© 2006 WebMD, Inc. All rights reserved.                                                                 ACS Surgery: Princ...
© 2006 WebMD, Inc. All rights reserved.                                                                  ACS Surgery: Prin...
© 2006 WebMD, Inc. All rights reserved.                                                                                   ...
© 2006 WebMD, Inc. All rights reserved.                                                                              ACS S...
© 2006 WebMD, Inc. All rights reserved.                                                          ACS Surgery: Principles a...
© 2006 WebMD, Inc. All rights reserved.                                                            ACS Surgery: Principles...
© 2006 WebMD, Inc. All rights reserved.                                                             ACS Surgery: Principle...
© 2006 WebMD, Inc. All rights reserved.                                                                                  A...
© 2006 WebMD, Inc. All rights reserved.                                                              ACS Surgery: Principl...
© 2006 WebMD, Inc. All rights reserved.                                                            ACS Surgery: Principles...
© 2006 WebMD, Inc. All rights reserved.                                                              ACS Surgery: Principl...
© 2006 WebMD, Inc. All rights reserved.                                                              ACS Surgery: Principl...
© 2006 WebMD, Inc. All rights reserved.                                                                              ACS S...
© 2006 WebMD, Inc. All rights reserved.                                                                             ACS Su...
Upcoming SlideShare
Loading in …5

Acs0707 Injuries To The Liver, Biliary Tract, Spleen, And Diaphragm


Published on

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Acs0707 Injuries To The Liver, Biliary Tract, Spleen, And Diaphragm

  1. 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 1 7 INJURIES TO THE LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM Jon M. Burch, M.D., F.A.C.S., and Ernest E. Moore, M.D., F.A.C.S. Injuries to the Liver adrenal gland (which is vulnerable because it lies directly beneath the peritoneal reflection) or the retrohepatic vena cava. When the ASSESSMENT ligaments have been divided, the right hemiliver can be rotated The initial step in the management of penetrating abdominal medially into the surgical field. Mobilization of the left hemiliver injuries and of blunt abdominal injuries in cases when nonopera- poses no unusual problems other than the risk of injury to the left tive treatment is contraindicated or has failed is exploratory lapa- hepatic vein, the left inferior phrenic vein, and the retrohepatic rotomy [see 7:6 Operative Exposure of Abdominal Injuries and Closure vena cava. of the Abdomen]. If optimal exposure of the junction of the hepatic veins and the Visualization of the right hemiliver [see Figure 1] is hindered by retrohepatic vena cava is necessary, the midline abdominal incision the posterior attachments and by the right lower costal margin. can be extended by means of a median sternotomy.The pericardi- Exposure of the right hemiliver is facilitated by elevating the right um and the diaphragm can then be divided toward the center of costal margin with a large Richardson retractor. Further exposure the inferior vena cava. This combination of incisions provides can be achieved with mobilization, which requires division of the superb exposure of the hepatic veins and the retrohepatic vena cava right triangular and coronary ligaments [see Figure 2]. In dividing while avoiding injury to the phrenic nerves. the superior coronary ligament, care must be taken not to injure Hepatic injuries are classified according to the grading system the lateral wall of the right hepatic vein; in dividing the inferior developed by the American Association for the Surgery of Trauma coronary ligament, care must be taken not to injure the right Committee on Organ Injury Scaling [see Table 1 and Figure 3].1 The Right Hemiliver (Right Liver) Left Hemiliver (Left Liver) Inferior Vena Cava Middle Hepatic Vein Right Hepatic Vein Left Hepatic Vein 2 8 1, 9 7 3 4 Falciform Ligament 5 Portal Vein 6 Common Hepatic Artery Common Bile Duct Right Posterior Right Anterior Left Medial Left Lateral Section Section Section Section Figure 1 Shown are the anatomic divisions of the liver.
  2. 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 2 Inferior Vena Cava Middle Right Hepatic Vein Hepatic Vein Right Triangular Coronary Ligament Ligament Left Hepatic Vein Left Triangular Ligament Left Branch of Portal Vein Figure 2 Depicted are the Falciform Ligament venous drainage and suspen- sory attachments of the liver. Right Branch Ligamentum of Portal Vein Teres Portal Vein grading scale ranges from I to VI, with I representing superficial ma, and if the liver is not the highest priority, temporary control lacerations and small subcapsular hematomas and VI representing of hepatic bleeding allows repair of other injuries without unnec- avulsion of the liver from the vena cava. Isolated injuries that are essary blood loss. The most useful techniques for the temporary not extensive (grades I to III) often require little or no treatment; control of hepatic hemorrhage are manual compression, perihe- however, extensive parenchymal injuries and those involving the patic packing, and the Pringle maneuver. juxtahepatic veins (grades IV and V) may require complex maneu- Periodic manual compression with the addition of laparotomy vers for successful treatment, and hepatic avulsion (grade VI) is pads is useful in the treatment of complex hepatic injuries to pro- lethal. vide time for resuscitation [see Figure 5].2-4 Hands and pads Clamping of the hepatic pedicle—the Pringle maneuver—is should be positioned to realign the liver in its normal anatomic helpful for evaluating grade IV and V hepatic injuries [see Figure 4]. position. Perihepatic packing with carefully placed laparotomy This maneuver allows one to distinguish between hemorrhage pads is capable of controlling hemorrhage from almost all hepat- from branches of the hepatic artery or the portal vein, which ceas- ic injuries.5-9 The right costal margin is elevated, and the pads are es when the clamp is applied, and hemorrhage from the hepatic strategically placed over and around the bleeding site [see Figure veins or the retrohepatic vena cava, which does not. When per- 6]. Additional pads may be placed between the liver and the forming the Pringle maneuver, we prefer to tear open the lesser diaphragm and between the liver and the anterior chest wall until omentum manually and place the clamp from the patient’s left the bleeding has been controlled.Ten to 15 pads may be required side while guiding the posterior blade of the clamp through the to control the hemorrhage from an extensive right lobar injury. foramen of Winslow with the aid of the left index finger. The Packing is not as effective for injuries to the left hemiliver, because advantages of this approach are the avoidance of injury to the with the abdomen open, there is insufficient abdominal and tho- structures within the hepatic pedicle, the assurance that the clamp racic wall anterior to the left hemiliver to provide adequate com- will be properly placed the first time, and the inclusion of a replac- pression. Fortunately, hemorrhage from the left hemiliver can be ing or accessory left hepatic artery between the blades of the controlled by dividing the left triangular and coronary ligaments clamp. and compressing the hemiliver between the hands. Two compli- cations may be encountered with the packing of hepatic injuries. MANAGEMENT OF INJURIES First, tight packing compresses the inferior vena cava, decreases venous return, and reduces left ventricular filling; hypovolemic Techniques for Temporary Control of Hemorrhage patients may not tolerate the resultant decrease in cardiac output. Temporary control of hemorrhage is essential for two reasons. Second, perihepatic packing forces the right diaphragm superior- First, during treatment of a major hepatic injury, ongoing hemor- ly and impairs its motion; this may lead to increased airway pres- rhage may pose an immediate threat to the patient’s life, and tem- sures and decreased tidal volume. Careful consideration of the porary control gives the anesthesiologist time to restore the circu- patient’s condition is necessary to determine whether the risk of lating volume before further blood loss occurs. Second, multiple these complications outweighs the risk of additional blood loss. bleeding sites are common with both blunt and penetrating trau- The Pringle maneuver is often used as an adjunct to packing
  3. 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 3 Table 1 AAST Organ Injury Scales for Liver, Biliary Tract, Diaphragm, and Spleen Injured Structure AAST Grade Characteristics of Injury AIS-90 Score Hematoma: subcapsular, nonexpanding, < 10% surface area 2 I Laceration: capsular tear, nonbleeding, < 1 cm parenchymal depth 2 Hematoma: subcapsular, nonexpanding, 10%–50% surface area; intraparenchymal, 2 II nonexpanding, < 10 cm in diameter Laceration: capsular tear, active bleeding, 1–3 cm parenchymal depth, < 10 cm in length 2 Hematoma: subcapsular, > 50% surface area, expanding; ruptured subcapsular hematoma with 3 III active bleeding; intraparenchymal, > 10 cm or expanding Laceration: > 3 cm parenchymal depth 3 Liver* Hematoma: ruptured intraparenchymal hematoma with active bleeding 4 IV Laceration: parenchymal disruption involving 25%–75% of hepatic lobe or 1–3 Couinaud’s 4 segments within a single lobe Laceration: parenchymal disruption involving > 75% of hepatic lobe or > 3 Couinaud’s segments 5 within a single lobe V Vascular: juxtahepatic venous injuries (i.e., injuries to retrohepatic vena cava or central major 5 hepatic veins) VI Vascular: hepatic avulsion 5 Gallbladder contusion/hematoma 2 I Portal triad contusion 2 Partial gallbladder avulsion from liver bed; cystic duct intact 2 II Laceration or perforation of gallbladder 2 Complete gallbladder avulsion from liver bed 3 III Extrahepatic biliary tree* Cystic duct laceration 3 Partial or complete right or left hepatic duct laceration 3 IV Partial common hepatic duct or common bile duct laceration (< 50%) 3 > 50% transection of common hepatic duct or common bile duct 3–4 V Combined right and left hepatic duct injuries 3–4 Intraduodenal or intrapancreatic bile duct injuries 3–4 I Contusion 2 II Laceration < 2 cm 3 Diaphragm† III Laceration 2–10 cm 3 IV Laceration > 10 cm, with tissue loss < 25 cm2 3 V Laceration with tissue loss > 25 cm2 3 Hematoma: subcapsular, nonexpanding, < 10% surface area 2 I Laceration: capsular tear, nonbleeding, < 1 cm parenchymal depth 2 Hematoma: subcapsular, nonexpanding, 10%–50% surface area; intraparenchymal, 2 nonexpanding, < 5 cm in diameter II Laceration: capsular tear, active bleeding, 1–3 cm parenchymal depth, not involving a trabecular 2 vessel Hematoma: subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with 3 Spleen* active bleeding; intraparenchymal, > 5 cm or expanding III Laceration: > 3 cm parenchymal depth or involving trabecular vessels 3 Hematoma: ruptured intraparenchymal hematoma with active bleeding 4 IV Laceration: laceration involving segmental or hilar vessels producing major devascularization 4 (> 25% of spleen) Laceration: completely shattered spleen 5 V Vascular: hilar vascular injury that devascularizes spleen 5 *Advance one grade for multiple injuries, up to grade III. †Advance one grade for bilateral injuries, up to grade III. AAST—American Association for the Surgery of Trauma
  4. 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 4 Bleeding is coming from right upper quadrant Take down falciform ligament. Inspect and palpate liver. Temporarily control bleeding with packing or Pringle maneuver, as needed. Make initial assessment of grade of liver injury. Minor injury (grade I or II) Moderate to severe injury (grade III, IV, or V); Moderate to severe injury (grade III, IV, or V); bleeding is controlled with Pringle maneuver bleeding is not controlled with Pringle maneuver Apply topical agents. Do not drain. Divide coronary and triangular ligaments and Divide coronary and triangular ligaments as needed to open liver parenchyma as needed to expose injuries. gain exposure. Close abdomen. Apply topical agents to areas with minimal injury. Use topical agents and buttressed sutures as indicated. For superficial injuries, ligate individual bleeding If bleeding persists, use packs, potentially as definitive vessels or close parenchyma with sutures. treatment. Bleeding is Bleeding continues Bleeding continues (mostly Bleeding is Bleeding continues controlled (mostly low pressure high pressure before Pringle controlled before Pringle maneuver) maneuver) Gain exposure as needed with Close abdomen Close abdomen extension of midline celiotomy into without drains. Suture bleeding vessels, Suture bleeding vessels, even without drains. median sternotomy. even those deep in the those deep in the parenchyma. Remove packs in Control bleeding with intrahepatic parenchyma. If necessary, ligate right 1 or 2 days. balloon tamponade, atriocaval Pack abdomen if necessary. or left hepatic artery. shunt, or vascular isolation, as Drain as indicated; close Drain as indicated; close necessary. abdomen. abdomen. Repair injury to hepatic vein or vena cava. Drain as indicated; close abdomen. Abdomen is not packed Abdomen is packed Remove packs in 1 or 2 days. Follow for postinjury complications (bleeding, abscess, hemobilia, etc.). Evaluate and treat with arteriography, embolization, imaging, and drainage, as indicated. Figure 3 Shown is an algorithm for the treatment of hepatic injuries. for the temporary control of hemorrhage.3 Over the years, the or tear through the parenchyma if placed over an injured area. An length of time for which surgeons believe a Pringle maneuver can alternative is the use of a liver clamp; however, the application of be maintained without causing irreversible ischemic damage to such devices is hindered by the variability in the size and shape of the liver has increased. Several authors have documented the the liver. We have not had consistent success with either of these maintenance of a Pringle maneuver for longer than 1 hour in methods. patients with complex injuries, without appreciable hepatic dam- Juxtahepatic venous injuries are technically challenging, diffi- age.4,10 When a life-threatening hepatic injury is encountered on cult to control with packing, and often lethal. Complex procedures entry into the abdomen, the Pringle maneuver should be per- may be required for temporary control of these large veins. Of formed immediately and perihepatic packs placed. Persistent these procedures, the most important are hepatic vascular isola- bleeding in the face of effective inflow occlusion implies that either tion with clamps, placement of the atriocaval shunt, and use of the the retrohepatic vena cava or hepatic vein has been injured. Moore-Pilcher balloon. Perihepatic packing is more likely to control bleeding from the Hepatic vascular isolation is accomplished by executing a retrohepatic vena cava. Pringle maneuver, clamping the aorta at the diaphragm, and Another technique for temporary control of hepatic hemor- clamping the suprarenal and suprahepatic vena cava.12 In patients rhage is the application of a tourniquet or a liver clamp.11 Once the scheduled for elective procedures, this technique has enjoyed near- bleeding hemiliver is mobilized, a 2.5 cm Penrose drain is wrapped ly uniform success, but in trauma patients, the results have been around the liver near the anatomic division between the left disappointing. The relative ineffectiveness of hepatic vascular iso- hemiliver and the right. The drain is stretched until hemorrhage lation with clamps in this setting is presumably due to the inabili- ceases, and tension is maintained by clamping the drain. ty of a patient in shock to tolerate an acute reduction in left ven- Unfortunately, tourniquets are difficult to use: they tend to slip off tricular filling pressure; on occasion, sudden death has occurred
  5. 5. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 5 rotated anteriorly to provide direct access to the posterior aspect of the retrohepatic vena cava. Anterior injuries of the large veins are repaired through an incision in the posterior aspect of the retrohepatic vena cava. The atriocaval shunt was designed to achieve hepatic vascular isolation while still permitting some venous blood from below the diaphragm to flow through the shunt into the right atrium.4 After a few early successes, the initial enthusiasm for the atriocaval shunt declined as high mortalities associated with its use began to be reported.15-20 Surgeons’ lack of familiarity with the technique; the manipulation of a cold, acidotic heart; and poor patient selection have all contributed to the poor overall results.13 A variation on the original atriocaval shunt has been described in which a 9 mm endotracheal tube is substituted for the usual large chest tube [see Figure 8].21 The balloon of the endotracheal tube makes it unnec- essary to surround the suprarenal vena cava with an umbilical tape. This minor change eliminates one of the most difficult maneuvers required for the original shunt procedure: because hemorrhage must be controlled by posterior pressure on the liver during the insertion of the shunt, access to the suprarenal vena cava is severely restricted, and thus, surrounding this vessel with an umbilical tape is almost impossible. A side hole must be cut in Figure 4 The Pringle maneuver controls arterial and portal vein the tube to allow blood to enter the right atrium. Care must be hemorrhage from the liver. Any hemorrhage that continues must taken to avoid damage to the integral inflation channel for the come from the hepatic veins. balloon. An alternative to the atriocaval shunt is the Moore-Pilcher bal- loon.21 This device is inserted through the femoral vein and on placement of the venous clamps.13 If, however, a trauma advanced into the retrohepatic vena cava. When the balloon is patient requiring hepatic vascular isolation has been maintained in properly positioned and inflated, it occludes the hepatic veins and a relatively normal physiologic condition, it is reasonable to con- the vena cava, thus achieving vascular isolation.The catheter itself sider this method. is hollow, and appropriately placed holes below the balloon permit An alternative approach to exposure of the retrohepatic vena cava and the hepatic veins has been developed in which vascular isolation of the liver is achieved by means of clamping and the suprahepatic vena cava is divided between vascular clamps [see Figure 7].14 The liver and the suprahepatic vena cava are then Figure 5 Manual compression of large hepatic injuries tem- Figure 6 Perihepatic packing is often effective in managing porarily controls blood loss in hypovolemic patients until the cir- extensive parenchymal injuries. It has also been successfully culating blood volume can be restored. employed for grade V juxtahepatic venous injuries.
  6. 6. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 6 Techniques for Definitive Management of Injuries Techniques available for the definitive management of hepatic Azygos Vein injuries range from manual compression to hepatic transplanta- tion. Grade I or II lacerations of the hepatic parenchyma can gen- erally be controlled with manual compression. If these injuries do not respond to manual compression, they can often be controlled with topical hemostatic measures. The simplest of these measures is electrocauterization, which can often control small bleeding vessels near the surface of the liver (though the machine’s power output may have to be increased). Bleeding from raw surfaces of the liver that does not respond to the electrocautery may respond to the argon beam coagulator. This device imparts less heat to the surrounding hepatic tissue and creates a more consistent eschar, which enhances hemostasis. Also useful in similar situations is micro- crystalline collagen in the powdered form. The powder is placed Inferior on a clean 10 × 10 cm sponge and applied directly to the oozing Vena Cava surface, with pressure maintained on the sponge for 5 to 10 min- utes. Thrombin can also be applied topically to minor bleeding injuries by saturating either a gelatin foam sponge or a microcrys- talline collagen pad and pressing it to the bleeding site. In previous years, there was interest in the use of “bathtub” fi- Adrenal Vein Renal Vein Figure 7 With hepatic vascular isolation accomplished, the suprahepatic vena cava is divided between clamps, and the liver and the suprahepatic vena cava are rotated anteriorly to afford access to the posterior aspect of the retrohepatic vena cava. blood to flow into the right atrium, in much the same way as the atriocaval shunt. At present, the survival rate for patients with jux- tahepatic venous injuries who are treated with this device is simi- lar to that for patients treated with the atriocaval shunt.18 Surgeons who attempt hepatic vascular isolation should be aware that none of these techniques provide complete hemostasis. Drainage from the right adrenal vein and the inferior phrenic veins and persistent hepatopetal flow resulting from unrecognized replacing or accessory left hepatic arteries contribute to this prob- lem. The relatively small volume of blood that continues to flow after vascular isolation is readily removed by means of suction. An adjunct to vascular isolation with clamps is venovenous bypass. This technique provides vascular decompression for the small bowel and maintains high cardiac filling pressures, which are often necessary. Venovenous bypass is accomplished by placing a catheter in the inferior vena cava via the femoral vein and a sec- ond catheter in the superior mesenteric vein [see Figure 9].22 A centrifugal pump withdraws blood from these veins and pumps it into the superior vena cava through a third catheter placed in the Figure 8 Shown is a method of achieving hepatic vascular isola- internal jugular vein. tion with a 9 mm endotracheal tube.
  7. 7. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 7 To Internal Jugular Vein Suprahepatic IVC Clamp Pump Figure 9 Shown is venove- Pringle nous bypass. Catheters are Maneuver placed into the inferior vena cava (IVC) and the superior mesenteric vein (SMV), and a Suprarenal centrifugal pump withdraws IVC Clamp blood from these veins and pumps it into the superior vena cava via a third catheter placed into the internal jugu- To SMV via IMV lar vein. To IVC via Femoral Vein or Greater Saphenous Vein brin glue (made by mixing concentrated human fibrinogen with a Although some grade III and IV lacerations respond to topical solution containing bovine thrombin and calcium) to treat hepat- measures, many do not. In these instances, one option is to suture ic lacerations.23,24 This substance has now been rendered obsolete the hepatic parenchyma. Although this hemostatic technique has by the commercial availability of numerous glues and sealants [see been maligned as a cause of hepatic necrosis, it still is frequently Table 2]. used.3,4,10,17,26,27 Suturing of the hepatic parenchyma is often Another relatively new hemostatic adjunct that can be highly employed to control persistently bleeding lacerations less than 3 useful in the setting of hepatic injury is recombinant activated fac- cm in depth; it is also an appropriate alternative for deeper lacer- tor VII (NovoSeven; Novo Nordisk, Copenhagen), which works by ations if the patient cannot tolerate the further hemorrhage asso- promoting coagulation at the lacerated edges of blood vessels. ciated with hepatotomy and selective ligation. If, however, the cap- Many trauma surgeons have personally witnessed the abrupt ces- sule of the liver has been stripped away by the injury, this tech- sation of hemorrhage when factor VII has been administered after nique is far less effective. other materials have failed. Although this agent seems at times to The preferred suture material is 0 or 2-0 chromic catgut have an almost magical effect, it does not always work, and it is attached to a large, blunt-tipped, curved needle; the large diame- extremely expensive; furthermore, the only prospective study to ter prevents the suture from pulling through Glisson’s capsule. For date that addressed the use of factor VII in trauma patients report- shallow lacerations, a simple continuous suture may be used to ed only a modest decrease in total blood use and failed to demon- approximate the edges of the laceration. For deeper lacerations, strate a survival advantage.25 For these reasons, many institutions, interrupted horizontal mattress sutures may be placed parallel to including ours (University of Colorado Health Sciences Center), the edges.When tying sutures, one may be sure that adequate ten- have created protocols for the use of factor VII. At our institution, sion has been achieved when hemorrhage ceases or the liver for factor VII to be used, (1) the patient must be salvageable; (2) the blanches around the suture. patient must have received at least 10 units of packed red blood Most sources of venous hemorrhage can be managed with cells (PRBCs) plus clotting factors; (3) surgical control of hemor- parenchymal sutures. Even injuries to the retrohepatic vena cava rhage must be achieved; and (4) the patient must still be experi- and the hepatic veins have been successfully tamponaded by clos- encing diffuse hemorrhage.The usual dose is 60 to 90 µg/kg, which ing the hepatic parenchyma over the bleeding vessels.13,28 Venous may be repeated once. It should be kept in mind that factor VII is hemorrhage caused by penetrating wounds traversing the central not a substitute for fresh frozen plasma and platelets and that ade- portion of the liver may be managed by closing the entrance and quate amounts of fibrin and platelets must be present for it to work. exit wounds with interrupted horizontal mattress sutures.
  8. 8. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 8 Table 2 Characteristics of Selected Commercially Available Tissue Glues and Sealants Tisseel VH* FloSeal* CoSeal* BioGlue† Human fibrinogen and throm- Contents bin; calcium chloride; Bovine gelatin and thrombin Polyethylene glycol Glutaraldehyde; bovine bovine aprotinin albumin Method of Cell-mediated inflammation absorption Fibrinolysis (10–14 days) Hydrolysis (30 days) Not absorbed (6 wk) (time) Physical Granular; conforms to irregular properties Flexible and elastic surfaces Clear hydrogel; flexible and elastic Ridged and inelastic Preparation time 7–15 min 1–2 min 1–2 min 1–2 min Tissue sealing and adher- General ence; hemostasis in venous Hemostasis in wet fields up to ar- Tissue sealing in dry fields Tissue sealing in dry fields applications oozing terial pressure Sealing of small vessels and synthetic Venous oozing; sealing of Specific grafts; prevention of adhesion in pedi- staple lines; decortication; Active bleeding Sealing of large vessels applications atric cardiac surgical patients; sealing pleurodesis of large vessels Means of Cannula; spray; minimally in- Cannula; minimally invasive Flexible cannula; spray; minimally inva- Cannula application vasive surgery surgery; 8 cm or 10 cm bulb tip sive surgery Limiting factors Arterial pressure Does not seal Wet field Wet field, nerves Set times 3 min 2 min 1 min 30 sec Stability 4 hr 2 hr 2 hr — *Baxter International, Deerfield, Illinois. †CryoLife, Inc., Kennesaw, Georgia. Although this measure may lead to the formation of intrahepatic because it does not stop hemorrhage from the portal and hepatic hematomas that may then become infected, the risk is reasonable venous systems.33 Its primary role is in the management of deep compared with the risks posed by an intracaval shunt or a deep injuries when application of the Pringle maneuver results in the ces- hepatotomy. Still, suturing of the hepatic parenchyma is not always sation of arterial hemorrhage. If the bleeding from the wound stops successful in controlling hemorrhage, particularly hemorrhage once the left or right hepatic artery is isolated and clamped, hepat- from the larger branches of the hepatic artery. If it fails, one must ic arterial ligation is a reasonable alternative to deep hepa- acknowledge the failure promptly and remove the sutures so that totomy. Generally, ligation of the right or left hepatic artery is well the wound can be explored. tolerated; however, ligation of the proper hepatic artery (distal to the Hepatotomy with selective ligation of bleeding vessels is an origin of the gastroduodenal artery) may produce hepatic necrosis. important technique that is usually reserved for deep or transhe- An alternative to suturing the entrance and exit wounds of a patic penetrating wounds. Most authorities prefer it to parenchy- transhepatic penetrating injury or to performing an extensive hepa- mal suturing3,4,10,29,30; some even favor it over placement of an atri- totomy is the use of an intrahepatic balloon.34 These devices are ocaval shunt for exposure and repair of juxtahepatic venous hand-crafted by the surgeon in the operating room. One method injuries.20 The finger-fracture technique is used to extend the of fashioning such a device is to tie a 2.5 cm Penrose drain to a hol- length and depth of a laceration or a missile tract until the bleed- low catheter [see Figure 11]. The balloon is then inserted into the ing vessels can be identified and controlled [see Figure 10]. It bleeding wound and inflated with a soluble contrast agent. If the should be remembered that considerable blood loss may be hemorrhage is controlled, a stopcock or clamp is used to occlude incurred with the division of viable hepatic tissue in the pursuit of the catheter and maintain the inflation. (It should be noted that the bleeding from deep penetrating wounds. As an alternative to finger balloon catheter may not be able to generate sufficient intra- fracture, we have begun to use the LigaSure vessel sealing system parenchymal pressure to tamponade major arterial hemorrhage.) (Valleylab, Boulder, Colorado) and have observed significant The balloon is left in the abdomen and removed at a subsequent decreases in blood loss with this device. operation after 24 to 48 hours. The hemorrhage may recur when An adjunct to parenchymal suturing or hepatotomy is the use of the balloon is deflated. the omentum to fill large defects in the liver and to buttress hepat- Resectional debridement is indicated for peripheral portions of ic sutures.The rationale for this use of the omentum is that it pro- nonviable hepatic parenchyma. Except in rare circumstances, the vides an excellent source for macrophages and fills a potential dead amount of tissue removed should not exceed 25% of the liver. space with viable tissue.31 In addition, the omentum can provide a Resectional debridement is performed by means of the finger-frac- little extra support for parenchymal sutures, often enough to pre- ture technique and is appropriate for selected patients with grade vent them from cutting through Glisson’s capsule. III to grade V lacerations. Because additional blood loss occurs Hepatic arterial ligation may be appropriate for patients with during removal of nonviable tissue, this procedure should be arterial hemorrhage from deep within the liver32; however, it plays reserved for patients who are in sound physiologic condition and only a limited role in the overall treatment of hepatic injuries, can tolerate additional blood loss.
  9. 9. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 9 results; however, in the setting of trauma, the mortality associated with this procedure exceeds 50% in most series.26,27,29,38-40 Consequently, hepatic resection is rarely performed in trauma patients, having been largely replaced by perihepatic packing, resectional debridement, and hepatotomy with selective ligation. Nonetheless, there are two circumstances in which anatomic resec- tion may still be a reasonable choice. The first is prompt resection in patients with extensive injuries of the left lateral section of the liver; because hemorrhage from the left hemiliver is easily con- trolled with bimanual compression, the risk of uncontrolled blood loss is not as high as it is with left or right anatomic hemihepatec- tomies. The second is delayed anatomic hemihepatectomy in patients whose hemorrhage has been controlled but whose left or right hemiliver is nonviable as a result of ligation or thrombosis of essential blood vessels. Because of the large mass of necrotic liver tissue, there is a high risk of subsequent infection or persistent hyperinflammation, setting the stage for the multiple organ dys- function syndrome (MODS). The necrotic hemiliver should be removed as soon as the patient’s condition permits. Hepatic transplantation has been successful in several trauma patients with devastating hepatic injuries who required total hepa- tectomy.41-44 In each of these five patients, the mean anhepatic period was approximately 24 hours. All five survived the trans- plantation, though two died of disseminated viral infections within 2 months of the procedure.Two others were alive and well 16 and 17 months after the procedure; no follow-up was reported for the Figure 10 Hepatotomy with selective ligation is an important fifth patient. Hepatic transplantation represents the ultimate technique for controlling hemorrhage from deep (usually pene- trating) lacerations. This technique includes finger fracture to expression of aggressive trauma care. All other injuries must be extend the length and depth of the wound until vessels or ducts are well delineated (particularly injuries to the CNS), and the patient encountered and controlled. must have an excellent chance of survival aside from the hepatic injury. High cost and limited availability of donors restrict the per- formance of hepatic transplantation for trauma, but it seems prob- Perihepatic packing is the most significant advance in the treat- able that this procedure will continue to be performed in extraor- ment of hepatic injuries to occur in the past 25 years.The practice dinary circumstances. of packing hepatic injuries is not a new one, but the concepts and techniques associated with it have changed. In the past, liver lacer- ations were packed with yards of gauze, and one end of the gauze strip was brought out of the abdomen through a separate stab wound35; the remainder of the gauze was then teased out of the wound over a period of days. Unfortunately, this approach often led to abdominal infection and failed to control the hemorrhage, and as a result, it eventually fell from favor. The current approach is not to place packing material in the laceration itself but rather to place it over and around the injury to compress the wound by compressing the liver between the anterior chest wall, the diaphragm, and the retroperitoneum.5-9 The abdomen is closed, and the patient is taken to the surgical intensive care unit for resus- citation and correction of metabolic derangements. Within 24 hours, the patient is returned to the OR for removal of the packs. Perihepatic packing is indicated for grade IV and V lacerations and for less severe injuries in patients who have a coagulopathy caused by associated injuries. A technique that may be attempted if packing fails is to wrap the injured portion of the liver with a fine porous material (e.g., poly- glycolic acid mesh) after the injured hemiliver has been mobi- lized.36,37 Using a continuous suture or a linear stapler, the surgeon constructs a tight-fitting stocking that encloses the injured hemiliv- er. Blood clots beneath the mesh, which results in tamponade of the hepatic injury. Although this technique is intuitively attractive, to date it has achieved only limited success. The final alternative for patients with extensive injuries to one Figure 11 A handmade balloon from a Robinson catheter and a hemiliver is anatomic hepatic resection. In elective circumstances, Penrose drain may effectively control hemorrhage from a trans- anatomic hemihepatectomies can be performed with excellent hepatic penetrating wound.
  10. 10. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 10 b a Figure 12 (a) The first step in mobilizing the spleen is to make an incision in the peritoneum and the endoabdominal fascia, beginning at the inferior pole and continuing posteriorly and superiorly. (b) The correct plane of dissection is between the pancreas and Gerota’s fascia. Subcapsular Hematoma recently, the use of large sump drains and closed suction drains An uncommon but troublesome hepatic injury is subcapsular has become increasingly popular. Several prospective and retro- hematoma, which arises when the parenchyma of the liver is dis- spective studies have demonstrated that the use of either Penrose rupted by blunt trauma but Glisson’s capsule remains intact. or sump drains carries a higher risk of intra-abdominal infection Subcapsular hematomas range in severity from minor blisters on than the use of either closed suction drains or no drains at all.45-47 the surface of the liver to ruptured central hematomas accompa- It is clear that if drains are to be used, closed suction devices are nied by severe hemorrhage [see Table 1]. They may be recognized preferred. What remains unclear, however, is whether closed suc- either at the time of the operation or in the course of CT scanning. tion drains are better or worse than no drains, particularly in view Regardless of how the lesion is diagnosed, subsequent decision of the advent of percutaneous catheter drainage. Patients who are making is often difficult. If a grade I or II subcapsular initially treated with perihepatic packing may also require hematoma—that is, a hematoma involving less than 50% of the drainage; however, drainage is not indicated at the initial proce- surface of the liver that is not expanding and is not ruptured—is dure, given that the patient will be returned to the OR within the discovered during an exploratory laparotomy, it should be left next 48 hours. alone. If the hematoma is explored, hepatotomy with selective li- MORTALITY AND COMPLICATIONS gation may be required to control bleeding vessels. Even if hepa- totomy with ligation is effective, one must still contend with dif- Overall mortality for patients with hepatic injuries is approxi- fuse hemorrhage from the large denuded surface, and packing mately 10%.The most common cause of death is exsanguination, may also be required. A hematoma that is expanding during oper- followed by MODS and intracranial injury. Three generalizations ation (grade III) may have to be explored. Such lesions are often may be made regarding the risk of death and complications: (1) the result of uncontrolled arterial hemorrhage, and packing alone both increase in proportion to the injury grade and to the com- may not be successful. An alternative strategy is to pack the liver plexity of repair; (2) hepatic injuries caused by blunt trauma carry to control venous hemorrhage, close the abdomen, and transport a higher mortality than those caused by penetrating trauma; and the patient to the interventional radiology suite for hepatic arteri- (3) infectious complications occur more often with penetrating ography and embolization of the bleeding vessels. Ruptured trauma.48 grades III and IV hematomas are treated with exploration and Postoperative hemorrhage occurs in a small percentage of selective ligation, with or without packing. patients with hepatic injuries. The source may be either a coagu- lopathy or a missed vascular injury (usually to an artery). In most Perihepatic Drainage instances of persistent postoperative hemorrhage, the patient is For years, all hepatic injuries were drained via Penrose drains best served by being returned to the OR. Arteriography with brought out laterally or through the bed of the resected 12th rib; embolization may be considered in selected patients. If coagula-
  11. 11. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 11 tion studies indicate that a coagulopathy is the likely cause of post- and Malignant Biliary Tract Disease].54-57 Treatment of injuries to operative hemorrhage, there is little to be gained by reoperation the left or right hepatic duct is even more difficult—so much so until the coagulopathy is corrected. that we question whether repair should even be attempted under Perihepatic infections occur in fewer than 5% of patients with emergency conditions. If only one hepatic duct is injured, a rea- significant hepatic injuries. They develop more often in patients sonable approach is to ligate it and deal with any infections or atro- with penetrating injuries than in patients with blunt injuries, pre- phy of the hemiliver rather than to attempt repair.58 If both ducts sumably because of the greater frequency of enteric contamina- are injured, each should be intubated with a small catheter brought tion. An elevated temperature and a higher than normal white through the abdominal wall. Once the patient has recovered suffi- blood cell count after postoperative day 3 or 4 should prompt a ciently, delayed repair is performed under elective conditions. search for intra-abdominal infection. In the absence of pneumonia, Injuries to the intrapancreatic portion of the CBD are treated by an infected line, or urinary tract infection, an abdominal CT scan dividing the duct at the superior border of the pancreas, ligating with intravenous and upper gastrointestinal contrast should be the distal portion, and performing a Roux-en-Y choledochoje- obtained. Many perihepatic infections can be treated with CT- junostomy. guided drainage; however, infected hematomas and infected The Roux-en-Y choledochojejunostomy is done in a single layer necrotic liver tissue cannot be expected to respond to percuta- with interrupted 5-0 absorbable monofilament sutures.To prevent neous drainage. Right 12th rib resection remains an excellent ischemia and possible stricture, no circumferential dissection of the approach for posterior infections and provides superior drainage in duct is performed. A round patch of approximately the same diam- refractory cases. eter as the CBD is removed from the seromuscular layer of the Bilomas are loculated collections of bile that may or may not be small bowel, but the mucosa and submucosa are only perforated, infected. If a biloma is infected, it is essentially an abscess and not resected. The posterior row of sutures is placed first, with full- should be treated as such; if it is sterile, it will eventually be thickness bites taken through both the duct and the small bowel. resorbed. Biliary ascites is caused by disruption of a major bile The anterior row is then completed. Finally, three or four 3-0 duct. Reoperation after the establishment of appropriate drainage polypropylene sutures are placed to secure the small bowel around is the prudent course. Even if the source of the leaking bile can be the anastomosis to the connective tissue of the porta hepatis. The identified, primary repair of the injured duct is unlikely to be suc- only purpose for these sutures is to spare the fragile anastomosis cessful. It is best to wait until a firm fistulous communication is any potential tension. No T tubes or stents are employed. Closed established with adequate drainage. suction drainage is added in the case of injuries to the intrapancre- Biliary fistulas occur in approximately 3% of patients with major atic portion of the duct or at the surgeon’s discretion. hepatic injuries.40 They are usually of little consequence and gen- Injuries to the gallbladder [see Table 1] are treated by means of erally close without specific treatment. In rare instances, a fistulous either lateral repair with absorbable sutures or cholecystectomy [see communication with intrathoracic structures forms in patients 5:21 Cholecystectomy and Common Bile Duct Exploration]; the deci- with associated diaphragmatic injuries, resulting in a bronchobil- sion between the two approaches depends on which is easier in a iary or pleurobiliary fistula. Because of the pressure differential given situation. Cholecystostomy is rarely, if ever, indicated. between the biliary tract and the thoracic cavity, most of these fis- tulas must be closed operatively; however, we know of one pleuro- biliary fistula that closed spontaneously after endoscopic sphinc- Injuries to the Spleen terotomy and stent placement. Splenic injuries [see Table 1] are treated operatively by means of Hemorrhage from hepatic injuries is often treated without iden- splenic repair (splenorrhaphy), partial splenectomy, or resection, tifying and controlling each bleeding vessel individually, and arter- depending on the extent of the injury and the condition of the ial pseudoaneurysms may develop as a consequence. As the patient.57,58 The continued enthusiasm for nonoperative manage- pseudoaneurysm enlarges, it may rupture into the parenchyma of ment of splenic injuries is driven, in part, by concern about the rare the liver, into a bile duct, or into an adjacent branch of the portal but often fatal complication known as overwhelming postsplenec- vein. Rupture into a bile duct results in hemobilia, which is char- tomy infection (OPSI). OPSI is caused by encapsulated bacteria acterized by intermittent episodes of right upper quadrant pain, (e.g., Streptococcus pneumoniae, Haemophilus influenzae, and upper GI hemorrhage, and jaundice; rupture into a portal vein Neisseria meningitidis) and is very resistant to treatment: mortality may result in portal vein hypertension with bleeding varices. Both may exceed 50%. OPSI occurs most often in young children and of these complications are exceedingly rare and are best managed immunocompromised adults and is uncommon in otherwise with hepatic arteriography and embolization. healthy adults. For this reason, splenic salvage is attempted more vigorously in pediatric patients than in adult ones [see Discussion, Nonoperative Management of Blunt Hepatic and Splenic Injuries, Injuries to the Bile Ducts and Gallbladder below]. Injuries to the extrahepatic bile ducts [see Table 1] can be caused To ensure safe removal or repair, the spleen should be mobilized by either penetrating or blunt trauma; however, they are rare in to the point where it can be brought to the surface of the abdom- either case.49-53 inal wall without tension. To this end, the soft tissue attachments The diagnosis is usually made by noting the accumulation of between the spleen and the splenic flexure of the colon must be bile in the upper quadrant during laparotomy for treatment of divided. Next, an incision is made in the peritoneum and the associated injuries.Treatment of common bile duct (CBD) injuries endoabdominal fascia, beginning at the inferior pole, 1 to 2 cm lat- after external trauma is complicated by the small size and thin wall eral to the posterior peritoneal reflection of the spleen, and con- of the normal duct, which render primary repair almost impossi- tinuing posteriorly and superiorly until the esophagus is encoun- ble except when the laceration is small and there is no tissue loss. tered [see Figure 12a]. Care must be taken not to pull on the spleen, When there is tissue loss or the laceration is larger than 25% to so that it will not tear at the posterior peritoneal reflection, causing 50% of the diameter of the duct, the best treatment option is a significant hemorrhage. Instead, the spleen should be rotated Roux-en-Y choledochojejunostomy [see 5:22 Procedures for Benign counterclockwise, with posterior pressure applied to expose the
  12. 12. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 12 peritoneal reflection. It is often helpful to rotate the operating table 20° to the patient’s right so that the weight of the abdominal vis- cera facilitates their retraction. A plane is thus established between the spleen and pancreas and Gerota’s fascia that can be extended to the aorta [see Figure 12b]. With this step, mobilization is com- plete, and the spleen can be repaired or removed without any need to struggle to achieve adequate exposure. Splenectomy [see 5:25 Splenectomy] is the usual treatment for hilar injuries or a pulverized splenic parenchyma. It is also indi- cated for lesser splenic injuries in patients who have multiple abdominal injuries and a coagulopathy, and it is frequently neces- sary in patients in whom splenic salvage attempts have failed. Partial splenectomy is suitable for patients in whom only a portion of the spleen (usually the superior or inferior half) has been destroyed. Once the damaged portion has been removed, the same methods used to control hemorrhage from hepatic parenchyma can be used to control hemorrhage from splenic parenchyma [see Figure 13]. When horizontal mattress sutures are placed across a raw edge, gentle compression of the parenchyma by an assistant facilitates hemostasis; when the sutures are tied and compression Figure 13 Methods for controlling hemorrhage from the splenic is released, the spleen will expand slightly and tighten the sutures parenchyma are similar to those for controlling hemorrhage from further. Drains are never used after completion of the repair or the hepatic parenchyma. Shown are interrupted mattress sutures resection. across a raw edge of the spleen. If splenectomy is performed, vaccines effective against the encapsulated bacteria are administered. The pneumococcal vac- cine is routinely given, and vaccines effective against H. influenzae through an abdominal incision. Because of the concave shape of and N. meningitidis should also be given if available. the diaphragm and the overlying anterior ribs, anterior diaphrag- matic injuries may be difficult to suture. Repair is greatly facilitat- ed by using a long Allis clamp to grasp part of the injury and evert Injuries to the Diaphragm the diaphragm. Lacerations are repaired with continuous No. 1 In cases of blunt trauma to the diaphragm, the injury is on the monofilament nonabsorbable sutures. Occasionally, with large left side 75% of the time, presumably because the liver diffuses avulsions or gunshot wounds accompanied by extensive tissue loss, some of the energy on the right side. With both blunt and pene- polypropylene mesh is required to bridge the defect. trating injuries [see Table 1], the diagnosis is suggested by an abnor- The explosive growth of laparoscopic procedures has led to the mality of the diaphragmatic shadow on chest x-ray. Many of these application of this technology for both diagnostic and therapeutic abnormalities are subtle, particularly with penetrating injuries, and purposes in trauma patients. In a number of patients with low further diagnostic evaluation may be warranted.The typical injury anterior thoracic stab wounds who otherwise were not candidates from blunt trauma is a tear in the central tendon; often, the tear is for a laparotomy, small diaphragmatic lacerations have been iden- quite large. Regardless of the cause, acute injuries are repaired tified and repaired with laparoscopy and stapling. Discussion Nonoperative Treatment of Blunt Hepatic and Splenic Morrison’s pouch, the left upper quadrant, or the pelvis, which Injury suggests a hemoperitoneum.This observation prompts a CT scan Only a few years ago, blunt and penetrating hepatic and splenic of the abdomen, which establishes the presence or absence of injuries were managed in a similar fashion on the basis of a posi- injuries to the liver or the spleen and, to some degree, serves as a tive diagnostic peritoneal lavage or the probability of peritoneal means of grading the severity of organ injury. Patients may be penetration: a laparotomy was performed, and the injured organs observed either in the SICU or on the ward, depending on the were identified and treated. Currently, although penetrating apparent severity of the parenchymal injury on the CT scan, the abdominal injuries are still treated in the same way, nearly all chil- presence and extent of any associated injuries, and the overall dren and 50% to 80% of adults with blunt hepatic and splenic hemodynamic status.69,70 injuries are treated without laparotomy.59-68 This remarkable The primary requirement for nonoperative therapy is hemody- change was made possible by the development of the high-speed namic stability.63-72 To confirm stability, frequent assessment of helical CT scanner, the replacement of diagnostic peritoneal vital signs and monitoring of the hematocrit are necessary. lavage by ultrasonography, and the growth of interventional Continued hemorrhage occurs in 1% to 4% of patients.65,66,68-73 radiology. Hypotension may develop, usually within the first 24 hours after The diagnosis of blunt abdominal trauma is suspected on the hepatic injury but sometimes several days later, especially when basis of the mechanism of injury and the presence of associated splenic injury is present.71,72 It is often an indication that opera- injuries (e.g., right or left lower rib fractures). Ultrasonographic tive intervention is necessary. A persistently falling hematocrit examination of the abdomen may reveal a fluid stripe in should be treated with PRBC transfusions. If the hematocrit con-
  13. 13. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 13 tinues to fall after two or three units of PRBCs, embolization of missed abdominal injuries, parenchymal infarction, infection, and the liver in the interventional radiology suite should be consid- bile leakage (a complication associated solely with hepatic ered.66 Overall, nonoperative treatment obviates laparotomy in injuries).59,62-64 Aseptic infarcts, infected hematomas, and bile col- more than 95% of cases.59-65 lections are suspected on the basis of a clinical picture suggestive of Out of concern over the risk of delayed hemorrhage or other infection and confirmed by CT -guided aspiration. Aseptic infarc- complications, follow-up CT scans have often been recommend- tion usually does not necessitate operative intervention. Fluid col- ed; unfortunately, there is no consensus as to when or even lections are drained, with the method depending on the viscosity of whether they should be obtained. Given that patients with grade I the fluid: CT -guided drainage may be effective in treating thin col- or II hepatic or splenic injuries rarely show progression of the lections, but operative intervention is required for thicker collec- lesion or other complications on routine follow-up CT scans, it is tions, those with solid components, and those for which percuta- reasonable to omit such scans if patients’ hematocrits remain sta- neous drainage was attempted without success. Extrahepatic bile ble and they are otherwise well. Patients with more extensive collections should be treated with percutaneous drainage under injuries often have a less predictable course, and CT scanning CT guidance. Most biliary fistulas close spontaneously; endoscop- may be necessary to evaluate possible complications. Routine ic stent placement may hasten closure in recalcitrant cases.74 scanning before discharge, however, is unwarranted. On the other Intrahepatic collections of blood and bile are managed expectant- hand, patients who participate in vigorous or contact sports ly. Complete absorption of large intrahepatic collections may take should have CT documentation of virtually complete healing several months. If a collection becomes infected, CT -guided aspi- before resuming those activities. ration is performed and drainage obtained as described. A more convenient and less expensive alternative to follow-up Missed enteric and retroperitoneal injuries are another cause of CT scanning is ultrasonographic monitoring of lesions. failed nonoperative treatment. Such injuries are present in 1% Ultrasonographic monitoring is particularly useful for following to 4% of patients in whom nonoperative treatment is attempt- up splenic injuries; however, it may not be useful for following up ed.59,61-64 High-quality images and expert interpretation minimize hepatic injuries, because the technology currently available is inca- the number of missed injuries on CT scans but cannot eliminate pable of reliably imaging the entire liver. them entirely. Therefore, patients must be watched carefully for Other complications of nonoperative therapy for blunt hepatic the development of peritoneal irritation and other signs of intra- and splenic injuries occur in 2% to 5% of patients; these include abdominal pathology. References 1. Moore EE, Cogbill TH, Jurkovich GJ, et al: caval shunt: facts and fiction. Ann Surg 207:555, patic wounds: case reports. J Trauma 31:408, 1991 Organ injury scaling: spleen and liver (1994 revi- 1988 25. Boffard KD, Riou B, Warren B, et el: sion). J Trauma 38:323, 1995 14. Buechter KJ, Gomez GA, Zeppa R: A new tech- Recombinant factor VIIa as adjunctive therapy 2. Hepatic trauma revisited. Feliciano DV, Pachter nique for exposure of injuries at the confluence for bleeding control in severely injured trauma HL, Eds. Curr Probl Surg 26, 1986 of the retrohepatic veins and the retrohepatic patients: two parallel randomized, placebo-con- vena cava. J Trauma 30:328, 1990 trolled, double-blind clinical trials. J Trauma 3. Moore EE: Critical decisions in the manage- 59:8, 2005 ment of hepatic trauma. Am J Surg 148:712, 15. Schrock T, Blaisdell FW, Matthewson C Jr: 1984 Management of blunt trauma to the liver and 26. Ochsner MG, Maniscalco-Theberge ME, hepatic veins. Arch Surg 96:698, 1968 Champion HR: Fibrin glue as a hemostatic 4. Feliciano DV, Mattox KL, Jordan GL, et al: agent in hepatic and splenic trauma. J Trauma Management of 1000 consecutive cases of 16. Bricker DL, Morton JR, Okies JE, et al: Surgical 30:884, 1990 hepatic trauma (1979–1984). Ann Surg management of injuries to the vena cava: chang- 204:438, 1986 ing patterns of injury and newer techniques of 27. Trunkey DD, Shires GT, McClelland R: repair. J Trauma 11:725, 1971 Management of liver trauma in 811 consecutive 5. Feliciano DV, Mattox KL, Burch JM, et al: patients. Ann Surg 179:722, 1974 Packing for control of hepatic hemorrhage. J 17. Yellin AE, Chaffee CB, Donovan AJ: Vascular Trauma 26:738, 1986 isolation in treatment of juxtahepatic venous 28. Levin A, Gover P, Nance FC: Surgical restraint injuries. Arch Surg 102:566, 1971 in the management of hepatic injury: a review of 6. Ivantury RR, Nallathambi M, Gunduz Y, et al: Charity Hospital experience. J Trauma 18:399, Liver packing for uncontrolled hemorrhage: a 18. Walt AJ: The mythology of hepatic trauma: or 1978 reappraisal. J Trauma 26:744, 1986 Babel revisited. Am J Surg 125:12, 1978 29. Lucas CE, Ledgerwood AM: Prospective evalu- 7. Carmona RH, Peck DZ, Lim RC: The role of 19. Millikan JS, Moore EE, Cogbill TH, et al: ation of hemostatic techniques for liver injuries. packing and planned reoperation in severe Inferior vena cava injuries: a continuing chal- J Trauma 16:442, 1976 hepatic trauma. J Trauma 24:779, 1984 lenge. J Trauma 23:207, 1983 30. Camona RH, Lim RC Jr, Clark GC: Morbidity 8. Cue JI, Cryer HG, Miller FB, et al: Packing and 20. Pachter HL, Spencer FC, Hofstetter SR, et al: and mortality in hepatic trauma: a 5 year study. planned reexploration for hepatic and retroperi- The management of juxtahepatic venous injuries Am J Surg 144:88, 1982 toneal hemorrhage: critical refinements of a use- without an atriocaval shunt. Surgery 99:569, 31. Moore FA, Moore EE, Seagrave A: ful technique. J Trauma 30:1007, 1990 1986 Nonresectional management of major hepatic 9. Beal SL: Fatal hepatic hemorrhage: an unre- 21. Pilcher DB, Harman PK, Moore EE: trauma: an evolving concept. Am J Surg solved problem in the management of complex Retrohepatic vena cava balloon shunt intro- 150:725, 1985 liver injuries. J Trauma 30:163, 1990 duced via the sapheno-femoral junction. J 32. Stone HH, Lamb JM: Use of pedicled omentum 10. Pachter HL, Spencer FC, Hofstetter SR, et al: Trauma 17:837, 1977 as an autogenous pack for control of hemor- Significant trends in the treatment of hepatic 22. Biffl WL, Moore EE, Franciose RJ: Venovenous rhage in major injuries of the liver. Surg Gynecol trauma: experience with 411 injuries. Ann Surg bypass and hepatic vascular isolation as adjuncts Obstet 141:92, 1975 215:492, 1992 in the repair of destructive wounds to the retro- 33. Mays ET: Lobar dearterialization for exsan- 11. Murray DH Jr, Borge JD, Pouteau GG: hepatic inferior vena cava. J Trauma 45:400, guinating wounds of the liver. J Trauma 12:397, Tourniquet control of liver bleeding. J Trauma 1998 1972 18:771, 1978 23. Kram HB, Nathan RC, Stafford FJ, et al: Fibrin 34. Flint LM, Polk HC: Selective hepatic artery li- 12. Heaney JP, Stanton WR, Halbert DS, et al: An glue achieves hemostasis in patients with coagu- gation: limitations and failures. J Trauma improved technic for vascular isolation of the lation disorders. Arch Surg 124:385, 1989 19:319, 1979 liver. Ann Surg 163:237, 1966 24. Berguer R, Staerkel RL, Moore EE, et al:Warning: 35. Poggetti RS, Moore EE, Moore FA, et al: 13. Burch JM, Feliciano DV, Mattox KL: The atrio- fatal reaction to the use of fibrin glue in deep he- Balloon tamponade for bilobar transfixing
  14. 14. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 7 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 14 hepatic gunshot wounds. J Trauma 33:694, 1992 drains in liver trauma. J Trauma 28:337, 1988 ma: identification of patterns of injury. J Trauma 36. Madding GF, Lawrence KB, Kennedy PA: War 51. Fabian TC, Croce MA, Stanford GG, et al: 39:344, 1995 wounds of the liver. Tex State J Med 42:267, Factors affecting morbidity after hepatic trauma. 66. Pachter HL, Knudson MM, Esrig B, et al: Status 1946 Ann Surg 213:540, 1991 of nonoperative management of blunt hepatic 37. Reed RL, Merrell RC, Meyers WC, et al: 52. Posner MC, Moore EE: Extrahepatic biliary injuries in 1995: a multicenter experience with Continuing evolution in the approach to severe tract injury: operative management plan. J 404 patients. J Trauma 40:31, 1996 liver trauma. Ann Surg 216:524, 1992 Trauma 25:833, 1985 67. Powell M, Courcoulas A, Gardner M, et al: 38. Jacobson LE, Kirton OC, Gomez GA:The use of 53. Ivatury RR, Rohman M, Nallathami M, et al: Management of blunt splenic trauma: significant an absorbable mesh wrap in the management of The morbidity of injuries of the extra-hepatic bil- differences between adults and children. Surgery major liver injuries. Surgery 111:455, 1992 iary system. J Trauma 25:967, 1985 122:654, 1997 39. Lim RC Jr, Knudson J, Steele M: Liver trauma: 54. Sheldon GF, Lim RC,Yee ES, et al: Management 68. Richardson JD: Changes in the management of current method of management. Arch Surg of injuries to the porta hepatis. Ann Surg injuries to the liver and spleen. J Am Coll Surg 104:544, 1972 202:539, 1985 200:648, 2005 40. Donovan AJ, Michaelian MJ, Yellin AE: 55. Feliciano DV, Bitondo CG, Burch JM, et al: 69. Sclafani SJA, Shaftan GW, Scalea TM, et al: Anatomical hepatic lobectomy in trauma to the Management of traumatic injuries to the extra- Nonoperative salvage of computed tomogra- liver. Surgery 73:833, 1973 hepatic biliary ducts. Am J Surg 150:705, 1985 phy–diagnosed splenic injuries: utilization of angiography for triage and embolization for 41. Defore WW, Mattox KL, Jordan GL, et al: 56. Bade PG, Thomson SR, Hirshberg A, et al: hemostasis. J Trauma 39:818, 1995 Management of 1590 consecutive cases of liver Surgical options in traumatic injury to the extra- trauma. Arch Surg 111:493, 1976 hepatic biliary tract. Br J Surg 76:256, 1989 70. Malhotra AK, Fabian TC, Crou MA, et al: Blunt hepatic injury: a paradigm shift from operative to 42. Esquivel CO, Bernardos A, Makowka L, et al: 57. Csendes A, Diaz JC, Burdiles P, et al: Late results nonoperative management in the 1990’s. Ann Liver replacement after massive hepatic trauma. of immediate primary end to end repair in acci- Surg 231:804, 2000 J Trauma 27:800, 1987 dental section of the common bile duct. Surg Gynecol Obstet 168:125, 1989 71. Sutyak JP, Chiu WC, D’Amelio LF, et al: 43. Angstadt J, Jarrell B, Moritz M, et al: Surgical Computed tomography is inaccurate in estimat- management of severe liver trauma: a role for 58. Howdieshell TR, Hawkins ML, Osler TM, et al: ing the severity of adult splenic injury. J Trauma liver transplantation. J Trauma 29:606, 1989 Management of blunt hepatic duct transection 39:514, 1995 44. Ringe B, Pichlmayr R, Ziegler H, et al: by ligation. South Med J 83:579, 1990 72. Croce MA, Fabian TC, Kudsk KA, et al: AAST Management of severe hepatic trauma by two- 59. Barrett J, Sheaff C, Abuabara S, et al: Splenic organ injury scale: correlation of CT-graded liver stage total hepatectomy and subsequent liver preservation in adults after blunt and penetrating injuries and operative findings. J Trauma 31:806, transplantation. Surgery 109:792, 1991 trauma. Am J Surg 145:313, 1983 1991 45. Jeng LB, Hsu C, Wang C, et al: Emergent liver 60. Feliciano DV, Spjut-Patrinely V, Burch JM, et al: 73. Gates JD: Delayed hemorrhage with free rupture transplantation to salvage a hepatic avulsion Splenorrhaphy: the alternative. Ann Surg complicating the nonsurgical management of injury with a disrupted suprahepatic vena cava. 211:569 1990 blunt hepatic trauma: a case report and review of Arch Surg 128:1075, 1993 61. Cogbill TH, Moore EE, Jurkovich JJ, et al: the literature. J Trauma 36:572, 1994 46. Fischer RP, O’Farrell KA, Perry JF Jr: The value Nonoperative management of blunt septic trau- 74. Sugimoto K, Asari Y, Sakaguchi T, et al: of peritoneal drains in the treatment of liver ma: a multicenter experience. J Trauma 29:1312, Endoscopic retrograde cholangiography in the injuries. J Trauma 18:393, 1978 1989 nonsurgical management of blunt liver injury. J 47. Noyes LD, Doyle DJ, McSwain NE: Septic com- 62. Meredith JW, Young JS, Bowling J, et al: Trauma 35:192, 1993 plications associated with the use of peritoneal Nonoperative management of blunt hepatic trau- drains in liver trauma. J Trauma 28:337, 1988 ma: the exception or the rule? J Trauma 36:529, 48. Kozar RA, Moore FA, Cothren CC, et al: 1994 Predicting hepatic-related morbidity associated 63. Pachter HL, Hofstetter ST: The current status of Acknowledgments with nonoperative management of complex nonoperative management of adult blunt hepatic blunt hepatic injuries: a multicenter trial. Arch injuries. Am J Surg 169:442, 1995 Figure 1 Tom Moore. Surg (in press) 64. Croce MA, Fabian TC, Menke PG, et al: Figures 2, 7, and 9 Thom Graves. 49. Jurkovich GJ, Hoyt DB, Moore FA, et al: Portal Nonoperative management of blunt hepatic trau- Figure 3 Marcia Kammerer. triad injuries: a multi-institutional study. J ma is the treatment of choice for hemodynami- Figures 4 through 6, 8, and 10 through 13 Susan Trauma 39:426, 1995. cally stable patients. Ann Surg 221:744, 1995 Brust, C.M.I. 50. Noyes LD, Doyle DJ, McSwain NE: Septic com- 65. Boone DC, Federle M, Billiar TR, et al: Table 2 Information provided by Baxter International, plications associated with the use of peritoneal Evolution of management of major hepatic trau- Deerfield, Illinois.