Operative Management of Adult Blunt Hepatic Trauma
Annotation for Point E
Once bleeding is controlled by the Pringle, actively bleeding vessels and injured bile ducts should be ligated. Although not performed as often with the increased use of packing, finger fracture of the hepatic parenchyma can aid in this endeavor. Placement of deep parenchymal sutures to obtain hemostasis is also an option, although there is a risk of tissue necrosis or injury to intact vessels and bile ducts.39 For hepatic parenchymal devascularization or destruction, resectional debridement along nonsegmental planes should be performed. The need for formal resection is rare, especially at the time of initial surgery. Perhaps Dr. Mays best described the indication for formal resection in his 1979 report: “major resection should be done only when an entire lobe of the liver is reduced to pulp.”40 Placement of a viable piece of omentum can fill in dead space and aid in hemostasis.37 Pachter et al.14,37 reported successful management of grade III and IV injuries by a combination of portal triad occlusion, finger fracture, and omental pack.