Operative Management of Adult Blunt Hepatic Trauma
Annotation for Point H
The precise timing for delayed laparotomy is not well defined, but should occur after the patient has been adequately resuscitated to include correction of hypothermia, acidosis, and coagulopathy. This is the time to remove packs and reevaluate the injured liver. Once packs are removed, assess for ongoing bleeding, biliary leak, and associated nonhepatic injuries. If nonviable parenchyma is noted, local resection is frequently all that is required. Formal resection, although commonly practiced in the past, is rarely indicated. University of Pittsburgh recently reported the safety of hepatic resection in the management of complex liver injuries.47 Reasons cited for resection included bleeding/vascular injury, parenchyma disruption, necrotic tissue, and intraparenchymal bile leak. Their excellent results suggest that delayed resection may be an option in select cases at institutions with the appropriate expertise.
A Cochrane Review examining the use of routine drainage for uncomplicated liver resections concluded that there is no evidence to support routine drainage.48 For trauma, studies have clearly demonstrated that the use of closed suction drainage is superior to open drainage and routine drainage is not warranted.49,50 In general, a drain should be considered when there is a suspected bile leak at the time of laparotomy, although this has not been well investigated.51 With perihilar injuries associated with large bile leaks, cholangiography can help identify injured ducts that are surgically accessible. Most cases of postoperative bile leaks or perihepatic abscesses (with or without placement of an operatively placed drain) can be successfully treated by percutaneous techniques.52 The majority of peripheral biliary leaks will seal without treatment, and continued high-output biliary drainage may warrant adjunctive endoscopic retrograde cholangiopancreatography and stenting. A multidisciplinary approach is useful in the management of postoperative hepatic complications and is discussed in the nonoperative blunt hepatic algorithm.53