Gastrointestinal Tract Injury – Operation

Management of Acute Trauma

R. Shayn Martin

J. Wayne Meredith

From Townsend CM: Sabiston Textbook of Surgery, 19th edition (Saunders 2012)

In contradistinction to spleen injuries, the operative intervention for liver trauma is less definitive and can be challenging. Therefore, hemodynamic decline requires operation but slow decreases in hemoglobin levels are at times tolerated and even occasionally treated with transfusion. This is especially true when there are other injuries that may account for some blood loss, and the decline in hemoglobin level may not be reflective of ongoing hepatic bleeding. Because many liver injuries are associated with some degree of hemoperitoneum, it is possible that a hollow visceral injury could be present but overlooked if the intra-abdominal fluid is attributed solely to the liver injury. Therefore, serial abdominal examinations to detect evidence of intestinal injury are an important part of nonoperative management of any solid abdominal organ.

In some cases, CT reveals a liver injury that demonstrates the extravasation of IV contrast from a disrupted vascular structure. These appear as a blush of high-density contrast, often within the injured-appearing hepatic parenchyma. In the setting of hemodynamic stability, this extravasation is usually contained within a pseudoaneurysm. The natural history of hepatic pseudoaneurysms is not exactly known but it is believed that they may be associated with an increased risk of delayed bleeding, especially when caused by hepatic arterial branches. A more recent advance in the management of hepatic pseudoaneurysms is the use of hepatic angiography, with embolization of blood vessels that demonstrate extravasation. Even with successful embolization, patients need standard surveillance, which is required for all hepatic injuries managed nonoperatively. When selected appropriately, the use of angioembolization has improved the rate of successful nonoperative management by reducing the number of conversions to operative therapy. This has also allowed many higher grade injuries that historically might have required operation to be managed without surgery.

The evolution of nonoperative approaches to liver trauma has required advances in evaluating and managing complications that arise. In addition to delayed rebleeding, these include bile leaks with biloma formation, hemobilia, and development of liver abscesses. Frequently, these are suggested by the development of abdominal symptoms, with or without evidence of systemic infection or inflammation. CT or, at times, ultrasound will identify the liver injury–related pathology. Percutaneous drainage guided by CT or ultrasound is usually successful in managing abscess or biloma. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is occasionally required to decompress the biliary tree and promote healing of a bile leak. Occasionally, a laparoscopy or laparotomy is necessary to manage biliary ascites not amenable to percutaneous drainage.

Operative management begins in the same fashion as with other abdominal injuries. A midline laparotomy is the most versatile approach for managing any liver injury that might be encountered. The falciform ligament is divided and perihepatic sponges are placed to manage bleeding from the liver temporarily. A fixed retractor is placed to expose the right upper quadrant structures. With perihepatic packing and manual compression, bleeding can be temporarily controlled and resuscitation provided. On patient stabilization, the packs are removed and the hepatic lacerations evaluated. Mild injuries with little or no ongoing bleeding may be managed with further compression, topical hemostatic agents, or suture hepatorrhaphy. Addressing these injuries may sometimes be facilitated by mobilizing the right or left hepatic lobes by dividing the triangular ligaments. This will allow injuries to be better exposed for interventions but may also allow better packing by optimizing anterior-to-posterior compression. Occasionally, however, the risks of mobilization should be carefully considered if there is the possibility that the attachments of the liver are providing lifesaving tamponade of retrohepatic bleeding. This combination of superficial techniques will successfully manage most liver injuries encountered.

In the setting of more severe bleeding, a Pringle maneuver is a valuable adjunct. The hepatoduodenal ligament is encircled with a vessel loop or vascular clamp to occlude hepatic blood flow from the hepatic artery and portal vein. This maneuver helps distinguish hepatic venous bleeding, which persists from a portal vein, and hepatic artery bleeding that slows, allowing identification of sources of hemorrhage. The hepatic laceration can then be explored and any actively bleeding vessels controlled with suture ligation. Grossly devitalized hepatic parenchyma should be débrided when accessible and drains should be placed when injuries appear to be at risk for a bile leak. When feasible, a vascularized pedicle of omentum may be packed within the liver injury to reduce parenchymal bleeding and promote healing of the laceration.

Liver injuries in the vicinity of the retrohepatic vena cava that are not actively bleeding may benefit most from packing alone, without operative exploration. There are many heroic techniques seen in the literature that describe methods of repairing retrohepatic vena cava injuries, but it is likely that the approach with the greatest likelihood of success is maintaining the body's natural tamponade of this low-pressure region when feasible. An atriocaval shunt (Shrock shunt) is one method that entails isolation of the retrohepatic vena cava by placing an intracaval shunt between the right atrium and infrahepatic vena cava. Isolation of the liver with an atriocaval shunt with the addition of a Pringle maneuver allows repair of the vena cava or hepatic veins without ongoing associated blood loss. Damage control techniques are often of great value because many patients who require operative intervention for liver injuries have already deteriorated physiologically. This approach includes control of surgical bleeding followed by aggressive perihepatic packing and temporary abdominal closure. It is fruitless to leave surgical bleeding and hope that packing alone will provide control. Similarly, it is futile to continue surgical attempts with sutures to control diffuse liver bleeding from coagulopathy. Patients are then resuscitated in the intensive care unit until hypothermia, coagulopathy, and acidosis resolve, at which time the abdomen is re-explored and the packs removed. Angiography with embolization after damage control may provide additional assistance with managing ongoing bleeding from hepatic artery branches, although the mortality rate in this patient cohort remains high.