Anatomic relationships are key to understanding the management of liver trauma. Blunt hepatic injury traverses almost exclusively along the segments of the liver. This most likely occurs due to the strength of the fibrous covering around the portal triad preventing injury from transecting these structures. However, the hepatic veins do not have a similar fibrous structure and therefore, having less resistance, are the primary structures injured in blunt trauma. Penetrating trauma, on the other hand, involves both venous and arterial injury with direct transection of any structure in the trajectory. These anatomic principles are key to understanding the rationale for making decisions in the management of liver trauma.
Hemodynamically Normal Patient With Blunt Injury
Nonoperative treatment of the hemodynamically normal patient with blunt injury has become the standard of care in most trauma centers (see Fig. 29-4). In 1995, Croce et al published a prospective trial of nonoperative management of liver injury.1 In this study, patients with all grades and volumes of hemoperitoneum were evaluated against operative controls. The investigators found that successful nonoperative management was possible in 89% of hemodynamically normal patients. Most blunt liver injuries produce hepatic venous injuries that are low pressure (3–5 cm H2O). Hence, hemorrhage usually stops once a clot forms on the area of disruption. Successful nonoperative therapy resulted in lower transfusion requirements, abdominal infections, and hospital lengths of stay. Hurtuk et al found that in the past 10 years there has been no effect on mortality in solid organ injury with the increased prevalence of nonoperative management.20 Coimbra et al reiterated these data by examining their experience in nonoperative treatment of grade III and IV hepatic injury.21 They reported no mortality in their nonoperatively managed patients. Richardson et al have recommended that hemodynamically stable patients who have received less than 4 units of blood can be safely managed nonoperatively.22 Unlike the spleen, liver-related bleeding can be made worse by operative intervention. Manipulation of venous injuries can result in massive hemorrhage and death.23
A study by Tinkoff et al showed that the need for operative intervention increases with liver grade, but grade alone is not an indication for operation. These data from the National Trauma Data Bank demonstrated that 73% of grade IV and 63% of grade V liver injuries could be successfully managed nonoperatively.24 A more recent retrospective study by the research consortium of New England Centers for Trauma examined nonoperative management of only grade IV and V injuries and reported an 8.8% failure rate for nonoperative management. Risk factors for failure were a presenting blood pressure of less than 100 mm Hg and the presence of associated abdominal injuries. Importantly, they found no increase in mortality in patients that failed initial nonoperative management.25 However, Polanco et al, using National Trauma Data Bank data from patients with liver AIS scores of greater than or equal to 4, asked the question, “has the pendulum swung too far?”26 In the study, they showed a rather alarming trend in the percentage of hypotensive patients that underwent attempted nonoperative management. Although only seven percent of the patients failed, those patients had a statistically significant increase in mortality. Age, sex, injury severity score (ISS), Glasgow Coma Score (GCS), and (not surprisingly) hypotension were predictors of unsuccessful nonoperative management. This paper highlights the importance of the initial management decision in patients with high-grade liver injuries. An additional factor favoring successful nonoperative management of high-grade liver injuries is the type of resuscitation strategy that is implemented. As recently shown by Shrestha et al, damage control resuscitation strategies increased successful nonoperative management and decreased mortality in a retrospective review of over 200 patients with grade IV and V hepatic injuries who received blood products.27 Importantly, there was no increase in liver-related complications.
The extent of hemoperitoneum, presence of contrast extravasation, or pseudoaneurysm are not contraindications for nonoperative management; however, these patients are at higher risk for nonoperative failure. A patient with a CT finding of contrast blush or extravasation may benefit from catheter-directed intravascular therapy and angioembolization, though the precise indications for angiography have not been well defined. Misselbeck et al reviewed their 8-year experience with hepatic angioembolization and found that hemodynamically stable patients with contrast extravasation on CT scan were 20 times more likely to require embolization than those without extravasation.28 Sivrikoz and colleagues have shown that angiography in severe blunt hepatic injury is associated with improved survival in both operatively and nonoperatively managed patients; however, patients managed with angiography did have more complications.29 Finally, Letoublon et al employed angioembolization for either active contrast extravasation seen on CT scanning in hemodynamically stable patients managed nonoperatively or as an adjunctive technique to control arterial bleeding despite laparotomy. They report a complication rate of 70% in their retrospective review.30
Complications of Nonoperative Blunt Hepatic Injury Management
Most, but not all, patients with blunt nonoperative liver injuries heal without complication.31 A retrospective multi-institutional study included 553 patients with grade III–V injury.32 Of these patients, 12.6% developed hepatic complications that included bleeding, biliary pathologies, abdominal compartment syndrome, and infection. Significant coagulopathy and grade V injury were found to be predictors of complication. Therefore, with current nonoperative management strategies, complications must be expeditiously recognized and dealt with appropriately.
One of the more frequent complications is bile leakage. Bilomas or bile leak can occur in 3–36% of nonoperatively managed patients.33 Hepatobiliary hydroxy iminodiacetic acid (HIDA) scan and MRCP have been used to localized bile leaks.34 Evidence of bile leak by HIDA scan does not mandate intervention. Hyperbilirubinemia, abdominal distention, and intolerance to feeding may all indicate a bile leak. CT scan or ultrasound evaluation with percutaneous drainage is the treatment for symptomatic leaks. Importantly, the majority of bile leaks occur after operative management. Anand et al found that only 8% of patients developed bile leak with high-grade liver injuries managed nonoperatively.35 For patients presenting with bile peritonitis and/or with large leaks not responsive to percutaneous drainage alone, the addition of endoscopic retrograde cholangiography (ERC) (Fig. 29-6) and biliary stent placement is effective.36 Sphincterotomy can also decrease the biliary pressure and allow healing of the bile leak.37 In some instances, actual stenting of a large ductal injury can be accomplished.38 Griffen et al have reported success with a combined laparoscopic and ERC approach. They described patients with biliary ascites taken to operating room for laparoscopic bile drainage and drain placement near the site of injury with postoperative ERC and bile duct stenting. They reported no septic complications and healing of the substantial biliary leaks.39 Hommes et al, in their prospective observational study, classified bile leaks as minor or major, with major defined as greater than 400 mL/d or leaks lasting greater than 14 days. Patients with major leaks underwent ERC and stenting while minor bile leaks nearly always resolved without ERC or other decompressive maneuvers.40
Endoscopic retrograde cholangiogram demonstrating a biliary leak in a patient with grade IV blunt hepatic injury.
Perihepatic abscesses have also been uncommonly encountered with nonoperative management (Fig. 29-7). The patient may exhibit signs of sepsis, abnormal liver function tests, abdominal pain, or food intolerance. Abscesses, like biliary collections, can often be managed by CT-guided drainage catheters. However, if the patient fails to improve with drainage and antibiotics, wide surgical drainage should be performed. This may involve merely incision and adequate drainage of the cavity or it may involve extensive debridement of the hepatic parenchyma.
CT scan demonstrating a hepatic abscess from a patient who had sustained a blunt hepatic injury.
Delayed hemorrhage after nonoperative management is fairly rare. Kozar et al reported a 13% overall incidence of liver-related complications in patients presenting with high-grade (grades III–V) injuries managed nonoperatively, with bleeding accounting for 8% of the complications.41 Bleeds occurred almost equally between early (<24 hours) and late (>24 hours) time periods post-injury. Late bleeds occurred only in patients with grade IV and V injuries, the majority of which were managed with angioembolization.
Devascularization and Hepatic Necrosis
Disruption of vascular inflow to a hepatic segment following trauma or post-angioembolization can lead to necrosis of that segment of liver. The consequences of necrosis may include elevation of liver transaminases, coagulopathy, bile leaks, abdominal pain, feeding intolerance, respiratory compromise, renal failure, and sepsis. Devascularization can be identified by CT scan. It can be differentiated from intraparenchymal hemorrhage when follow-up CT scans reveal segments of liver that remain devascularized or have foci of air within the devascularized area.42 Hepatic necrosis requiring operative debridement occurs much less frequently in patients managed nonoperatively.
Hemobilia can occur after blunt hepatic injury. In 1871, Quincke described the triad of right upper quadrant pain, jaundice, and upper GI bleeding that indicated hemobilia. This triad may not be evident in the trauma patients with hemobilia.43 In a 1994 study, three patients developed hemobilia with massive upper gastrointestinal hemorrhage following blunt hepatic injury.44 The authors concluded that hepatic artery pseudoaneurysm with hemobilia is predisposed by bile leak and that angiographic embolization was appropriate for patients without sepsis and with small cavities. However, formal hepatic resection or drainage, after angiographic vascular control, may be necessary for septic patients or those with large cavities. Hemobilia is much less common with the prevalence of nonoperative management.
Systemic Inflammatory Response
Nonoperatively treated patients with inadequately drained bile or blood collections may be susceptible to the development of systemic inflammatory responses syndrome. Franklin et al and Letoublon et al advocate laparoscopic evacuation of undrained bile or hemoperitoneum at post-injury days 3–5.45,46 They report a marked decrease in the inflammatory response in many of these patients.
Large subcapsular hematomas have been described to elevate intraparenchymal pressures high enough to cause segmental portal hypertension and hepatofugal flow.47 This “compartment syndrome of the liver” was described in a patient managed nonoperatively whose decreasing hematocrit and increasing liver function tests promoted angiographic examination revealing the hepatofugal flow in the right portal vein. After operative drainage of the tense hematoma, the patient did well with reversal of flow and viability of the right lobe liver tissue. This type of compressive complication has also been described causing Budd–Chiari syndrome when hematoma results in intrahepatic vena cava compression or hepatic venous obstruction.48 With the frequent use of CT scanning, previously unidentified complications of liver injury may be seen. Figure 29-8 shows a series of CT scan images of a patient that underwent operative control of liver bleeding with packing followed immediately by CT scanning. Thrombosis of the retrohepatic cava was seen, with clot extending up to the right atrium. Approximately 24 hours after packs were removed and therapeutic anticoagulation was started.
CT scans from a patient who underwent perihepatic packing then immediate postoperative scanning. Images reveal a retrohepatic caval thrombus that extends proximally to the atrial caval junction.
Follow-Up CT Scanning of Blunt Hepatic Injury
Definitive data on the value of follow-up CT scanning of blunt hepatic injury are not available. Some published reports suggest postobservation CT scans on those with more severe (grade III–V) injuries. Cuff et al reported that of the 31 patients who received follow-up CT scans 3–8 days post-injury, only 3 patients’ scans affected future management.49 Additionally, the three scans that affected management were obtained due to a change in clinical picture and not merely routine. Cox et al concluded from their follow-up of 530 patients, including 89 grade IV or V, that follow-up CT scans are not indicated as part of the nonoperative management of blunt liver injuries.50 There are certain patterns of injury that may be at higher risk of biliary complications, such as a cleft injuries, suggesting that routine follow scans may aid in diagnosis.51 Unfortunately, the time to onset of biliary complications can range from days to weeks, making a recommendation difficult.41 Currently, follow-up CT scans are generally indicated only for those patients who develop signs or symptoms suggestive of hepatic abnormality.
Length of Observation, Venous Thromboembolic Prophylaxis, and Resumption of Activity
Bed rest and prolonged periods of in-hospital observation are no longer advocated. Parks et al concluded in their retrospective study of 591 patients with blunt liver injuries that the length of in-hospital observation should be based solely on clinical criteria and they recommended discharge in patients with a normal abdominal examination and stable hemoglobin.52 Though data is retrospective and studies are small, existing data suggest that early (defined as ≤48 hours) institution of chemical thromboembolic prophylaxis is safe.53,54 Resumption of normal activity also seems safe, but the period of time needed to refrain from high-risk activities, such as contact sports, remains unclear. Most hepatic injuries seem to have resolved by CT in 4 months, but whether this period of time is optimal, is unknown. A contrary approach to this practice can be based on some interesting animal studies. Dulchavsky et al found in animal studies that hepatic wound burst strength at 3 weeks was as great or greater than uninjured hepatic parenchyma.55 This is most likely a result of fibrosis throughout the injured parenchyma and Glisson’s capsule. This study suggests that activity can be resumed about 1 month after injury, though human studies have not been performed.
Hemodynamically Normal Patient With Penetrating Injury
Nonoperative Management of Penetrating Injury
Peritoneal penetration has mandated operative exploration for many years. However, many trauma centers have adopted selective nonoperative management of knife stab wounds to the right upper quadrant. The work of Nance and Cohn in 1969 supported this nonoperative care in patients with stab wounds who were hemodynamically normal and had no evidence of peritoneal irritation.56 Since then, reports of successful nonoperative management of gunshot wounds (GSW) have been published. Renz and Feliciano prospectively treated 13 patients with right thoracoabdominal GSW nonoperatively.57 The rationale behind this management is that the wounds caused by small caliber weapons may produce injury to diaphragm and liver only, sparing any intestinal injury. The authors stressed the importance of serial abdominal exams and contrast CT scanning in their successful nonoperative management of penetrating injury. Other centers concur with this selective nonoperative management.58,59 Demetriades et al even reported successful nonoperative management of penetrating grade III and IV liver injuries that required angioembolization.60 The criteria for nonoperative management include those patients who are hemodynamically normal, have no peritoneal signs, and are not mentally impaired. These patients then undergo contrast-enhanced CT scan to rule out other abdominal visceral injury. Serial abdominal exams as well as close hemodynamic monitoring are also implemented. Triple-contrast CT of 86 abdominal GSW, as reported by Shanmuganathan et al, had a sensitivity and specificity of 97% and 98%, respectively.61 Velmahos et al do not use triple-contrast CT and report a sensitivity and specificity of 90.5% and 96%, respectively, in diagnosing intra-abdominal organ injuries requiring surgical intervention.62
Missed or deliberate nonrepair of small diaphragmatic lesions may lead to long-term adverse sequelae, not only of diaphragmatic herniation, but also of possible bilio-pleural fistula.63 Late intervention for other missed injury (eg, duodenal injury) may also lead to substantial morbidity. Nonoperative management of right upper quadrant penetrating trauma must be performed at a center with sufficient resources that has not only the capability of close continuous monitoring, but also CT radiology accessibility and immediate operating room availability.
Operative Management of Patients With Minor Liver Injury
The decision for operative intervention of incidental liver injury may develop due to laparotomy for penetrating injury, patient instability, or concomitant internal injury. The incision of choice remains the midline incision from the xiphoid to the pubis with full surgical prep of the chest, abdomen, and groins, thus the ability to rapidly access all cavities. Not only will the operating surgeon be able to gain access to the hepatic region, but the entire peritoneal cavity will also be able to be inspected and manipulated. On opening the peritoneal cavity, attention should first be focused on the rapid evacuation of old blood and stopping ongoing hemorrhage. Laparotomy pads should be used to clear the peritoneal cavity of clot. In minor liver injury, the bleeding from the liver can initially be managed with packing of the hemorrhagic area. While packs are in place, the remainder of the peritoneal cavity should be inspected for bowel and other solid organ injury. Many minor liver injuries do not require operative fixation and nonbleeding wounds should not be probed or otherwise manipulated, as this may exacerbate the situation and cause dislodgement of clot. Small wounds of the liver parenchyma with minimal bleeding may be able to be controlled with electrocautery, argon beam coagulation, or topical hemostatics. Small to moderate bleeding cavities may first be inspected for any obvious bleeding vessels that can be ligated. Next, packing a tongue of omentum, with its vascular supply intact, into the wound halts most moderate bleeding. Stone and Lamb first described this technique in 1975.64 Wrapping a column of absorbable gelatin sponge with oxidized regenerated cellulose makes another beneficial device. This is then inserted like a plug into deeper bleeding cavities. Omentum is often then brought up into the wound and secured to increase hemostasis. These maneuvers are very successful in the management of minor liver injury.
Operative Management of Patients With Major Liver Injury
Lucas and Ledgerwood reported in 2009 that a surgical resident would perform a liver hemostatic technique only 1.2 times during their training.65 With the increasing utilization of nonoperative management, gaining and maintaining the necessary skills to control major hepatic bleeding is a challenge.
Patients with major hepatic trauma may present with hemodynamic instability, and thus should be taken expeditiously to the operating room for definitive management. As in minor injury, the most optimal incision for expected major liver injury is the midline incision. Once the peritoneum is entered in these patients, a large amount of blood may be evacuated, which decreases the natural tamponade of a large hemoperitoneum. Adequate resuscitation is key and if not already accomplished, massive transfusion protocol should be activated. Manual compression of obvious injury will decrease bleeding (Fig. 29-9). It is imperative that the anesthesia team is allowed to catch up with blood loss prior to proceeding. Fluids should be warmed and coagulopathy corrected, keeping in mind current recommendations for coagulation products given in ratios approaching 1:1:1 packed red cells to fresh frozen plasma to platelets, and the minimization of crystalloid. Once the patient has been adequately resuscitated, a more thorough exam of the peritoneal cavity must be completed. If indeed the bleeding source is localized to the liver and bleeding continues after manual compression is released, then the portal triad should be identified and a Pringle maneuver performed (Fig. 29-10).
Manual compression of major liver injury.
The Pringle maneuver controls arterial and portal vein hemorrhage from the liver. Any hemorrhage that continues must come from the hepatic veins. (Reproduced with permission from Burch JM, Moore EE. Injuries to the liver, biliary tract, spleen, and diaphragm. In: Wilmore DW, ed. ACS Surgery: Principles & Practice. New York, NY: WebMD Corporation; 2002.)
Much controversy has evolved around the normothermic ischemic time produced by the use of the Pringle maneuver. Many authors have advocated clamping for 20 minutes and then allowing reperfusion for 5 minutes.66,67 This practice has not been proven to be beneficial in traumatic liver injury and may exacerbate bleeding. Multiple studies have emerged indicating that longer portal triad occlusion can be accomplished with similar results. In one study describing the management of 1000 cases of hepatic trauma, the Pringle maneuver was utilized for between 30 and 60 minutes in many of the high-grade injuries without adverse sequela.68 Pachter et al managed 81 patients with the assistance of the Pringle maneuver for up to 75 minutes without any apparent morbidity from the procedure.69 Therefore, it seems that longer normothermic ischemic time can be used without added morbidity in the severely injured liver, though attempts to limit ischemic time should be made. The Pringle maneuver often does not control all bleeding. It will control the inflow bleeding from the hepatic artery and portal vein, but not the retrograde bleeding from the vena cava and hepatic veins. Therefore, if bleeding persists with the portal triad clamped, retrohepatic caval injury should be suspected.
Though human data are still limited, clinical experience and animal data suggest the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is useful for temporizing non-compressible torso trauma.70,71 It is the practice of many surgeons at the shock trauma center and increasingly at other trauma centers, to place femoral arterial access, and if needed, a REBOA catheter if the patient does not respond to resuscitation (Fig. 29-11). As smaller diameter resuscitative balloons become available in the United States, the need for subsequent arteriotomy repair will be minimized, and the procedure will become safer.
Photo of a REBOA catheter (left) and a plain abdominal radiograph from a patient with a grade V blunt hepatic injury that had a REBOA catheter deployed in Zone 1 (arrow) in the emergency room prior to operative exploration.
Hemostatic Maneuvers for Severe Parenchymal Injury
Perihepatic packing has become the most widely used and successful method for management of severe liver injury. Laparotomy pads are packed around the liver, thus compressing the wound between the anterior chest wall, diaphragm, and retroperitoneum. This “damage control” approach provides hemostasis while the patient is able to be hemodynamically optimized in the intensive care unit (ICU) as well as provides pressure on the wound to achieve hemostasis. Beal reported an 86% survival rate in 35 patients in whom perihepatic packing was used.72 In order to provide the tamponade necessary for effective packing, the surgeon must mobilize the liver by taking down the right and left triangular, coronary, and falciform ligaments. If, however, there is obvious hematoma in a ligament, this area should not be entered. Hematoma in the ligament may indicate a vena caval or hepatic vein injury, and mobilization may lead to rapid exsanguination The decision to pack must be made early in the exploration, in order to provide the best chances for patient survival.73 Indeed, early packing is associated with the increased survival of liver trauma patients. Richardson et al found that the death rate associated with packing significantly decreased after 1989 and was linked to less packing time, as was demonstrated by a decrease in the average blood loss despite the equal severity of injury.23 One of the difficulties with packing comes with removal. Often, the bare liver area that has become hemostatic is now adherent to the packs. Pulling off the packs can then cause further bleeding. Different solutions to this problem have been described, from wetting the gauze with saline on removal to a more innovative technique described by Feliciano and Pachter who suggest placing a nonadherent plastic drape directly on top of the hepatic surface, followed by laparotomy pads above this plastic interface.74 An important issue regarding abdominal packing is abdominal closure. These patients will undoubtedly require significant resuscitation. Abdominal compartment syndrome can be a life-threatening consequence. Abdominal compartment syndrome can be avoided in these patients by leaving the fascia and skin edges open and placing a temporary closure device over the open abdomen, remembering that abdominal compartment syndrome can still complicate an open abdomen.
Packing is often useful in blunt, venous injury, but cannot be expected to provide hemostasis in major arterial injury. Major arterial injury is often seen with penetrating trauma and therefore packing in penetrating bleeding may be less successful. It is important to stress that arterial bleeding is not the target with packing; instead definitive surgical ligation is required.
The timing of packing removal continues to be the subject of debate. Correction of coagulopathy, acidosis, and hypothermia can almost always be accomplished within 24–48 hours of packing. Intra-abdominal sepsis is a risk of prolonged packing. Krige et al found that packs that remained for more than 3 days had an 83% incidence of developing perihepatic sepsis, whereas those left less than 3 days had a 27% chance of sepsis.75 A 1986 report found a 10.2% sepsis rate for patients who had packs removed within 24–48 hours along with complete clot evacuation and debridement of devitalized tissue.76 Caruso et al advocate the removal of packs at 36–72 hours, because they have experienced a higher rate of repacking for recurrent hemorrhage in the group of patients who had their packs removed earlier.73 Nicol et al reported a significantly higher repacking rate in those hemodynamically stable patients whose packs were removed at 24 hours compared to those patients whose packs were removed after 48 hours.77 It would seem that with current damage control resuscitative strategies, which encourage rapid correction of coagulopathy, packing removal can be safely accomplished based more on physiologic parameters rather than strictly on time.
Grade III and IV liver lacerations often do not respond to the more topical procedures listed for minor injury control. One of the oldest reported techniques to control deep parenchymal bleeding is direct suturing of the tissue with large, blunt-tipped 0-chromic suture. Utilizing a large blunt needle prevents the suture from tearing through Glisson’s capsule when tying. The stitches can be continuous, or if a deeper laceration is encountered, a mattress configuration. This technique is most appropriate for lacerations less than 3 cm in depth. It is best to avoid the direct suture approach as blind passage of these large blunt needles may injure bile ducts and vascular structures thereby leading to possible intrahepatic hematomas or hemobilia. Of note, hepatic necrosis can occur with the use of liver sutures especially if tied too tightly.
More severe parenchymal laceration may involve larger branches of the hepatic artery or portal system, and will not respond to packing or parenchymal suturing. In these cases, finger fracture has been described (Fig. 29-12).70 The utilization of this technique involves careful extension of the laceration using finger fracture or clamping of the hepatic parenchyma as dissection proceeds through the liver. The fracture continues until bleeding vessels can be identified and then controlled with clips, ligation, or direct repair. Ordoñez et al published a series of penetrating hepatic injuries with 20.8% mortality for grade IV injuries and 70% for grade V.78 The authors concluded that intraparenchymal exploration and selective vessel ligation is useful in patients that fail packing and Pringle maneuvers.
Hepatotomy with selective ligation is an important technique for controlling hemorrhage from deep (usually penetrating) lacerations. This technique includes finger fracture to extend the length and depth of the wound (A), division of vessels or ducts encountered (B), and repair of any injuries to major veins (C). (Reproduced with permission from Burch JM, Moore EE. Injuries to the liver, biliary tract, spleen, and diaphragm. In: Wilmore DW, ed. ACS Surgery: Principles & Practice. New York, NY: WebMD Corporation; 2002.)
Omental packing has been used successfully on its own as well as in conjunction with other techniques of hemorrhage control. Omental packing fills the potential dead space with viable tissue that also is a source of macrophage activity. The technical aspects of this process include first mobilizing the greater omentum from the transverse mesocolon in the avascular plane. Next, the omentum is mobilized from the greater curvature preserving the usually right gastroepiploic vascular pedicle (Fig. 29-13). The tongue of omentum is then placed into the injury defect. The ability to achieve hemorrhage cessation with this method reiterates that most hepatic bleeding is venous. Tamponade with viable omental packing is superior to most of the direct techniques of hemorrhage control.
Omental mobilization employed for liver packing.
Penetrating tracts through the hepatic tissue provide another challenge for the surgeon. Often, these are of great depth and length, therefore making visualization of the entire injury impossible. Management of these injuries has included packing of omentum into the tract for hemostasis. Also, devices such as the rolled cellulose-covered gelatin sponge can be inserted into the tract for hemostasis. Balloon tamponade has also been advocated which entails placing the balloon, typically a penrose drain tied at both ends and inflated with fluid, into the track (Fig. 29-14). If successful tamponade has been achieved, the balloon is left in the abdomen and removed 24–48 hours later at a second laparotomy. A similar technique using a Foley balloon has been described, where a Foley is inserted into the tract and inflated.79 If there is continued active bleeding, the catheter is moved back or forward and inflated again. If bleeding continues through the catheter, but not out of tract, the balloon is proximal to the bleeder and needs to be repositioned deeper. If the bleeding continues from the tract orifice, then the balloon must be repositioned further out of the tract. Once the catheter is positioned, drains are placed in the area. The drains and catheter are brought out through the skin. The Foley can be removed after deflation produces no further signs of bleeding or at the time of the next planned reexploration. Sengstaken–Blakemore tubes have also been used in these situations.80
A handmade balloon from a Robinson catheter and a Penrose drain may effectively control hemorrhage from a transhepatic penetrating wound. (Reproduced with permission from Burch JM, Moore EE. Injuries to the liver, biliary tract, spleen, and diaphragm. In: Wilmore DW, ed. ACS Surgery: Principles & Practice. New York, NY: WebMD Corporation; 2002.)
Deep, small-diameter penetrating injury may continue to bleed from the depths of the wound. In these instances dissection down to the injured liver segment may be necessary. Another alternative may be angioembolization for these lesions if the patient can be stabilized for the procedure.
Anatomic resections for severe hepatic trauma were often performed in the late 1960s and early 1970s In most, but not all series, mortality was prohibitively high.81 Resection fell out of favor until recently, when several groups reported more favorable results. Polanco et al reported on their experience of patients who underwent hepatic resection during their initial operation, with a morbidity of 30% and a mortality of 17.8%.82 The authors recommended hepatic resection in patients with massive bleeding related to a hepatic venous injury that must be repaired directly, massive destruction of hepatic tissue, and in patients with a major bile leak from a proximal main intrahepatic bile duct. Of the 56 patients undergoing resection, 42 had some type of resection performed during the initial surgical procedure.
Hepatic arterial ligation can be a useful maneuver either in the operating room or with the aid of angiography. Operative hepatic artery ligation is rarely used today, as angioembolization is used more liberally.28 If a patient has a noticeable decrease in bleeding after the Pringle maneuver has been performed, hepatic artery ligation can be considered if attempts at direct vessel ligation or control are not possible and bleeding cannot be controlled sufficiently to permit time for angioembolization. When the portal vein remains patent, the chance for severe hepatic dysfunction after hepatic artery ligation is minimal.83,84 However, with patients who have undergone significant hypoperfusion due to traumatic shock, hepatic artery ligation may produce enough further ischemia to produce necrosis or sepsis.85
Currently, most centers are advocating a multimodality approach to hepatic arterial bleeding. The role of interventional radiology has gained significant importance in the role of bleeding control after packing. Sclafani et al, in 1984, reported on the successful selective arterial embolization of severely injured liver parenchyma after packing.86 Angiography has become an important step in the management algorithm for severe liver injury. One report stated that an approach for high-grade liver injury includes “immediate surgery for control of life-threatening hemorrhage, the use of complex surgical techniques to address these injuries, the institution of early hepatic packing and immediate postoperative hepatic angiography and angioembolization.” In this report of 22 patients that had sustained grade IV and V injury, 15 underwent angiographic embolization (10 had been previously packed). All of these procedures were successful in arresting the continued bleeding.87 Therefore, it cannot be overemphasized that the care for severe hepatic parenchymal injury requires not only operative skill but also the judgment to determine the time for packing and collaboration with specialists trained in angioembolization of the liver, whether they be surgical or radiologic (Fig. 29-15).
(A) Hepatic pseudoaneurysm; (B) coiled hepatic pseudoaneurysm.
Hepatic transplantation has been successfully reported. This is assuredly a drastic approach to traumatic injury and is an alternative for very few patients. The patient must have an overall excellent chance of survival with minimal concomitant injury, especially other intra-abdominal or neurologic injury. Also, if a trauma patient requires a transplant, it must be completed immediately; waiting for a donor organ to arrive is not an option. Case reports from Philadelphia and Miami describe successful transplantation.88,89 These cases present the requirements for possible transplantation as the patients had a single liver injury, no neurologic compromise, the achievement of hemodynamic stability, corrected coagulopathy, and the ability to obtain a donor organ within 36 hours of an anhepatic state.
In a 2013 report from Kaltenborn et al, a series of 12 patients undergoing liver transplantation for trauma had and overall mortality was 42%. Of survivors, retransplantation was necessary in 25%.90
Juxtahepatic Liver Injuries
Injury to the juxtahepatic veins includes either the retrohepatic cava or the hepatic veins. In an excellent article by Buckman et al, they divide these injuries into two categories: intraparenchymal and extraparenchymal.91 Intraparenchymal injuries include hepatic vein injuries within the body of the liver. Bleeding therefore occurs through the injured liver. Extraparenchymal injuries would encompass the hepatic veins external to the liver and the retrohepatic cava. Life-threatening bleeding from these injuries occurs if the supporting structures, mainly the suspensory ligaments and diaphragm, are disrupted. Therefore, exposure of a major venous injury may release the tamponade and result in free bleeding and exsanguination. As Buckman et al outlined, there are three main strategies described to deal with these mortal injuries. The first is to directly repair the venous injury with or without vascular isolation. The second is with a lobar resection. The third is by using a strategy of tamponade and containment of the venous bleeding. Once a juxtahepatic injury is identified, manual compression should be maintained on the liver while plans for repair are being carried out. These should include activation of a massive transfusion protocol, active warming, and a call for additional help in the operating room.
Direct venous repair without shunting has been advocated by Pachter and Feliciano. They described occlusion of the portal triad for a significant time, mobilization of the liver with medial rotation, and efficient finger fracture to the site of injury.92 With these methods, they reported a 43% (6/14) survival. Chen et al have published similar results with a 50% survival.93 Results, however, are not always so favorable.
Various shunting maneuvers have been attempted when complete vascular control of the liver is required. Schrock et al first introduced the atriocaval shunt in 1968 (Fig. 29-16).94 The goal is to shunt the blood from the infrahepatic vena cava, bypassing the retrohepatic cava, and directing flow into the atria. This, along with the Pringle maneuver, is theoretically used to create a bloodless field. Unfortunately, of the approximately 200 cases published using atriocaval shunting, only at best 10–30% survive their injury.23 The caveats of this maneuver include the need to plan for the procedure essentially before proceeding with the operation. All the equipment must be ready and a thoracoabdominal exposure is necessary. Shunting a patient cannot be successfully accomplished if the patient has already had major blood loss, becomes coagulopathic, or has inadequate operative incisional exposure. Shunting, in general, is not often used at present.
(A) A hole is cut in the right atrial appendage above a 2-0 silk purse-string suture. A Satinsky clamp maintains vascular control. (B) Final position of No. 36 chest tube acting as an atriocaval shunt. Note the extra hole cut in the chest tube at the level of the right atrium. All holes in the chest tube are outside the umbilical tapes, thereby forcing blood from the lower half of the body and the kidneys through the shunt. (Reproduced with permission from Feliciano DV, Pachter HL. Hepatic trauma revisited. Curr Probl Surg. 1989;26:499.)
Other shunting procedures have been utilized as well. Pilcher et al, in 1977, reported on a balloon shunt introduced through the saphenofemoral junction.95 This occlusive method has had some anecdotal success and avoids emergent thoracotomy without destruction of the surrounding ligamentous tamponade.96 The multi-institutional trial results in 1988 however did not show any survival benefit of the balloon shunt versus the atriocaval shunt.97 Insertion of a REBOA catheter may also be of value. Total vascular occlusion has been successfully employed in a small number of patients.98,99 Vascular clamps are placed on the porta, suprarenal inferior vena cava, and the suprahepatic inferior vena cava via a sternotomy. If clamping is tolerated, a direct vessel repair can accomplished. However, hypovolemic patients will not tolerate total vascular occlusion. It is best performed at the time of delayed laparotomy for those patients who respond to initial packing. Venovenous bypass has been used in some institutions as well.100,101 Again, this method requires considerable planning but obviates the hemodynamic instability of caval occlusion and ligamentous disruption. It allows for active rewarming of the patient and may be a better option for hemodynamically unstable patients who do not respond to packing. In general, direct approaches to vein repair are difficult and can often result in a profuse uncontrolled bleeding situation, especially since even the most veteran surgeon has little experience in these uncommon injuries.
This has been described to access retrohepatic caval injury, though with prohibitively high mortality. In certain circumstances, when the dissection has already been done by the injury itself, resection for debridement may be indicated. Current data do not promote anatomic resection for major venous injury unless direct repair is necessary and no other choices are available.
Endoluminal stent grafts are now available for many uses. Reports of using the fenestrated grafts in blunt trauma have been reported.102 The graft used by Watarida et al was homemade and stayed patent at the 16-month follow-up. More successful reports of commercially available fenestrated grafts used in retrohepatic vena caval injuries are surfacing. These grafts are being placed both after “damage control” laparotomy and prior to laparotomy when the lesion is seen on CT.103,104 Hommes et al report the survival of a patient with intraoperative placement of an endovascular stent graft into the IVC for a juxtahepatic IVC injury with parenchymal packing.105 Though these stenting procedures are not yet commonplace, increased use may occur as technology continues to increase.
Tamponade With Containment
At this time it seems that the most successful method of managing severe retrohepatic or hepatic venous injury is by using tamponade and containment. Direct repair of damaged vessels continues to have a very high morbidity even in the most experienced hands. Resection also has shown itself to be a morbid alternative with the survival data primarily being in the hands of experienced hepatobiliary surgeons in somewhat stable patients. In Memphis, the mortality of patients with juxtahepatic venous injuries treated with omental packing was 20.5%.106 Another article emphasizing packing included 14 patients with hepatic vein injury and 6 patients with retrohepatic vena caval injury with an overall mortality of only 14%.72 Cue et al depict four patients with retrohepatic vena cava, hepatic vein injury, or both who underwent initial packing and survived.107
Overall, the best approach to severe liver injury includes (1) expedient recognition and operative intervention of unstable hemorrhaging patients, (2) mobilization of the liver ligaments not directly involved with hematoma to better visualize the injury, (3) placement of a viable omental tongue into parenchymal defects, (4) rapid determination of the need for gauze packing when direct surgical maneuvers fail, and (5) angiographic embolization of hepatic arterial injured branches when ongoing hemorrhage or CT blush is seen.
The use of closed-suction drains has clearly been proven to be superior over Penrose drain use in a number of publications. A 1991 study reported a perihepatic abscess rate of 6.7% with no drain, 3.5% with closed suction, and 13% with Penrose drainage.106 A study from Charity Hospital found an abscess rate of 1.8% in those with no drainage, 0% abscess rate in those with closed suction, and 8.3% abscess rate in those with open drains.108 Examination of these figures, however, indicates no significant difference in abscess rate between the no drainage group versus the closed-suction cohort. Indeed, in a review of 161 significant liver injuries, 78 patients underwent closed-suction drainage and 83 were left without a drain.109 The injury grade, blood loss, shock, specific injuries severity, and associated injuries were similar in the two groups. There was no difference in mortality, abscess formation, or biliary fistula between the two groups. Thereby, the study concluded that drainage should be done only in injuries with obvious bile leaks noted at the time of laparotomy. This viewpoint is reiterated in a 1988 article stating that the presence of hypotension and multiple transfusions are more predictive of abscess formation than drain placement.108 A Cochrane review of elective (nontrauma) liver resections also concluded that there was no data to support routine drainage.110
With the current use of interventional radiology techniques, routine drainage has become less of an issue. Most centers will treat patients expectantly and only place drains in patients with obvious bile leaks. If indeed a collection or abscess develops, virtually all can be dealt with by percutaneous tube placement under radiologic guidance.
Complications of Operative Management
Postoperative hemorrhage is not a common occurrence. Most series quote a 2–7% hemorrhagic complication rate.74,97 Falling serial hematocrits, increasing abdominal distention, and episodes of hypotension or tachycardia mark continued bleeding. The inability to operatively control the bleeding is often confounded by hypothermia and coagulopathy. Unstable patients need operative intervention and may in fact need reexploration of previously packed areas in order to specifically identify the bleeding source. The areas of bleeding must then be addressed by utilizing the previously discussed maneuvers of severe injury control. Kutcher et al have recently examined the sensitivity and specificity of early postoperative CT scanning after laparotomy for hepatic trauma and concluded that it identifies clinically relevant ongoing bleeding, and is sufficiently sensitive and specific to guide triage to angiography.111 Importantly, Alarhayem et al have shown that patients with a blush on CT scan but a negative angiogram still have a significant risk of recurrent hemorrhage, suggesting high risk patients should undergo angioembolization.112
Abdominal Compartment Syndrome
Abdominal compartment syndrome may develop with packing and continued fluid requirements in these severely ill patients. Crystalloid should be minimized, bladder pressure can be serially measured, and the transition from abdominal hypertension to abdominal compartment syndrome should warrant decompressive midline laparotomy or reopening of the fascia in postoperative patients. With changing practices of resuscitation, the incidence of abdominal compartment syndrome has decreased but has not been eliminated.
Immediate attention should be given to a patient who develops a significant upper gastrointestinal bleed following liver repair. Many times this is the only symptom that can point to the development of hemobilia. The often-mentioned signs and symptoms of hemobilia—jaundice, right upper quadrant pain, and falling hematocrit—are common occurrences in most patients after severe liver injury and therefore make the diagnosis of hemobilia difficult. The incidence of hemobilia ranges anywhere from 0.3% to 1.2%.44,113 The presentation may be days to weeks post-injury. Classically, blood is seen emanating from the ampulla of Vater on upper endoscopy, though bleeding may not always be present at the time of endoscopy. Angiography will frequently delineate a pseudoaneurysm and can allow for embolization of the damaged vessel.114,115 Operative debridement and drainage may be necessary if a large cavity has formed or sepsis is apparent, but is rarely necessary.44
Biliovenous fistulas have also been described by Clemens and Wittrin in the literature, but are quite rare.116 This entity occurs as the bilious venous blood dissolves in the bloodstream and is carried directly to the right heart. Therefore, one sees a patient with a drastically rising bilirubin with relatively normal liver function tests. Glaser et al discussed three cases of bilhemia, which were identified by ERC.117 The management of these cases involved a left hemi-hepatectomy in the first, spontaneous resolution in the second, and controlled biliary fistula in the last. Another method of control included placement of a constant suction T tube with subsequent resolution.118 Although spontaneous resolution has occurred, this entity can have a high mortality if left unaddressed.
Biliary fistulae are one of the complications that a surgeon is likely to encounter. Biliary fistula can account for up to 22.5% of traumatic liver management complications.87 Overall, biliary fistulae seem to occur in about 4–6% of patients who undergo operative management of severe liver injury.119,120 Some bile duct injuries are obvious intraoperatively with significant bile staining and a visibly disrupted bile duct. Many persistent fistulae may, however, manifest from smaller radicals, which retract into the liver parenchyma and are not visualized. Drain placement at the time of laparotomy is usually indicated with obvious bile staining. It is common for liver injuries to have transient early postoperative serosanguinous and bilious drainage. Bilious drainage of at least 50 mL/d that continues after 2 weeks is considered a biliary fistula.97 Also, persistent earlier drainage of over 300–400 mL of bile a day should be cause for further evaluation.
The diagnosis of a biliary injury can be done by a fistulogram if a drain is in place, HIDA scan (though not anatomically exact), MRCP, or typically, ERC. Major left or right bile duct injury often requires further intervention for closure. In the past the surgical approach was recommended with resection or Roux-en-Y procedures predominating. More recently, nonoperative approaches have proven successful. Percutaneous stenting of injuries and drainage of biloma collections has been utilized.121 Also, many reports are surfacing of management using ERC sphincterotomy with stenting and percutaneous drainage of biloma. One study described five patients with intra-hepatic bile duct injuries.122 The injuries included left main hepatic duct, right second-order bile duct, and more peripheral lesions. All were successfully managed nonoperatively. Repeat ERC of these patients led the authors to conclude that “therapeutic ERC and percutaneous interventional radiology can both treat the complication of the ductal injury and allow healing of the ductal disruption.” Confirmation of healing of major ductal injury after ERC stenting and percutaneous drainage has been documented.87 For bile fistulae that do not involve a main bile duct, drainage alone will provide adequate treatment and other maneuvers are rarely necessary.
Major hepatic necrosis can be a complication of the multimodality management of severe liver injury. At the Shock Trauma Center, Dabbs et al found that 29 of 30 patients encountered with major hepatic necrosis underwent initial operative intervention and 87% underwent damage control laparotomy.123 Many of the patients then had embolizations performed, making their risk of major hepatic necrosis between 65% and 68%. A large number of these patients then required resection of their necrotic hepatic parenchyma. Both serial debridements and formal lobectomy were performed, but lobectomy was associated with fewer procedures overall and a lower complication rate.124
Thoracobiliary fistulae are also encountered with traumatic liver injury. Though it is a rare complication, identification and management can prevent the morbidity of progression to bronchobiliary fistula, which leads to a protracted and complicated clinical course. Many of these injuries occur after thoracoabdominal penetrating injury. Often the patient does well initially with resolution of hemothorax, no evidence of jaundice, and stabilization of liver injury only to become significantly tachypneic a week or more later. One report described the treatment of a thoracobiliary fistula with chest tube drainage and ERC.125 One patient returning for routine follow-up was operatively managed with thoracic and abdominal drains and diagnosed from an abnormal chest x-ray and subsequent CT. Rothberg et al promote operative intervention in order to evaluate for significant diaphragmatic injury, liver necrosis, or lung necrosis with possible bronchial involvement.126
Penetrating injury can potentially provide a means for many severe fistula communications. Pleurocaval fistula may result from thoracoabdominal injury. This fistula may be the source of life-threatening air embolism.127 Arterioportal fistula are associated with initial hemorrhage and subsequent portal hypertension.128 One case report described a GSW that formed a left hepatic artery to portal vein fistula. This fistula was able to be successfully managed by intravascular embolization. Portosystemic venous shunts have also been reported in severe blunt liver injury.129
Traumatic Extrahepatic Biliary Tract Injury
Extrahepatic biliary and portal triad injuries make up only about 0.07–0.21% of all trauma admissions at level I trauma centers.130,131 Though these injuries are rare, their evaluation and management prove difficult. Technical problems including continued hemorrhage, adjacent organ injury, and small duct size can prove difficult. A timely diagnosis and treatment method may prove to be the survival difference in patients with these severe injuries. In a Seattle paper, 38% were a result of blunt mechanisms, similar to the 31% with blunt mechanism quoted in a 1995 multi-institutional trial.130,131 Injury to this area carries an overall 50% mortality, with vascular injury (portal vein or hepatic artery) being the most morbid. When examining those with both portal vein and hepatic artery injury, the mortality is 99%. It is evident that the management of these injuries is a significant challenge. Most street weapons are now of high caliber and medium to high velocity. These weapons usually do not result in simple, single injury. Instead, multiple injuries to the liver, porta, vena cava, and surrounding viscera most often occur. Not only are these portal triad injuries difficult to manage, but also the specific injury cannot be identified preoperatively, therefore, intraoperative decision making is crucial.
Injury Types and Diagnostics
Gallbladder injury accounts for up to 66% of extrahepatic biliary tract injuries.132 Injury can be from either blunt or penetrating mechanisms. Blunt injury often involves avulsion, contusion, or perforation. Therefore if an isolated gallbladder injury is seen on CT scan or at the time of injury, additional intra-abdominal injuries should be suspected. Gallbladder injuries can be successfully evaluated by CT (Fig. 29-17). The findings of an ill-defined contour of the wall, collapse of the lumen, or intraluminal hemorrhage, highly suggest blunt gallbladder injury.133 Blood in the gallbladder can cause stasis and blockage of the cystic duct, which may present as acute cholecystitis.134 Patients may also present with bile peritonitis and right upper quadrant pain. Ultrasound examination in gallbladder injury has not been formally evaluated, but intuitively should provide useful information about this injury. Despite these diagnostic methods, the diagnosis of gallbladder injury is most often secured at laparotomy, at which time cholecystectomy is the suggested therapy.
CT scan revealing a distended gallbladder filled with blood (dark arrow) in a patient with blunt abdominal trauma and virtually no peritoneal signs.
Bile duct injury is most often encountered in penetrating injury.130 Blunt ductal injury is most likely to happen where the bile duct is fixed to its surroundings, for example, the pancreaticoduodenal junction.135 In a multi-institutional trial it was found that blunt injuries were predominately a complete transaction, whereas penetrating injuries were partial 75% of the time.130
Extra-hepatic bile duct injuries are evident in two distinct settings: first, at the time of laparotomy for a patient in shock with other severe liver, vascular, pancreatic, or duodenum injury; second, in a late presentation often more than 24 hours and up to 6 weeks after the original injury time. The patients with late presentation may develop jaundice, abdominal distention and pain, intolerance to enteral feeding, fever, or worsening base deficit due to bilious ascites or infection.131
Evaluation of the stable patient with CT scan or ultrasound in the acute setting will not be able to differentiate abdominal blood with biliary leak. There may be some indication of pancreatic head fullness, duodenal thickening, or portal edema but these are nonspecific findings. In the presence of bile staining during an operative procedure and no obvious injury, a cholangiogram through the gallbladder can be helpful.135 DPL has also shown a lack of specificity for biliary injury as duodenal, small bowel, and liver injuries may produce bile.136 Also, the small amount of bile may be obscured by the presence of blood in the peritoneum with the DPL. Late presenters of bile duct injury cannot be recognized until symptoms are apparent. At that time CT, ultrasound, or ERC can be used to visualize bile collections and localize injury.137
Management of Extrahepatic Biliary Injuries
Extrahepatic biliary injuries remain a rare entity. A 12-year experience from the Royal Melbourne Hospital in Australia noted a 0.1% incidence of biliary tract injuries amongst all patients.138 Seventy-seven percent were the result of blunt trauma and 23% from penetrating mechanisms. Ninety-seven percent of patients had concomitant injuries, thus illustrating the importance of full exploration and abdominal evaluation.
The tenets described for major liver injury apply to portal injury as well. A generous midline incision should be made, followed by evacuation of blood clot and hemoperitoneum with urgent packing of bleeding structures. The patient should be resuscitated and coagulopathy correction initiated. Hematoma or bleeding around, or within, the hepatoduodenal ligament or severe parenchymal injury leading to the porta hepatis should raise suspicion of a portal triad injury. Bile staining should also be fully investigated, as 12% of bile duct injuries may be missed at the initial operation.135 The Pringle maneuver may be helpful in decreasing the inflow to a portal triad injury. In order to obtain adequate examination and exposure for repair, a wide right medial visceral rotation should be performed, which includes mobilizing the ascending and hepatic flexure areas of the colon, thus exposing the duodenum. Similarly, a full Kocher maneuver should mobilize the duodenum and head of the pancreas medially to expose the inferior vena cava.
Isolated gallbladder injury is most often managed with open cholecystectomy. However, there have been reports of laparoscopic cholecystectomy in penetrating trauma.139 This procedure should be done with great reserve, since many gallbladder injuries are associated with other intra-abdominal injuries in both penetrating and blunt trauma. Though the laparoscope can give a good superficial exam of the peritoneal cavity, visualization of the duodenum, pancreas, and porta hepatis is, in most hands, not sufficient. Minor gallbladder contusions can often be managed nonoperatively,140,141 but may lead to cholecystitis or delayed rupture. Cholecystectomy should also be performed on all patients with injury to the cystic duct or right hepatic artery that would eliminate the blood supply to the gallbladder.
Bile duct injury should be addressed after hemorrhage has been controlled. In the patient who remains in shock and coagulopathic, packing and placement of drains in the area of the biliary injury is adequate until reexploration is performed. In the somewhat more stable patient who is becoming coagulopathic, a small T tube placed in the injured duct will provide adequate drainage until a formal repair can be accomplished.142 With a partial transection of a right or left hepatic duct, insertion of a small T tube into the common hepatic duct with a long limb traversing the partially transected area, even without suturing, may provide enough support for full healing.143
For the stable patient, definitive repair is preferred at the first operation. Four broad categories of biliary duct injury have been described: (1) avulsion of cystic duct or small laceration, (2) transection without loss of tissue, (3) extensive defect in the wall, and (4) segmental loss of ductal tissue.143
Avulsions and small lacerations in the duct can be repaired primarily with 6-0 polyglycolic suture making sure not to narrow the lumen. A T tube with a limb under the repair can be used; however, this may be difficult to insert in a patient with a normal sized duct. The techniques used to place a T tube may also devascularize an already compromised duct. For avulsions in which primary repair may narrow the lumen, a piece of the cystic duct or proximal gallbladder wall can be used for the repair.144
Penetrating injury very occasionally results in a transection of the bile duct without significant tissue loss. In these instances, an end-to-end anastomosis can be performed. One must be sure to perform minimal dissection around the duct or the lacerated ends in order to maintain adequate blood supply for healing. Tension on the anastomosis will most certainly lead to stricture. Ivatury et al reported a 55% stricture rate in the end-to-end anastomoses that then required enteric conversion.145 Similarly, Stewart and Way had success in 67% of patients initially managed with Roux-en-Y for complete duct laceration following laparoscopic cholecystectomy, with failure in all lacerations treated with end-to-end anastomosis.146
Extensive wall defects and segmental tissue loss require biliary-enteric anastomosis (Fig. 29-18). In the past many methods of “patching” were attempted. Saphenous vein grafts have had difficulties with shrinking and fibrosis, which then required stenting.147 Prosthetic patches and jejunal mucosal patches have also been tried with anecdotal success only.148
Roux-en-Y choledochojejunostomy. Anastomosis is performed in a one-layer fashion. The T tube is brought out through a separate proximal stab wound. The gallbladder has been removed.
Deciding which type of biliary-enteric anastomosis to perform depends on the injury location, access, and size of the duct. Roux-en-Y hepaticojejunostomy with cholecystectomy and T-tube drainage is the most utilized approach to complex injury. A retrocolic Roux limb of at least 40 cm long is created and can be brought up to the common hepatic duct or even to the hilar plate, similar to the Kasai procedure. An avulsion of the hepatic ducts at the bifurcation can be managed by suturing the ducts together medially before the end-to-side hepaticojejunostomy.149 If the distal common duct is not found due to its retraction behind the pancreas, drainage of the area may be all that is necessary.136 Roux-en-Y choledochojejunostomy with cholecystectomy and T-tube drainage is also useful for the management of common bile duct injury. However, the vascularity in this anastomosis is crucial and any sign of common bile duct vascular injury would lead the surgeon to construct an anastomosis closer to the common hepatic duct. Cholecystojejunostomy and ligation of the very distal common bile duct is a possibility if intraoperative cholangiography reveals a patent cystic duct. This is a viable option especially in patients with small caliber ducts or instability.
Blunt distal hepatic duct injury is rare. However, the surgical treatment of these injuries must be individualized to each situation. Both right and left hepatic duct injuries have been reported.150,151 Biliary-enteric anastomosis are sometimes possible right at the hilar plate; however, if the repair is difficult, ligation of a left or right duct has been reported to lead to atrophy of the involved lobe, not biliary cirrhosis.152
Stenting in biliary anastomosis is a controversial topic. Surgeons in favor of stenting report that stenting allows for decompression, when edema post-trauma may be significant, as well as allows access for cholangiography. T tubes must exit the duct outside of the repair area or stricture will result. Enteric stents are not necessary and some surgeons feel comfortable without their use, stating that a foreign body in an already small duct may promote stricture or obstruction.153 Morbidity data cannot support a definitive answer for or against stenting, therefore a stent must be used at the discretion of the surgeon, taking each situation separately.
When ampullary or intrapancreatic bile duct injury is discovered, a pancreaticoduodenectomy may be appropriate if duodenal and pancreatic injury is also seen. An isolated ampullary primary repair or reimplantation may be possible. Hepatic resection is necessary only in the case of combination injury to the liver parenchyma and hepatic duct traversing that segment.143
The major complications associated with biliary duct injury are fistula and stricture. A fistula may be able to be nonoperatively managed with drainage. Persistent fistula may require reexploration. Strictures may present with recurrent cholangitis or biliary cirrhosis. Stenting by endoscopists has become frequent; however, long-term results are not conclusive. A recent publication used an aggressive technique of placing an increasing number of stents until complete disappearance of the biliary stricture occurred. Though the authors did have a complication rate of 9%, their mean duration of treatment was 12 months with a 48.8-month stricture-free interval post treatment thus far.154 Conversely, Johns Hopkins reported their experience with operative management of all postoperative bile duct strictures and had a 98% success rate.155