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able maybe used with graded closure and tension slowly applied to thin down the parenchyma, prior to stapling. Care should be taken not to fracture the parenchyma and lacerating the duct. There is no difference in pancreatic leak rates between the stapled versus the handsewn approach. In our hands, handsewing of the pancreatic stump has achieved good results.

When a handsewn closure is used, the surgeon tries to identify the very small main pancreatic duct. This identication, although difcult, is possible in most cases. If used correctly modern electrocautery devises do not cause as much tissue damage and discoloration and so they can be used to divide the pancreas without making identication of the duct more difcult. The pancreatic duct when identied is closed using a nonabsorbable 5/0 suture using a gure-of-eight stitch. Although the different techniques of closure of the pancreatic stump aim at controlling the bleeding as well as a leak from the pancreatic duct by compressing them within the pancreatic tissue, applying the gure-of-eight stitch at the pancreatic duct separately can diminish the risk of stula formation.

The pancreatic stump should be closed by inserting overlapping interrupted mattress sutures of polypropylene or silk. Which is the best way for inserting these mattress sutures? There is a tendency for the surgeon to move the needle holder, while inserting sutures, from away toward his/her body (in the right-handed surgeon, from the right to the left). So in the case of the pancreas, the mattress stitch will be inserted from the posterior pancreatic surface to the anterior and then from the anterior to the posterior. Consequently, the stitch will be knotted on the posterior surface of the pancreas. As the normal pancreatic tissue is very soft, it is important, when the surgeon puts tension on the knot, to do it in such a way that it compresses the occluded pancreatic tissue but does not cut through it. This can be better achieved when the knot is in front, so that more controlled tension is applied with the two index ngers. Therefore, the mattress stitch is inserted “backhanded” (remember the surgeon is standing on the patient’s right side) starting from the anterior surface to the posterior and back from the posterior to the anterior. The rst knot—the one that counts—should be straight and double, so that appropriate tension can be applied and it does not give way while “relaxing” it on throwing the second knot.

If the pancreas is very swollen, as happens frequently in patients with blunt transection of the body of the pancreas especially when there is a delayed presentation—a stapler should not be used. The clips are too small to include the whole width of the transected pancreas. In this case, a thick stitch is used (usually stitches with high tensile strength like 0, 1, and 2, which are also thicker). This helps the surgeon in two ways: rst, the needle is longer, so that the surgeon includes in his/her bite the whole cut surface of the pancreas,

and, second, as the stitch is thicker, there is less chance of cutting through the parenchyma—“like a hot wire through Swiss cheese.”

The distal pancreas should be removed together with the spleen. If the patient is physiologically stable (usually in isolated pancreatic injuries), an attempt can be made to preserve the spleen. This means additional time to dissect small perforating vessels originating from splenic vasculature on the posterior pancreas surface. When a splenic preserving approach is employed, we prefer the conventional approach with preservation of the splenic vein and artery as opposed to the Warshaw technique that relies on the short gastrics blood supply to perfuse the spleen. As a rule, we do not attempt splenic preservation when we are performing distal pancreatectomy for trauma in adults. In the damage control scenario, pancreatic duct ligation has been advocated as a technique available when faced with an unstable patient unable to tolerate further operations. The experience in trauma surgery is, however, limited.

If a splenectomy is performed, remember to give the patient pneumococcal vaccine 2–3weeks after the procedure to help reduce the incidence of overwhelming postsplenectomy sepsis from encapsulated bacteria.

A parenchymal injury to the head without major duct disruption requires good suction drainage alone. If one is unable to classify the ductal injury in the head, then our recommendation is to err on the conservative side and only drain the head. Should an injury to the main pancreatic duct (MPD) be missed and a pancreatic stula develop, endoscopic intervention with ERCP and MPD stenting works well in our experience to stop the leak. We do not advocate major resections of the head unless there is a dened major injury to the duodenal-ampullary complex or the missile has essentially divided the pancreas for you. When the head of the pancreas is shattered and there is a signicant duodenal injury and minimal dissection is required to remove the head, a pancreaticoduodenectomy is performed. When dividing the uncinate process of the pancreas as it runs posterior to the portal vein/superior mesenteric vein (PV/SMV), it is important to identify by palpation where the superior mesenteric artery runs to the left of the veins. Traction on the pancreas head during the process of dividing the uncinate process can tent up the artery, and injury to the SMA is possible at this point. As a matter of fact the uncinate process can be left on the portal vein making the resection of the head of the pancreas less tedious.

The remaining issue is the timing of the reconstruction. In experienced hands and with a stable patient without the need for damage control, an immediate reconstruction can be performed. However, this is the exception. We advocate that the reconstruction is performed at a second procedure, delayed for 48–72h to address the patient’s general condition as per damage control guidelines. Again, it is the pancreatic recon-

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struction that is difcult due to the normal pancreas and small duct. We make no recommendation as to the type of pancreatic reconstruction that should be employed. Our own practice is to perform a posterior pancreaticogastrostomy. Then a proximal gastrojejunostomy is fashioned followed about 10 cm distally with a side-to-side hepaticojejunostomy. There is some suggestion that the gallbladder can be used as a conduit for biliary reconstruction. We think this is unnecessary and unwise and recommend routine cholecystectomy. In addition, the bile duct is also usually not dilated, and care and experience should be employed to prevent postoperative strictures of the bile duct anastomosis. Should the bile duct be small, mobilize the common bile duct proximally and identify the left hepatic duct. Open the anterior wall of the common hepatic duct onto the left hepatic duct for at least 2cm. During this dissection, a small branch of the hepatic artery crosses the left hepatic duct and is often divided at this point. This vessel is hard to identify before you cut it and can be controlled with a small suture or diathermy. A note of caution at this point is important, and preservation of the blood supply to the biliary tree is very important. Excessive mobilization can devascularize the bile ducts resulting in late ischemic strictures. A side-to-side hepaticojejunostomy using a 4/0 or 5/0 monolament absorbable, as originally described by Hepp and Couinaud, is then performed. The bowel loop is brought antecolic based on the evidence that this reduces the incidence of delayed gastric emptying it is worth mentioning that if a narrow common bile duct is ligated during the initial operation, it will be dilated at the time of the reconstruction, making the Hepp and Couinaud anastomosis, technically easier.

The challenge in the patient without a shattered head of pancreas is to identify the major injury to the ampulla. If the ampulla is not accessible through the duodenal injury, some recommend an on-table cholangiogram to identify the injury. In our experience, this is usually not required and can be very difcult from a logistics point of view in the middle of the night. The damage control approach is very valuable in this setting and allows one to revisit the decision-making in the cold light of day with all the resources available. This may include MRCP.

With the growing evidence that minimally invasive interventions such as ERCP and EUS can assist in managing post-trauma complications to the pancreas, especially in the blunt trauma setting, if at operation a borderline indication for a pancreaticoduodenectomy exists, we would recommend drainage and referral to a center where endoscopic and interventional radiological expertise exist.

In the situation where there is a signicant injury to the duodenum with a borderline injury to the pancreas with an intact ampulla, we believe that a well-placed purse-string suture, occluding the pylorus and placing it from inside the

stomach in addition to a gastrojejunostomy using the same gastric incision made to insert the above purse string should be performed (pyloric exclusion). The duodenal injury should be closed with meticulous interrupted monolament sutures. If there is a concomitant biliary injury, a cholecystectomy and placement of a T-tube into the common bile duct can be added to divert the bile from the duodenum or from the site of injury. Pyloric exclusion can be considered for Grade III and IV injuries. It has largely been abandoned, but it can be a valuable adjunct in rare situations. In over 90% of patients the pyloric exclusion will open, meaning that it does not require a separate procedure during recovery. In recent years there have been unfavorable reports of pyloric exclusion, which have discouraged its use. Cruvinel Neto etal. performed a literature review of pyloric exclusion in complex duodenal injuries (Grade III and above). Although pyloric exclusion was not associated with improved outcome, it was noted that all the data came from retrospective studies and that there was insufcient high-level data to abandon this approach.

We believe, in general, that with the advent of endoscopic interventions and the progress made in interventional radiology, the aggressive approach to pancreatic injuries should be reviewed. Clearly, when there is signicant parenchymal and MPD disruption to the left of the PV/SMV, resectional surgery is required. However, in borderline cases, when the MPD integrity is uncertain or the status of the ampullary complex poorly dened, the value of intraoperative techniques to identify and classify the injury is uncertain and is not reliable enough and is meddlesome and should be avoided. However, what has not been mentioned is the role of intraoperative ultrasound. No studies have been reported dening the role and benet, if any, from intraoperative ultrasound. This tool is common place in an HPB theater, and ultrasound of the pancreas is a very valuable way of looking for small lesions in the pancreas and their relationship to the MPD, which is well seen.

Postoperative complications are common and are often due to the associated injuries. The complications related to the pancreas are mainly related to surgical site infections, pancreatico-cutaneous stulae, and the development of pancreatic and peripancreatic uid collections.

Surgical site infections are usually treated using interventional radiological techniques. However, if bowel stulae resulting in intra-abdominal collections occur and are associated with pancreatic duct leaks, in addition to the radiological interventions, the duct leak must be addressed.

Pancreatic stulae are the most signicant of the primary pancreatic complications. They have a signicant associated morbidity if not treated adequately, and this may require a number of simultaneously employed techniques. The initial problem is to dene a clinically signicant stula. In the lit-

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erature, there are numerous classications and consensus statements. The ISGPF guidelines are used to dene postoperative pancreatic stula. A leak of amylase-rich uid persisting for several days and having clinical implications should be dened as a stula. The role of the volume of uid in the denition is unclear. We consider a daily output of between 50 and 100mL to be signicant. In such a patient, the rst step is to exclude a peripancreatic collection that is not adequately addressed by the drain. CECT scan is the investigation of choice. If there is a collection, percutaneously placed pigtail drains are inserted. Control of the stula is the main objective in this situation. Can we avoid the development of stulae? The role of octreotide in the postoperative period is not well dened. Some work from Heidelberg in Germany suggests a real benet in reducing the postoperative stula rate. This has not been shown in the trauma situation. We do not use it routinely, but if there is real concern regarding the risk of a stula in an individual patient, we would use it. In well-established postoperative stulae, we would routinely use octreotide in addition to TPN or semi-elemental enteral feeds. In a low-output stula, we would start with enteral semi-elemental oral feeds. If the stula output does not increase, we continue with this regimen. However, if the output is very high or increases with enteral feeding, we convert to TPN as our primary nutritional support. ERCP and MPD stenting does have a role in managing these ductal leaks. The main issue is, however, timing. If the leak is controlled, then there is no rush and the patient’s general condition will determine the timing. In addition, many low-output stulae will close spontaneously within a few days and do not require endoscopic interventions. It is difcult to move an unstable patient to the ERCP suite, and, therefore, when the patient is stable, and the stula persists longer than 5–7days, we perform ERCP, and if a duct disruption is dened, a small pancreatic duct sphincterotomy is performed and a 7fr plastic stent inserted. Removal of the stent should be as soon as possible to prevent damage to the duct. We recommend removal within 4–6weeks of the stulae clinically closing.

Pancreatic pseudocysts usually present as a delayed presentation. This can be when a minor pancreatic injury was missed or after the removal of the surgically placed drains when the extent of the ductal injury was underestimated. The management of pancreatic pseudocysts is beyond the scope of this chapter. Our primary approach is always endoscopic, and today this is usually endoscopic ultrasound guided. However, other endoscopic approaches including ERCP and transpapillary stenting have been shown to work and can be employed. Surgical cystenterostomy should be avoided as minimally invasive approaches are usually successful.

In conclusion, penetrating injuries to the pancreas are usually diagnosed at operation. The well-established proto-

cols determining damage control and the management of penetrating injuries to the abdomen should be followed. When pancreatic injuries are present, the aim of the surgery is primarily to identify the extent of the parenchymal injury and the degree of duct disruption. All minor injuries and indeterminate injuries should be treated with suction drains. Resection should be reserved for injuries to the left of the PV/SMV and should include a splenectomy. Pancreaticoduodenectomy should be only performed when the injury is of such a nature that the head of the pancreas is already divided or where the injury to the duodenalampullary complex prevents reconstruction. We recommend a two-stage resection and reconstruction. Duodenal exclusion techniques are again becoming accepted, and we certainly believe in the right setting they should be used. A more conservative approach to pancreatic injuries can be justied by the increasing reports of success in treating pancreatic sequelae with endoscopic and radiological interventions. The initial treatment is usually successful in most trauma units. More advanced injuries and complications should be referred to specialized pancreatic units where experience and access to advanced endoscopy usually exist.

Important Points

• Isolated pancreatic injuries are rare, and it is the associated injuries that result in the high morbidity and mortality in pancreatic trauma.

• Preoperative diagnosis of pancreatic injuries is difcult.

• Guiding principles for operative treatment:

– Identify the extent of the parenchymal injury. – Assess possibility of injury to the main pancreatic

duct.

• Evaluation of the pancreatic injury requires full mobilization of the affected part of the pancreas.

• Major injuries to the left of the portal vein/superior mesenteric vein require resection with splenectomy. Minor injuries should be adequately drained.

• Where possible, major injuries to the head of the pancreas are treated with drainage alone. Resection is indicated where there is a major injury to the duodenal-ampullary complex or when the resection is almost completed by the mechanism of injury. This should be done as stage procedure—usually as part of damage control surgery.

• The availability of endoscopic techniques to manage postoperative leaks from the pancreas supports a more conservative approach to surgical therapy.

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Suggested Reading

Buchler M, Friess H, Klempa I, Hermanek P, Sulkowski U, Becker H,

Schafmayer A, Baca I, Lorenz D, Meister R.Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg. 1992;163:125–30.

Degiannis E, Krawczykowski D, Velmahos GC, Levy RD, Souter I,

Saadia R. Pyloric exclusion in severe penetrating injuries of the duodenum. World J Surg. 1993;17:751–4.

Degiannis E, Levy RD, Potokar T, Lennox H, Rowse A, Saadia

R.Distal pancreatectomy for gunshot injuries of the distal pancreas. Br J Surg. 1995;82:1240–2.

Degiannis E, Levy RD, Velmahos GC, Potokar T, Florizoone MG,

Saadia R.Gunshot injuries of the head of the pancreas: conservative approach. World J Surg. 1996;20:68–71.

Degiannis E, Bowley DM, Smith MD.Non-operative management of

splenic injury in adults– current management status and controversies. S Afr J Surg. 2003;41:33–4.

Degiannis E, Glapa M, Loukogeorgakis SP, Smith MD.Management of

pancreatic trauma. Injury. 2008;39:21–9.

Heitsch RC, Knutson CO, Fulton RL, Jones CE. Delineation of

critical factors in the treatment of pancreatic trauma. Surgery. 1976;80:523–9.

Krige JE.Pancreatic trauma. In: Nicol AJ, Steyn E, editors. Handbook

of trauma. Cape Town: Oxford University Press; 2004. p.258–65.

Krige JE, Nicol AJ, Navsaria PH, Jones O, Bornman PC.Emergency

pancreatoduodenectomy for complex pancreatic trauma. HPB Surg. 2005;7:104.

Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR,

Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG. Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum. J Trauma. 1990;30:1427–9.

Wisner DH, Hoyt DB.Denitive care phase: abdominal injuries. In:

Greeneld LJ, editor. Surgery: scientic principles and practice. Philadelphia: JP Lippincott; 1993. p.305–10.

Yilmaz TH, Hauer TJ, Smith MD, Degiannis E, Doll D. Operative

techniques in pancreatic trauma – a heuristic approach. Injury. 2013;44:153–5.

Liver andExtrahepatic Bile Ducts

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FrederickMillham

Penetrating liver injury offers surgeons a wide spectrum of challenges ranging from deciding upon non-operative management to devising strategies to manage complex combined hepatic vascular and biliary injuries. The successful care for complex penetrating liver injuries requires a broad range of skills, from the ability to expose and control bleeding rapidly, to the ability to coordinate care of an unstable patient over a long period. A theme pervading all management of complex liver injuries, though, is the simple notion that, ultimately, the liver is a forgiving organ, if one can keep the patient from bleeding to death on the day of injury or dying of sepsis from leaking bile later on, even the most complex injuries can be managed successfully. Damage control in the face of complex or multiple injury with bleeding arrestable with compression is the standard of care. We will discuss management of liver and extrahepatic biliary injuries separately.

52.1 Immediate Considerations

Choosing a management strategy for penetrating liver injury is informed by several factors known immediately on patient presentation. First, and most important, is hemodynamic stability. Patients who are in persistent shock due to penetrating injury always require immediate surgical intervention. More challenging from a decision-making standpoint are patients who may have shown some early signs of shock but who have responded well to either time or resuscitation. For these patients there may be an opportunity to obtain imaging that will support a non-operative strategy. A good general principle is to avoid axial imaging in patients in shock. Critical

F. Millham (*) Department of Surgery, Harvard Medical School, Boston, MA, USA

South Shore Health System, Weymouth, MA, USA e-mail: fmillham@southshorehealth.org;

FMILLHAM@PARTNERS.ORG

review of vital signs and patient’s acid–base status is important when considering non-operative management of any visceral injury.

A second consideration is the mechanism of injury.

Penetrating injuries to the liver can be conveniently divided into three categories: (1) stab and other low-energy wounds, (2) low-energy gunshot wounds, and (3) high-energy gunshot wounds or wounds due to military ordnance. Hemodynamically stable stab wound victims who have no evidence of active or ongoing bleeding can be safely managed by observation. Mortality in this setting is a function of laceration of a named vessel such as the vena cava or hepatic vein. If there is low suspicion for vascular injury, observation is the best strategy. Low-velocity gunshot wound patients who are hemodynamically stable can also be observed provided there is convincing evidence on axial imaging that the liver injury is tangential and not associated with extravasation of blood. High-velocity gunshot wounds, or other wounds caused by military ordnance, may create extensive wounds to the liver. The inelastic structure of the liver does not respond well to the physics of high-energy projectiles, which tend to create complex, shattered, wounds, challenging to even the most skilled surgical management.

52.2 Non-operative Management

Patients who arrive with normal vital signs and who do not appear to be in shock or to be actively bleeding are good candidates for non-operative management. CT scanning done with dynamic contrast injection, and delayed imaging, can exclude active liver bleeding and support a strategy of observation alone in such patients. Should CT scanning show arterial extravasation, angio-embolization is an excellent intervention. Simple tangential stab or low-velocity gunshot wounds rarely require aggressive operative intervention. In some cases, drainage of the perihepatic space may be necessary to control bile leakage. When bile collections occur

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subsequent to admission, these drains can be placed laparoscopically.

Injuries to the retrohepatic vena cava, if not bleeding, may also be managed non-operatively. Here a good rule of thumb is “don’t poke a skunk.” Stable non-expanding pericaval hematomas only become problems when surgeons expose them. The careful trauma surgeon is willing to observe these injuries carefully from a far. Some authorities report excellent outcomes with endovascular stenting of vena caval injuries in case reports, though the literature is thin on this subject. In the absence of active bleeding doing nothing may be the best option.

52.3 Operative Management

As a rule, one should manage penetrating abdominal injury through a midline incision. There is always enough uncertainty regarding projectile trajectory to make the midline the safest route of approach. As with any trauma laparotomy, prep and expose the patient from the neck to the mid thighs.

There are several keys to the operative management of penetrating liver injuries. First, one must fully mobilize the liver by taking down all of its ligamentous attachments to the diaphragm. Using a Metzenbaum scissor, divide the falciform and coronary ligaments completely (Fig.52.1). This is necessary to expose the liver entirely for inspection but more importantly, to facilitate compression of the liver as a means of hemostasis. If the liver is fractured to any extent by the injury, attempting compression without full mobilization risks extending the existing injury. In the case where there is active bleeding from the liver substance, following mobilization of the liver the surgeon or assistant should manually compress the liver by placing the left hand over the right lateral portion of the liver and the right hand over the left lobe and pressing the liver together (Fig.52.2). In most cases, this will slow or stop bleeding from the liver substance and allow

Fig. 52.1 First step in controlling liver bleeding: completely mobilize the liver from the diaphragm

F. Millham

Fig. 52.2 Second step in controlling liver bleeding: manual compression with hands compressing both lobes toward the hepatic hilum

a chance both for resuscitation and assessment of the extent of injury. In the setting of a low velocity GSW or SW, where the overall structure of the liver is intact, it is probably safe to compress without mobilization. If there is suspicion of bleeding from the retrohepatic inferior vena cava or the hepatic veins, it is important to pack the site of bleeding without rst mobilizing the liver. This way appropriate pressure will be exerted on these low-pressure conduits, which will not be possible if the liver ligaments are severed, resulting in a “oppy” liver. If this does not control the bleeding and only then the surgeon should proceed to mobilization of the liver to get access of the bleeding large veins.

The next key step is to distinguish between arterial and venous injury. A surgical truism states: “Arterial bleeding scares the amateurs; venous bleeding scares the professionals”. The Pringle maneuver is useful to distinguish amateur from professional bleeding from a penetrating liver injury. One can accomplish it in a matter of seconds by passing ones left index nger through the Foramen of Winslow and directing it anteriorly through the lesser omentum (gastrohepatic ligament). One does this bluntly. Once the ngertip appears, sweep a ¾ in. Penrose drain around the porta hepatis in the same manner one encircles the spermatic cord during a hernia repair. The Penrose can then be tightened with a Kelly clamp to occlude all inow to the liver (Fig.52.3a, b). The time inow occlusion starts should be recorded. Ideally, hepatic ischemia should be limited to 30min or less. If this arrests the bleeding, then arterial hemorrhage is almost always the problem. If bleeding persists, then injury to a hepatic vein or adjacent vena cava should be suspected.

In the case of brisk arterial bleeding, threatening immediate exsanguination, ligation of the common hepatic artery or the right or left hepatic artery is an alternative. With the

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Fig. 52.3 (a) Pringle maneuver step A: insert left index nger into the foramen of Winslow, then push the ngertip through the lesser omentum (aka: gastrohepatic ligament). (b) Pringle maneuver step B: encir-

Penrose drain—Pringle tourniquet on downward traction, one can nd the hepatic artery by rst identifying the common bile duct and looking medially.

If pressure on the packs is necessary to arrest bleeding, a temporary abdominal closure device can be employed. Should it not, closing the upper abdomen with towel clips may be necessary to maintain pressure. If one has ligated or embolized the right hepatic artery, the gallbladder will be devascularized and should be removed.

In cases where a low velocity gunshot wound has bored a hole through the liver parenchyma, temporary control can be achieved through internal balloon compression. Using a ¾ in. Penrose drain and a red rubber catheter, one fashions a balloon compression device by tying one end of the Penrose off and the other around the red rubber. This device is guided down the missile track and inated with saline.

If the Pringle maneuver does not arrest the bleeding, then assume venous injury. At this point it is important to evaluate the vena cava for injury. Many times, the real source from liver injuries is in fact the vena cava or the junction of the vena cava and hepatic veins. Vena caval injuries can be classied into three types: suprahepatic, retrohepatic, and infrahepatic.

If a suprahepatic injury is suspected, proceed directly to a thoracoabdominal approach. While a “hockey-stick” inci-

Penrose drain

Pringle maneuver

cle the porta hepatis with a ¾ in. Penrose drain hooked around the index nger, then tourniquet the porta by twisting the drain and securing with a Kelly clamp

sion into the costal cartilages from the superior pole of the midline wound is possible, I prefer to perform median sternotomy in cases where injury to the cava appears to be in the “no man’s land” between the liver and heart. These wounds have a very high mortality. Successful management requires rapid control, which is best gained by dividing the sternum and diaphragm. The sternum is best divided with a powerdriven sternal saw. Finger dissection in the suprasternal notch to keep the innominate veins away from the saw blade is a good rst step. Next, with the saw guard introduced through the sternal notch and on upward traction the sternum can be opened in a matter of seconds. A Finochietto retractor or similar rib spreader can provide access to the heart and mediastinum. Take quickly down the pericardium and anterior attachments of the mediastinum with scissors. Divide the diaphragm with the cautery down onto the caval hiatus. This should expose the injured segment. A side biting vascular clamp is usually the simplest tool for controlling the injury. Once the clamp is on blood return to the heart will be minimal. Mortality for these injuries is very high. It is essential that one works with alacrity in the setting.

Retrohepatic caval injuries are among the most challenging injuries the trauma surgeon faces. In the setting of penetrating trauma, where bleeding is not contained within a soft tissue space, the vena cava must be exposed rapidly. In

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F. Millham

patients where the liver is relatively large or the exposure is difcult, access to the chest as described above may be useful. Generally, however, it is not necessary to open the chest to approach the retrohepatic vena cava. Having already mobilized the ligamentous attachments, it is possible to rotate the liver medially exposing the retrohepatic cava. If the injury involves the intrahepatic portion of the cava, it may be necessary to take down the small veins draining directly from the substance of the liver into the vena cava. These usually number between 7 and 14 and in an emergency can be well managed with small clips. Failure to control these veins will result in creation of an additional source of bleeding. Inow and outow occlusion of the cava above and below the injury can be usually achieved with direct compression using sponge sticks. As in the suprahepatic vena cava injury, there is a high premium on efciency. Having 3-0 or 4-0 vascular nylon suture ready on a long needle driver prior to diving in to the retrohepatic space is a good idea.

Injuries to the infrahepatic cava can be exposed by the socalled Brasch-Cattell maneuver, where one should open the white line of Toldt in the right paracolic gutter and sweep the right colon medially on its mesentery. Mobilize the duodenum medially in a similar way. Sponge sticks are useful here too for proximal and distal control in a hurry. Traditionally, it has been thought that it is necessary to preserve at least 25% of the lumen of the vena cava above the kidneys. Recent experience indicates less lumen may be acceptable, it is certainly better to leave a conduit of diminished diameter than ligate the cava or, worse, have a patient expire while performing an interposition graft. Endovascular balloon occlusion, similar to REBOA, has been reported as a method for bleeding control prior to open repair of inferior IVC injury. Endovascular stenting is emerging as an option for management of penetrating injures infrahepatic vena cava. There may be a role for directing patients with suspected caval injury to a hybrid operating suite, should one be available and appropriate staff are available.

Where patients are unstable and complex injury of the infrahepatic vena cava precludes a simple vascular repair, ligation is an acceptable option.

Patient suffering from multiple gunshot wounds to the liver or injuries caused by high-velocity rounds or military ordinance may have complex, massive, liver fractures, difcult to control by packing. These wounds are fortunately rare in civilian practice. Bleeding uncontrollable by packing disqualies the patient for a damage control procedure. It is in this setting that maneuvers such as hepatic exclusion may be the only option. With the Pringle tourniquet engaged, the hepatic inow and outow controlled with sponge sticks, one looks for the dominant sources of hemorrhage and clips or ligates them. In limited cases formal lobectomy may be preferable if the injury is limited to an anatomic lobe or segment.

More advanced techniques such as veno-venous bypass for hepatic exclusion have been used by some centers to

manage complex liver injuries. These methods usually require existing experience and rapid access to extracorporeal circulation technology and expertise. These techniques are difcult to improvise or implement without planning ahead of time.

If bleeding is indeed uncontrollable with packing, and a transplant program is available, a last effort at salvage may include hepatectomy with hope for an emergency transplant. This option is obviously limited to a small number of centers and even then, unlikely to succeed.

52.4 Extrahepatic Biliary Injury

Penetrating injury of the extra patent bile ducts is relatively uncommon, and usually occurs in conjunction with a more serious injury to a vascular or other visceral structure. Injuries to the extrahepatic biliary system are far more common in the setting of cholecystectomy. Experience managing misadventures in this setting is useful in informing our approach to penetrating injury of the common bile duct.

Isolated injury of the common bile duct can be repaired primarily if caused by an edged weapon. However, most penetrating trauma victims are young people with no pre- existing biliary pathology. The common duct in such patients is a small, more delicate structure with a diameter of 5mm or less. Therefore, a better plan is to repair injuries of the common bile duct over a T-tube or stent. Biliary stents can be placed operatively through the injury and passed down through the ampulla Vater for later endoscopic recovery. My preference is to close simple wounds in small ducts over an appropriately sized T-tube. The T-tube can be removed 4–6weeks postoperatively following a normal cholangiogram.

Complex injuries of the extrahepatic biliary tree, involving loss of a segment of the common bile duct or signicant injury of the origin of the common bile duct from the right and left hepatic duct, require more complex management. Injuries of this type occurring in isolation can be managed in one step with a choledocho or hepato-jejunostomy, best constructed as a Roux-en-Y limb. Ureteral stents are a useful adjunct that one can place through the anastomotic region and bring out through the anterior abdominal wall downstream. Tack the mid portion of the Roux limb to the anterior abdominal wall, and bring the stents out as one might a feeding jejunostomy tube.

In the face of aggressive hemorrhage or injuries to other vital organs, it is not necessary to repair the common bile duct at the rst operative encounter. The management principles are simple: control bile leakage and prevent or manage sepsis. Damage control in this setting may be as simple as tying the end of the hepatic or common duct around ureteral stents, brought out with ample additional closed suction drainage. If the ducts are not identiable, provide adequate drainage by placing ample closed suction drains as adequate.

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If bile leakage and sepsis are controlled, biliary enteric continuity can be re-established weeks or even months later when other problems have been settled.

52.5 Conclusion

Penetrating liver and extrahepatic biliary injury represent a wide spectrum of disease, from the mundane to the lethal. Patients with non-bleeding injuries do not require surgical intervention. Successful management of complex hepatobiliary injury frequently requires a damage control philosophy. The initial approach to such patients may involve “simply” stopping the bleeding and draining the bile, leaving denitive restoration of biliary enteric drainage for another day. Endovascular techniques such as embolization and stenting represent important methods that are part of a multidisciplinary approach these injuries may demand.

Important Points

• Don’t poke a skunk: non-bleeding injuries can usually be watched.

• In a crisis: damage control is the path to success.

• Stop the bleeding today, x the biliary anatomy tomorrow.

• Mobilize the liver before attempting compression or packing.

• If the Pringle maneuver arrests life-threatening bleeding, ligate, or embolize.

• If the Pringle maneuver does not control life-threatening bleeding look to the vena cava.