**6.2. Gallbladder and extrahepatic bile ducts injuries**

Injuries of the gallbladder are treated by lateral suture or cholecystectomy, whichever is easier.

**6.3. Spleen injuries**

**Grade Injury description**

I **Hematoma:** subcapsular, <10% of the surface area

**Laceration:** >3 cm in parenchymal depth

within a single lobe

within a single lobe

VI **Vascular:** hepatic avulsion

**Laceration:** capsular tear, <1 cm in parenchymal depth

**Laceration:** 1–3 cm in parenchymal depth, <10 cm in length

bleeding; intraparenchymal, >10 cm or expanding or ruptured

IV **Hematoma:** ruptured intraparenchymal hematoma with active bleeding

**Table 3.** American Association for the Surgery of trauma liver injury scale.

II **Hematoma:** subcapsular, 10–50% surface area, intraparenchymal, 10 cm in diameter

III **Hematoma:** subcapsular, >50% of surface area or expanding or ruptured subcapsular hematoma with active

**Laceration:** parenchymal disruption involving 25–75% of a hepatic lobe or one to three Couinaud segments

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V **Laceration:** parenchymal disruption involving >75% of a hepatic lobe or more than three Couinaud segments

**Vascular:** juxtahepatic venous injuries (i.e., retrohepatic vena cava or central major hepatic veins)

spleen are more vigorous in children [27].

**Figure 3.** Grade III AAST liver injury, contrast enhanced CT image.

Splenic injuries are treated nonoperatively, by splenic repair, partial splenectomy, or resection, depending on the extent of the injury and the condition of the patient [25]. Enthusiasm for splenic salvage has been driven by the evolving trend toward nonoperative management of solid organ injuries, and the rare but often fatal complication of overwhelming postsplenectomy infection which is caused by encapsulated bacteria (e.g., *Haemophilus influenzae*, *Streptococcus pneumoniae*, *Neisseria meningitidis*) [26]. For this reason attempts to salvage the

Hilar injuries or pulverized splenic parenchyma are usually treated by splenectomy.

Injuries of the extrahepatic bile ducts are challenge. Because of the proximity of the portal vein, hepatic artery, and vena cava associated vascular injuries are common and the patient's physiologic status is often poor. Sometimes laparoscopic injuries may occur (**Table 4**).

Injuries of the hepatic ducts are almost impossible to satisfactorily repair under emergency circumstances. One approach is to intubate the duct for external drainage and attempt a repair when the patient recovers. Alternatively, the duct can be ligated if the opposite lobe is normal and uninjured (see also **Figure 4** for gallbladder injury).


**Table 3.** American Association for the Surgery of trauma liver injury scale.

**Figure 3.** Grade III AAST liver injury, contrast enhanced CT image.

### **6.3. Spleen injuries**

Most sources of venous hemorrhage within the liver can be managed with parenchymal sutures, and even injuries of the retrohepatic vena cava and hepatic veins have been success-

Venous hemorrhage due to penetrating wounds that transverse the central portion of the liver can be managed by suturing the entrance and exit wounds with horizontal mattress sutures. Although intrahepatic hematomas may form that can become infected, this may be preferable to an intracaval shunt or deep hepatotomy. Suturing of the hepatic parenchyma is not always

Hepatic arterial ligation may be appropriate for patients with recalcitrant arterial hemorrhage from deep within the liver. However, its utility is limited since hemorrhage from the portal and hepatic venous systems will continue. Arterial ligation is a reasonable alternative to a deep hepatotomy particularly in unstable patients [22]. While ligation of the right or left hepatic artery is well tolerated in humans, ligation of the proper hepatic artery is not necessar-

An uncommon but perplexing hepatic injury is the subcapsular hematoma. This lesion occurs when the parenchyma of the liver is disrupted by blunt trauma, but Glisson's capsule remains intact. The hematoma may be recognized either at the time of the surgery or preoperatively if a CT is performed. Regardless of how the lesion is diagnosed, subsequent decision making

Resectional debridement is indicated for the removal of peripheral portions of nonviable hepatic parenchyma. The mass of tissue removed should rarely exceed 25% of the liver. Since additional blood loss may occur, it should be reserved for patients who are in good metabolic

Omentum has been used to fill large defects in the liver. The rationale for this is that it provides an excellent source of macrophages and that it fills a potential dead space with a viable tissue. The omentum can also provide a little additional support for parenchymal sutures and

Since hemorrhage from hepatic injuries is often treated without identifying and controlling each individual bleeding vessel, arterial pseudoaneurysm may develop (**Table 3**). If the pseudoaneurysm enlarges, it will eventually rupture into the parenchyma of the liver, a bile duct,

Injuries of the gallbladder are treated by lateral suture or cholecystectomy, whichever is easier. Injuries of the extrahepatic bile ducts are challenge. Because of the proximity of the portal vein, hepatic artery, and vena cava associated vascular injuries are common and the patient's

Injuries of the hepatic ducts are almost impossible to satisfactorily repair under emergency circumstances. One approach is to intubate the duct for external drainage and attempt a repair when the patient recovers. Alternatively, the duct can be ligated if the opposite lobe is normal

physiologic status is often poor. Sometimes laparoscopic injuries may occur (**Table 4**).

is often strong enough to prevent them from cutting through Glisson's capsule [24].

fully tamponaded by closing the hepatic parenchyma over the bleeding vessel [20].

successful in controlling the hemorrhage particularly if it is of arterial origin [21].

ily associated with survival. The fate of the dearterialized lobe is unpredictable [23].

condition and who will tolerate additional blood loss.

or into adjacent portal venous branch (**Figure 3**).

**6.2. Gallbladder and extrahepatic bile ducts injuries**

and uninjured (see also **Figure 4** for gallbladder injury).

is often difficult.

84 Trauma Surgery

Splenic injuries are treated nonoperatively, by splenic repair, partial splenectomy, or resection, depending on the extent of the injury and the condition of the patient [25]. Enthusiasm for splenic salvage has been driven by the evolving trend toward nonoperative management of solid organ injuries, and the rare but often fatal complication of overwhelming postsplenectomy infection which is caused by encapsulated bacteria (e.g., *Haemophilus influenzae*, *Streptococcus pneumoniae*, *Neisseria meningitidis*) [26]. For this reason attempts to salvage the spleen are more vigorous in children [27].

Hilar injuries or pulverized splenic parenchyma are usually treated by splenectomy.


**Table 4.** Strasberg classification of laparoscopic bile duct injury.

**Figure 4.** Longitudinal section of gallbladder (ultrasound view), parietal thickening with multiple echogenic layers intermingled with fluid.

The failure rate of nonoperative management of splenic injuries in adults increases with grade of splenic injury; Grade I, 5%; Grade II, 10%; Grade III, 20%; Grade IV, 33%; and Grade V, 75% in adults but not in children. Most failures occur within 72 h of injury [29]. Patients with significant splenic injuries treated nonoperatively should be observed in a monitored unit and have immediate access to a CT scanner, a surgeon, and operating room [30]. Changes in physical examination, hemodynamic stability, ongoing blood, or fluid requirements indicate the need for laparotomy. Arteriography with embolization has been reported to increase the success rate [31].

**Figure 5.** Interrupted pledgeted sutures may effectively control hemorrhage from the cut edge of the spleen.

Diaphragmatic injuries are frequently difficult to detect initially.

**6.4. Diaphragm injuries**

**Grade Injury description**

I **Hematoma:** subcapsular, <10% of the surface area

**Laceration:** Capsular tear, <1 cm parenchymal depth

intraparenchymal hematoma >5 cm or expanding

**Vascular:** Hilar vascular injury that devascularizes spleen

**Table 5.** American Association for the Surgery of trauma spleen injury scale.

V **Laceration:** Completely shattered spleen

II **Hematoma:** subcapsular, 10–50% surface area, intraparenchymal, 5 cm in diameter **Laceration:** 1–3 cm parenchymal depth, trabecular vessels not involved

**Laceration:** >3 cm parenchymal depth or involving trabecular vessels

III **Hematoma:** subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma,

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IV **Laceration:** Involves segmental or hilar vessels producing major devascularization (>25% of spleen)

Splenectomy also indicates for lesser splenic injuries in patients who have developed a coagulopathy and have multiple abdominal injuries, and it is usually necessary in patients with failed splenic salvage attempts [28] (**Table 5**).

If splenectomy is performed, vaccines against the encapsulated bacteria are administered (**Figure 5**).


**Table 5.** American Association for the Surgery of trauma spleen injury scale.

**Figure 5.** Interrupted pledgeted sutures may effectively control hemorrhage from the cut edge of the spleen.

The failure rate of nonoperative management of splenic injuries in adults increases with grade of splenic injury; Grade I, 5%; Grade II, 10%; Grade III, 20%; Grade IV, 33%; and Grade V, 75% in adults but not in children. Most failures occur within 72 h of injury [29]. Patients with significant splenic injuries treated nonoperatively should be observed in a monitored unit and have immediate access to a CT scanner, a surgeon, and operating room [30]. Changes in physical examination, hemodynamic stability, ongoing blood, or fluid requirements indicate the need for laparotomy. Arteriography with embolization has been reported to increase the success rate [31].

### **6.4. Diaphragm injuries**

Splenectomy also indicates for lesser splenic injuries in patients who have developed a coagulopathy and have multiple abdominal injuries, and it is usually necessary in patients with

**Figure 4.** Longitudinal section of gallbladder (ultrasound view), parietal thickening with multiple echogenic layers

If splenectomy is performed, vaccines against the encapsulated bacteria are administered

failed splenic salvage attempts [28] (**Table 5**).

(**Figure 5**).

intermingled with fluid.

**Type Criteria**

86 Trauma Surgery

A Cystic duct leak or leak from small ducts in the liver bed

C Transection without ligation of an aberrant right hepatic duct

B Occlusion of an aberrant right hepatic duct

D Lateral injury to a major bile duct E1 Transection >2 cm from the hilum E2 Transection <2 cm from the hilum

E4 Separation of major ducts in the hilum E5 Type C injury plus injury in the hilum

**Table 4.** Strasberg classification of laparoscopic bile duct injury.

E3 Transection in the hilum

Diaphragmatic injuries are frequently difficult to detect initially.

The presence of abdominal contents in the thorax may not be obvious on initial chest X-ray. Insertion of a nasogastric tube may facilitate the diagnosis. However, diaphragmatic injuries may be missed even on initial CT scan (**Figures 6** and **7**).

Most duodenal hematomas in children can be managed nonoperatively with nasogastric suc-

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Duodenal perforations can be caused by both blunt and penetrating trauma. Blunt injuries are difficult to diagnose because the contents of the duodenum have a neutral pH, few bacteria, and are often contained by the retroperitoneum. Mortality may exceed 30% if the lesion is not

tion and parenteral nutrition.

identified and treated within 24 h.

V Massive disruption to pancreatic head

I Hematoma with minor contusion/laceration but without duct injury

IV Proximal laceration or parenchymal injury with injury to bile duct/ampulla

**Table 6.** American Association for Surgery in trauma pancreatic trauma grading system.

II Major contusion/laceration but without duct injury

III Distal laceration or parenchymal injury with duct injury

**Grade Pancreatic injury**

**Figure 8.** "Seat belt sign".

Laparoscopy has also been used to evaluate potential diaphragmatic injuries [32].

Undiagnosed diaphragmatic injuries are a significant cause of morbidity and mortality.

### **6.5. Duodenum injuries**

Duodenal hematomas are caused by a direct blow to the abdomen and occur more often in children than adults. Blood accumulates between the seromuscular and submucosal layers, eventually causing obstruction.

**Figure 6.** Hump sign of the diaphragmatic injury in CT scan (showed by arrows).

**Figure 7.** Band sign in diaphragmatic injury.

Most duodenal hematomas in children can be managed nonoperatively with nasogastric suction and parenteral nutrition.

Duodenal perforations can be caused by both blunt and penetrating trauma. Blunt injuries are difficult to diagnose because the contents of the duodenum have a neutral pH, few bacteria, and are often contained by the retroperitoneum. Mortality may exceed 30% if the lesion is not identified and treated within 24 h.


**Table 6.** American Association for Surgery in trauma pancreatic trauma grading system.

**Figure 8.** "Seat belt sign".

The presence of abdominal contents in the thorax may not be obvious on initial chest X-ray. Insertion of a nasogastric tube may facilitate the diagnosis. However, diaphragmatic injuries

Laparoscopy has also been used to evaluate potential diaphragmatic injuries [32].

Undiagnosed diaphragmatic injuries are a significant cause of morbidity and mortality.

Duodenal hematomas are caused by a direct blow to the abdomen and occur more often in children than adults. Blood accumulates between the seromuscular and submucosal layers,

may be missed even on initial CT scan (**Figures 6** and **7**).

**Figure 6.** Hump sign of the diaphragmatic injury in CT scan (showed by arrows).

**6.5. Duodenum injuries**

88 Trauma Surgery

eventually causing obstruction.

**Figure 7.** Band sign in diaphragmatic injury.
