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MODULE 4�Hepatobiliary and Spleen

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Let’s start with the basics…

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Liver (Hepatic Blood Supply)

  • Dual blood supply: Approximately 75% from hepatic portal vein, 25% from the hepatic artery.

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Spleen (Splenic Blood Supply)

  • Primarily from the splenic artery, which is a branch of the celiac trunk. 
  • Splenic artery travels along the superior border of the pancreas before reaching the spleen. 
  • Splenic vein drains blood from the spleen, joining with the superior mesenteric vein to form the hepatic portal vein.

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Liver Anatomy

Middle Hepatic Vein

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Posterior Short Hepatic Veins

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Caution:

Mobilizing R sided ligaments may open contained hematoma

Suspensory Ligaments of Liver

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Major Liver Injuries

TYPE 1: MOST COMMON

TYPE 2

Injury to intra-parenchymal hepatic veins/bleeding thru liver

Injury to retro hepatic veins with bleeding from around liver

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Recreate 3-D Anatomy of Liver

“PUSH”

(Bimanual Compression)

“PACK”

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Packing, Packing, Packing!!!

Controlling Liver Hemorrhage

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  1. If hemorrhage is controlled by packing, leave packs and do nothing further
  2. Some relatively simple injuries may be definitively fixed by suture, cautery, argon beam, glue, or omental packing

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Managing Liver Trauma

“PATCH”with Omentum

“PLUG” balloon tamponade

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  1. Use fingers through foramen of Winslow to identify portal triad – place a vascular clamp
  2. Pringle may slow bleeding, and diagnose arterial source. You still have to find and fix the problem

Managing Liver Trauma with Pringle Maneuver

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Managing Intra-parenchymal Bleeding:�Finger Fracture Technique

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  • If packing and Pringle does NOT control bleeding, retro-hepatic/hepatic venous injury is the likely source.
  • Consider:
    • Liver Mobilization
    • Total Hepatic Vascular Isolation (Heaney maneuver)

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Managing Liver Trauma

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Extension of the incision into the chest and division of the diaphragm may facilitate exposure and mobilization of the liver.

Liver Mobilization

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Liver Mobilization to Expose Retro-hepatic Cava

Divide Falciform Ligament

Dissection of the leaflets of the falciform ligament is continued posteriorly, being careful to avoid injury to the major hepatic veins. 

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Mobile Right Lobe of the Liver

Mobile right lobe (RL) of the liver by taking down the right triangular ligament (arrow) from the diaphragm (*). Take down the right triangular (TL) and coronary (CL) ligaments to mobilize the right lobe medially to expose the IVC and the short hepatic veins. 

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Right Lobe of the Liver Mobilization

The right lobe of the liver has been mobilized medially, revealing the inferior vena cava (IVC), the short hepatic veins (*), and the right renal vein (arrow).

Hepatic Veins

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Left Lobe Liver Mobilization

Mobilize the left lobe of the liver by taking down the left triangular, falciform, and the left coronary ligaments. 

  • Divide the hepatoduodenal and gastrohepatic ligaments access the lesser sac, the portal vein, the medial aspect of the IVC, and the caudate lobe of the liver (if required).
  • Take down the ligament (star) to enter the gastrohepatic space and expose the diaphragmatic crus (arrow), the caudate lobe (CL) of the liver, and the medial aspect of the IVC.

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Heaney Maneuver

  • Total vascular isolation by obtaining supra- and intra- hepatic IVC control
  • Options for supra-haptic IVC control:
    • Below the diaphragm
    • Division of the diaphragm
    • Through the pericardium (transdiaphragmatic pericardial window)
    • Through the right thorax above the diaphragm (Right ALT)
  • The Heaney Maneuver involves clamping the suprahepatic and infrahepatic IVC and applying the Pringle maneuver. The technique results in severe acute decrease in venous return to the heart with a possible outcome being sudden cardiac arrest. 

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Heaney Maneuver�Below the Diaphragm

1. Mobilize the suspensory ligaments to expose the supra-hepatic IVC between the liver and diaphragm

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Heaney Maneuver

2. Retract the liver caudally and anteriorly, with the suprahepatic IVC grasped between fingers

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3. Place a posteriorly directed vascular clamp to occlude the IVC. 

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Heaney Maneuver

Hepatic Venovenous Bypass Technique

1. Elevate the liver cephalad and dissect the hepatoduodenal window.

2. Mobilize the duodenum medially to gain visualization of:

  • The Short segment of the infrahepatic IVC between the caudate lobe (*) of the liver
  • The right (white star) and left (black star) renal veins
  • The nearby portal triad (PT) 

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Heaney Maneuver

Hepatic Venovenous Bypass Technique

2. Retract the liver caudally and anteriorly, with the suprahepatic IVC grasped between fingers

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3. Place a posteriorly directed vascular clamp to occlude the IVC. 

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  • Controlling suspected retrohepatic caval bleeding with initial packing should preclude liver mobilization in the acute setting
  • Liver mobilization in the acute setting may unleash uncontrolled bleeding that will require more drastic (and often lethal) maneuvers
    • Retrohepatic vascular structures can be easily injured by traction or errant dissection
    • Too much mobilization – un-roofing a contained retro-hepatic hematoma
    • Tearing small veins behind the liver

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Liver Mobilization

Pitfalls

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Common Bile Duct Anatomy

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Common Bile Duct Exposure

Incision and Exposure

  • Midline incision is acceptable; right upper quadrant subcostal incision is more common.
  • Use self-retaining retractors to provide good visualization.
  • Retract the liver superiorly, the duodenum inferiorly, and the stomach to the left.

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Common Bile Duct Exposure

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Dissection and Identification

  • Carefully lyse any adhesions around the injured bile duct
  • Identify the cystic duct, which may be ligated to prevent gallstone migration. 
  • Identify the CBD by following the cystic duct or by dissecting in the area of the porta hepatis. 

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Common Bile Duct Exploration

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Exploration & Treatment

Once the common bile duct is exposed, it can be explored for stones using various techniques (e.g, cholangiography, choledochoscopy). 

Longitudinal incision common bile duct (↑)

Low CBD stricture, with a length of the common hepatic duct stump of >2 cm (↑)

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  • Stones can be extracted using baskets, balloons, or other instruments. 
  • Two stay stitches to create a diamond shape (-4-0 or 5-0 PDS)
  • Clear stones with:
    • Pituitary scoop
    • Randall stone forceps
    • Fogarty catheter (4F)

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Common Bile Duct Exploration

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Common Bile Duct Bypass

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Bile Duct Jejunum Roux-Y Anastomosis

A bile duct-jejunum Roux-en-Y anastomosis is a surgical procedure where a section of the jejunum (a part of the small intestine) is used to bypass a blockage or injury in the bile duct, connecting it to the liver's bile ducts. This creates a new pathway for bile to flow from the liver to the intestines, bypassing the obstruction. 

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Spleen Anatomy

Gastrosplenic

Ligament

Splenorenal Ligament

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Spleen and Splenic Injuries

AAST Spleen Trauma Classifications  

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Management of Splenic Injuries

Splenorrhaphy 

Repair the injured spleen through sutures, mesh, or other methods to control bleeding. 

  • Suture Repair: Directly suturing the laceration or tear. 
  • Mesh Wrapping: Using absorbable mesh to provide support and tamponade bleeding. 
  • Partial Splenectomy: Removing the injured portion of the spleen while preserving the healthy tissue. 

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For severe injury, splenectomy (spleen removal) may be necessary. Open, laparoscopic and robotic techniques may be used. 

Open Splenectomy: The traditional approach, involving a larger incision for access to the spleen. This is often necessary for unstable patients with polytrauma or other severe injuries. 

Laparoscopic Splenectomy: For more stable patients with less severe injuries. Option may not be available in expeditionary environments. 

Robotic-Assisted Splenectomy: Similar to laparoscopic, but with enhanced dexterity and visualization. 

Management of Splenic Injuries

Splenectomy 

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Emergent Exposure of the Spleen and Splenic Injuries

  • Make a generous midline incision, with the operating surgeon on the right side of the patient.
  • It is important to remember the anatomical relationship of the spleen to the kidney and the tail of the pancreas
  • The spleen is a posterolateral structure and must be mobilized to the midline for evaluation and management. 

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Mobilization of the Spleen

  • To mobilize the spleen, divide the attachments (splenophrenic, splenorenal, splenocolic, and splenogastric) that connect it to surrounding structures.
  • The spleen is grasped with the surgeon’s nondominant hand and mobilized anteromedially to the midline by carefully dividing the ligaments using long scissors or electrocautery

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Mobilization of the Spleen

  • In the setting of trauma, the ligaments may have already been partially or completely disrupted, and rapid blunt dissection may be possible.
  • Placing laparotomy pads behind the spleen may assist in elevating it medially and anteriorly. 
  • Once the spleen is mobilized, the hilum can be controlled with digital occlusion. 

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Exposure of the Splenic Hilum

  • To expose the splenic hium, divide and ligate the short gastric vessels in the gastrosplenic ligament, taking care to avoid injury to the stomach.
  • The decision to salvage the spleen or perform a splenectomy requires consideration of the total complexity of the patient’s injuries and potential for future blood loss.
  • In general, if a patient has other injuries or physiologic perturbations, splenectomy is the default. 

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Divide & Ligate Vessels of Splenic Hilum

  • The splenic hilum (white star) has been isolated distal to the tail of the pancreas (yellow star). The vessels can be ligated and divided.
  • The vessels of the splenic hilum can be dissected out (individually or en bloc) and ligated.

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Splenectomy  

  • Alternatively, the hilar vessels can be divided with a stapling device
  • Care must be taken not to injure the tail of the pancreas when clamping or dividing the splenic hilum.