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D. Hannoun and C. D. Best
injuries on an RUG will appear as a disruption of the normally concentric urethra from the meatus to the bladder
neck. A partial disruption represents extravasation along the
course of the urethra with some contrast instillation into the
bladder, whereas a complete disruption will fail to ll the
bladder at all, with contrast accumulating in a periurethral or
perivesical location.
The management of urethral injuries can be divided simply into immediate open surgical repair versus temporary
urinary diversion with suprapubic or urethral catheter
placement. With temporary urinary diversion, delayed
repair and/or reconstruction would be performed, if necessary, 6–12weeks following the injury. In any situation, the
initial management of urethral injury should proceed rst
and foremost with prompt bladder decompression and
broad- spectrum antibiotics. The controversial aspect of
managing penetrating urethral injury, however, is whether
immediate open repair versus diversion with delayed repair
and reconstruction should be performed. In a recent study
and review of posterior urethral injuries with pelvic fractures, immediate open repair was associated with a 49%
stricture rate, 21% incontinence rate, and 56% impotence
rate. When primary realignment was performed, the stricture rate remained at 53%, but the incontinence and impotence rate dropped to 5% and 36%, respectively. When
suprapubic urinary diversion was the initial management
option, the urethral stricture rate rose to 97%, with a 4%
incontinence and 19% impotence rate. In a recent retrospective series by Hadjizacharia etal., 14 patients presenting with an acute urethral injury were managed with
immediate endoscopic realignment (IER), compared to
seven patients treated with delayed (open) therapy. The outcomes of the study showed the immediate realignment
group to have a lower rate of stricture formation (14%)
compared to the delayed therapy group (100%). In addition, the authors found a shorter time to spontaneous voiding in the immediate realignment group (35 ± 23 days)
compared to the delayed therapy group (229±79days). A
long-term review at the same institution had similar results.
Thirty-ve patients with posterior, acute urethral injury
underwent immediate endoscopic realignment. Five of
these patients had penetrating injury as the mechanism.
After 18months, the rate of stricture formation was stable
at 17%. Only three of the six patients who developed stricture required urethroplasty, and none of the patients with
penetrating mechanism went on to develop stricture. In
general, no single treatment protocol will t each patient
perfectly. Therefore, the overall clinical status of the patient
as well as concomitant injuries should be taken into account
before nal management decisions are made. These same
complications do not apply to penetrating injuries, with the
exception of stricture rates. The high impotence and incontinence rates are more specic to the nature of the pelvic
fracture injury. Penetrating injuries are more common in
the anterior urethra, with less disruption of the surrounding
neurovascular bundles.
Immediate surgical repair of posterior urethral injuries is
indicated in the presence of a concurrent bladder neck or rectal injury to prevent subsequent urinary incontinence, stula
formation, or persistent leak. Urinary continence is a function of both the internal and external sphincter mechanisms.
Posterior urethral injuries are usually associated with damage to the external sphincter mechanism for urinary continence. This would leave the internal sphincter, located at the
bladder neck, as the only remaining source of urinary continence. For this reason, any bladder neck injuries should be
explored and repaired immediately; without proper repair
and reapproximation of the sphincter, eventual urinary
incontinence is almost guaranteed. In the absence of a bladder neck or rectal injury, posterior urethral injuries should be
managed with temporary urinary diversion via suprapubic or
urethral catheter placement. The placement of a urethral
catheter in the presence of a urethral injury is called immediate endoscopic (or primary) realignment (IER). Regardless
of mechanism, posterior urethral injuries are initially managed with an attempt at immediate endoscopic realignment.
Traverse the normal urethral mucosa by using exible cystoscopy with low-ow irrigation. Once you reach the site of
injury, the cystoscope is often successful in identifying some
normal mucosa or the other side of the defect (Fig. 55.3).
Once across the defect and into the bladder with the cystoscope, advance a guidewire into the bladder. Then remove
the cystoscope and place a Council tip Foley catheter over
the wire and into the bladder. This allows urethral drainage
without necessitating surgery. The majority will heal without
signicant stricture. If attempts at IER are unsuccessful, a
suprapubic tube can be placed, followed by delayed denitive repair.
Anterior urethral injuries can also be repaired early on
with open surgery, especially in the setting of low-velocity
penetrating injuries where major tissue destruction has not
occurred. In the presence of major tissue destruction, excessive and often inadvertent tissue debridement may take place,
which can further the risk of ischemic stricture development.
In cases of anterior urethral repair for pendulous urethral
injuries, approach with a circumcision/degloving penile incision and proceed to local debridement of nonviable tissue,
spatulation of the two urethral ends, and a tension-free anastomosis of the lacerated corpus spongiosum and urethra with
interrupted absorbable sutures over a 14–16 Fr urethral catheter. For bulbar urethral injuries, place the patient in the dorsal lithotomy position, and make a vertical perineal incision
to gain access to the bulbar urethra. Carry a tension-free urethral anastomosis; perform it over a 16–18 Fr catheter in this
relatively dilated portion of the urethra. Keep the catheter in
place for a minimum of 10–14days, and perform a pericath-
55 Lower Genitourinary Injuries
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Fig. 55.3 Once you reach the
site of urethral injury, the
cystoscope is often successful
in identifying some normal
mucosa or the other side of
the defect
463
Cystoscope
Injury
eter RUG prior to removal to ensure no further extravasation.
The presence of extravasation warrants continued catheter
drainage.
Urinary diversion with delayed repair is another management option, especially when the patient is too unstable for
surgery or if the injury is very posterior. If IER fails, urinary
diversion can be performed with suprapubic cystostomy tube
placement (percutaneous versus open). Open suprapubic
cystostomy placement will guarantee placement into the
bladder, allow concomitant bladder repair if present, and
allow bladder neck reconstruction if an injury is found. Open
tube placement will also allow antegrade urethral endoscopy
and urethral catheter placement if initial catheter placement
or retrograde urethroscopy failed to reach the bladder. The
other option for suprapubic cystostomy tube placement is a
percutaneous kit, which is less invasive than the open suprapubic tube placement and can be performed under mild sedation. Blind urethral catheter placement, on the other hand,
can be attempted in the setting of small, partial lacerations,
and in general should be avoided because of the risk of transforming a partial laceration to a full circumferential transection. Again, we emphasize obtaining an RUG if any index of
suspicion for urethral injury is present. However, the catheter
can be safely placed under direct visualization with retrograde urethroscopy and catheter placement over a wire. As
an alternative, antegrade urethroscopy can be performed at
the time of open pelvic surgery or during repair of a concomitant bladder rupture with passage of the scope down the
urethra and out of the meatus. This will allow tying of a catheter to the cystoscope with a silk suture or over a wire and
retrograde passage of the catheter into the bladder as the cystoscope is withdrawn.
In summary, penetrating injuries to the urethra, testicles,
and external genitalia usually take the form of gunshot and
stab wounds. The importance of the mechanism of injury
cannot be overemphasized, and combined with a very thorough and detailed physical examination, it will lead the diagnostician to the correct diagnosis. If ever in doubt, or the
mechanism does not seem correct, perform radiological
studies to further delineate any underlying injuries, which
may of course change the course of management. Other lifethreatening injuries should always maintain a higher priority,
but it is the responsibility of the trauma and urology team to
work together and maintain effective communication to
deliver the best possible care.
Important Points
• An Inferior Vena Cava (IVP) or CAT Scan (CT) alone is
not always reliable to demonstrate bladder rupture. This
requires a high-pressure cystogram.
• Undiagnosed bladder rupture in the presence of pelvic
fracture can lead to serious complications.
• Urethral injury can be associated with rupture of the
bladder.
Suggested Reading
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Chapple C, et al. Consensus statement on urethral trauma. BJU Int.
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Dierks PR, et al. Sonography and penile trauma. J Ultrasound Med.
1983;2:417–9.
Fedel M, etal. The value of magnetic resonance imaging in the diag-
nosis of suspected penile fracture with atypical clinical ndings. J
Urol. 1996;155:1924–7.
Gross M, etal. Rupture of the testicle: the importance of early surgical
treatment. J Urol. 1969;101:196–7.
Hadjizacharia P, etal. Evaluation of immediate endoscopic realignment
as a treatment modality for traumatic urethral injuries. J Trauma.
2008;64(6):1443–9.
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D. Hannoun and C. D. Best
Jeffrey RB, etal. Sonography of testicular trauma. Am J Roentgenol.
1983;141:993–5.
Jezior JR, et al. Management of penile amputation injuries. World J
Surg. 2001;25:1602–9.
Koga S, et al. Sonography in fracture of the penis. Br J Urol.
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Koraitim MM.Pelvic fracture urethral injuries: evaluation of various
methods of management. J Urol. 1996;156:1288–91.
Lupetin AR, et al. The traumatized scrotum: ultrasound evaluation.
Radiology. 1983;148:203–7.
McAninch JW, et al. Major traumatic and septic genital injuries. J
Trauma. 1984;24:291–8.
McAninch JW, etal. Management of genital skin loss. Urol Clin North
Am. 1989;16:387–97.
McAninch JW, etal. Traumatic and reconstructive urology. Philadelphia:
W.B.Saunders Company; 1996. p.347–55, 543–50.
Morey AF, etal. Consensus on genitourinary trauma: external genitalia.
BJU Int. 2004;94:507–15.
Mydlo JH. Surgeon experience with penile fracture. J Urol.
2001;166:528–9.
Nicolaisen GS, etal. Rupture of the corpus cavernosum: surgical man-
agement. J Urol. 1983;130:917–9.
Pliskow RJ, et al. Corpus cavernosography in active fracture of the
penis. Am J Roentgenol. 1979;133:331–2.
Sandler CM, et al. Lower urinary tract trauma. World J Urol.
1998;16:69–75.
Tan LB, etal. Traumatic rupture of the corpus cavernosum. Br J Urol.
1991;68:626–8.
Wein AJ, et al. Campbell-Walsh urology. 9th ed. Saunders-Elsevier;
2007. p.2649–73. Chapter 83.
Major Abdominal Veins
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PeepTalving, StenSaar, andKenjiInaba
56
Abdominal vascular insults are among the most lethal injuries caused by penetrating trauma. Not infrequently, multiple
concomitant vascular injuries, including arterial, can be
encountered in addition to associated injuries to nonvascular
viscera. The incidence of major abdominal veins injured in
descending order includes the inferior vena cava (IVC),
external iliac veins, renal veins, common iliac veins, superior
mesenteric vein (SMV), internal iliac veins, portal vein,
splenic vein, hepatic veins, inferior mesenteric vein (IMV),
and retrohepatic vena cava.
Victims of penetrating vascular trauma may present with
complete or relative hemodynamic stability if there is containment of the retroperitoneal vascular injury. If, however,
the vascular lesion is bleeding freely into the peritoneal cavity, the patient will present unstable. Most often, a combination of free hemorrhage and partial containment is
encountered. The presence of shock mandates immediate
exploratory laparotomy after obtaining a baseline type and
crossmatch, complete blood count (CBC), and coagulation
prole. Chest and abdominal plain radiographs with entry
and exit markers (electrocardiogram (ECG) electrodes, paper
clips) in the emergency department (ED) can be quickly
obtained to help delineate the trajectory of the offending
missile and structures at risk. When a vascular injury is suspected, time is of paramount importance, and surgeon’s
experience is reected by the speed at which the patient is
rushed to the OR. Only amateurs walk to the OR with a
hypotensive victim of penetrating trauma. Besides hypotension, peritonitis also mandates an emergent trip to the operat-
P. Talving (*) ·S. Saar
Division of Acute Care Surgery, Department of Surgery, North
Estonian Medical Center, Tallinn, Estonia
Department of Surgery, University of Tartu, Tartu, Estonia
e-mail: peep.talving@regionaalhaigla.ee
K. Inaba
Division of Trauma and Surgical Critical Care, Department of
Surgery, Keck School of Medicine, University of Southern
California, LAC + USC Medical Center, Los Angeles, CA, USA
e-mail: kinaba@surgery.usc.edu
ing room. A study from one of the largest Level 1 trauma
centers in the USA noted that a hemodynamically stable
cohort of patients sustaining a penetrating abdominal injury
presenting with peritonitis as the sole indication for laparotomy had an intra- abdominal vascular injury rate of 11%,
with subsequent intraoperative hypotension and a transfusion requirement seen in 25% and 39%, respectively.
Finally, patients presenting in extremis or in cardiac arrest
will be subjected to resuscitative thoracotomy in the ED as
described in Chap. 16. The need for thoracotomy, however,
reects a dire physiological state, and very few patients subjected to resuscitative thoracotomy for a subdiaphragmatic
vascular injury are expected to survive. In the recent decade,
resuscitative endovascular balloon occlusion of the aorta
(REBOA) has been introduced for selected patients as an
alternative to aortic cross clamping. REBOA does not allow
direct cardiac resuscitation; however, it provides minimally
invasive aortic occlusion. In penetrating abdominal vascular
injury, Zone I of the aorta is the target for aortic occlusion.
Do not spend excessive time inserting intravenous lines in
the ED if not necessary. Do not induce anesthesia in the ED
as this will result in a pharmacological sympathectomy, and
your patient may arrest before reaching the OR.Do notify
the blood bank early about a possible massive transfusion
protocol while rushing the patient to the OR.From the ED,
alert the OR that an emergency laparotomy is on its way,
allowing the preparation of both a vascular and a sternotomy/
thoracotomy tray, xed retractor system to optimize exposure, headlights, two suction devices, lots of laparotomy
pads, and a primed autotransfusion device. Large bore
venous access above the diaphragm must be obtained in the
OR.With the potential of iliac vein or IVC injury, obtaining
venous access in the groin may result in your massive transfusion efforts ending up in the abdominal cavity or in the
retroperitoneal space. Infuse blood products early with blood
loss because excessive administration of crystalloids will
dilute clotting factors resulting in coagulopathy and rebleeding, in addition to predisposing your patient to a systemic
inammatory response as well as subsequent abdominal
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_56
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Zone IZone IIZone II
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compartment syndrome. Ensure that the rst blood draw for
typing is sent to the lab as soon as possible in order to expedite the release of type-specic or ideally fully matched
blood. This will allow the conservation of uncrossmatched
blood. We maintain a ready supply of prethawed liquid
plasma, which is dispensed as type specic. As soon as this
is dispensed, more is thawed to replace the units removed
from the blood bank. They are sent in a cooler to prevent the
wastage of those units not used. One OR nurse is designated
as the blood coordinator to ensure that accurate two-way
communication occurs, facilitating delivery while decreasing wastage. When the massive transfusion protocol is
required, i.e., more than six units of red blood cells within
24h of admission, the transfusion practice should aim for a
1:1:1 ratio of red blood cells, plasma, and platelets, respectively. Per the emerging evidence, cold-stored low-titer group
O whole blood is making comeback and may be a signicant
benet in exsanguinating patients as it seems to be safe,
saves time to replace the lost volume and all components are
delivered in the whole blood units.
In the OR, the patient should be prepared with their arms
abducted at 90° and the skin cleaned from the chin to the
knees to allow maximal exibility in access. The skin and
fascia are divided along its full length from the xiphoid process to the symphysis, also called “from Cape to Cairo”
incision. Once anesthesia is prepared for hypotension, you
can go ahead and decompress the hemoperitoneum, which
may induce signicant bleeding and hypotension. You
should at this point eviscerate the small bowel, scoop the
blood and clots out of the peritoneal cavity, and apply direct
pressure on the site of hemorrhage with laparotomy pads. If
not localizable, four-quadrant packing may be used. In
severe hypotension, consider aortic inow control by compressing the aorta with your thumb and index nger at the
aortic hiatus below the left hepatic lobe. To apply a vascular
clamp at the hiatus is quite ineffective due to the diffuse
neuronal tissue around the aorta causing the clamp to slide
off the aorta. Dividing the left diaphragmatic crus with long
Metzenbaum scissors at 2 o’clock exposes the very distal
thoracic aorta that has no surrounding neurobrous tissue
and allows clamp placement. Try not to attempt aortic inow
control by making an additional incision into the left chest
as these patients are already cold and coagulopathic. If
resuscitative thoracotomy was performed in the ED, the aortic clamp should already be controlling inow.
Autotransfusion of shed blood from the peritoneal cavity is
controversial with a concomitant hollow viscus injury; however, for vascular injuries, if cell salvage is available, this
should be utilized.
Your next step is to identify major injuries with vascular
lesions taking precedence. The retroperitoneum is broken
P. Talving et al.
Zone III
Fig. 56.1 Functional zones of the retroperitoneum
into functional zones (Fig.56.1). With a few exceptions that
will be discussed in this chapter, for penetrating injuries, all
retroperitoneal hematomas are explored. Zone I is the central
zone divided into supramesocolic and inframesocolic
regions, which extends from the aortic hiatus to the sacral
promontory containing the aorta and major branches, IVC
with its major tributaries, portal vein, SMV, and central renal
vessels. Zone II contains the renal hilum and parenchyma
and Zone III the iliac vessels. A sophisticated trauma surgeon may also dene a Zone IV in the retrohepatic space
behind the liver containing the retrohepatic IVC and hepatic
veins. This is an area you should avoid exploring unless your
patient is exsanguinating from a decompressed retrohepatic
venous injury. Retrohepatic IVC injuries are associated with
a very high mortality rate, and there are no series available to
convincingly support any recommendation over avoiding the
exposure of these structures if at all possible. If contained, it
is best to do nothing. If uncontained, the goal should be to
pack and institute damage control. If packing does not prevent exsanguination, try repacking. If this does not work,
desperate alternatives such as total hepatic exclusion with
atrio-caval shunting may be considered. Although there are
multiple case reports describing atrio-caval shunting, very
few survivors attest to the devastating nature of this injury.
Right gonadal
internal iliac v v.
Suprahepatic
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Once an intra-abdominal venous injury is identied, you
should immediately be planning out your potential operative
strategies: to ligate the injured vessel, to shunt it, or to
attempt to repair it. All major abdominal veins are depicted
in Fig.56.2 and Table56.1 and marked as amenable for liga-
Fig. 56.2 Ligatable (white),
potentially ligatable (gray),
and preferably non-ligatable
abdominal veins (black)
Portal v.
tion with relative impunity, ligate with consideration, and
ligate in life-threatening scenarios only. All treatment decisions must be made in the context of the patient’s physiological condition at the time of laparotomy.
IVC
Hepatic v.
Splenic v.
SMV
Right renal v.
v.
Right common iliac v.
Right external iliac v.
IVC
IVC
Right and left
Inferior mesenteric
Left renal v.
proximal left
renal v.
Left gonadal v.
(ligate prox.
renal v.
with impunity)
Left common iliac v.
Left external iliac v.
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P. Talving et al.
Table 56.1 Quick overview of management options while dealing
with abdominal veins
Ligate with impunity Recommendation
Infrarenal IVC Wrap and elevate lower
Common iliac vein Wrap and elevate lower
External iliac vein Wrap and elevate lower
Internal iliac vein
Inferior mesenteric vein
Splenic vein
Ligate with the following considerations
Right renal vein Right nephrectomy
Left renal vein, distal to gonadal
vein
Hepatic veins Follow-up liver ischemia
Ligate only in lifesaving scenario
Suprarenal/perirenal IVC Consider renal replacement
Superior mesenteric vein Second look for gut ischemia
Portal vein Second look for gut ischemia
extremities
extremity
extremity
Left nephrectomy
therapy
56.1 IVC Injury
Approximately 1 out of every 50 patients with a gunshot
wound to the abdomen will have an IVC injury. Prehospital
mortality is close to 50%, and the survival of those who
reach the hospital alive is reported to range between 20% and
40%. Commonly, injury to the IVC will be associated with
multiple visceral injuries. As a rule of thumb, the infrarenal
IVC can be ligated, perirenal IVC ligation may result in
nephrectomy/nephrectomies, and the suprarenal IVC should
be repaired, shunted, and/or packed if at all possible.
56.1.1 Exposure
Injury to the IVC presents at laparotomy with a hematoma or
hemorrhage from Zone I, most commonly to the right of the
midline. After evacuating the blood from the abdominal cavity and direct control of the hemorrhage with compression,
consider aortic inow control at the aortic hiatus. The next
step is a right medial visceral rotation, which along with a
Kocher’s maneuver will expose the entire infrahepatic
IVC.This may result in major hemorrhage. For this very reason, before visceral rotation, ensure that you have multiple
sponges on sticks, vessel loops, vascular clips, laparotomy
pads, intravascular occlusion catheters, vascular instruments,
and 4-0 vascular sutures on a large needle. Place a xed
retractor to maximize exposure, and warn your anesthesia
colleagues that, in short order, major hemorrhage may occur.
Start the exposure by dividing the avascular colonic peritoneal attachments at the line of Toldt from the ileocecal region
up to the hepatic exure (Fig.56.3). With an IVC injury, the
blood will have tracked out laterally completing the majority
of the dissection. The Kocher’s maneuver reects the duodenum and the head of the pancreas to the left facilitating the
exposure of injuries of the perirenal/suprarenal IVC.Multiple
options exist for controlling the IVC hemorrhage. The immediate goal is directed digital control of the injury or proximal
and distal pressure on the IVC using sponges on a stick. With
local control, vessel loops or vascular clamps can be used for
more denitive control. With vascular clamps, one must be
careful not to cause iatrogenic injuries when dealing with
veins. If the injury is small, a side-biting Satinsky clamp may
cover the entire length of the injury. Rapid control will minimize further blood loss and decrease the chance of air embolism. If tolerated, the Trendelenburg position prior to
denitive repair may also obviate venous air embolism. If
bleeding from the IVC continues after proximal and distal
occlusion, the cause of bleeding is the lumbar veins. There
are four to ve pairs of lumbar veins entering the infrarenal
IVC from the posterior aspect of the vessel. To access them,
you need to rotate the IVC slightly and apply vascular clips,
vessel loops, or ligatures on the lumbar veins. Dividing the
lumbar veins after ligation improves the exposure of the posterior aspect of the IVC if necessary for repair. In repairing a
wound of the perirenal IVC, you will also need to occlude
temporarily the renal veins with vessel loops or vascular
clamps.
56.1.2 Repair
There are numerous options for repairing the IVC (Fig.56.4).
Lateral repair with nonabsorbable monolament suture is
your rst-line therapy. When using the side-biting Satinsky
clamp, in some settings you may run a suture line on top of
the clamp (Fig.56.5). If control was obtained with a laparotomy sponge, roll your compressive pads along the IVC,
and, as soon as you identify the vessel wound edges, apply a
Babcock clamp to close the visualized segment. Continue
rolling your pad followed by the application of additional
Babcock clamps until the vein wound is entirely clamped.
The suture line can then run under the Babcock clamps
removing each as the suture line progresses. In stab wounds,
the vein laceration may be amenable for repair without stenosis (Fig. 56.6). A missile injury, however, will blow a
larger hole into the IVC (Fig.56.7), and lateral repair will
cause signicant stenosis of the vessel (Fig.56.8). If this stenosis approaches 50%, consider repairing with a polytetrauoroethylene (PTFE) patch. Always look for a
through-and-through injury. Attempt to close posterior
wounds by rotating the vessel and ligating and dividing the
lumbar veins if required. If this is not possible, another
option is to extend the anterior wound and look for a posterior wound from within the vessel lumen. However, a repair
C
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Fig. 56.3 Access to the
infrahepatic inferior vena cava
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Suprarenal IVC
Perirenal
Infrarenal IV
Fig. 56.4 Inferior vena cava repair options
Common iliac
Fig. 56.5 The side-biting Satinsky clamp is used to control inferior
vena cava injury. (Courtesy of Dr. D.Demetriades)
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Fig. 56.6 Knife injury to the infrarenal inferior vena cava repaired
with lateral venorrhaphy resulting in about 10% stenosis. (Courtesy of
Dr. D.Demetriades)
P. Talving et al.
Fig. 56.8 Gunshot injury to the infrarenal inferior vena cava repaired
with lateral venorrhaphy resulting in about 40% stenosis. (Courtesy of
Dr. P.Talving)
from within the vessel lumen is clearly thrombogenic and
thus should be deployed only if lateral repair is not amenable. You should make every attempt to repair the suprarenal
and perirenal IVC as ligation is associated with a high rate of
renal failure. You may consider shunting the vessel if repair
is not feasible as in a damage control setting. For infrarenal
injuries, if the repair is highly complex or the patient is physiologically compromised, proceed with early ligation.
56.1.3 Complications
Fig. 56.7 Gunshot injury to the infrarenal inferior vena cava. (Courtesy
of Dr. P.Talving)
The morbidity associated with IVC repair is due to venous
stasis below the repair or ligation site. Elevation and wrapping of the lower extremities with elastic bandage following
surgery, in the OR, will alleviate the edema in the lower
extremities. Long-term outcomes are very ill-dened. If
there was visible stenosis at the time of repair, you may consider thromboprophylaxis once the patient is stabilized in the
intensive care unit with low molecular weight heparin.
56.2 Portal Vein Injuries
Portal vein injuries are associated with an extremely high
mortality ranging between 40% and 70% among victims
who arrive to the ED alive. Associated with the portal vein
injury may be injury to the SMV, renal vessels, suprarenal
IVC, pancreas, liver, biliary tree, or bowel.
Portal v.
Hepatic a.
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56.2.1 Exposure
The portal vein starts at the conuence of the SMV and
splenic vein behind the neck of the pancreas. After coursing
behind the rst portion of the duodenum, it enters the posterior aspect of the hepatoduodenal ligament. When dealing
with a portal vein injury, you will notice either a hematoma
or brisk dark hemorrhage in the supramesocolic central retroperitoneum either at the mesenteric root or in the hepatoduodenal ligament. Also, there may be massive bleeding
from the wound in the pancreatic neck or head. Such venous
bleeding can originate either from the suprarenal IVC or portal vein. Most commonly, portal vein injuries are combined
with an injury to the suprarenal IVC. Again, you must be
ready to obtain rapid local control of the vascular injury. The
vast majority of those who reach the OR alive will exsanguinate during the exploration while unroong the hematoma.
Your primary aim is to arrest the bleeding by applying local
compression and if required controlling the aortic inow at
the hiatus. Parallel to this, volume restoration with blood
products requires constant communication with the anesthesia team. To approach the portal vein for suprapancreatic or
retropancreatic injuries, the same exposure principles apply.
Start with a right medial visceral rotation followed by a
Kocher maneuver, which exposes the posterior and lateral
aspects of the suprapancreatic portal vein (Fig.56.9). While
progressing with exposure, you are looking for three “Bs”:
blood, bile, and/or bubbles consistent with bleeding, biliary
tree, and/or duodenal injury, respectively. Divide the cystic
duct, and attempt to obtain vascular control by identifying
the injury and applying vascular clamps proximally and distally. Avoid iatrogenic injuries to the hepatic artery and common bile duct. Whereas many experienced trauma surgeons
would discourage pancreatic division unless the injury has
already been done so, if exposure does not allow the
visualization of the injury, stapled pancreatic division may
be required.
56.2.2 Repair Versus Ligation
Always stay in damage control mode while dealing with
these potentially lethal injuries. The goal is lateral venorrhaphy or, if this is not possible, ligate immediately. Important
is to make an immediate decision about one technique to
control the injury as there is no time for a second attempt.
Clinical evidence is available that survival rates are reasonable when the ligation is done in very early stages of intervention. Ligation of the portal vein requires that the hepatic
artery be intact. If not, options include for the stable patient
an interposition graft of the saphenous vein and, if not, shunting with delayed reconstruction.
Fig. 56.9 Access to the
portal vein
Bile
duct
IVC
Right
kidney
Duodenum
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