clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Special Maneuvers in Liver Trauma

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STEP 6

Resectional débridement

Devitalized hepatic tissue needs to be removed because of the risk of abscess.

The hepatic parenchyma is divided along the line of fracture in the plane between

devascularized liver and the remaining parenchyma using the back of the scalpel

handle. When resistance is encountered, this indicates the elastic tissue of vessels or

biliary ducts, which are doubly clamped, divided and suture ligated. In most instances,

a non-anatomical resection rather than a standard anatomical hepatectomy is preferred.

A major hepatectomy is rarely indicated in the presence of extended injuries.

STEP 7

Ruptured subcapsular hematoma

In case of a ruptured subcapsular hematoma, hemostasis is performed using an argon

beam coagulator and the capsula is glued onto the bleeding parenchyma. The glue can

be injected between the parenchyma and the glissonian capsule. Alternatively, the

dissecting sealer (Tissue Link) can be used.

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STEP 8

Methylene blue test and cholangiography

Special Maneuvers in Liver Trauma

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STEP 9

Packing

Packing is the mainstay of damage control. The principle is to perform a compression of

the liver against the diaphragm (upper and posterior direction), which works very well

for venous bleeding. Gauze swabs are placed around the liver – not inside the lesion –

in order to compress the fracture and keep the compression against the diaphragm.

However, no pack should be placed between the liver and the diaphragm to avoid a

compression of portal veins and vena cava compromising venous return and resulting

in decreased cardiac inflow and a portal venous thrombosis. However, the elevation of

the diaphragm leads to a high peak airway pressure with hypoventilation which needs

to be taken into account in the postoperative care.

The abdomen is closed under tension without drainage to maintain pressure on the

packs. The increased intra-abdominal pressure represents a major risk for an abdominal

compartment syndrome and therefore needs to be checked regularly.

If the hemorrhage is not controlled, manual compression is performed again and the

liver is packed one more time. If this does not lead to control of the bleeding, partial or

total vascular exclusion of the liver needs to be performed (Step 10).

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STEP 10

Vascular control

If packing fails to control hemorrhage in complex liver injuries, the Pringle maneuver

allows hemorrhage control from the hepatic artery and portal venous system. The tech-

nique also helps to rule out other sources of bleeding such as retrohepatic veins and the

vena cava. If this does not lead to control of the bleeding (grade VI lesions), total

vascular exclusion of the liver is performed by clamping the supradiaphragmatic IVC

after sternotomy and the infradiaphragmatic IVC (see chapter “Techniques of Vascular

Exclusion and Caval Resection”). The appropriate and early use of vascular control

allows for accurate identification of the injury and the control of hemorrhage.

STEP 11

Hepatic venous exclusion

In case of a retrohepatic caval injury, an atrial-caval shunt to the superior vena cava or

a hepatic venovenous bypass should be employed additionally to the Pringle maneuver

early in the operation to preserve venous return while repairing the retrohepatic caval

injury. An atrial-caval shunt can be performed with a large chest tube through the right

atrial appendage placed and advanced into the IVC distal to the renal veins. Additional

side holes are cut in the tube at the atrial level. Tourniquets are tightened around the

Special Maneuvers in Liver Trauma

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STEP 12

Intrahepatic balloon tamponade

Hemorrhage control for through-and-through penetrating liver injuries can be

achieved by an intrahepatic balloon, avoiding an extensive hepatotomy (tractotomy).

The intrahepatic balloon is created from a Penrose drain that acts as a balloon and

hollow catheter. Inflation of the balloon causes a tamponade within the liver

parenchyma. Alternatively a simple Foley catheter can be taken. The tamponade is

maintained for 48h.

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Postoperative Management

■

Postoperative care on the intensive care unit requires a correction of hypovolemia

and the “triad of death”: hypothermia, acidosis, and coagulopathy.

■

Frequent intra-adominal pressure measurements by means of a Foley catheter in the

bladder should be made after primary closure of the abdomen to detect the develop-

ment of an abdominal compartment syndrome.

■

If packing is decided upon, a planned reintervention (second look) with removal of

the packs, as well as repacking, definitive hemostasis and definitive abdominal

closure or abdominal vacuum assisted closure, is necessary after the resuscitation

period. The time point of the second look depends on rewarming, correction of

acidosis and coagulopathy, which usually takes 24–48h.

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Procedures

En Bloc Pancreas-Liver Procurement

STEP 1

Access to the abdominal vessels

A midline xyphopubic incision is performed. After exploration of the abdominal organs

for previously undiagnosed pathologies, the white line of Toldt is incised, the right

colon is mobilized to the left, duodenum and bowel are extensively kocherized, and the

peritoneal root of the mesentery is divided from the right iliac fossa to the ligament of

Treitz.

Technique of Multi-Organ Procurement (Liver, Pancreas, and Intestine)

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STEP 2

Preparation of the major abdominal vessels

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STEP 3

Access to the pancreas