Operative Techniques for Severe Liver Injury

173 Pages·2015·10.565 MB·English

by  Rao R. Ivatury (eds.)

Rao R. Ivatury
Editor
Operative
Techniques for
Severe Liver Injury
123
Operative Techniques for Severe
Liver Injury

Rao R. Ivatury
Editor
Operative Techniques
for Severe Liver Injury
Editor
Rao R. Ivatury, MD, MS, FACS
Department of Surgery
Virginia Commonwealth University
Richmond , VA
USA
Videos to this book can be accessed at http://www.springerimages.com/
videos/978-1-4939-1199-8
ISBN 978-1-4939-1199-8 ISBN 978-1-4939-1200-1 (eBook)
DOI 10.1007/978-1-4939-1200-1
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Library of Congress Control Number: 2014950056
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Foreword
T his is a unique book with chapters written by a unique grouping of surgeons
about a unique organ. Although this organ – the liver – is often not the only
organ injured, it is frequently the injury to the liver and its integrated vascular
structures that determine the ultimate outcome of the patient. Therefore, this
book is a valuable resource for anyone, whether surgeon, emergency physi-
cian, radiologist, vascular interventionalist, anesthesiologist, or others, inter-
acting in the management of the patient with a liver injury. It will be a
valuable, in-depth source document, as well as a ready reference.
T he selected authors of the chapters in this book are internationally recog-
nized, skilled technicians, teachers, and writers. Each has written other chap-
ters and journal articles relating to liver injuries, and each has ruminated
publicly and privately about never having enough time or space to give justice
to this extensive subject. This comprehensive work allows adequate space to
thoroughly and completely cover all aspects of the injured liver. The chapters
are organized logically, with an orderly fl ow.
As all authors are experienced and extremely capable surgeons and writ-
ers, differing but equally acceptable approaches and opinions may be
expressed. And differences will continue to occur, to include even, perhaps,
new surgeon-directed endovascular therapy in the operating room for liver
injuries. These accepted variations are what allow for, and, indeed, encourage
academic scientifi c comparisons, which form the basis of large prospective
clinical studies (and future editions).
This book focuses on technique – the technical aspects of exposure of
hepatic and juxta-hepatic injuries, control of bleeding, and management of
the injuries. Each chapter contains some history, some technique, and some
data to support the author’s conclusions, along with journal references, but it
remains a book on technique. Surgeons like and are attracted to books on
technical process, for that is what we do. It is our genomic craft. The life and
function of our patients depend on the surgeon’s ability to know the anatomy,
understand the injury, have an ability to control hemorrhage, and expose the
injury, and, of course, reconstruct the anatomy as well as possible.
A nalysis of the chapter titles of this book reveals several that have not
been traditionally part of past texts relating to liver injury. Several chapters at
the end of the book underscore the benefi t of linking the advances in trauma
surgery to advances in simulation, transplantation, and non-trauma hepato-
biliary surgery.
v
vi Foreword
Finally, this is an ideal technical textbook to be recommended to acute
care/trauma/emergency surgeons who want to continue on the cutting edge of
being a “top knife surgeon.”
Kenneth L. Mattox, MD, FACS
Distinguished Service Professor
Baylor College of Medicine
Chief of Staff/Chief of Surgery
Ben Taub General Hospital
Houston, TX, USA
Pref ace
I n the present era of non-operative management of solid organ injuries, oper-
ative control of hemorrhage from liver injury has become an increasingly rare
phenomenon. Damage control operations with liver packing and subsequent
angio-embolization, even in situations when they may not be the most opti-
mal approach, have become the popular methods of care. Consequently, the
younger trauma surgeon has minimal experience in advanced surgical tech-
niques of controlling hemorrhage. This surgical immaturity and inexperience
are a tremendous handicap when faced with an unstable patient exsanguinat-
ing from a complex liver injury. The critical surgical skills in treating a
crushed liver are now a lost art. Other factors also seem to contribute to this
loss of surgical expertise. Several studies have now established that the opera-
tive experience of the surgical residents has declined due to restriction of duty
hours. For instance, Lucas reported that recent graduating chief surgical resi-
dents performed a mean of 1.2 operations for hemostasis with liver injuries
with most having no experience with complex techniques of liver injury man-
agement such as tractotomy or hepatic resection [1]. This becomes a serious
issue when the inexperienced surgeon is faced with high grade solid organ
injury in the hemodynamically unstable patient. Perihepatic packing, damage-
control laparotomy, and angio-embolization are valuable ancillary techniques
in such situations but are only ancillary to skillful operative techniques of
bleeding control.
It is apparent, therefore, that the students and practitioners of trauma sur-
gery must be prepared for the intra-operative challenge of uncontrollable
hemorrhage from a ruptured liver or a torn retrohepatic vein. Unfortunately,
our current training programs are more complete in the education of pre- and
post-operative affairs rather than intra-operative techniques themselves.
S everal options are currently under way to remedy this situation.
Simulators, animal laboratories, and cadaveric dissections are being incorpo-
rated into the curriculum of the trainee in an attempt to give the students of
trauma the necessary skills and confi dence. What is perhaps equally impor-
tant is the prelude for these hands-on exercises by “how-I-do-it” tutorials
from seasoned “master surgeons” who gained their expertise from their
everyday experience on the battle fi eld of civilian trauma.
This book on the surgical approaches to the severely injured liver is a col-
lection of these tutorials narrated by the masters themselves. It aims to bring
all available techniques of hemostasis of a complex liver injury into one
detailed volume. Their text is supplemented with line drawings, operative
vii
viii Preface
pictures, cadaveric dissections, and even images of simulation. Videos of
important techniques bring to life the static text of descriptions. It is hoped
that the reader will fi nd these helpful to consult, even in the middle of a dif-
fi cult operation. The fi nal chapters of the book discuss the future of training
in operative trauma surgery: animal lab, simulators, and time on hepato-
biliary and/or transplantation services to correct a critical defi ciency in our
surgical training.
The distinguished authors of this volume were asked to describe their
approach to liver injury as a personal account (“this is all about you in the
O.R.”) and they contributed their time and expertise very generously. The
readers will note that some steps in liver injury management are repeated in
multiple chapters. This is deliberately allowed so that the authors can set the
stage for their step-wise, escalating maneuvers for the control of complex
injuries. The personalized individual “tricks” of these brilliant surgeons are
worth noting carefully by reading between the lines of what appears to be a
repetitive description. I owe much credit and many thanks to my young and
brilliant colleague Francisco Collet M.D. for his crisp videos of operating
techniques. I have admired his skill for a long time and his real-time videos
of life-threatening situations in the operating room are an inspiration. Gautam
Ivatury lent his time and voice very graciously for the videos. My thanks also
to Joni Fraser at Springer for her immense help in seeing this work to comple-
tion. First and last, this book would not have been completed without the
encouragement and patience of Leela, my spouse and partner.
T he painful memories of lost battles with severe liver injury in the operat-
ing room are the inspiration behind this work. This labor of love would be
entirely worth it, if one life can be saved by timely and appropriate surgical
intervention.
Reference
1 . Lucas CE, Ledgerwood AM. The academic challenge of teaching psychomotor skills
for hemostasis of solid organ injury. J Trauma. 2009;66:636–40.

Richmond, VA, USA Rao R. Ivatury MD, MS, FACS
Contents
1 Surgical Anatomy of the Liver . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Thomas M. Scalea and Brandon R. Bruns
2 Treatment of Liver Injuries: An Overview . . . . . . . . . . . . . . . . 9
Charles E. Lucas and Anna M. Ledgerwood
3 Resuscitation Maneuvers for “Extremis” . . . . . . . . . . . . . . . . . 29
Thomas M. Scalea
4 Massive Hepatic Hemorrhage: Identifi cation . . . . . . . . . . . . . . 35
Adrian W. Ong , Vicente Cortes , and Aurelio Rodriguez
5 Massive Hepatic Hemorrhage:
Initial Steps in Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Juan A. Asensio , Juan Manuel Verde , Patrizio Petrone ,
Alejandro J. Pérez-Alonso , Corrado Marini ,
and Anthony Policastro
6 Liver Trauma: Parenchymal Repair
and Resectional Debridement. . . . . . . . . . . . . . . . . . . . . . . . . . . 57
H. Leon Pachter and S. Rob Todd
7 Parenchyma: Formal Lobectomy. . . . . . . . . . . . . . . . . . . . . . . . 67
Andrew B. Peitzman and James Wallis Marsh
8 Vascular Injuries of Porta Hepatis. . . . . . . . . . . . . . . . . . . . . . . 79
Jordan A. Weinberg and Timothy C. Fabian
9 Juxtahepatic Venous Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
L. D. Britt
10 Juxtahepatic Venous Injuries: Emergency Measures,
Defi nitive Control, and Atriocaval Shunts. . . . . . . . . . . . . . . . . 95
Donald D. Trunkey and K. Shad Pharaon
11 Long Penetrating Tracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Rao R. Ivatury
12 Liver Packing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
David V. F eliciano
ix