1) Hemodynamically stable patients with evidence of vascular injury on CT or signs of persistent bleeding should undergo angiography for splenic injuries. The role of angiography for other high-risk splenic injuries without clear vascular injuries on CT is unclear. 2) For liver injuries, packing is usually sufficient to control bleeding for most injuries. Pringle maneuver, total vascular exclusion, or post-op angiography may be needed for the uncommon patients with continued bleeding. 3) Balloon tamponade can successfully arrest hemorrhaging in over 90% of cases but overall mortality remains high, especially for injuries of the face, neck, and heart. Survival is better for liver injuries controlled with balloon tamponade

1. Solid Organ Injuries
Chad G. Ball, MD, MSc, FRCSC, FACS
Hepatobiliary, Pancreas, Trauma and Acute Care Surgery
University of Calgary

2. SPLEEN INJURIES

3. • All hemodynamically stable patients with evidence of a vascular
injury on CT (PSA ; AV fistula ; active bleeding)
• The role of angiography in other high risk patients (Grade 3-4-5;
large hemoperitoneum) w/o vascular injuries on CT is unclear
• Experience largely based from one centre
• Low threshold to recommend angio in patients with signs of
persistent bleeding or increase in symptoms who remain HD stable.
Who should undergo angiography…
3

4. • Delayed vascular injuries (PSA) are rare but do exist (2-3 %)
– Low grade injuries are at lower risks of latent PSA (but not
zero risk…)
• The significance and risk of rupture of a delayed PSA is unknown
(same as early PSA ?)
• Follow-up imaging of splenic injuries managed non-operatively
varies from center to center
Utility of follow-up
imaging…
4

5. IN-HOSPITAL MANAGEMENT ???
5
• Activity level ?
• Timing of DVT prophylaxis ?

6. • > 90% of failures of non-operative management will occur in
the first 72 hours post-injury
• A large number of retrospective studies suggest that a patient
with no signs of persistent bleeding could be safely discharged
home after 72 hours or less of observation
• Clear discharge instructions...
• Where is the patient going...
When should a patient be discharged?
6

7. KIDNEY INJURIES

8. Indications for Nephrectomy
• Renal cause of ongoing hemorrhage in the
context of persistent hypotension
• Complete avulsion of kidney
• Persistent ‘unwellness’ and/or sepsis
• Persistent urinoma in the context of poor urinary
diversion
• Mechanisms are not absolute dictators

9. Blunt Renal Artery Thrombosis
• “Stretch” injury
• Nonoperative, unless:
• Sepsis
• Chronic pain
• Rarely, systemic hypertension
• Endovascular stenting:
• Early
• Improved success (59% vs. 17%)

10. LIVER INJURIES

11. Intrahepatic Anatomy

12. Extrahepatic Anatomy

13. Hepatic Trauma
Unstable
Responder Non Responder
CT Scan OR
Blush No Blush
IR Embo Admit
Stable
CT Scan
Blush No Blush
IR Embo Admit
EFAST EFAST

14. Described Hemostasis Options
• Packs only (reconstitution)
• Topical hemostatic agents
• Topical energy instruments
• Sutures
• Finger fracture + suture
• Clamp tractotomy + suture
• Stapled tractotomy + suture
• Resectional debridement
• Anatomical debridement
• Surgical Segmentectomy
• Surgical lobectomy
• Hepatic artery ligation
• Total vascular exclusion
• Atrial-Caval shunt + repair
• Veno-veno bypass + repair
• Complete hepatectomy
• Embolization
• Balloon tamponade

15. Described Hemostasis Options
• Packs only (reconstitution)
• Topical hemostatic agents
• Topical energy instruments
• Sutures
• Finger fracture + suture
• Clamp tractotomy + suture
• Stapled tractotomy + suture
• Resectional debridement
• Anatomical debridement
• Surgical Segmentectomy
• Surgical lobectomy
• Hepatic artery ligation
• Total vascular exclusion
• Atrial-Caval shunt + repair
• Veno-veno bypass + repair
• Complete hepatectomy
• Embolization
• Balloon tamponade

16. Described Hemostasis Options
• Packs only (reconstitution)
• Topical hemostatic agents
• Topical energy instruments
• Sutures
• Finger fracture + suture
• Clamp tractotomy + suture
• Stapled tractotomy + suture
• Resectional debridement
• Anatomical debridement
• Surgical Segmentectomy
• Surgical lobectomy
• Hepatic artery ligation
• Total vascular exclusion
• Atrial-Caval shunt + repair
• Veno-veno bypass + repair
• Complete hepatectomy
• Embolization
• Balloon tamponade

17. Tips and Tricks
• Wrap the liver in a sterile plastic layer prior to re-packing
• ALL major procedures should be completed < 60 minutes
• Temporary Abdominal Closure
• Slight delay in returning to theater for the repeat laparotomy
• Ensure you have a fixed retractor and all your instruments
• Leave the falciform ligament intact in R sided blunt trauma

18. Pringle Maneuver

19. EARLY Pringle
Hemorrhage !!
IVC Hepatic Vein
No Hemorrhage
Call for assistance
Prepare equipment
Ligate the hepatic artery*
• Place the Pringle clamp early
• Hypotensive patients tolerate prolonged Pringles poorly
• Be wary of the replaced left hepatic artery

20. Total Vascular Exclusion
• Infrahepatic IVC
• Suprahepatic IVC*
• Porta Hepatis (Pringle)

21. TVE

22. Total Vascular Exclusion
• Infrahepatic IVC
• Suprahepatic IVC*
• Porta Hepatis (Pringle)
• Aorta

23. “Mobilize the Right Lobe”

24. “TVE + Direct Repair”

25. Endoscopic Stapler

26. Direct Branches

27. Balloon Tamponade

29. Balloon Tamponade

30. Results - Balloon Catheters
• Overall mortality = 66%
• Successful in arresting hemorrhage = 93%*
• Mean indwelling times :
– Iliac = 31 hours
– Liver = 53 hours
– Carotid / Skull base = 78 hours
• Among early deaths (physiologic exhaustion) :
– Heart = 5
– Nasopharynx = 3
– Liver = 3
– Orbit = 1
– Innominate vein = 1
• 64% of patients with facial/neck injuries died of TBI
Ball CG, et al. A decade’s experience with balloon catheter tamponade of hemorrhaging injuries. J Trauma,

31. Results - Balloon Catheters
• Overall mortality = 66%
• Successful in arresting hemorrhage = 93%*
• Mean indwelling times :
– Iliac = 31 hours
– Liver = 53 hours
– Carotid / Skull base = 78 hours
• Among early deaths (physiologic exhaustion) :
– Heart = 5
– Nasopharynx = 3
– Liver = 3
– Orbit = 1
– Innominate vein = 1
• 64% of patients with facial/neck injuries died of TBI
Ball CG, et al. A decade’s experience with balloon catheter tamponade of hemorrhaging injuries. J Trauma,

32. Survival
Liver 8 / 12 (67%)
Extremity Vascular (Femoral / Popliteal) 2 / 3 (67%)
Abdominal Vascular (Iliac) 2 / 4 (50%)
Cardiac 3 / 8 (38%)
Face / Pharynx 1 / 12 (8%)
Carotid 0 / 1
Great Vessels (Innominate) 0 / 1
Subclavian Vascular 0 / 1
Axillary Vascular 0 / 1
Retroperitoneum 0 / 1
Ball CG, et al. A decade’s experience with balloon catheter tamponade of hemorrhaging injuries. J Trauma,

33. Survival
Liver 8 / 12 (67%)
Extremity Vascular (Femoral / Popliteal) 2 / 3 (67%)
Abdominal Vascular (Iliac) 2 / 4 (50%)
Cardiac 3 / 8 (38%)
Face / Pharynx 1 / 12 (8%)
Carotid 0 / 1
Great Vessels (Innominate) 0 / 1
Subclavian Vascular 0 / 1
Axillary Vascular 0 / 1
Retroperitoneum 0 / 1
Ball CG, et al. A decade’s experience with balloon catheter tamponade of hemorrhaging injuries. J Trauma,

34. Ligation vs. Repair vs. Shunt

35. Atrial – Caval Shunt
• Few Survivors
• Trigger early
• 2 experienced surgical teams
• Have the kit/equipment available

36. Complications
• Biloma / Infected biloma
– Laparoscopic washout and drainage
• Hepatic failure (shock liver +/- inflow occlusion)
– Standard supportive care
• Persistent bile leaks
– ERCP intrabiliary stent placement
• Biliary Fistulae
– Biliary-bronchopleural

37. The Aquamantys

38. Hand piece

40. Rules of Thumb…
• Bad spleen injuries go in the bucket!
• Bad kidney injuries go in the bucket!!
• Packing controls 98% of hepatic injuries
• Be prepared for the 2% outliers
– Pringle / TVE / Post-op angiography-portography
• Complete your operation in less than 1 hour !
• Flailing and indecision lead to patient death
• Balloons and Allis clamps are our best friends

41. Thank-you!Thanou!
Thank-you!