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Right hepatectomy in the treatment of liver trauma
Right Hepatectomy in the Treatment of Liver Trauma
M. P. Mercadier, MD, FACS (Hon), Paris, France J.-P. Clot, MD, Paris, France J.-P. Cady, MD, Paris, France
The increasing frequency of liver trauma, which chiefly results from the increasing number of traffic accidents, calls attention to these injuries since the problems concerning their management are not entirely solved and treatment remains a subject of controversy. Since the classic methods of treatment of severe lesions have been found to be inadequate and since new discoveries have been made regarding the anatomy of the liver, hepatectomy is becoming increasingly favored by surgeons. To justify this preference, we would like to report our experience with ten cases of severe liver trauma treated by right hemihepatectomy, amputation having been effected by finger dissection, which limits the time of clamping of the portal pedicle. Clinical Material
Between May 1970 and August 1971, resection of the right lobe of the liver for trauma was performed on our service for six men and four women between the ages of fourteen and forty-seven years. Nine of the ten patients had suffered blunt trauma and were treated by right lobectomy. The tenth patient had received a steel arm injury and was treated by atypical right liver resection. These patients are divided into two groups: those operated upon immediately on our service (five patients) and those reoperated upon in our service after having first been treated elsewhere (five patients).
From the Department of Surgery, Hdpital de la Piti6, Paris 13, France. Presented at the Twelfth Annual Meeting of the Society for Surgery the Alimentary Tract, Atlantic City, New Jersey, June 19-20. 1971.
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Five patients were admitted directly to our service as emergency cases of severe hepatic lesions. The diagnosis of hematoperitoneum, suspected on clinical examination, was substantiated by the fact that pure blood was obtained by peritoneal puncture. The diagnosis of liver injury was based on the site of the trauma. Another five wounded patients were referred to our service for reintervention, their liver injuries having been diagnosed during exploratory laparotomy performed on a nonspecialized service. In three patients very serious hepatic lesions had made it impossible to assure satisfactory hemostasis during the first operation. A m&he (plug of lint used to dilate wounds) had simply been inserted and the patients transferred as “catastrophes.” All had to be reoperated upon immediately for massive hemoperitoneum. All had received at least 20 units of blood prior to their transfer. Because of the critical conditions of these patients, we were not able to make a complete preoperative biologic investigation. In two of these three patients the abdominal wounds were accompanied by craniocerebral injuries. Two cases were particularly significant. In both patients the rupture of the liver was not very important and the tear had been sutured hurriedly without precise identification of the vascular lesions and therefore without elective hemostasis. Consequently, a hematoma developed in the center of the right lobe, followed by necrosis, secondary infection, and post-traumatic hemobilia. The fact that it took several days for this condition to develop made it possible for us to record a complete picture including clinical (associated lesions), biologic (functional disorders), and arteriographic (dye leakage) data.
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Pathologic Considerations. Eight patients operated as straight or delayed emergencies had sustained important parenchymal lesions with injuries to the intrahepatic blood vessels. The parenchymal lesions were of three kinds: (1) One patient had a perforating wound of the posterior segments VII and VIII. (2) One patient had an anteroposterior fracture of segment V extending to segment VIII. (3) Five patients presented with bursting of the right lobe of the liver: in three of them the posterior part of the liver was the most damaged; in another the lateral part (segments VI and VII) was damaged; and the fifth had massive destruction of the liver parenchyma. All these wounds were associated with important venous lesions: In three cases there was rupture of the right suprehepatic vein. In another case we found a lateral tear of the inferior yena cava due to detachment of the right suprahepatic vein. The resulting hemorrhage was abundant and uncontrollable in spite of the clamping of the portal pedicle. In four cases red blood issued from deep segmental arteries, the vascular rupture being accompanied by rupture of the corresponding bile ducts. An escape of bile therefore accompanied the hemorrhage which could be controlled by temporary clamping of the portal pedicle. In this type of injury, which is the most frequent, it is always possible to explore the depth of the fractured parenchyma and ligate the blood vessels and broken bile ducts. Hepatectomy is justified only when most of the right lobe has been devitalized by hemostatic maneuvers. Associated lesions were usually noted. Six patients had the following abdominal lesions: tearing of the diaphragm (one patient), rupture of the spleen (two patients), right renal and suprarenal lesions (three patients). In addition to the abdominal wounds, other injuries were noted: craniocerebral trauma (two patients), fracture of the petrous bone (one patient), bursting injury of the thorax (one patient), pleuropulmonary wound (one patient), fracture of the humerus (one patient). Actually, the prognosis is essentially based on these associated injuries since severe wounds of the right lobe of the liver can be satisfactorily removed by right hepatectomy. On two occasions we had to operate because of complications ensuing after a classic treatment: simple suture as the initial repair of a transverse rupture of the liver. The first patient, in addition to having necrosis of segment VIII secondary to the ligature of the right paramedian vessels, had fractures of the thorax and pelvis. In the other patient hematoma secondary to a segmental artery wound had developed in the central part of the liver and was a source
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of hemobilia; this patient had also suffered a craniocerebral trauma and dislocation of the knee joint. Mortality. Of ten patients operated upon there were four fatalities. One patient died at the end of the operation. At the preagonal stage he presented a wound of the vena cava and suprahepatic vein. Irreversible cardiac arrest occurred at the very point at which the situation appeared satisfactory. We thought that this fatal occurrence might be the consequence of hypothermia induced by massive fresh blood transfusions. One patient died twenty-four hours postoperatively. He had suffered cranioencephalic injuries and sank into a gradually deepening coma. Another death occurred on the fourth postoperative day. The patient had been transported from a place more than 200 kilometers distant, and hepatectomy had to be performed after an ineffectual m& chage had been attempted. He did not recover from the anesthesia and had to be placed under artificial ventilation; however, cardiac arrhythmia developed, ending in terminal collapse. The last death occurred in a fourteen year old child in whom we performed hepatectomy for a central lobular hematoma. Prior to surgery the boy had been comatose, showing decerebrate bilateral rigidity. Although in his particular case there was no abdominal or metabolic problem, he died on the twenty-fifth postoperative day from a syndrome of Candida albicans meningitis. Complications. In addition to the associated lesions, we had to deal with a number of postoperative complications. There were four cases of pleural and parietal infection. We have not seen any cases of subphrenic abscess, probably because we always occlude the diaphragmatic dead space by “paletot” suture of the diaphragm. In one patient (case VII) anuria had appeared immediately, and this condition had been complicated secondarily by moderate but repeated digestive hemorrhages. The patient was cured, without sequelae, after numerous sessions of extrarenal dialysis. Favorable Postoperative Course. Six of ten patients were saved after careful postoperative resuscitation; to date, they have had no sequelae. In those patients who had a favorable postoperative course, a practically constant finding has been an intractable tachycardia with a pulse rate averaging 120 per minute and the frequent occurrence of hyperpyrexia which subsided only with the administration of corticoids. The biological tests always showed disturbance at an early stage. The average values were as follows:
The American Journal 01 Surgery
Right Hepatectomy
serum glutamic pyruvic transaminase, 200 units dehydrogenase, 500 mu /ml (elevated) ; lactic (elevated); prothrombin level, 75 per cent (lowered); serinemia, 35 gm/L (lowered); blood urea nitrogen, 0.60 gm/L (temporarily elevated). The flocculation and phosphatase levels were not altered. These biologic indexes became less abnormal after approximately one month. Systematic exploration after three months, of the remaining portion of the liver by scintiscanning and elective arteriography always showed compensatory hypertrophy of the left lobe of the liver with the hepatic mass filling the space left empty by amputation. Comments Diagnosis. Three possibilities should be considered in diagnosing hepatic lesions of traumatic origin: 1. An abdominal contusion may be accompanied by a state of shock, whether or not there are associated factors explaining the patient’s critical condition, such as craniocerebral, rachidian, or medullary lesions, thoracic wounds, or multiple fractures. In such cases we find that abdominal tapping with a dialyzing trocar or abdominal lavage with 500 cc of physiologic saline solution is extremely useful; for us this is a routine practice. Once hemoperitoneum has been ascertained, it is more difficult to decide whether bleeding results from rupture of the liver rather than from a liver wound. Bradycardia, although considered a classic sign, is really of little diagnostic value; serum transaminase determination is too time-consuming; and emergency celiac arteriography is not always feasible, due to the patient’s serious condition or to the circumstances of the emergency. In practice, the patient is placed on the operating table in the position required for surgery of the liver, permitting an appropriate approach (which will be discussed). 2. The patient may have already undergone surgery as a temporary measure, and will present with persistent hemorrhage. This situation raises no diagnostic problem; proper steps must be taken to reoperate immediately. 3. Wounded patients, already operated upon, may have developed complications such as recurrence of bleeding, hemobilia, sequestration, or abscess formation. In each case the characteristic symptoms make it possible to identify the cause. In this situation selective celiac arteriography proves to be the procedure of choice for it localizes the central or peripheral site of the vascular lesions and detects the eventu-
Volume 124, September 1972
for Liver Trauma
al existence of central lobar hematoma. Additionally scintiscanning of the liver shows the importance of parenchymal damage. Once the diagnosis has been made in these widely varying circumstances, the surgical procedure to follow does not change. Technic. The surgical approach: The incision must allow complete exploration of the abdominal cavity and, if necessary, full exposure of the right lobe of the liver. Therefore we habitually place the patient on the operating table in a left lateral decubitus position (45 degrees) to prepare a broad thoracoabdominal field, and we start the abdominal incision by a right median or paramedian incision crossing the umbilicus. The findings at exploration determine the course to be followed. When the lesions involve the left lobe of the liver, the incision is extended upward, resecting the xiphoid process if necessary; this is sufficient for left hepatectomy, especially in the child or adolescent whose thorax is supple and can easily be raised with a retractor. When the right lobe of the liver is damaged, the median or paramedian incision is extended towards the eighth rib, thereby achieving a thoracophrenolaparotomy passing in the eighth space of the eighth rib bed. This is the only way to obtain perfect control of the right lobe of the liver, of its vessels, and of the inferior vena cava. However, there are two drawbacks to this method: it is difficult to remove the spleen and, even more important, there is a risk of respiratory sequelae. When exploration rules out hepatic lesions in a patient presenting with abdominal wounds, one simply has to remove the cushion holding him turned to the left and the patient will be in the usual dorsal decubitus position for abdominal surgery. Exploration: The operation begins with a swift exploration of the entire abdominal cavity. This makes it possible to detect the eventual coexistence of associated lesions, especially of the spleen and large vessels. If a liver injury is discovered, a loop is placed immediately around the liver pedicle. When hemorrhage is moderate, we take the time to perform a thorough careful exploration and, if necessary, to complete it by preoperative cholangiography to obtain a precise identification of the lesions. As a rule, these lesions do not require hepatectomy. When there is profuse hemorrhage, a brief clamping of the pedicle enables the surgeon to determine whether the hemorrhage is from a portal or a caval wound. A portal hemorrhage will be checked by the clamping. If the bleeding persists, its source is usually to be found either in the right suprahepatic vein or in the inferior vena cava, as we have had opportu-
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nities to observe in four of our ten cases. Such venous wounds are responsible for profuse hemorrhage of dark blood and entail a non-negligible risk of gas embolism. To control them, at least partially and temporarily, one must resort to massive tight tamponade since clamping of the inferior vena cava above and below the level of the liver is contraindicated. In portal vein hemorrhage the time permissible for pedicle clamping is fifteen minutes in normothermia. This could be increased to twenty and even thirty minutes when local hypothermia is induced by iced serum. We did not have to apply this measure, although we did consider doing so, since the body temperature of both patients concerned spontaneously fell by one or two degrees after several blood transfusions . Hepatectomy:
We have adopted a simple technic of hepatectomy whereby control of hemorrhage is assured by the clamping of the portal pedicle and a rapid exeresis. As soon as we find that hepatectomy is justified, we proceed with the clamping of the portal pedicle and section of the right triangular ligament, and we then perform hepatectomy by retrograde digitoclasis from down upward, when the lesions lie anteriorly. The right hepatic lobectomy is thus effected in ten minutes and with little blood loss. When the posterior part of the liver is ruptured, we give our immediate attention to direct control of the suprahepatic segment of the inferior vena cava and of the right suprahepatic vein. This type of hepatectomy with transparenchymal control of the intrahepatic blood vessels and bile ducts, using Ton Tha Tung’s technic, has been blamed for devascularizing the remaining hepatic tissue. In reality, this danger can be averted by progressing along the interlobar scissura, on the right of the median suprahepatic vein, and ligating each vascular element individually and precisely, any mass ligature being definitely avoided. The important thing is to leave the surface of the raw section neat and of normal color, and to check any bleeding or bile leakage. Right, so-called anatomic, hepatectomy by primary ligature of the blood vessels, following LortatJacob’s technic, should be an elective operation for large tumors since dissection of the blood vessels is a time-consuming procedure. The problem is more complicated when the hemorrhage originates in the suprahepatic vein or in a lateral tear of the vena cava. Many authors have studied it and the following solutions have been suggested: (1) Hemostasis by clamping of the inferior vena cava in the pericardial sac and above the renal
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vein, as described by Lortat-Jacob for elective hepatectomy. However, the time allowed for this clamping is of necessity very limited because of the risk of cardiac arrest due to the lack of blood supply to the right side of the heart. (2) Intubation of the inferior vena cava above the renal veins and the shutting of this internal shunt by means of suprahepatic and subhepatic loops, as experimentally tried by Couinaud. (3) Counter-current intubation of the inferior vena cava through the right auricle by means of a cardiac bypass pen number 34 to 38, opening in the atrium, with clamping above the suprahepatic and renal veins, as tried experimentally by Schroch. (4) Intubation of the inferior vena cava, current-wise, by introducing below the renal veins an anesthesia cannula of large caliber bearing lateral windows and a bulb iriflating at the level of the suprahepatic veins. (5) Partial hemostasis by laterally clamping the inferior vena cava above and below the liver by means of vein clamps. Nevertheless, ingenious as they may be, all these procedures are extremely difficult to use; by the time they can be put in practice the patient is exsanguinated and the heart depleted of blood, and cardiac arrest occurs. Exploration and biliary decompression: Once hepatectomy is effected, we have made it a practice to perform cholangiography, using an iodine solution which is opaque under x-rays and stained with methylene blue in order to detect any escape of bile. We believe that this precaution is important in preventing to a certain extent the formation of a biliary fistula or subphrenic abscess since any point of leakage detected is immediately sealed. We like to complete this exploration of the biliary tree by draining it. If the common bile duct is large enough, which is exceptional, a T-shaped drain is introduced. Otherwise, the drainage is effected through the cystic duct since the gallbladder has to be removed during hepatectomy. We never have resorted to sphincterotomy of the sphincter of Oddi recommended by some authors as a corollary of hepatic lobectomy. At present, the principle of biliary drainage is a subject of controversy. However, in our experience drainage has been completely satisfactory and has never caused any complication. It has enabled us to verify by postoperative cholangiography the efficacy of the bile duct ligatures and to follow the expansion of the hepatic remnant. After perfect hemostasis and the impermeability of the bile ducts have been assured, the operation is completed by extensive drainage of the right subdiaphragmatic space. The omentum or a sheet of re-
The
American
Journal
of Surgery
Right Hepatectomy
sorbable coagulating substance (Sponge1 or, preferably, Sorbacel) is applied to the raw surface of hepatic parenchyma. The pleural cavity is closed over a double drain which is closely watched during the immediate postoperative period. Resuscitation. Intraoperation resuscitation cannot be a matter of improvisation. The success of the operation depends on its efficacy. It is essential to be ready for certain measures such as: (1) preparing several points of access to the superior vena cava for rapid massive transfusions proportionate to blood loss in order to prevent the heart being depleted of blood; (2) repeated blood tests during surgery to monitor any change in blood coagulability and to prevent fibrinolysis or coagulopathy; (3) alkalinization during pedicle clamping; (4) control of the body temperature and of the temperature of the blood transfused, since too important a lowering of the body temperature may cause fibrillation followed by cardiac arrest; (5) permanent control of the arterial blood pressure, venous pressure, and urinary output, and constant cardioscopic control. Postoperative resuscitation calls for equally careful cooperation on the part of the team in charge. Resuscitation is relatively simple when hepatectomy has been performed under satisfactory conditions in a patient presenting no injury other than the liver trauma. However, resuscitation is extremely delicate in a patient having suffered multiple injuries, or when surgery has been complicated by some accident such as shock, cardiac arrest, gas embolism, or coagulopathy. Artificial ventilation, careful correction of metabolic or coagulation disorders, or extrarenal dialysis in case of acute renal insufficiency may then prove necessary and require continuous supervision. Indications. Right hemihepatectomy for traumatic lesions of the right lobe of the liver must be reserved for very specific and comparatively rare occasions. We believe that emergency right hemihepatectomy is justified only in severe hepatic lesions. It is justified when there are considerable parenchymal lacerations equivalent to an actual bursting of the liver and any conservative measures are bound to fail due to devascularization and to the lesions of the suprahepatic veins or inferior vena cava resulting from the liver rupture. The prognosis then is grave, with a 75 per cent mortality, since hemostasis cannot be assured by the classic methods. Right hepatectomy may be considered when deep fractures of the liver involve important blood vessels and bile duct pedicles. In such cases, hemostasis is
Volume 124, September 1972
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made possible by good exposure of the lesions; but the peripheral segment deprived of its blood supply is doomed to necrosis and its complications. Right hemihepatectomy is indispensable as a deferred emergency procedure when hemostasis of a severe hepatic lesion could be effected only precariously. The problems involved, however, are somewhat similar to those of the classic methods and the risk of postoperative infection is definitely greater, at least according t-, our own experience. Seconda LIright hemihepatectomy is indicated to deal with ;he complications arising from hepatic rupture such as recurrent intraperitoneal hemorrhage, acute anemia from continuous hemobilia, and extensive intraparenchymal hematoma. Summary
Right hemihepatectomy was performed over period of a few months in ten patients as a straight or deferred emergency or as secondary treatment. Six of the patients operated on are alive and well; the remaining four patients died, not as a result of the operation, but in each case because of an associated lesion, especially severe craniocerebral trauma with immediate coma. In four cases the hepatic lesions included a tear of the inferior vena cava, a source of hemorrhage which proved uncontrollable by the classic methods: two of these patients are cured, and two died, but they also had a craniocerebral lesion. These facts encourage us to propose right hemihepatectomy as a method of treatment of severe lesions of the right lobe of the liver. Whereas the socalled “anatomic” hepatectomy is indicated for the excision of hepatic tumors, we recommend for the management of liver trauma a more rapid, less anatomic exeresis, namely, hepatectomy by finger fracture, limiting the pedicle clamping time to.fifteen minutes (this time can be extended to as much as thirty minutes under moderate [35” F] hypothermia). Hemihepatectomy for trauma to the right lobe of the liver is justified only in very special cases: bursting of the right hepatic lobe, uncontrollable hemorrhage resulting from a tear to the right suprahepatic vein or an injury to the inferior vena cava, and complications secondary to rupture of the liver. It is indicated when life cannot be saved by lesser procedures, which should be ascertained beforehand by all possible means. In the hands of experienced surgeons, hemihepatectomy should further lower the mortality rate from severe liver trauma, although the prognosis may depend on associated lesions.
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References 1. Ackroyd FW, Pollard J, McDermott WV: Massive hepatic resection in the treatment of severe liver trauma. Amer J Sorg 117: 442, 1969. 2. Albo D, Christensen C, Rasmussen BL, King TC: Massive liver trauma involving the suprarenal vena cava. Amer J Surg 118: 960, 1969. 3. Amerson JR, Stone HH: Experiences in the management of hepatic trauma. Arch Surg 100: 150, 1970. 4. Aroncenk F, Bengmark S, et al: Liver resection for blunt injuries to liver. Surgery 63: 2, 5. Fekete F, Guillet R: Les traumatismes du foie. Congres Francais de Chirurgie 1969. Paris, Masson, 1969. 6. Fekete F, Guillet R, Guiuli R, Goyer B: Les lesions du pe dicule hepatique, des veines sus-hepatiques et de la veine cave inferieure associees aux traumatismes du foie. Hemobilies traumatiques. Ann Chir 23: 1187, 1969. 7. Ludbs CE, Walt AJ: Critical decisions in liver trauma. Arch Sorg 101: 277, 1970.
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8. Merendino KA, Dillard DH. Commock EE: The concept of surgical biliary decompression in the management of liver trauma. Surg Gynec Obstef 117: 285, 1963. 9. Payne WD, Terz JJ, Lawrence W: Major hepatic resection for trauma. Ann Surg 170: 929, 1969. 10. Pilcher: Penetrating injuries of the liver in Vietnam. Ann Surg 170: 5, 1969. 11. Pinkerton JA, Sawyers JL, Foster JH: A study of the postoperative course after hepatic lobectomy. Ann Surg 173: 800, 1971. 12. Schroch HT, Blaisdell WF, Mathewson C: Management of blunt trauma of the liver and hepatic veins. Arch Surg 96: 689,1968. 13. Vandooren M, et al: Le clampage vasculaire dans les hepatectomies d’urgence. Mem Acad Chir 96: 8, 1969. 14. Viard H: Les Hepatectomies Majeures. Paris, L’Expansion Scientifique Francaise, 1970. 15. Walt AJ: The surgical management of hepatic trauma and its complications. Ann Roy Co// Surg Eng 45: 319, 1969. 16. Weichert RF: Blunt injury to intrahepatic vena cava and hepatic veins with survival. Amer J Surg 121: 3, 1971.
The American Journal of Surgery
M. P. Mercadier, MD, FACS (Hon), Paris, France J.-P. Clot, MD, Paris, France J.-P. Cady, MD, Paris, France
The increasing frequency of liver trauma, which chiefly results from the increasing number of traffic accidents, calls attention to these injuries since the problems concerning their management are not entirely solved and treatment remains a subject of controversy. Since the classic methods of treatment of severe lesions have been found to be inadequate and since new discoveries have been made regarding the anatomy of the liver, hepatectomy is becoming increasingly favored by surgeons. To justify this preference, we would like to report our experience with ten cases of severe liver trauma treated by right hemihepatectomy, amputation having been effected by finger dissection, which limits the time of clamping of the portal pedicle. Clinical Material
Between May 1970 and August 1971, resection of the right lobe of the liver for trauma was performed on our service for six men and four women between the ages of fourteen and forty-seven years. Nine of the ten patients had suffered blunt trauma and were treated by right lobectomy. The tenth patient had received a steel arm injury and was treated by atypical right liver resection. These patients are divided into two groups: those operated upon immediately on our service (five patients) and those reoperated upon in our service after having first been treated elsewhere (five patients).
From the Department of Surgery, Hdpital de la Piti6, Paris 13, France. Presented at the Twelfth Annual Meeting of the Society for Surgery the Alimentary Tract, Atlantic City, New Jersey, June 19-20. 1971.
Volume 124, September 1972
of
Five patients were admitted directly to our service as emergency cases of severe hepatic lesions. The diagnosis of hematoperitoneum, suspected on clinical examination, was substantiated by the fact that pure blood was obtained by peritoneal puncture. The diagnosis of liver injury was based on the site of the trauma. Another five wounded patients were referred to our service for reintervention, their liver injuries having been diagnosed during exploratory laparotomy performed on a nonspecialized service. In three patients very serious hepatic lesions had made it impossible to assure satisfactory hemostasis during the first operation. A m&he (plug of lint used to dilate wounds) had simply been inserted and the patients transferred as “catastrophes.” All had to be reoperated upon immediately for massive hemoperitoneum. All had received at least 20 units of blood prior to their transfer. Because of the critical conditions of these patients, we were not able to make a complete preoperative biologic investigation. In two of these three patients the abdominal wounds were accompanied by craniocerebral injuries. Two cases were particularly significant. In both patients the rupture of the liver was not very important and the tear had been sutured hurriedly without precise identification of the vascular lesions and therefore without elective hemostasis. Consequently, a hematoma developed in the center of the right lobe, followed by necrosis, secondary infection, and post-traumatic hemobilia. The fact that it took several days for this condition to develop made it possible for us to record a complete picture including clinical (associated lesions), biologic (functional disorders), and arteriographic (dye leakage) data.
353
Mercadier,
Clot, and Cady
Pathologic Considerations. Eight patients operated as straight or delayed emergencies had sustained important parenchymal lesions with injuries to the intrahepatic blood vessels. The parenchymal lesions were of three kinds: (1) One patient had a perforating wound of the posterior segments VII and VIII. (2) One patient had an anteroposterior fracture of segment V extending to segment VIII. (3) Five patients presented with bursting of the right lobe of the liver: in three of them the posterior part of the liver was the most damaged; in another the lateral part (segments VI and VII) was damaged; and the fifth had massive destruction of the liver parenchyma. All these wounds were associated with important venous lesions: In three cases there was rupture of the right suprehepatic vein. In another case we found a lateral tear of the inferior yena cava due to detachment of the right suprahepatic vein. The resulting hemorrhage was abundant and uncontrollable in spite of the clamping of the portal pedicle. In four cases red blood issued from deep segmental arteries, the vascular rupture being accompanied by rupture of the corresponding bile ducts. An escape of bile therefore accompanied the hemorrhage which could be controlled by temporary clamping of the portal pedicle. In this type of injury, which is the most frequent, it is always possible to explore the depth of the fractured parenchyma and ligate the blood vessels and broken bile ducts. Hepatectomy is justified only when most of the right lobe has been devitalized by hemostatic maneuvers. Associated lesions were usually noted. Six patients had the following abdominal lesions: tearing of the diaphragm (one patient), rupture of the spleen (two patients), right renal and suprarenal lesions (three patients). In addition to the abdominal wounds, other injuries were noted: craniocerebral trauma (two patients), fracture of the petrous bone (one patient), bursting injury of the thorax (one patient), pleuropulmonary wound (one patient), fracture of the humerus (one patient). Actually, the prognosis is essentially based on these associated injuries since severe wounds of the right lobe of the liver can be satisfactorily removed by right hepatectomy. On two occasions we had to operate because of complications ensuing after a classic treatment: simple suture as the initial repair of a transverse rupture of the liver. The first patient, in addition to having necrosis of segment VIII secondary to the ligature of the right paramedian vessels, had fractures of the thorax and pelvis. In the other patient hematoma secondary to a segmental artery wound had developed in the central part of the liver and was a source
354
of hemobilia; this patient had also suffered a craniocerebral trauma and dislocation of the knee joint. Mortality. Of ten patients operated upon there were four fatalities. One patient died at the end of the operation. At the preagonal stage he presented a wound of the vena cava and suprahepatic vein. Irreversible cardiac arrest occurred at the very point at which the situation appeared satisfactory. We thought that this fatal occurrence might be the consequence of hypothermia induced by massive fresh blood transfusions. One patient died twenty-four hours postoperatively. He had suffered cranioencephalic injuries and sank into a gradually deepening coma. Another death occurred on the fourth postoperative day. The patient had been transported from a place more than 200 kilometers distant, and hepatectomy had to be performed after an ineffectual m& chage had been attempted. He did not recover from the anesthesia and had to be placed under artificial ventilation; however, cardiac arrhythmia developed, ending in terminal collapse. The last death occurred in a fourteen year old child in whom we performed hepatectomy for a central lobular hematoma. Prior to surgery the boy had been comatose, showing decerebrate bilateral rigidity. Although in his particular case there was no abdominal or metabolic problem, he died on the twenty-fifth postoperative day from a syndrome of Candida albicans meningitis. Complications. In addition to the associated lesions, we had to deal with a number of postoperative complications. There were four cases of pleural and parietal infection. We have not seen any cases of subphrenic abscess, probably because we always occlude the diaphragmatic dead space by “paletot” suture of the diaphragm. In one patient (case VII) anuria had appeared immediately, and this condition had been complicated secondarily by moderate but repeated digestive hemorrhages. The patient was cured, without sequelae, after numerous sessions of extrarenal dialysis. Favorable Postoperative Course. Six of ten patients were saved after careful postoperative resuscitation; to date, they have had no sequelae. In those patients who had a favorable postoperative course, a practically constant finding has been an intractable tachycardia with a pulse rate averaging 120 per minute and the frequent occurrence of hyperpyrexia which subsided only with the administration of corticoids. The biological tests always showed disturbance at an early stage. The average values were as follows:
The American Journal 01 Surgery
Right Hepatectomy
serum glutamic pyruvic transaminase, 200 units dehydrogenase, 500 mu /ml (elevated) ; lactic (elevated); prothrombin level, 75 per cent (lowered); serinemia, 35 gm/L (lowered); blood urea nitrogen, 0.60 gm/L (temporarily elevated). The flocculation and phosphatase levels were not altered. These biologic indexes became less abnormal after approximately one month. Systematic exploration after three months, of the remaining portion of the liver by scintiscanning and elective arteriography always showed compensatory hypertrophy of the left lobe of the liver with the hepatic mass filling the space left empty by amputation. Comments Diagnosis. Three possibilities should be considered in diagnosing hepatic lesions of traumatic origin: 1. An abdominal contusion may be accompanied by a state of shock, whether or not there are associated factors explaining the patient’s critical condition, such as craniocerebral, rachidian, or medullary lesions, thoracic wounds, or multiple fractures. In such cases we find that abdominal tapping with a dialyzing trocar or abdominal lavage with 500 cc of physiologic saline solution is extremely useful; for us this is a routine practice. Once hemoperitoneum has been ascertained, it is more difficult to decide whether bleeding results from rupture of the liver rather than from a liver wound. Bradycardia, although considered a classic sign, is really of little diagnostic value; serum transaminase determination is too time-consuming; and emergency celiac arteriography is not always feasible, due to the patient’s serious condition or to the circumstances of the emergency. In practice, the patient is placed on the operating table in the position required for surgery of the liver, permitting an appropriate approach (which will be discussed). 2. The patient may have already undergone surgery as a temporary measure, and will present with persistent hemorrhage. This situation raises no diagnostic problem; proper steps must be taken to reoperate immediately. 3. Wounded patients, already operated upon, may have developed complications such as recurrence of bleeding, hemobilia, sequestration, or abscess formation. In each case the characteristic symptoms make it possible to identify the cause. In this situation selective celiac arteriography proves to be the procedure of choice for it localizes the central or peripheral site of the vascular lesions and detects the eventu-
Volume 124, September 1972
for Liver Trauma
al existence of central lobar hematoma. Additionally scintiscanning of the liver shows the importance of parenchymal damage. Once the diagnosis has been made in these widely varying circumstances, the surgical procedure to follow does not change. Technic. The surgical approach: The incision must allow complete exploration of the abdominal cavity and, if necessary, full exposure of the right lobe of the liver. Therefore we habitually place the patient on the operating table in a left lateral decubitus position (45 degrees) to prepare a broad thoracoabdominal field, and we start the abdominal incision by a right median or paramedian incision crossing the umbilicus. The findings at exploration determine the course to be followed. When the lesions involve the left lobe of the liver, the incision is extended upward, resecting the xiphoid process if necessary; this is sufficient for left hepatectomy, especially in the child or adolescent whose thorax is supple and can easily be raised with a retractor. When the right lobe of the liver is damaged, the median or paramedian incision is extended towards the eighth rib, thereby achieving a thoracophrenolaparotomy passing in the eighth space of the eighth rib bed. This is the only way to obtain perfect control of the right lobe of the liver, of its vessels, and of the inferior vena cava. However, there are two drawbacks to this method: it is difficult to remove the spleen and, even more important, there is a risk of respiratory sequelae. When exploration rules out hepatic lesions in a patient presenting with abdominal wounds, one simply has to remove the cushion holding him turned to the left and the patient will be in the usual dorsal decubitus position for abdominal surgery. Exploration: The operation begins with a swift exploration of the entire abdominal cavity. This makes it possible to detect the eventual coexistence of associated lesions, especially of the spleen and large vessels. If a liver injury is discovered, a loop is placed immediately around the liver pedicle. When hemorrhage is moderate, we take the time to perform a thorough careful exploration and, if necessary, to complete it by preoperative cholangiography to obtain a precise identification of the lesions. As a rule, these lesions do not require hepatectomy. When there is profuse hemorrhage, a brief clamping of the pedicle enables the surgeon to determine whether the hemorrhage is from a portal or a caval wound. A portal hemorrhage will be checked by the clamping. If the bleeding persists, its source is usually to be found either in the right suprahepatic vein or in the inferior vena cava, as we have had opportu-
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nities to observe in four of our ten cases. Such venous wounds are responsible for profuse hemorrhage of dark blood and entail a non-negligible risk of gas embolism. To control them, at least partially and temporarily, one must resort to massive tight tamponade since clamping of the inferior vena cava above and below the level of the liver is contraindicated. In portal vein hemorrhage the time permissible for pedicle clamping is fifteen minutes in normothermia. This could be increased to twenty and even thirty minutes when local hypothermia is induced by iced serum. We did not have to apply this measure, although we did consider doing so, since the body temperature of both patients concerned spontaneously fell by one or two degrees after several blood transfusions . Hepatectomy:
We have adopted a simple technic of hepatectomy whereby control of hemorrhage is assured by the clamping of the portal pedicle and a rapid exeresis. As soon as we find that hepatectomy is justified, we proceed with the clamping of the portal pedicle and section of the right triangular ligament, and we then perform hepatectomy by retrograde digitoclasis from down upward, when the lesions lie anteriorly. The right hepatic lobectomy is thus effected in ten minutes and with little blood loss. When the posterior part of the liver is ruptured, we give our immediate attention to direct control of the suprahepatic segment of the inferior vena cava and of the right suprahepatic vein. This type of hepatectomy with transparenchymal control of the intrahepatic blood vessels and bile ducts, using Ton Tha Tung’s technic, has been blamed for devascularizing the remaining hepatic tissue. In reality, this danger can be averted by progressing along the interlobar scissura, on the right of the median suprahepatic vein, and ligating each vascular element individually and precisely, any mass ligature being definitely avoided. The important thing is to leave the surface of the raw section neat and of normal color, and to check any bleeding or bile leakage. Right, so-called anatomic, hepatectomy by primary ligature of the blood vessels, following LortatJacob’s technic, should be an elective operation for large tumors since dissection of the blood vessels is a time-consuming procedure. The problem is more complicated when the hemorrhage originates in the suprahepatic vein or in a lateral tear of the vena cava. Many authors have studied it and the following solutions have been suggested: (1) Hemostasis by clamping of the inferior vena cava in the pericardial sac and above the renal
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vein, as described by Lortat-Jacob for elective hepatectomy. However, the time allowed for this clamping is of necessity very limited because of the risk of cardiac arrest due to the lack of blood supply to the right side of the heart. (2) Intubation of the inferior vena cava above the renal veins and the shutting of this internal shunt by means of suprahepatic and subhepatic loops, as experimentally tried by Couinaud. (3) Counter-current intubation of the inferior vena cava through the right auricle by means of a cardiac bypass pen number 34 to 38, opening in the atrium, with clamping above the suprahepatic and renal veins, as tried experimentally by Schroch. (4) Intubation of the inferior vena cava, current-wise, by introducing below the renal veins an anesthesia cannula of large caliber bearing lateral windows and a bulb iriflating at the level of the suprahepatic veins. (5) Partial hemostasis by laterally clamping the inferior vena cava above and below the liver by means of vein clamps. Nevertheless, ingenious as they may be, all these procedures are extremely difficult to use; by the time they can be put in practice the patient is exsanguinated and the heart depleted of blood, and cardiac arrest occurs. Exploration and biliary decompression: Once hepatectomy is effected, we have made it a practice to perform cholangiography, using an iodine solution which is opaque under x-rays and stained with methylene blue in order to detect any escape of bile. We believe that this precaution is important in preventing to a certain extent the formation of a biliary fistula or subphrenic abscess since any point of leakage detected is immediately sealed. We like to complete this exploration of the biliary tree by draining it. If the common bile duct is large enough, which is exceptional, a T-shaped drain is introduced. Otherwise, the drainage is effected through the cystic duct since the gallbladder has to be removed during hepatectomy. We never have resorted to sphincterotomy of the sphincter of Oddi recommended by some authors as a corollary of hepatic lobectomy. At present, the principle of biliary drainage is a subject of controversy. However, in our experience drainage has been completely satisfactory and has never caused any complication. It has enabled us to verify by postoperative cholangiography the efficacy of the bile duct ligatures and to follow the expansion of the hepatic remnant. After perfect hemostasis and the impermeability of the bile ducts have been assured, the operation is completed by extensive drainage of the right subdiaphragmatic space. The omentum or a sheet of re-
The
American
Journal
of Surgery
Right Hepatectomy
sorbable coagulating substance (Sponge1 or, preferably, Sorbacel) is applied to the raw surface of hepatic parenchyma. The pleural cavity is closed over a double drain which is closely watched during the immediate postoperative period. Resuscitation. Intraoperation resuscitation cannot be a matter of improvisation. The success of the operation depends on its efficacy. It is essential to be ready for certain measures such as: (1) preparing several points of access to the superior vena cava for rapid massive transfusions proportionate to blood loss in order to prevent the heart being depleted of blood; (2) repeated blood tests during surgery to monitor any change in blood coagulability and to prevent fibrinolysis or coagulopathy; (3) alkalinization during pedicle clamping; (4) control of the body temperature and of the temperature of the blood transfused, since too important a lowering of the body temperature may cause fibrillation followed by cardiac arrest; (5) permanent control of the arterial blood pressure, venous pressure, and urinary output, and constant cardioscopic control. Postoperative resuscitation calls for equally careful cooperation on the part of the team in charge. Resuscitation is relatively simple when hepatectomy has been performed under satisfactory conditions in a patient presenting no injury other than the liver trauma. However, resuscitation is extremely delicate in a patient having suffered multiple injuries, or when surgery has been complicated by some accident such as shock, cardiac arrest, gas embolism, or coagulopathy. Artificial ventilation, careful correction of metabolic or coagulation disorders, or extrarenal dialysis in case of acute renal insufficiency may then prove necessary and require continuous supervision. Indications. Right hemihepatectomy for traumatic lesions of the right lobe of the liver must be reserved for very specific and comparatively rare occasions. We believe that emergency right hemihepatectomy is justified only in severe hepatic lesions. It is justified when there are considerable parenchymal lacerations equivalent to an actual bursting of the liver and any conservative measures are bound to fail due to devascularization and to the lesions of the suprahepatic veins or inferior vena cava resulting from the liver rupture. The prognosis then is grave, with a 75 per cent mortality, since hemostasis cannot be assured by the classic methods. Right hepatectomy may be considered when deep fractures of the liver involve important blood vessels and bile duct pedicles. In such cases, hemostasis is
Volume 124, September 1972
for Liver Trauma
made possible by good exposure of the lesions; but the peripheral segment deprived of its blood supply is doomed to necrosis and its complications. Right hemihepatectomy is indispensable as a deferred emergency procedure when hemostasis of a severe hepatic lesion could be effected only precariously. The problems involved, however, are somewhat similar to those of the classic methods and the risk of postoperative infection is definitely greater, at least according t-, our own experience. Seconda LIright hemihepatectomy is indicated to deal with ;he complications arising from hepatic rupture such as recurrent intraperitoneal hemorrhage, acute anemia from continuous hemobilia, and extensive intraparenchymal hematoma. Summary
Right hemihepatectomy was performed over period of a few months in ten patients as a straight or deferred emergency or as secondary treatment. Six of the patients operated on are alive and well; the remaining four patients died, not as a result of the operation, but in each case because of an associated lesion, especially severe craniocerebral trauma with immediate coma. In four cases the hepatic lesions included a tear of the inferior vena cava, a source of hemorrhage which proved uncontrollable by the classic methods: two of these patients are cured, and two died, but they also had a craniocerebral lesion. These facts encourage us to propose right hemihepatectomy as a method of treatment of severe lesions of the right lobe of the liver. Whereas the socalled “anatomic” hepatectomy is indicated for the excision of hepatic tumors, we recommend for the management of liver trauma a more rapid, less anatomic exeresis, namely, hepatectomy by finger fracture, limiting the pedicle clamping time to.fifteen minutes (this time can be extended to as much as thirty minutes under moderate [35” F] hypothermia). Hemihepatectomy for trauma to the right lobe of the liver is justified only in very special cases: bursting of the right hepatic lobe, uncontrollable hemorrhage resulting from a tear to the right suprahepatic vein or an injury to the inferior vena cava, and complications secondary to rupture of the liver. It is indicated when life cannot be saved by lesser procedures, which should be ascertained beforehand by all possible means. In the hands of experienced surgeons, hemihepatectomy should further lower the mortality rate from severe liver trauma, although the prognosis may depend on associated lesions.
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References 1. Ackroyd FW, Pollard J, McDermott WV: Massive hepatic resection in the treatment of severe liver trauma. Amer J Sorg 117: 442, 1969. 2. Albo D, Christensen C, Rasmussen BL, King TC: Massive liver trauma involving the suprarenal vena cava. Amer J Surg 118: 960, 1969. 3. Amerson JR, Stone HH: Experiences in the management of hepatic trauma. Arch Surg 100: 150, 1970. 4. Aroncenk F, Bengmark S, et al: Liver resection for blunt injuries to liver. Surgery 63: 2, 5. Fekete F, Guillet R: Les traumatismes du foie. Congres Francais de Chirurgie 1969. Paris, Masson, 1969. 6. Fekete F, Guillet R, Guiuli R, Goyer B: Les lesions du pe dicule hepatique, des veines sus-hepatiques et de la veine cave inferieure associees aux traumatismes du foie. Hemobilies traumatiques. Ann Chir 23: 1187, 1969. 7. Ludbs CE, Walt AJ: Critical decisions in liver trauma. Arch Sorg 101: 277, 1970.
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8. Merendino KA, Dillard DH. Commock EE: The concept of surgical biliary decompression in the management of liver trauma. Surg Gynec Obstef 117: 285, 1963. 9. Payne WD, Terz JJ, Lawrence W: Major hepatic resection for trauma. Ann Surg 170: 929, 1969. 10. Pilcher: Penetrating injuries of the liver in Vietnam. Ann Surg 170: 5, 1969. 11. Pinkerton JA, Sawyers JL, Foster JH: A study of the postoperative course after hepatic lobectomy. Ann Surg 173: 800, 1971. 12. Schroch HT, Blaisdell WF, Mathewson C: Management of blunt trauma of the liver and hepatic veins. Arch Surg 96: 689,1968. 13. Vandooren M, et al: Le clampage vasculaire dans les hepatectomies d’urgence. Mem Acad Chir 96: 8, 1969. 14. Viard H: Les Hepatectomies Majeures. Paris, L’Expansion Scientifique Francaise, 1970. 15. Walt AJ: The surgical management of hepatic trauma and its complications. Ann Roy Co// Surg Eng 45: 319, 1969. 16. Weichert RF: Blunt injury to intrahepatic vena cava and hepatic veins with survival. Amer J Surg 121: 3, 1971.
The American Journal of Surgery