Operative Management of Adult Blunt Hepatic Trauma

Annotation for Point G

If significant bleeding persists after a Pringle maneuver, juxtahepatic venous injury to the retrohepatic vena cava or major hepatic veins must be suspected. Every effort should be made to control bleeding by packing. Buckman et al.42 make a strong argument against any type of direct repair, citing evidence of improved mortality by omental and/or gauze packing. If significant bleeding refractory to packing mandates further operative intervention at the time of initial laparotomy, mortality is high irrespective of approach. Dismal results with direct repair alone led to the introduction of vascular isolation with shunting. Isolation entails control of the hepatic artery and portal vein by a Pringle maneuver, control of the subhepatic, suprarenal cava, and control of the suprahepatic cava. The atriocaval shunt was introduced by Schrock et al.12 but has largely been abandoned due to high associated mortality except in the hands of surgeons experienced in its placement. Newer strategies of vascular isolation such as venovenobypass can be useful if available and performed before significant shock, hypothermia, and coagulopathy.43  This procedure entails vascular isolation along with establishment of femoral to axillary or jugular venovenobypass. It can also be used at the time of delayed laparotomy for patients who initially respond to packing. Finally, there are several case reports on the use of fenestrated stent grafts by surgeons familiar with their use.44–46