010

2. Introduction
 Extrahepatic biliary and portal triad injuries make up
0.07-.21% of all trauma admissions.
 Although rare, detection and management may be very
difficult
 Injury to this area may carry a 50% mortality, with injury
to the vascular structures being worse
 Most patients do not have an inury to one structure or
another, but actually have a combination of injuries to
multiple organs
 Liver
 Porta
 Vena Cava
 Pancreas
 Surrounding viscera

3. Anatomy

4. Discussion
 Gallbladder
 Portal Vein
 Hepatic Artery
 Common Bile Duct
 Pancreaticoduodenectomy

6. Gallbladder
 Accounts for up to 66% of extrahepatic
biliary tract injury
 May be either blunt or penetrating
 Blunt
 Avulsion
 Contusion
 Perforation
 Penetrating
 May involve anywhere from the body to the cystic
duct

7. Diagnosis
 Physical Exam
 Bile Peritonitis/RUQ Pain
 Late
 Cholecystitis – blockage of the cystic duct with blood clots
 CT Scan
 Ill-defined contour of the GB wall
 Collapse of the lumen
 Intraluminal Hemorrhage
 Ultrasound
 Has not been formally evaluated
 Laparotomy

8. Operative Management
 Open Cholecystectomy
 Almost every case
 Must also be considered in patient’s where there is injury to
cystic duct or R Hepatic Artery
 Laparoscopic Cholecystectomy
 Not recommended
 GB rarely injured alone
 Other injuries missed
 Non-operatively
 Minor GB contusions
 May lead to cholecystitis or rupture in the future
 Cholecystorraphy
 Minor GB lacerations

9. Open Cholecystectomy

11. Portal Vein
 Most of the mortality
associated with Portal
Vein injury is caused
by exanguination prior
to laparotomy
 Associated with almost
a 70% risk of
concomitant major
vascular injury

12. Location of Portal Vein Injury
 The location of the
injury is most likely
within the
hepatoduodenal
ligament.
 Look for hematoma or
bleeding around/within the
hepatoduodenal ligament
during laparotomy

13. Presentation/Diagnosis
 Majority
 HEMORRHAGIC
SHOCK!!
 Few patients may initially
respond to resucitative
measures…smaller
injuries
 CT Scan
 Periportal fluid
 Hepatic injury
 Active extravasation

14. Operative Management
 Again, patients usually arrive in
hemorrhagic shock…therefore treat with
the same initial principles.
 Midline Laparotomy
 Evacuation of clots/hemoperitoneum
 Urgent Packing
 Allow for the Anesthesia team to catch up with
blood products/fluid

15. Operative Management
 Right-sided medial visceral rotation
 Mobilize the ascending colon and hepatic
flexure to expose the duodenum, head of the
pancreas and IVC
 Initial control, may be obtained by a
Pringle Manuever, manual compression or
pressure packs
 If possible obtain proximal and distal
control

16. Pringle Manuever

17. Operative Management
 Lateral Venorrhaphy
 Saphenous
Vein/Interposition
Grafts
 End-to-End Primary
Repair
 Portal Caval Shunt
 Directly above the
injury
 Superior Mesenteric to
Splenic Vein shunts

18. Operative Managemnt
 Portal Vein Ligation
 Initial rise in portal pressure
 Drop in systemic pressure
 Await formation of collaterals
 Require MASSIVE fluid resuscitation
 Develop bowel wall edema
 May lead to abdominal compartment syndrome
 Abdomen shoule be left open
 Mortality is very high
 Requires a second-look laparotomy
 Evaluate bowel viability

20. Presentation/Diagnosis
 Blunt injury is fairly rare
 If present, occurs near the parenchyma
 Penetrating injury in the Porta may involve the
Hepatic Artery, as well as other structures
 Patients usually present in shock
 Dx: Laparotomy
 Late presentations are rare
 Pseudoaneurysm
 Thrombosis
 AV Fistula

21. Operative Management
 Again, patients usually arrive in
hemorrhagic shock…therefore treat with
the same initial principles.
 Midline Laparotomy
 Evacuation of clots/hemoperitoneum
 Urgent Packing
 Allow for the Anesthesia team to catch up with
blood products/fluid

22. Operative Management
 Again, mobilize the ascending colon and hepatic
flexure for adequate exposure and visualization.
 Manual compression/Pringle Manuever
 Primary Repair
 Interposition Grafts
 Hepatic Artery Ligation
 Approximately 75% of blood flow via the portal
system
 Even so, ligation of the Hepatic Artery should only be
done in extreme circumstances because there have
been reports of hepatic ischemia and necrosis
 Also, remember to also perform a cholecystectomy

23. Hepatic Artery – Primary Repair

25. Common Bile Duct
 Occurs most commonly with penetrating
injury
 Usually partial transection
 If injured via blunt mechanism, it usually
occurs where the bile duct is fixed to
nearby structures (pancreaticoduodenal
junction)
 Usually complete transection

26. Diagnosis
 Diagnosis
 Early
 During laparotomy, pt in shock with multiple injuries
 Liver
 Pancreas
 Duodenum
 Vascular
 Late
 24hr – 6wks
 Jaundice
 Abdominal distension/Pain
 Intolerence to TF
 Sepsis
 Bilious Ascites

27. Evaluation
 CT Scan
 Usually nonspecific
 Cannot differentiate blood from bile
 Pancreatic head fullness
 Duodenal thickening
 Portal edema
 DPL
 Lack of specificity
 Injuries to other structures may also produce bile
 Bile may be obscured by the presence of blood
 Laparotomy (may require a cholangiogram)
 Bile staining
 Late Presenters
 May require CT Scan, U/S, or ERCP

28. Operative Management
 Address CBD only after hemorrhage is
controlled.
 Damage Control – Drainage
 Jackson-Pratt
 T-Tube
 “Stable” Patients
 4 Types of Injuries
 Avulsion of cystic duct/small laceration
 Transection without tissue loss
 Extensive defect in the wall
 Segmental loss of ductal tissue

29. Avulsion of Cystic Duct
 Primary repair
 6-0 Prolene
 Be careful not to narrow duct
 Consider using a piece of the cystic duct or
gallbladder wall
 May require a T-Tube
 Be aware that some techniques used to place T-
tube may actually damage the duct
 ERCP with Stent Placement

30. Transection (No tissue loss)
 End-to-End Anastomosis
 Minimal dissection
 Devascularization will lead to stricture at a later date which
may require an enteric conversion
 No tension
 Devascularization will lead to stricture at a later date which
may require an enteric conversion

31. Extensive Defects (Tissue Loss)
 Biliary Enteric Anastomosis
 Roux-en-Y hepaticojejunostomy
 May even be sutured at the bifurcation or even the
hilar plate
 Roux-en-Y choledochojejunostomy
 Vascularity is crucial…
 Cholecystojejunostomy
 Patent cystic duct is necessary
 Viable solution in patients with small caliber ducts
or unstable patients

32. Hepaticojejunostomy

33. Roux-en-Y Choledochojejunostomy

34. Extensive Defects (Tissue Loss)
 Ligation of Hepatic Duct (Right or Left)
 Usually leads to atrophy of the affected side,
not biliary cirrhosis

35. To Stent or Not To Stent?
 Stent
 Allows for decompression
 Allows access for cholangiography
 T-tubes must exit outside the repair area or
stricture will result
 No Stent
 Foreign body in an already small duct
promotes stricture or obstruction
 Use at your discretion…

36. Ampulla/Intrapancreatic Injury
 Consider pancreaticoduodenectomy if
duodenum and pancreas are also injured.
 If not, consider transduodenal
sphinteroplasty or ampullary re-
implantation
 Consider more specialized consultation

37. Pancreaticoduodenectomy
 Whipple Procedure aka Pancreaticoduodenectomy may be required
for severe duodenal injuries that involve the main pancreatic duct
and the CBD or ampulla
 Indications include:
 Massive, uncontrollable bleeding from the HOP or adjacent vascular
structures
 Massive and unreconstructable injury to the main pancreatic duct in the
head
 Combined unreconstructable injuries of:
 Duodenum and HOP
 Duodenum, HOP, and CBD
 Almost never performed during the 1st operation
 Approximately 30-40% mortality rate with patients that require
trauma Whipple

38. Pancreaticoduodenectomy
 Whipple Procedure (18 steps)
 Mobilize the right colon
 Kocher maneuver of the duodenum
 Enter lesser sac by taking off the omentum from transverse colon (left to
right)
 Ligate the right gastroepiploic vein by finding the gastrocolic trunk.
 Ligate the gastroduodenal artery.
 Dissect in the porta hepatis and isolate the CBD with an umbilical tape
 Perform a cholecystectomy (sometimes lasts)
 Perform the gastrectomy or transect with GIA just distal to pylorus
(preferred)
 Transect the neck of the pancreas
 Ligate mesenteric vessels in proximal jejunum and perform jejunal
transection
 Dissect the head of the pancreas from the retroperitoneum

39. Pancreaticoduodenectomy
 Whipple Procedure (con’t)
 Transect the CBD
 Remove the specimen
 Bring loop of jejunum up in retrocolic or retromesenteric
position
 Perform choledochojejunostomy (interrupted 4-0 or 5-0
prolene)
 Perform pancreaticojejunostomy (interrupted 4-0 to 6-0
prolene)
 Perform gastrojejunostomy (retrocolic)
 Close fascia with #2 nylon from both ends

40. Whipple (No Reconstruction)

41. Pancreaticoduodenectomy

42. Whipple Specimen

43. Conclusion
 Injuries to the extrahepatic biliary and vascular
stuctures are very rare.
 They are closely located to multiple major
organs (liver, duodenum, pancreas), therefore
their injury may be masked by greater
destruction.
 As a Trauma surgeon, one must be aware of
multiple techniques on how to quickly access
these structures and make rapid decisions about
repair verses damage control manuevers.

44. References…
 Feliciano DV, Mattox KL, Moore EE:
Trauma 6th Ed: CH 32 Liver and Biliary
Tract; 2008
 van Heerden JA, Farley DR: Operative
Techniques in General Surgery Vol 2,
No 3; Complex Hepatc Injuries 206-20;
2000