SOLID ORGAN INJURIES SPLEEN , LIVER , PANCREAS 2013

Abdominal Injuries 5 pillars Solid Organs: Bleed, shock Hollow Organs: Leak, peritonitis Retroperitoneum: pancreas, large vessels Urinary system Diaphragm The immunologic function is probably the most important factor in deciding to salvage the organ or not.

Mechanism of injuries Blunt: Penetrating stab: Penetrating gun shot: spleen, liver, and small bowel Penetrating stab: liver, small bowel, diaphragm, colon Penetrating gun shot: small bowel, liver, colon

Splenic Function Immunologic filter Produces tuftsin and properdin Primary remover of non-opsonized bacteria Produces tuftsin and properdin Properdin vital component of alternate pathway of complement activation Immunoglobulin production The immunologic function is probably the most important factor in deciding to salvage the organ or not.

Splenic Anatomy 100-250 grams 200 cc/min blood flow Splenic artery 85%-extrasplenic bifurcation 15%-extrasplenic trifurcation Ligamentous attachments stomach, kidney, diaphragm, colon Most of the blood supple comes in through the splenic artery. In 85% of patients the artery bifurcates in the other 15% it trifurcates, however the anatomy to where it goes into the hylium is not common from person to person.

This chart shows some of the vessel anatomy of the splenic artery coming in.

Diagnosis of Splenic Injury Physical examination - poor sensitivity Ultrasound - nonspecific DPL-too sensitive, ? role in nonoperative management CT-most common in hemodynamically stable pts Laparoscopy-has not found a universal role The spleen is common injured in blunt trauma but can be injured in penetrating injuries as well. The CT scan is the best to show exactly what type of splenic injury you have.

Grading of spleen injuries is listed here Grading of spleen injuries is listed here. I don’t think it will have much to do with what you are going to do. It’s going to depend more on your situation.

Management of Splenic Injuries Factors Influencing Decision Age of patient- >55yo splenectomy better Success of non-operative management- 68-83% Risk of missed injury Risk of OPSI-0.026-1.0% over lifetime Risk of blood transfusion-0.014% per unit Risk of nontherapeutic laparotomy-0.01-6.0% A lot of the guidelines used you need to orient yourself to situation that you are in, peacetime or wartime. What are your resources. People > 55 do not respond well to non-operative management so doing splenectomy early is best. If your non-operatively managing but their symptoms get worse, operate. Post-operative infection is probably < 1%

Non-Operative Management Proper patient selection Bed rest 2-3 days Serial physical exams, Hcts x 24-48 hours Follow-up CT scan at 3-5 days Overall hospitalization 5-10 days Severe injuries-3 months no contact sports Proper patient selection also depends on your situation and what resources you have to back you up. Severe injuries are greater than grade II in a health patient.

Non-operative management Embolisation Trans-arterial catheter  aorta  splenic artery Partial or total splenic embolization Splenic immunocompetence is preserved after splenic artery angio-embolisation

Operative Management Midline incision, pack, examine abdomen Systematic splenic mobilization Splenorrhaphy- Cautery, surgicell, pledgetted sutures, mesh wrapping Splenectomy- life threatening bleeding Autotransplantation-experimental Vaccination-Pneumococcus, H. influenza, N. meningitidis Splenorrhaphy takes about 30 minutes versus the 15 minutes it takes to remove the spleen, so in a forward surgery situation splenectomy is probably preferable. This is also true in instances where you have a long evacuation time and you don’t want to run the risk of them de-stabilizing outside the facility. You want to make sure they get these immunizations before they leave the theater.

Complications Pneumonia most common Subphrenic Abscess 3-13% Recurrent bleeding - up to 45 days 1% re-operative rate (for haematoma, or abscess drainage for example) Acute gastric distention- kids usually Thrombocytosis (very high platelets) Bleeding at 45 days is very rare, it’s more common at about 7 days. Thrombocytosis can be a problem so you need to watch their platlet counts after surgery.

Nausea, vomiting, confusion, sepsis Mortality 50-70% OPSI Nausea, vomiting, confusion, sepsis Mortality 50-70% Vaccine provides 60% protection Best timing of vaccine unknown Proper counseling a must Sensitive to malaria Overall Post Splenectomy Infection Rate is rare. They need to be well counseled so if they start to have problems they will seek medical attention.

HEPATIC INJURIES ANATOMY INJURY CLASSIFICATION INITIAL PATIENT MANAGEMENT OPERATIVE TECHNIQUES SPECIAL TOPICS JUXTAHEPATIC VENOUS INJURIES SUBCAPSULAR / INTRAHEPATIC HEMATOMAS EXTRAHEPATIC BILIARY TREE INJURIES COMPLICATIONS Most commonly injured in stab wounds and blunt injuries Present as bleeding with hemodynamic instability It’s important to know the anatomy of the liver so you can deal with the problems. Injury classification applied to peacetime situations where you can decide what course of management to pursue.

ANATOMY LIGAMENTOUS ATTACHMENTS TRIANGULAR CORONARY FALCIFORM COUINAUD CLASSIFICATION OF LOBAR / SEGMENTAL DIVISIONS The most important thing to know in treating liver trauma is how to mobilize the liver.

Liver injury scales are important to know, especially in relation to non-operative management. Typically if you can avoid operating on liver trauma it’s better to. If your situation can allow you to do that. It’s coming down to that grade 6 injuries we prefer to manage them non-operatively if they are stable. Getting these lesions intra-operatively is pretty much associated with high blood loss, and extensive morbidity. There have been cases where these patients have been managed non-operatively and these venous injuries just heal themselves if you can allow them to tamponade that area. Grade I and II injuries typically the vast majority of the time don’t need a lot of management if the patients are stable. They won’t need much in the way of ICU or hospital stay. Grade III and IV lesions you will most likely watch them in the hospital and watch them for complications such as Biliary tract fistulas.

Any of these varieties of liver injuries this is where the back-round comes

DIAGNOSIS OF LIVER INJURY ATLS primary / secondary surveys Peritoneal signs - exploration Hemodynamic instability - US or DPL Stable – CT scan with contrast (embolization) Non-operative management : hemodynamic stability, no other suspected injuries, alert patient*, ICU monitoring, accessible for re-examination, minimal transfusions This is the same as in all trauma patients.

LIVER -Penetrating Wounds STAB WOUNDS LOCAL WOUND EXPLORATION ULTRASOUND DPL ? LAPAROSCOPY GUNSHOT WOUNDS EXPLORE ? ROLE FOR ULTRASONOGRAPHY ? ROLE FOR LAPAROSCOPY The liver is a commonly injured organ with penetrating wounds mainly because of size. You can do local wound exploration for stab wound to see if the wound tract goes into the liver. GSW’s to the abdomen need to be explored.

OPERATIVE TECHNIQUES MANUAL COMPRESSION EXPOSURE(INCISION + LIGAMENTS) PRINGLE MANEUVER (32-75 MINUTES) Portal vein; hepatic artery: block inflow of blood; find source of bleeding TOPICAL HEMOSTATIC AGENTS BOVIE / ARGON BEAM COAGULATOR FIBRIN GLUE The most important thing when your in the OR with a liver trauma is know where you are. In terms of temperature, the patients hemodynamics, etc. This is the point where damage control becomes truly the most important thing you can do for the patient. The most important thing to get control of these is by using manual compression realizing that almost universally not to retract against the falciform ligment. If you get control of the bleeding by compression, find out where you are hemodynamically before you go looking for the injury. Again exposure is the most important thing you need, if you can’t get good exposure through a midline incision then you can “T” the incision off along the costal margin and into the right chest to improve exposure. That’s kind of unusual in the trauma situtaion, usually you can mobilize the liver enough to pack it off. A left lateral injury is probably one of the few injuries where you can entertain resecting the liver. That’s an area where you can quickly mobilize and control the blood supply. Again the most important things are exposure, mobilization (releasing the ligamentous attachments), and maual compression. Pringle maneuver (hepatic inflow occlusion) is done by coming around through frame of winslow and encircleing the entire duodenal/hepatic pedicle. You can do this for over an hour and not kill off the liver. It will stem the tide a little but won’t eliminate it. You can over-sew blood vessels you can see but putting sutures through the liver is probably not a good idea. The main thing is not to get into trouble, standing there trying to treat an injury while the patient gets hypo-tensive, coagulopathic, and cold. If packing works, pack it off and come back another day.

Manual compression, you really don’t want to put your hand on it, use sponges.

OPERATIVE TECHNIQUES Tractotomy / individual vessel and duct ligation Omental packing Resectional debridement Absorbable mesh wrapping For injuries that are actually stable enough that you can look at, you can open the tract and attempt to visually ligate the blood vessels, realizing that you need to have an idea of where your ligating these vessels. Vessels doen in the hilium, probably not a good idea, peripheral vessels that typically you can get to are OK but if your down past the middle hepatic vein, your close to the hylar structures even if you don’t know your there. Stay away from that if you can avoid it. You need to be delicate, if you tie your sutures tight your going to tear the tissue and just cause more damage. Another option is to use a vascular stapler, but minimize that if possible. It’s better to pack the tract, either with laps or you can use a penrose drain, put it through the tract and blow it up with saline and that will tamponade the bleeding, essentially blowing up a sausage in there. Omentum packing is another option, it may help to decrease sponges. It’s a good idea to put plastic under your laps. That way when you start taking them off, you won’t debride the liver and start the bleeding again. Resectional debridement is not a good idea unless you obviously have some dead liver tissue hanging there. When you go in and remove your packs you should try to minimally debride dead liver tissue. Wrapping the liver with mesh, you need to completely mobilize the liver to do this, all the way around.

It would be nice if it looked like this in a real situation, but typically there will be bleeding from the hepatic vein. One thing that may work here is you can ligate but get big purchases. You may also be able to under resuscitate them and that may help until you get the bleeding controlled. Also remember that there isn’t any valves in the hepatic system so the injuries will bleed back at you.

OPERATIVE TECHNIQUES Drainage (grade III or better) Laparotomy pad packing - remove before 3 days if possible *Deep sutures *Hepatic artery ligation *Anatomic lobectomy *avoid if possible Drainage is important once you get the bleeding under control, especially in Grade III injuries. It prevents formation of biliary fistulas.

Draining things, you can close over lesions with big sutures and pack omentum over the crack. Chromic with blunt needles and you need to be a couple of centimeters out. You also don’t want to pull the edges together tightly but just enough to tamponade the venous bleeding. To drain put drains on top and under the liver.

OPERATIVE TECHNIQUES HEAT CONSERVATION SPEED / EFFICIENCY COUNTS BEGINS WITH INITIAL PATIENT CONTACT LIMIT HEMORRHAGE SPEED / EFFICIENCY COUNTS EQUATES TO PROMPT DECISION-MAKING DAMAGE CONTROL SURGERY: quick, manage bleeding and contamination; continue resus in ICU PREVENT TRIAD OF ACIDOSIS, COAGULOPATHY AND HYPOTHERMIA (affects clotting mechanism) Heat conservation is important and speed is important. You don’t want to be standing there, watching the liver bleed and then decide where you are and where you are going. You really need to communicate with your team and have people that will communicate when they are getting into trouble.

Control of Transhepatic Penetrating Wound Again showing here for trans-hepatic GSW’s, Penrose through the tract and inflating it.

Juxtahepatic Venous Injury Early recognition Big (chest) incisions (laparotomy and thoracotomy) Atrial-caval shunt or caval balloon shunt Direct attack with or without hepatic vascular isolation Packing alone For juxtahepatic injuries basically your dealing with vena caval injuries and the liver is in the way, exposure, exposure, exposure. A couple of different incisions you can use; you can do a full laparotomy and sternotomy and take the diaphragm down to get to the supra hepatic cava there and get control, you also want to get control of the cava just below the liver. You can do a total hepatic exclusion; if you can get control of the porta, cava above and below the liver. But again for these types of situations 80% of these people will bleed to death before you can do anything. It’s important to know when they have these types of injuries so when you mobilize the liver somebody with this injury will start to exsanquinate on you. The other incision you can do which is a little more time consuming is open them up with a midline lap and split it off through the right chest. It’s a harder incision to close if they survive. Direct attack, if you can’t get control you need to hang it up. You need to get to these injuries fast. These types of injuries in the field are going to be difficult because you’ll wind up expending all your resources.

Atrial-Caval Shunt Through the right atrial appendage and down the cava. You also want to make sure you’re above the renals with your occlusion. Use a chest tube or ET Tube and make sure you cut holes so the blood will drain into the Right Atrium. It also makes a good transfusion line as you can transfuse directly into the R Atrium. Everybody talks about this, but I don’t know anybody who’s done it.

Subcapsular Hepatic Hematomas During non-operative treatment , operate for: On-going hemorrhage Progressive expansion by ct scan Signs of infection Deteriorating transaminase measurements Intra-operative, if not expanding: Leave alone in stable patients The only time you want to do anything with these is if you have progression or expansion. If you have one and it’s not expanding keep everyone away from it, because once you open the capsule and if you have other injuries you’ll have a bleeding mess.

Extrahepatic Biliary Tract Injury Rare: 3-5% of all abdominal trauma Gallbladder (most common) cholecystectomy CBD > RHD> LHD <50% circumference - repair with or without T-tube; drain >50% circumference - duct enterostomy; drain These are rare and most involve the gallbladder. Before you take the gallbladder out, most of the time, you should do some type of cholangiogram, so you can visualize the biliary tract. Common bile duct is injured more commonly than the others and that is because the others are intra parenchemal

If your going to do one of these if your going to sew, less stitches are better, you don’t need an absolute air tight seal. You want to get stitches into the serosa of the small bowel and poke a hole in the small bowel. Do not dissect the bile duct down, If you dissect you can knock the hepatic artery off you’ll get a stricture. Sew it into something, over a stint, the uglier it is the better it will work.

COMPLICATIONS Recurrent bleeding - 2% to 7% Fever - 65% to 75%, grade 3 or more Abscess - 2% to 10% (increased by shock, transfusion, colon injury) Biloma / biliary fistula - 5% to 28% Hemobilia - extremely rare; 1/3 have jaundice, upper GI bleed, right upper quadrant pain Arterial portal venous fistula Recurrent bleeding is the biggest complication. Fever is important as some of these patients will develop abcesses.

Damage Control Considerations Deep suturing Packing Omental packing Drains Antibiotics Atrial-caval shunts CT scan / non-operative management Suturing should be avoided but if you have to – take big bites and just use enough tension to tamponade the bleeding. Packing is good using laps or omentum Make sure you drain the area Keep them on antibiotics Atrial-caval shunts – a good picture Remember to scan than 3-7 days for non-operative management

PANCREATIC INJURY RETRO-PERITONEAL ORGAN PENETRATING INJURY – IS THE DUCT INTACT ? BLUNT INJURY – TRANSECTION OF GLAND OVER THE VERTEBRAL COLUMN

PANCREATIC INJURY DIAGNOSIS DIFFICULT HIGH INDEX OF SUSPICION CLINICAL EXAMINATION NOT HELPFUL U/S, CT SCAN IF STABLE SERUM AMYLASE (increased? Duct intact? >>) do ERCP

Diaphragmatic injury Traumatic rupture (blunt trauma) More common on left side (85%) Tear posterolateral from hiatus Herniation of stomach, colon, spleen into chest Penetrating injury usually a small hole, on either side

Diaphragmatic injury Diagnosis: clinical difficult Bowel sounds in chest on auscultation CXR: high diaphragm on left side, or diaphragm invisible Confirmation by passing a nasogastric tube, which can be seen in stomach in chest Chronic: contrast studies (Ba meal or enema)

Diaphragmatic injury Laparoscopy (or thoracoscopy) for diagnosis Repair: surgical, via laparotomy (or thoracotomy), or endoscopic technique Pitfall: PPV (positive pressure ventilation) reduced the abdominal organs from chest

Questions?