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Successful management of hepatic vein injury from blunt trauma in children
Successful Management of Hepatic Vein Injury From Blunt Trauma in Children
Dale Cob, MD, Dallas, Texas John Crighton, MD, Springfield, Missouri Larry Schorn, MD, Dallas, Texas
The majority of deaths from blunt liver trauma in children are the result of exsanguination [l-3]. Mortality was 22 percent in 64 children under age 12 with liver injuries seen on the surgical service at the University of Texas Health Science Center at Dallas [4]. Half of the deaths were due to the liver injury,
and all of them resulted from exsanguination. Analysis of these fatalities disclosed a number of remarkable similarities in both the circumstances surrounding the injury and the type of hepatic injury sustained. The liver injury was characteristically the only injury and was most often the result of an auto-pedestrian accident. The liver wounds also were remarkably similar. They were large stellate fractures on the posterolateral aspect of the right lobe of the liver and extended cephalad and medially, disrupting the coronary ligament as they continued through the bare area into the hepatic veins and occasionally the inferior vena cava (Figure 1). All deaths from injury to the liver had these features. Material
and Methods
Patients: Hepatic vein injuries may have an obscure clinical presentation. On admission, four of the children who bled to death had hypotension and abdominal tenderness. The seriousness of the injury was immediately obvious, and therapy prompt and appropriate. However, three other children were not considered seriously injured. From the Divisionof Pediatric Sugery. The Universityof Texas Southwestem Medical School, Dallas, Texas, and Lester E. Cox Medical Center, wingfield, Missouri. Requests for reprints should be addressed to Dale Coin, MD, Division of Pediatric Surgery, The University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard. Dallas, Texas 75235. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-8, 1980.
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One was judged well enough for roentgenographic evaluation of a fractured rib. However, on returning from the x-ray department, he collapsed from shock. Laparotomy revealed a liver laceration extending into the right hepatic vein. Hemorrhage was massive and the patient died during operation. A 2 year old girl was transferred from a hospital outside the city with a blood pressure of 90150 mm Hg, very mild abdominal tenderness and no apparent serious injury. However, 3 hours later she became severely hypotensive, and emergency laparotomy disclosed a large laceration of the right lobe of the liver extending into the right hepatic vein. Uncontrolled hemorrhage resulted in death. A 5 year old girl was admitted to the emergency room shortly after being struck by an automobile. Blood pressure was 144/90 mm Hg, and she had minimal abdominal tenderness. Four hours after her arrival, the hematocrit dropped from 37 to 27.5 percent. During evaluation for this decrease in hematocrit, the blood pressure became unobtainable. The patient was immediately taken to the operating room, where a laceration of the right lobe of the liver, extending into the right hepatic vein, was discovered. She died from this injury. Management: The operative management of these seven patients who died was critically reviewed. Large quantities of intraabdominal blood often obscured the site of bleeding. Frequently, the spleen was inappropriately the first organ examined and was normal. The bleeding was then identified as coming from the right lobe of the liver. Attempts were usually made to visualize the point of bleeding. Control of bleeding from the right lobe of the liver was frequently difficult. Blood volume replacement and the control of bleeding were often independent of one another. In none of the seven patients was blood volume adequately restored or hemorrhage controlled during laparotomy, despite blood administration in excess of five times the blood volume. Frequently, attempts were made to control bleeding from the hepatic vein when the child was severely hypovolemic. Intracaval shunts were used without success in several instances.
The American Journal of Surgery
Hepatic Vein Injury in Children
These tragic experiences have caused us to he alert to the possibility of this potentially fatal injury in any child with blunt abdominal trauma. Unfortunately, this injury has no manifestations that distinguish it from less serious injuries. Only surgical exploration soon after injury will save these children. Because bleeding can be massive, crossmatching is done for at least twice the child’s blood volume. All fluid and blood is given intravenously through the arms. The operative management of these injuries is extremely important if one is to achieve a successful result. Our analysis of these cases has led to the following operative approach. These dangerous liver wounds consist of large stellate fractures on the posterolateral aspect of the liver, which disrupt the coronary ligament and extend through the bare area into the hepatic veins and the inferior vena cava. Upon entering the abdominal cavity, the surgeon can immediately identify this potentially fatal injury by running his hand over the posterior and lateral aspect of the liver, finding the coronary ligament disrupted. It is wise to avoid downward traction on the liver to visualize the area of injury until blood volume has been adequately restored because such a maneuver frequently results in severe hemorrhage and perhaps cardiac arrest. Bleeding can be controlled by tamponading the liver against the diaphragm by pressing the liver upward and backward. It is also helpful to cross clamp the porta hepatis with a vascular clamp. At that time, the measured and estimated blood loss is tallied and a volume of blood equal to that amount is infused. After restoration of an adequate circulating blood volume, a direct approach is made to the hepatic vein entrance into the inferior vena cava. In some children, this can be done without extending the original midline incision. However, if control is not obtained with the first attempt, the incision is extended as a median sternotomy or, less preferably, as a right thoracotomy. The diaphragm is incised through the pericardium. Incising the diaphragm makes it easy to secure control of the inferior vena cava and hepatic veins. The inferior vena cava can be partially occluded and the hepatic vein completely occluded. After suturing the injury of the hepatic vein and inferior vena
cava, bleeding sites in the liver can be suture ligated before removing the vascular clamp from the porta hepatis. A debridement-type resection may be necessary if there is devitalized liver tissue.
Case Reports Case 1. A 22 month old boy weighing 11.4 kg was playing under supervision in his back yard when he pulled a concrete birdbath over on himself. The child was taken to an emergency room near his home where he had labored respirations, a pulse of 160 beats/min and blood pressure of NO/50 mm I%g. He had diffuse abdominal tenderness. A roentgenogram of his abdomen had a “ground glass” appearance. At the time of transfer, the child had labored respirations, a pulse of 140 beats/min and an unobtainable blood pressure. A subclavian catheter was inserted and lactated Ringer’s solution and type-specific whole blood were rapidly infused. Paracentesis obtained nonclotting blood. The abdomen was entered through a long midline incision and 300 ml of blood was evacuated. A large fracture of the lateral aspect of the right lobe of the liver extended into the right hepatic vein and inferior vena cava. The coronary ligament was disrupted. As the injury was being examined, cardiac arrest occurred. External massage restored the heartbeat. The liver was compressed against the diaphragm and compression maintained while another arm cutdown was done and whole blood was administered. The blood pressure returned to 90 mm Hg. The portal triad was isolated and cross clamped. Downward traction on the right lobe of the liver exposed the area of injury. There was moderate bleeding from the site but, with repeated attempts, it was controlled by applying a partial occlusion vascular clamp across the vena cava at the entrance of the right hepatic vein. The wound in the right hepatic vein and inferior vena cava was repaired. Major arterial bleeding points from the liver were controlled with individual suture ligatures. A large portion of the right lobe of the liver was resected, and the liver edges were approximated with chromic sutures. The area was drained. The child received
~RONARY / I
LIGAMENT \
HEyTIC
61~
Figure 1. The type of liver Injury that is frequent/y fatal is a /arge stellate fracture through the bare area of the liver into the hepatic veins. The coronary ligament Is d/srupted.
Volume 140, bember
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2,500 ml of whole blood, the estimated blood loss. The calculated blood volume was 912 ml. The platelet count was 40,000 postoperatively, and he had bleeding through the drain site for several hours. He required another 1,500 ml of whole blood, fresh frozen plasma and several platelet infusions during the next 24 hours. The bleeding stopped on the first postoperative day. Respiration was maintained with a volume ventilator for 24 hours postoperatively. He had moderate drainage through the drain sites for 3 days postoperatively. He was well enough to take food on the third postoperative day. The serum bilirubin level reached a peak of 3.2 mg/lOO ml and serum glutamic oxalacetic transaminase was slightly elevated. At the time of discharge on the 10th postoperative day, hemoglobin was 14 mg/lOO ml. Case 2. A 7 year old boy weighing 28 kg was admitted to the emergency room after being run over by an automobile. Blood pressure was 90/60 mm Hg and pulse 130 beata/min. He was extremely short of breath, diaphoretic and in acute distress. He had diminished breath sounds on each side of the chest; a chest tube was inserted on each side to release bilateral pneumothorax. He had mild abdominal tenderness, and paracentesis yielded blood. A cathether was inserted in the left subclavian vein for the administration of lactated Ringer’s solution. Blood was cross matched. Blood pressure remained stable until he was taken to the operating room. The abdomen was opened through a long midline incision and 600 ml of nonclotting blood was evacuated. Palpation of the liver disclosed a large laceration of the posterior aspect of the right lobe of the liver that extended through the coronary ligament. Bleeding was profuse. The liver was compressed against the diaphragm until the estimated blood loss had been replaced. The area of the laceration was then exposed with downward traction of the liver. A partial occlusion clamp was placed across the inferior vena cava, and a right hepatic vein injury was identified and sutured. A portion of the right lobe of the liver was resected. This resected specimen weighed 124 g. The area of injury was drained. He received 2,500 ml of whole blood to replace the estimated blood loss. The calculated blood volume was 2,400 ml. Chest tubes were removed on the third and fourth days after injury. The liver drains were removed on the 7th day and he was discharged on the 10th day.
Case 3. A 3 year old girl weighing 14.5 kg was brought to the emergency room after being struck by an automobile. On admission the child was unconscious. She had abrasions over the right side of the face, forehead and both flanks. Blood pressure was 100/70 mm Hg and pulse 120 beats/ min. While being examined, she regained consciousness. She had no abdominal tenderness. Abdominal paracentesis recovered blood. Lactated Ringer’s solution was started intravenously in the left arm and right leg. Blood pressure decreased to 50/30 mm Hg and the abdomen became distended. The rate of administration of lactated Ringer’s solution was increased while blood was being cross
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matched. Palpation of the right upper quadrant of the abdomen detected an area of coolness that disappeared when fluid administration in the right leg was stopped and reappeared when it was restarted. The child was taken immediately to the operating room, where blood pressure was 90/60 mm Hg. The abdomen was entered through a long midline incision, and 400 ml of blood was evacuated from the abdominal cavity. A large laceration was present in the right lobe of the liver beginning on the posterolateral surface and extending cephalad and medially toward the diaphragm. The coronary ligament was disrupted. Downward traction on the laceration resulted in brisk bleeding, which was controlled by pushing the liver against the diaphragm. Compression was maintained until the measured blood loss was replaced. The chest was then entered through the sixth intercostal space. This incision was connected to the abdominal incision by transecting the intervening costal cartilages, and an incision was made in the diaphragm to expose the inferior vena cava. A laceration of the right hepatic vein extending into the inferior vena cava was identified. Hemorrhage from this area was controlled by placing an index finger directly over the laceration and suturing the cava underneath the finger. The hepatic vein was controlled by tenting it up at its entrance into the inferior vena cava and continuing the suture along its lateral aspect until the first tributary was reached. At this point it was ligated. A medial tributary was left intact. A row of interlocking chromic sutures was placed in the right lobe of the liver along the plane of the laceration, and a major portion of the right lobe was removed. The resected specimen weighed 160 g. Remaining bleeding points in the liver were ligated with fine absorbable sutures. The vascular clamp, which had been placed across the porta hepatis before thoracotomy, was removed. The total period of occlusion was 14 minutes. There was no other intraabdominal injury. The patient received 960 ml of whole blood for an estimated blood loss of 1,100 ml. The calculated blood volume was 1,160 ml. Postoperatively the patient was awake and alert, the hemoglobin was 15.4 mg/lOO ml and the hematocrit 46 percent. The results of liver function studies were normal, with the highest bilirubin level reaching 0.8 mg/lOO ml. The chest tube was removed on the fourth postoperative day but was later reinserted because of the accumulation of pleural fluid. With the exception of this minor complication, the child’s postoperative convalescence was uneventful. She was discharged on the 18th day after injury. Case 4: A 2 year old girl weighing 12 kg was brought to the emergency room after being struck by a car. Blood pressure was 110/60 mm Hg and pulse 150 beats/min. She was slightly pale and lethargic and her respirations were labored at 30lmin. She had abrasions on the right side of the head and on the back of the right side of the chest. The abdomen was not tender. Abdominal paracentesis yielded nonclotting blood. Intravenous infusions were started in both arms. Blood was cross matched. She had no hypotension preoperatively.
The American Journal of Surgery
Hepatic Vein Injury in Children
The patient’s abdomen was entered through a long midline incision, and approximately 800 ml of blood was evacuated. There was a large laceration on the right lobe of the liver that extended cephalad toward the diaphragm. The coronary ligament was disrupted. Bleeding from this area was profuse. The liver was compressed against the diaphragm and the porta hepatis was cross clamped with a vascular clamp. The blood volume was restored during a 10 minute waiting period, and median sternotomy was performed. The vena cava above and below the diaphragm was exposed by an incision in the diaphragm. A partial occlusion clamp was placed on the inferior vena cava at the point of entrance of the hepatic vein. This stopped the bleeding from the vena cava. The plane of the laceration was followed across the midportion of the liver to a bleeding point from the left hepatic vein. The bleeding was stopped by applying a vascular clamp. The vein was repaired. The right lobe of the liver was partially transected. A portion of it was debrided and the bleeding sites were sutured with absorbable sutures. The edges of the right lobe were then approximated with 1-O chromic sutures. Vascular clamps on the porta hepatis and the inferior vena cava were released. The total period of occlusion was 22 minutes. Large Penrose drains were brought out through the bed of the 12th rib, which was resected intraabdominally. The estimated blood loss of 1,100 ml was replaced intraoperatively with 1,000 ml of whole blood. The calculated blood volume was 960 ml. Postoperatively the patient recevied an additional 140 ml of packed red blood cells. Hemoglobin stabilized at 11 mg/lOO ml. Her postoperative convalescence was complicated by atelectasis of the right lung. which responded to treatment. Thoracentesis was performed on the 8th day and again on the 13th day postoperatively because of the accumulation of pleural fluid. The bilirubin reached a high of 2 mg/lOO ml on the second postoperative day when the serum glutamic oxalacetic transaminase was 660 units. After recovery from the pulmonary difficulties, her convalescence was uneventful, and she was discharged on the 13th day after injury.
Comments Almost all deaths from blunt injury to the liver in children occur because of exsanguination. These fatal injuries are characteristically in the right lobe of the liver and extend through the coronary ligament and the bare area of the liver to involve the hepatic veins and the inferior vena cava. Frequently, they are the only important injury the child has. Injury usually results from the child’s being struck by an automobile. The seriousness of the injury may be immediately apparent because of shock and abdominal distention. Rapid infusion of fluid and blood and emergency surgery are required to save the child. Howver, many children with this injury are stable for a period and may not appear seriously injured. Unfortunately, there are no reliable criteria for identi-
Volume140,December1990
fying children with this potentially fatal injury. If one waits for the development of peritoneal irritation or a decrease in blood pressure or in the blood count, the opportunity to save the child may be lost because the initial period of stability is followed by sudden shock so severe that it is frequently impossible to restore the blood volume. Once profound shock occurs, the patients usually cannot be saved. In over 60 children with blunt liver wounds, analysis for factors that would help in detecting these lethal injuries failed to identify any. The clinical finding of tachycardia and a look of distress are not specific or sufficiently different from signs in other children with blunt abdominal trauma. The only way to save these children is to operate on them as soon after injury as possible. Blood in the peritoneal cavity is the most reliable sign of intraabdominal injury and has continued to be our indication for laparotomy. Paracentesis or peritoneal lavage is done for abdominal pain or tenderness, altered states of consciousness that make abdominal examination unreliable, multiple system injury, or shock without an obvious cause. An additional criterion is a force or mechanism that might injure the liver, such as a fall from a height, an automobile-pedestrian accident or a heavy object falling on the child. Children with hemoperitoneum are operated on as quickly as possible. The four children successfully treated for hepatic vein injuries were operated on within 2 hours of their initial evaluation. The antithesis of this approach is the increasingly popular selective nonoperative management of children with abdominal trauma [5-71. Its success in selected instances is well documented. However, children with liver lacerations that extend into the hepatic vein deteriorate so rapidly that it is doubtful they can be saved by an approach that waits for clinical deterioration. There is usually insufficient time for successful treatment once sudden, profound shock has occurred. Early surgery for hemoperitoneum gives the best chance for survival. The infusion of balanced salt solution through arm veins is important. Fluid administered intravenously through a leg will run into the peritoneal cavity if there is a hepatic vein injury that extends into the inferior vena cava. This was dramatically illustrated in case 3 by the cold spot that appeared on the upper abdomen when the leg infusion was running and then disappeared when the infusion was stopped. Routinely, children are cross matched for twice their blood volume. Type-specific or 0 negative blood is given if the blood pressure does not respond to lactated Ringer’s solution. To avoid hypothermia, the blood is warmed if possible as it is being adminis-
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tered. Hypothermia adversely affects organ perfusion and contributes to acidosis and myocardial irritability. However, an adequate rate of blood administration takes precedence over blood warming. Temperature control is aided by a warming blanket on the operating table and by instilling warm &ne into the abdominal cavity when circumstances permit. The operative management is critical. The abdomen is entered through a long midline incision (Figure 2a). Because the liver is the most common site of lethal hemorrhage in a child, the first maneuver upon entering the abdomen is for the surgeon to run his hand over the lateral aspect of the liver seeking a laceration (Figure 2b). If a liver laceration extends through the coronary ligament, there is a good possibility that a hepatic vein injury exists. Further exposure of the wound is deferred until the blood volume is replaced. Bleeding from the bare area of the liver is controlled by tamponading the liver against the diaphragm. Cross clamping the porta
hepatis with a vascular clamp also helps diminish bleeding while the blood volume is being restored (Figure 2~). Blood is suctioned out of the abdomen and other sites of bleeding are looked for, although it is rare for children with liver and hepatic vein injuries to have other intraabdominal injuries. The volume of blood removed from the abdomen is replaced with an equal volume of blood. It is helpful if there are two intravenous sites in the arm with large bore tubes through which blood can be administered. After the blood volume is adequately replaced, the area of injury is inspected. In children it is relatively easy, through a laparotomy incision, to retract the liver downward to expose the hepatic veins. The surgeon’s hand can completely encompass the right lobe of the liver, and it is important in retracting the liver downward to avoid opening the wound. The hepatic vein and inferior vena caval injury should be visualized and controlled without inordinate bleeding on the first attempt. If this is not
Figure 2. a, a midline incision can be extended as a median sternotomy or right thoracotomy if intraabdominai exposure is not adequate. b, a large fracture in the right lobe of the liver extending through the bare area is searched for upon first entering the abdomen. c, bleeding can be controlled by compressing the liver against the diaphragm and by clamping the porta hepatis while the blood volume Is restored. d, occlusion proximal and distal to the injury. e, the method used in case 3 for obtaining control of the hepatic vein without the use of an occluding clamp.
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The American Journal of Surgery
Hepatic Vein Injury in Children
possible, the liver is compressed against the diaphragm, and the abdominal incisionis extended as a median sternotomy. The diaphragm is incised near or through the pericardium in an anterior to posterior direction to expose the hepatic vein entrance into the inferior vena cava. A partial occlusion clamp can be placed on the inferior vena cava and the liver wound examined to find the bleeding hepatic vein as it exits the liver. Appropriate vascular clamps are placed, and the vein is sutured (Figure 2d). Bleeding sites from the liver are sutured with absorbable sutures. Identification of these points is aided by intermittently releasing the clamp on the porta hepatis. Mattress sutures are used if ligation of specific bleeding points does not control the hemorrhage. Debridement-type resection of devitalized liver is done, and wide drainage through the bed of the 12th rib is recommended for these large liver wounds. This can be done by intraabdominal resection of the 12th rib [a]. The object in the treatment of these injuries is to gain control before blood loss exceeds one blood volume. This was accomplished in three of the patients reported on herein. In case 1, the operative blood replacement was 2.5 times the blood volume because of persistent attempts to gain control of the hepatic veins through the abdomen. The large amount of blood replaced resulted in coagulopathy, which responded to the postoperative administration of platelets, fresh frozen plasma and blood. Earlier control of hemorrhage would have prevented this. All four of the hepatic veins were repaired without the use of shunts in the inferior vena cava. Frequently, valuable time and blood are lost with the insertion of internal shunts. Their use may divert the surgeon’s attention from assessing the adequacy of the blood volume replacement, which is far more important to the patient’s survival. The insertion of shunts either through the atrium or the inferior vena cava requires practice and teamwork which a crisis situation does not allow. For surgeons inexperienced in shunt placement, their use can be a disaster. Even when skillfully inserted, a large amount of blood is lost as the shunt is inserted past the site of hepatic vein injury. Experimentally, shunts placed in the inferior vena cava of normovolemic adult baboons during the clamping of the porta hepatis and the hepatic veins failed to provide sufficient venous return to the heart to maintain an adequate cardiac output. The cardiac output was 0.8 liters/min in shunted animals compared with 3.6 liters/min in nonshunted animals (Coln and Horton, unpublished data). For these reasons, we believe that shunts are neither necessary nor indicated in the management of hepatic vein injuries in children. Volume 140, December 1980
Summary In children, the majority of deaths from blunt trauma to the liver are caused by large stellate fractures of the posterolateral aspect of the right lobe of the liver with extension into the hepatic veins. Four children with such injuries were successfully treated. Hypotension and abdominal tenderness are not early manifestations of this highly lethal injury in children. When an appropriate mechanism for liver injury exists, paracentesis or peritoneal lavage, followed by prompt laparotomy for hemoperitoneum, gives the best chance for early and successful treatment. Large cannulas in arm veins and cross matching for twice the patient’s blood volume are used when there is a possibility of a liver injury. The important aspects of operative management are identification of the injury when the abdomen is first opened and prompt control of bleeding. The possibility of hepatic vein injury exists if the surgeon finds the coronary ligament disrupted by a large liver laceration on the posterolateral liver surface. Compressing the liver against the diaphragm will usually control the bleeding while blood replacement is accomplished. The hepatic vein entrance into the inferior vena cava is then exposed using a median sternotomy, if necessary. Partial occlusion of the inferior vena cava can usually be safely done with this direct approach if the blood volume has been restored. Frequently, valuable time and blood are lost if attempts are made to insert internal shunts. References 1. Kaufman J, BurringtonJD. Liver trauma in children. J Pediatr Surg 197 1;6:565-94. 2. Suson EM, Klutz D, Kottmeier PK. Liver trauma in children. J Pediatr Surg 1975;10:411-7. 3. Stone HH, Ansley JD. Management of liver trauma in children, J Pediatr Surg 1977;12:3-8. 4. Schorn L, Coln D. Liver injuries in children (in press). 5. Ritchie JP, Fonkalsrud EW. Subcapsular hematoma of the liver. Arch Surg 1972;164:781-5. 6. Douglas 61, Simpson JS. The conservative management of splenic trauma. J Pediatr Surg 1971;6:565-70. 7. Ein SH. Shandling B, Simpson JS, Stephens CA. Nonoperative management of traumatized spleen in children: how and why. J Pediatr Surg 1978;13:117-9. 8. Coln D. A technique of drainage through the bed of the twelfth rib. Surg Gynecol Obstet 1975;141:608-9.
Discussion Ronald C. Elkins (Oklahoma City, OK): In any patient with this difficulty or trauma who has major intraabdominal hemorrhage, operative management is the only approach. Exposure of the inferior vena cava at the level of the diaphragm or the hepatic veins is far easier through a median sternotomy. If coronary ligament disruption is associated with hepatic vein injury, then I think an ex863
Coln et al
tended tient.
incision
is a cheap price to pay to save the pa-
Ernest E. Moore (Denver, CO): In adults, as in children, the errors include (1) delay in diagnosis, (2) inadequate resuscitation before or during operation, (3) poor operative approach including neglecting porta hepatis occlusion, and (4) overlooking important factors in the genesis of intractable coagulopathy (hypothermia, acidosis and incomplete blood component replacement). In adults we rely on an intracaval shunt when a major hepatic vein is involved and usually resect the right lobe to gain access to this difficult area. My questions are: (1) How long did you interrupt the porta hepatis, and what is a safe occlusion time? (2) Did you interrupt the vena cava both above and below the liver, and for how long? (3) Since hypothermia is a problem in children, what temperatures do you feel are optimal in these patients? (4) Finally, what if you have a diagnostic peritoneal lavage clearly positive in the pediatric age group? Should they all undergo prompt laparotomy, as for adults?
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Dale Coln (closing): If the coronary ligament is disrupted, there is a good possibility of hepatic vein injury. After blood volume replacement, intraabdominal attempts at gaining control can be made. If unsuccessful, then I think the incision needs to be extended. Our longest period of occlusion of the porta hepatis was 22 minutes. I do not know the occlusion time on the inferior vena cava. We try to only partially occlude the inferior vena cava. We gain access to the inferior vena cava through the central tendon of the diaphragm onto the entrance of the hepatic veins into the cava. After applying a partial occlusion clamp on the anterior wall of the cava, we find the hepatic vein on the liver side and either cross clamp it or tamponade it with a sponge. The caval side of the injury is repaired first. I do not like the temperature to get below 36°C. After the bleeding is controlled, warm saline can be poured into the abdominal cavity. Also, the warming blanket can be turned up. We do not observe any child with positive findings on peritoneal lavage.
The American Journal of Surgery
Dale Cob, MD, Dallas, Texas John Crighton, MD, Springfield, Missouri Larry Schorn, MD, Dallas, Texas
The majority of deaths from blunt liver trauma in children are the result of exsanguination [l-3]. Mortality was 22 percent in 64 children under age 12 with liver injuries seen on the surgical service at the University of Texas Health Science Center at Dallas [4]. Half of the deaths were due to the liver injury,
and all of them resulted from exsanguination. Analysis of these fatalities disclosed a number of remarkable similarities in both the circumstances surrounding the injury and the type of hepatic injury sustained. The liver injury was characteristically the only injury and was most often the result of an auto-pedestrian accident. The liver wounds also were remarkably similar. They were large stellate fractures on the posterolateral aspect of the right lobe of the liver and extended cephalad and medially, disrupting the coronary ligament as they continued through the bare area into the hepatic veins and occasionally the inferior vena cava (Figure 1). All deaths from injury to the liver had these features. Material
and Methods
Patients: Hepatic vein injuries may have an obscure clinical presentation. On admission, four of the children who bled to death had hypotension and abdominal tenderness. The seriousness of the injury was immediately obvious, and therapy prompt and appropriate. However, three other children were not considered seriously injured. From the Divisionof Pediatric Sugery. The Universityof Texas Southwestem Medical School, Dallas, Texas, and Lester E. Cox Medical Center, wingfield, Missouri. Requests for reprints should be addressed to Dale Coin, MD, Division of Pediatric Surgery, The University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard. Dallas, Texas 75235. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-8, 1980.
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One was judged well enough for roentgenographic evaluation of a fractured rib. However, on returning from the x-ray department, he collapsed from shock. Laparotomy revealed a liver laceration extending into the right hepatic vein. Hemorrhage was massive and the patient died during operation. A 2 year old girl was transferred from a hospital outside the city with a blood pressure of 90150 mm Hg, very mild abdominal tenderness and no apparent serious injury. However, 3 hours later she became severely hypotensive, and emergency laparotomy disclosed a large laceration of the right lobe of the liver extending into the right hepatic vein. Uncontrolled hemorrhage resulted in death. A 5 year old girl was admitted to the emergency room shortly after being struck by an automobile. Blood pressure was 144/90 mm Hg, and she had minimal abdominal tenderness. Four hours after her arrival, the hematocrit dropped from 37 to 27.5 percent. During evaluation for this decrease in hematocrit, the blood pressure became unobtainable. The patient was immediately taken to the operating room, where a laceration of the right lobe of the liver, extending into the right hepatic vein, was discovered. She died from this injury. Management: The operative management of these seven patients who died was critically reviewed. Large quantities of intraabdominal blood often obscured the site of bleeding. Frequently, the spleen was inappropriately the first organ examined and was normal. The bleeding was then identified as coming from the right lobe of the liver. Attempts were usually made to visualize the point of bleeding. Control of bleeding from the right lobe of the liver was frequently difficult. Blood volume replacement and the control of bleeding were often independent of one another. In none of the seven patients was blood volume adequately restored or hemorrhage controlled during laparotomy, despite blood administration in excess of five times the blood volume. Frequently, attempts were made to control bleeding from the hepatic vein when the child was severely hypovolemic. Intracaval shunts were used without success in several instances.
The American Journal of Surgery
Hepatic Vein Injury in Children
These tragic experiences have caused us to he alert to the possibility of this potentially fatal injury in any child with blunt abdominal trauma. Unfortunately, this injury has no manifestations that distinguish it from less serious injuries. Only surgical exploration soon after injury will save these children. Because bleeding can be massive, crossmatching is done for at least twice the child’s blood volume. All fluid and blood is given intravenously through the arms. The operative management of these injuries is extremely important if one is to achieve a successful result. Our analysis of these cases has led to the following operative approach. These dangerous liver wounds consist of large stellate fractures on the posterolateral aspect of the liver, which disrupt the coronary ligament and extend through the bare area into the hepatic veins and the inferior vena cava. Upon entering the abdominal cavity, the surgeon can immediately identify this potentially fatal injury by running his hand over the posterior and lateral aspect of the liver, finding the coronary ligament disrupted. It is wise to avoid downward traction on the liver to visualize the area of injury until blood volume has been adequately restored because such a maneuver frequently results in severe hemorrhage and perhaps cardiac arrest. Bleeding can be controlled by tamponading the liver against the diaphragm by pressing the liver upward and backward. It is also helpful to cross clamp the porta hepatis with a vascular clamp. At that time, the measured and estimated blood loss is tallied and a volume of blood equal to that amount is infused. After restoration of an adequate circulating blood volume, a direct approach is made to the hepatic vein entrance into the inferior vena cava. In some children, this can be done without extending the original midline incision. However, if control is not obtained with the first attempt, the incision is extended as a median sternotomy or, less preferably, as a right thoracotomy. The diaphragm is incised through the pericardium. Incising the diaphragm makes it easy to secure control of the inferior vena cava and hepatic veins. The inferior vena cava can be partially occluded and the hepatic vein completely occluded. After suturing the injury of the hepatic vein and inferior vena
cava, bleeding sites in the liver can be suture ligated before removing the vascular clamp from the porta hepatis. A debridement-type resection may be necessary if there is devitalized liver tissue.
Case Reports Case 1. A 22 month old boy weighing 11.4 kg was playing under supervision in his back yard when he pulled a concrete birdbath over on himself. The child was taken to an emergency room near his home where he had labored respirations, a pulse of 160 beats/min and blood pressure of NO/50 mm I%g. He had diffuse abdominal tenderness. A roentgenogram of his abdomen had a “ground glass” appearance. At the time of transfer, the child had labored respirations, a pulse of 140 beats/min and an unobtainable blood pressure. A subclavian catheter was inserted and lactated Ringer’s solution and type-specific whole blood were rapidly infused. Paracentesis obtained nonclotting blood. The abdomen was entered through a long midline incision and 300 ml of blood was evacuated. A large fracture of the lateral aspect of the right lobe of the liver extended into the right hepatic vein and inferior vena cava. The coronary ligament was disrupted. As the injury was being examined, cardiac arrest occurred. External massage restored the heartbeat. The liver was compressed against the diaphragm and compression maintained while another arm cutdown was done and whole blood was administered. The blood pressure returned to 90 mm Hg. The portal triad was isolated and cross clamped. Downward traction on the right lobe of the liver exposed the area of injury. There was moderate bleeding from the site but, with repeated attempts, it was controlled by applying a partial occlusion vascular clamp across the vena cava at the entrance of the right hepatic vein. The wound in the right hepatic vein and inferior vena cava was repaired. Major arterial bleeding points from the liver were controlled with individual suture ligatures. A large portion of the right lobe of the liver was resected, and the liver edges were approximated with chromic sutures. The area was drained. The child received
~RONARY / I
LIGAMENT \
HEyTIC
61~
Figure 1. The type of liver Injury that is frequent/y fatal is a /arge stellate fracture through the bare area of the liver into the hepatic veins. The coronary ligament Is d/srupted.
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2,500 ml of whole blood, the estimated blood loss. The calculated blood volume was 912 ml. The platelet count was 40,000 postoperatively, and he had bleeding through the drain site for several hours. He required another 1,500 ml of whole blood, fresh frozen plasma and several platelet infusions during the next 24 hours. The bleeding stopped on the first postoperative day. Respiration was maintained with a volume ventilator for 24 hours postoperatively. He had moderate drainage through the drain sites for 3 days postoperatively. He was well enough to take food on the third postoperative day. The serum bilirubin level reached a peak of 3.2 mg/lOO ml and serum glutamic oxalacetic transaminase was slightly elevated. At the time of discharge on the 10th postoperative day, hemoglobin was 14 mg/lOO ml. Case 2. A 7 year old boy weighing 28 kg was admitted to the emergency room after being run over by an automobile. Blood pressure was 90/60 mm Hg and pulse 130 beata/min. He was extremely short of breath, diaphoretic and in acute distress. He had diminished breath sounds on each side of the chest; a chest tube was inserted on each side to release bilateral pneumothorax. He had mild abdominal tenderness, and paracentesis yielded blood. A cathether was inserted in the left subclavian vein for the administration of lactated Ringer’s solution. Blood was cross matched. Blood pressure remained stable until he was taken to the operating room. The abdomen was opened through a long midline incision and 600 ml of nonclotting blood was evacuated. Palpation of the liver disclosed a large laceration of the posterior aspect of the right lobe of the liver that extended through the coronary ligament. Bleeding was profuse. The liver was compressed against the diaphragm until the estimated blood loss had been replaced. The area of the laceration was then exposed with downward traction of the liver. A partial occlusion clamp was placed across the inferior vena cava, and a right hepatic vein injury was identified and sutured. A portion of the right lobe of the liver was resected. This resected specimen weighed 124 g. The area of injury was drained. He received 2,500 ml of whole blood to replace the estimated blood loss. The calculated blood volume was 2,400 ml. Chest tubes were removed on the third and fourth days after injury. The liver drains were removed on the 7th day and he was discharged on the 10th day.
Case 3. A 3 year old girl weighing 14.5 kg was brought to the emergency room after being struck by an automobile. On admission the child was unconscious. She had abrasions over the right side of the face, forehead and both flanks. Blood pressure was 100/70 mm Hg and pulse 120 beats/ min. While being examined, she regained consciousness. She had no abdominal tenderness. Abdominal paracentesis recovered blood. Lactated Ringer’s solution was started intravenously in the left arm and right leg. Blood pressure decreased to 50/30 mm Hg and the abdomen became distended. The rate of administration of lactated Ringer’s solution was increased while blood was being cross
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matched. Palpation of the right upper quadrant of the abdomen detected an area of coolness that disappeared when fluid administration in the right leg was stopped and reappeared when it was restarted. The child was taken immediately to the operating room, where blood pressure was 90/60 mm Hg. The abdomen was entered through a long midline incision, and 400 ml of blood was evacuated from the abdominal cavity. A large laceration was present in the right lobe of the liver beginning on the posterolateral surface and extending cephalad and medially toward the diaphragm. The coronary ligament was disrupted. Downward traction on the laceration resulted in brisk bleeding, which was controlled by pushing the liver against the diaphragm. Compression was maintained until the measured blood loss was replaced. The chest was then entered through the sixth intercostal space. This incision was connected to the abdominal incision by transecting the intervening costal cartilages, and an incision was made in the diaphragm to expose the inferior vena cava. A laceration of the right hepatic vein extending into the inferior vena cava was identified. Hemorrhage from this area was controlled by placing an index finger directly over the laceration and suturing the cava underneath the finger. The hepatic vein was controlled by tenting it up at its entrance into the inferior vena cava and continuing the suture along its lateral aspect until the first tributary was reached. At this point it was ligated. A medial tributary was left intact. A row of interlocking chromic sutures was placed in the right lobe of the liver along the plane of the laceration, and a major portion of the right lobe was removed. The resected specimen weighed 160 g. Remaining bleeding points in the liver were ligated with fine absorbable sutures. The vascular clamp, which had been placed across the porta hepatis before thoracotomy, was removed. The total period of occlusion was 14 minutes. There was no other intraabdominal injury. The patient received 960 ml of whole blood for an estimated blood loss of 1,100 ml. The calculated blood volume was 1,160 ml. Postoperatively the patient was awake and alert, the hemoglobin was 15.4 mg/lOO ml and the hematocrit 46 percent. The results of liver function studies were normal, with the highest bilirubin level reaching 0.8 mg/lOO ml. The chest tube was removed on the fourth postoperative day but was later reinserted because of the accumulation of pleural fluid. With the exception of this minor complication, the child’s postoperative convalescence was uneventful. She was discharged on the 18th day after injury. Case 4: A 2 year old girl weighing 12 kg was brought to the emergency room after being struck by a car. Blood pressure was 110/60 mm Hg and pulse 150 beats/min. She was slightly pale and lethargic and her respirations were labored at 30lmin. She had abrasions on the right side of the head and on the back of the right side of the chest. The abdomen was not tender. Abdominal paracentesis yielded nonclotting blood. Intravenous infusions were started in both arms. Blood was cross matched. She had no hypotension preoperatively.
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The patient’s abdomen was entered through a long midline incision, and approximately 800 ml of blood was evacuated. There was a large laceration on the right lobe of the liver that extended cephalad toward the diaphragm. The coronary ligament was disrupted. Bleeding from this area was profuse. The liver was compressed against the diaphragm and the porta hepatis was cross clamped with a vascular clamp. The blood volume was restored during a 10 minute waiting period, and median sternotomy was performed. The vena cava above and below the diaphragm was exposed by an incision in the diaphragm. A partial occlusion clamp was placed on the inferior vena cava at the point of entrance of the hepatic vein. This stopped the bleeding from the vena cava. The plane of the laceration was followed across the midportion of the liver to a bleeding point from the left hepatic vein. The bleeding was stopped by applying a vascular clamp. The vein was repaired. The right lobe of the liver was partially transected. A portion of it was debrided and the bleeding sites were sutured with absorbable sutures. The edges of the right lobe were then approximated with 1-O chromic sutures. Vascular clamps on the porta hepatis and the inferior vena cava were released. The total period of occlusion was 22 minutes. Large Penrose drains were brought out through the bed of the 12th rib, which was resected intraabdominally. The estimated blood loss of 1,100 ml was replaced intraoperatively with 1,000 ml of whole blood. The calculated blood volume was 960 ml. Postoperatively the patient recevied an additional 140 ml of packed red blood cells. Hemoglobin stabilized at 11 mg/lOO ml. Her postoperative convalescence was complicated by atelectasis of the right lung. which responded to treatment. Thoracentesis was performed on the 8th day and again on the 13th day postoperatively because of the accumulation of pleural fluid. The bilirubin reached a high of 2 mg/lOO ml on the second postoperative day when the serum glutamic oxalacetic transaminase was 660 units. After recovery from the pulmonary difficulties, her convalescence was uneventful, and she was discharged on the 13th day after injury.
Comments Almost all deaths from blunt injury to the liver in children occur because of exsanguination. These fatal injuries are characteristically in the right lobe of the liver and extend through the coronary ligament and the bare area of the liver to involve the hepatic veins and the inferior vena cava. Frequently, they are the only important injury the child has. Injury usually results from the child’s being struck by an automobile. The seriousness of the injury may be immediately apparent because of shock and abdominal distention. Rapid infusion of fluid and blood and emergency surgery are required to save the child. Howver, many children with this injury are stable for a period and may not appear seriously injured. Unfortunately, there are no reliable criteria for identi-
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fying children with this potentially fatal injury. If one waits for the development of peritoneal irritation or a decrease in blood pressure or in the blood count, the opportunity to save the child may be lost because the initial period of stability is followed by sudden shock so severe that it is frequently impossible to restore the blood volume. Once profound shock occurs, the patients usually cannot be saved. In over 60 children with blunt liver wounds, analysis for factors that would help in detecting these lethal injuries failed to identify any. The clinical finding of tachycardia and a look of distress are not specific or sufficiently different from signs in other children with blunt abdominal trauma. The only way to save these children is to operate on them as soon after injury as possible. Blood in the peritoneal cavity is the most reliable sign of intraabdominal injury and has continued to be our indication for laparotomy. Paracentesis or peritoneal lavage is done for abdominal pain or tenderness, altered states of consciousness that make abdominal examination unreliable, multiple system injury, or shock without an obvious cause. An additional criterion is a force or mechanism that might injure the liver, such as a fall from a height, an automobile-pedestrian accident or a heavy object falling on the child. Children with hemoperitoneum are operated on as quickly as possible. The four children successfully treated for hepatic vein injuries were operated on within 2 hours of their initial evaluation. The antithesis of this approach is the increasingly popular selective nonoperative management of children with abdominal trauma [5-71. Its success in selected instances is well documented. However, children with liver lacerations that extend into the hepatic vein deteriorate so rapidly that it is doubtful they can be saved by an approach that waits for clinical deterioration. There is usually insufficient time for successful treatment once sudden, profound shock has occurred. Early surgery for hemoperitoneum gives the best chance for survival. The infusion of balanced salt solution through arm veins is important. Fluid administered intravenously through a leg will run into the peritoneal cavity if there is a hepatic vein injury that extends into the inferior vena cava. This was dramatically illustrated in case 3 by the cold spot that appeared on the upper abdomen when the leg infusion was running and then disappeared when the infusion was stopped. Routinely, children are cross matched for twice their blood volume. Type-specific or 0 negative blood is given if the blood pressure does not respond to lactated Ringer’s solution. To avoid hypothermia, the blood is warmed if possible as it is being adminis-
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tered. Hypothermia adversely affects organ perfusion and contributes to acidosis and myocardial irritability. However, an adequate rate of blood administration takes precedence over blood warming. Temperature control is aided by a warming blanket on the operating table and by instilling warm &ne into the abdominal cavity when circumstances permit. The operative management is critical. The abdomen is entered through a long midline incision (Figure 2a). Because the liver is the most common site of lethal hemorrhage in a child, the first maneuver upon entering the abdomen is for the surgeon to run his hand over the lateral aspect of the liver seeking a laceration (Figure 2b). If a liver laceration extends through the coronary ligament, there is a good possibility that a hepatic vein injury exists. Further exposure of the wound is deferred until the blood volume is replaced. Bleeding from the bare area of the liver is controlled by tamponading the liver against the diaphragm. Cross clamping the porta
hepatis with a vascular clamp also helps diminish bleeding while the blood volume is being restored (Figure 2~). Blood is suctioned out of the abdomen and other sites of bleeding are looked for, although it is rare for children with liver and hepatic vein injuries to have other intraabdominal injuries. The volume of blood removed from the abdomen is replaced with an equal volume of blood. It is helpful if there are two intravenous sites in the arm with large bore tubes through which blood can be administered. After the blood volume is adequately replaced, the area of injury is inspected. In children it is relatively easy, through a laparotomy incision, to retract the liver downward to expose the hepatic veins. The surgeon’s hand can completely encompass the right lobe of the liver, and it is important in retracting the liver downward to avoid opening the wound. The hepatic vein and inferior vena caval injury should be visualized and controlled without inordinate bleeding on the first attempt. If this is not
Figure 2. a, a midline incision can be extended as a median sternotomy or right thoracotomy if intraabdominai exposure is not adequate. b, a large fracture in the right lobe of the liver extending through the bare area is searched for upon first entering the abdomen. c, bleeding can be controlled by compressing the liver against the diaphragm and by clamping the porta hepatis while the blood volume Is restored. d, occlusion proximal and distal to the injury. e, the method used in case 3 for obtaining control of the hepatic vein without the use of an occluding clamp.
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possible, the liver is compressed against the diaphragm, and the abdominal incisionis extended as a median sternotomy. The diaphragm is incised near or through the pericardium in an anterior to posterior direction to expose the hepatic vein entrance into the inferior vena cava. A partial occlusion clamp can be placed on the inferior vena cava and the liver wound examined to find the bleeding hepatic vein as it exits the liver. Appropriate vascular clamps are placed, and the vein is sutured (Figure 2d). Bleeding sites from the liver are sutured with absorbable sutures. Identification of these points is aided by intermittently releasing the clamp on the porta hepatis. Mattress sutures are used if ligation of specific bleeding points does not control the hemorrhage. Debridement-type resection of devitalized liver is done, and wide drainage through the bed of the 12th rib is recommended for these large liver wounds. This can be done by intraabdominal resection of the 12th rib [a]. The object in the treatment of these injuries is to gain control before blood loss exceeds one blood volume. This was accomplished in three of the patients reported on herein. In case 1, the operative blood replacement was 2.5 times the blood volume because of persistent attempts to gain control of the hepatic veins through the abdomen. The large amount of blood replaced resulted in coagulopathy, which responded to the postoperative administration of platelets, fresh frozen plasma and blood. Earlier control of hemorrhage would have prevented this. All four of the hepatic veins were repaired without the use of shunts in the inferior vena cava. Frequently, valuable time and blood are lost with the insertion of internal shunts. Their use may divert the surgeon’s attention from assessing the adequacy of the blood volume replacement, which is far more important to the patient’s survival. The insertion of shunts either through the atrium or the inferior vena cava requires practice and teamwork which a crisis situation does not allow. For surgeons inexperienced in shunt placement, their use can be a disaster. Even when skillfully inserted, a large amount of blood is lost as the shunt is inserted past the site of hepatic vein injury. Experimentally, shunts placed in the inferior vena cava of normovolemic adult baboons during the clamping of the porta hepatis and the hepatic veins failed to provide sufficient venous return to the heart to maintain an adequate cardiac output. The cardiac output was 0.8 liters/min in shunted animals compared with 3.6 liters/min in nonshunted animals (Coln and Horton, unpublished data). For these reasons, we believe that shunts are neither necessary nor indicated in the management of hepatic vein injuries in children. Volume 140, December 1980
Summary In children, the majority of deaths from blunt trauma to the liver are caused by large stellate fractures of the posterolateral aspect of the right lobe of the liver with extension into the hepatic veins. Four children with such injuries were successfully treated. Hypotension and abdominal tenderness are not early manifestations of this highly lethal injury in children. When an appropriate mechanism for liver injury exists, paracentesis or peritoneal lavage, followed by prompt laparotomy for hemoperitoneum, gives the best chance for early and successful treatment. Large cannulas in arm veins and cross matching for twice the patient’s blood volume are used when there is a possibility of a liver injury. The important aspects of operative management are identification of the injury when the abdomen is first opened and prompt control of bleeding. The possibility of hepatic vein injury exists if the surgeon finds the coronary ligament disrupted by a large liver laceration on the posterolateral liver surface. Compressing the liver against the diaphragm will usually control the bleeding while blood replacement is accomplished. The hepatic vein entrance into the inferior vena cava is then exposed using a median sternotomy, if necessary. Partial occlusion of the inferior vena cava can usually be safely done with this direct approach if the blood volume has been restored. Frequently, valuable time and blood are lost if attempts are made to insert internal shunts. References 1. Kaufman J, BurringtonJD. Liver trauma in children. J Pediatr Surg 197 1;6:565-94. 2. Suson EM, Klutz D, Kottmeier PK. Liver trauma in children. J Pediatr Surg 1975;10:411-7. 3. Stone HH, Ansley JD. Management of liver trauma in children, J Pediatr Surg 1977;12:3-8. 4. Schorn L, Coln D. Liver injuries in children (in press). 5. Ritchie JP, Fonkalsrud EW. Subcapsular hematoma of the liver. Arch Surg 1972;164:781-5. 6. Douglas 61, Simpson JS. The conservative management of splenic trauma. J Pediatr Surg 1971;6:565-70. 7. Ein SH. Shandling B, Simpson JS, Stephens CA. Nonoperative management of traumatized spleen in children: how and why. J Pediatr Surg 1978;13:117-9. 8. Coln D. A technique of drainage through the bed of the twelfth rib. Surg Gynecol Obstet 1975;141:608-9.
Discussion Ronald C. Elkins (Oklahoma City, OK): In any patient with this difficulty or trauma who has major intraabdominal hemorrhage, operative management is the only approach. Exposure of the inferior vena cava at the level of the diaphragm or the hepatic veins is far easier through a median sternotomy. If coronary ligament disruption is associated with hepatic vein injury, then I think an ex863
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tended tient.
incision
is a cheap price to pay to save the pa-
Ernest E. Moore (Denver, CO): In adults, as in children, the errors include (1) delay in diagnosis, (2) inadequate resuscitation before or during operation, (3) poor operative approach including neglecting porta hepatis occlusion, and (4) overlooking important factors in the genesis of intractable coagulopathy (hypothermia, acidosis and incomplete blood component replacement). In adults we rely on an intracaval shunt when a major hepatic vein is involved and usually resect the right lobe to gain access to this difficult area. My questions are: (1) How long did you interrupt the porta hepatis, and what is a safe occlusion time? (2) Did you interrupt the vena cava both above and below the liver, and for how long? (3) Since hypothermia is a problem in children, what temperatures do you feel are optimal in these patients? (4) Finally, what if you have a diagnostic peritoneal lavage clearly positive in the pediatric age group? Should they all undergo prompt laparotomy, as for adults?
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Dale Coln (closing): If the coronary ligament is disrupted, there is a good possibility of hepatic vein injury. After blood volume replacement, intraabdominal attempts at gaining control can be made. If unsuccessful, then I think the incision needs to be extended. Our longest period of occlusion of the porta hepatis was 22 minutes. I do not know the occlusion time on the inferior vena cava. We try to only partially occlude the inferior vena cava. We gain access to the inferior vena cava through the central tendon of the diaphragm onto the entrance of the hepatic veins into the cava. After applying a partial occlusion clamp on the anterior wall of the cava, we find the hepatic vein on the liver side and either cross clamp it or tamponade it with a sponge. The caval side of the injury is repaired first. I do not like the temperature to get below 36°C. After the bleeding is controlled, warm saline can be poured into the abdominal cavity. Also, the warming blanket can be turned up. We do not observe any child with positive findings on peritoneal lavage.
The American Journal of Surgery