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 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014950056 © Springer Science+Business Media New York 2015 This work is subject to copyright. 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Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) 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