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. 2020 Dec 30;51(4):e4134365. doi: 10.25100/cm.v51i4.4422.4365
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Damage Control in Penetrating Liver Trauma: Fear of the Unknown

Control de Daños en Trauma Hepático Penetrante: El Miedo a Lo Desconocido

Carlos A Ordoñez 1,2,3,✉, Michael W Parra 4, Mauricio Millán 3,5, Yaset Caicedo 6, Mónica Guzmán-Rodríguez 7, Natalia Padilla 6, Juan Carlos Salamea-Molina 8,9, Alberto García 1,2,3, Adolfo González-Hadad 2,10,11, Luis Fernando Pino 2,10, Mario Alain Herrera 2,10, Fernando Rodríguez-Holguín 1, José Julián Serna 1,2,3,10, Alexander Salcedo 1,2,3,10, Gonzalo Aristizábal 1, Claudia Orlas 12,13, Ricardo Ferrada 2,11, Thomas Scalea 14, Rao Ivatury 15
PMCID: PMC7968427  PMID: 33795903

Abstract

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Key words: REBOA, REBOVC, penetrating hemodynamically unstable liver trauma, blood loss Surgical, laparotomy, abdominal Injuries, liver, hospital emergency service, algorithms

Remark

1) Why was this study conducted?
The liver is the most commonly affected solid organ in cases of abdominal trauma. This article aims to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury.
2) What were the most relevant results of the study?
It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients
3) What do these results contribute?
To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.
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Introduction

The liver is the most commonly affected solid organ in cases of abdominal trauma 1 . Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of Damage Control Surgery (DCS) accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible Computed Tomography (CT) as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management (NOM) in hemodynamically stable trauma victims with liver injuries 2 , 3 . However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage 4 , 5 . Even to this day in age, these injuries create a sense of fear among the treating surgical staff mostly based on their own personal inexperience: “To fear is to fear the unknown.” The aim of this article is to reduce this fear by performing an extensive review of the literature and proposing a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus from the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia.

This article is a consensus that synthesizes the experience earned during the past 30 years in trauma critical care management of the severely injured patient from the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia which is made up of experts from the University Hospital Fundación Valle del Lili, the University Hospital del Valle "Evaristo García", the Universidad del Valle and Universidad Icesi, the Asociación Colombiana de Cirugia, the Pan-American Trauma Society and the collaboration of national and international specialists of the United States of America and Latin America.

Liver Trauma

Liver injury occurs mainly in males under the age of 40 and worldwide the most common mechanism is blunt trauma which accounts for more than two-thirds of them 6 - 8 . In Latin-America however, the most common mechanism of liver trauma is penetrating injury (62%) and in Colombia the most common penetrating mechanism is gunshot wounds (88.64%), followed by stab wounds (11.36%) 1 . We have also found that 60% of patients who have penetrating liver trauma have a severe injury that requires complex surgical repair (AAST Grades III-V) (Table 1) 9 , 10 . Approximately 86% of these patients have concomitant intra-abdominal injuries which include the colon (34%), followed by the stomach and duodenum (30%) 6 . Overall mortality ranges between 22% - 66% and factors such as age over 65 and low socio-economic status are associated with higher mortality rates 1 , 6 , 8 , 11 .

Table 1. The American Association for the Surgery of Trauma (AAST) Classification of Liver Injury 10 .

Grade Description
I Subcapsular hematoma <10% surface area
Parenchymal laceration <1 cm depth
Capsular tear
II Subcapsular hematoma 10-50% surface area; intraparenchymal hematoma < 10 cm in diameter
Laceration 1-3 cm in depth and ≤10 cm length
III Subcapsular hematoma >50% surface area; ruptured subcapsular or intraparenchymal hematoma
Intraparenchymal hematoma >10 cm
Laceration >3 cm depth with active bleeding.
IV Parenchymal disruption involving 25-75% of a hepatic lobe or liver injury that involving 1-3 liver segments with active bleeding
V Parenchymal disruption >75% of hepatic lobe or more than 3 liver segments
Juxtahepatic venous injury to include retrohepatic vena cava and central major hepatic veins
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The high rate of liver injury in cases of abdominal trauma can be explained by the location of the organ and its size. Penetrating injuries to the liver can cause severe hemorrhage that requires early surgical intervention, in which a rapid control of the source of bleeding should be achieved given that hemorrhage is the main cause of death in these patients 12 , 13 . Inadequate or delayed control of ongoing surgical hemorrhage can lead to the lethal diamond of hypothermia, coagulopathy, acidosis, and hypocalcemia. This is why patients require correction of these parameters via damage control resuscitation (DCR) and rewarming in the intensive care unit (ICU) prior to definitive surgical repair.

Initial Approach and Diagnosis

Liver trauma management in hemodynamically stable patients has rapidly evolved and NOM is currently the standard of care when feasible. Up to 33% of cases of penetrating liver trauma can be treated with NOM and close ICU surveillance 3 , 7 . But such care is not indicated in patients who arrive to the Emergency Department (ED) hemodynamically unstable (Systolic Blood Pressure (SBP) <90 mmHg), those who are not responders to initial resuscitation and/or have positive peritoneal signs on initial examination. These patients should undergo immediate stabilization according to ATLS guidelines, follow DCR principles, and require surgical intervention 14 .

Surgical Management of Hemodynamically Unstable Penetrating Liver Injuries

DCS has been proposed as the standard of care for cases of severe liver trauma with hemodynamic instability that require initial operative management, which consists of an abbreviated laparotomy, liberal use of the Pringle Maneuver, an effective peri-hepatic packing, intra-hepatic selective vessel ligation (SVL), routine use of angiography for possible embolization and early ICU transfer for correction of patient’s physiology abnormalities 15 , 16 . We prospectively evaluated patients with penetrating liver trauma and found that 77% (68) received DCS with an overall mortality of 15.9%. In our review of these cases, we discovered that there were no clear-cut indications or consensus on their management and steps to follow 9 , 17 .

Herein, based on our experience and with the consensus of leading experts in trauma care we propose a new algorithm for the management of penetrating liver trauma patient that arrives hemodynamically unstable ( Figure 1 ):

Figure 1. Surgical Management of Hemodynamically Unstable Penetrating Liver Trauma.

Figure 1

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  • STEP 1: Massive transfusion protocol (MTP) is activated, an introducer sheath is inserted via the common femoral artery and a high flow venous catheter is placed via the common femoral vein. This can be done in the ED and/or in the operating room (OR).

  • STEP 2: An exploratory laparotomy is performed immediately; the hemoperitoneum is evacuated, quantified, and auto-transfused when possible, followed by a systematic four-quadrant abdominal cavity packing. Time is given to the anesthesiologist for DCR via the previously activated MTP. Systematic four-quadrant unpacking leaving the right upper quadrant last. A direct exam of the liver is performed to identify if the injury is simple (AAST Grade I-II) or complex (AAST Grade III-V) (Table 1). If the liver injury is simple without active bleeding then perform direct compression, apply topical hemostatic agents and/or perform simple primary suture repair (hepatorrhaphy). Even simple liver lacerations may require direct selective intra-hepatic vessel and/or peripheral bile duct ligation.

  • STEP 3: Complex liver injuries with active bleeding require direct packing of the injury site alongside peri-hepatic packing. If the bleeding stops, then complete DCS and leave the patient packed. The patient should immediately undergo a liver angiogram in the angio/hybrid room to further delineate any ongoing surgical bleeding that if present should be managed with selective endovascular angioembolization. The patient should then be transferred to the ICU to complete DCR, rewarming, acid-base, coagulopathy, and hypocalcemia correction.

  • STEP 4: If bleeding persists then a Pringle Maneuver should be performed and time is given to the anesthesiologist to catch up and achieve DCR.
    • If the bleeding is controlled and the patient regains hemodynamic stability, then the wound should be unpacked and selective vessel and/or peripheral bile duct ligation of the exposed liver laceration should be performed. Once this is done then the Pringle should be removed and the repair re-examined to rule out any ongoing surgical bleeding.
    • If ongoing surgical bleeding is present, then the Pringle Maneuver should be reapplied and the suture ligation of the bleeding vessel performed. This step can be repeated as needed notwithstanding that the Pringle Maneuver should not be in place more than 30 minutes at any given continuous time span. The patient should then be re-packed and DCS completed.
    • All patients should undergo a liver angiogram in the angio/hybrid room to further delineate any ongoing surgical bleeding that if present should be managed with selective endovascular angioembolization. The patient should then be transferred to the ICU to complete DCR, rewarming, acid-base, coagulopathy and hypocalcemia correction.

  • STEP 5: If despite intra and peri-hepatic packing and a Pringle Maneuver in place, there is still active surgical bleeding from the liver then the placement and inflation of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter in Zone I should be considered via the previously placed femoral arterial line. Simultaneously, the large high flow femoral venous catheter should be exchanged over a guidewire for an introducer sheath with the aim of floating up and inflating a Resuscitative Endovascular Balloon Occlusion of the Vena Cava (REBOVC) at the level of the retrohepatic vena cava with the goal of achieving proximal and distal vascular control of a possible retro/suprahepatic vessel injury.

  • STEP 6: Once placement confirmation of both the REBOA and the REBOVC has been achieved (Figure 2) then unpacking of the liver with selective ligation of all mayor intra-hepatic and/or suprahepatic bleeding vessels should be done. If surgical bleeding control is achieved, then re-pack the liver, remove the REBOA/REBOVC re-confirming control of hemorrhage and complete DCS. The patient should undergo a liver angiogram in the angio/hybrid room to further delineate any ongoing surgical bleeding that if present should be managed with selective endovascular angioembolization. The patient should then be transferred to the ICU to complete DCR, rewarming, acid-base, coagulopathy, and hypocalcemia correction.

  • STEP 7: If surgical bleeding is not achieved then the source is an injury of the retrohepatic vena cava and a right medial visceral rotation of the liver is required to expose and repair the injury. If surgical bleeding control is achieved, then re-pack the liver, remove the REBOA/REBOVC re-confirming control of hemorrhage and complete DCS. The patient should undergo a liver angiogram in the angio/hybrid room to further delineate any ongoing surgical bleeding that if present should be managed with selective endovascular angioembolization. The patient should then be transferred to the ICU to complete DCR, rewarming, acid-base, coagulopathy, and hypocalcemia correction.

  • STEP 8: Once the patient has been adequately resuscitated in the ICU (between 24-72 hours), then the patient should be taken back to the OR for packing removal, abdominal washout and definitive abdominal wall closure. If the patient suffered sustained any associated bowel injuries that were initially managed by resection and left in discontinuity then bowel continuity should be restored at this time if feasible. If liver bleeding ensues then follow Steps 1-7 again until control of surgical bleeding has been achieved.

Figure 2. (A) Complex Penetrating Liver Injury; (B) Combined Open and Endovascular Liver Isolation with REBOA, REBOVC and Pringle Maneuver. The open and endovascular liver isolation is achieved performing the REBOA in Zone 1 and REBOVC at the level of the retrohepatic vena cava with the goal of achieving proximal and distal vascular control of a possible retro/suprahepatic vessel injury. The Pringle maneuver is obtained via the hepatoduodenal ligament clamping.

Figure 2

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Discussion

A consensus on the management of penetrating liver trauma with hemodynamic instability is critical due to its high mortality rate and the different approaches to resolve them among surgeons throughout the world. The later has hindered the decision-making process of many physicians when confronted with these scenarios 18 , 19 . We propose a new clear management algorithm in which damage control strategies have been included and we introduce the use of REBOA and REBOVC as adjuvants for hemorrhage control.

Mortality rates of severe liver injuries can be up to 70%, and the main determinants of outcome are initial pH, base deficit, intraoperative blood loss and post-traumatic coagulopathy 11 , 16 , 20 . This explains the need for early activation of an institutional MTP in these cases to effectively stabilize the patient. Current surgical management of liver hemorrhage is based on direct pressure, packing of the wound, the Pringle Maneuver; hepatorrhaphy, selective vessel ligation, leaving the abdomen open and completion of DCR in the ICU 21 . It is also important to reiterate the importance of not removing the abdominal packing prior to the initial 24 hours of DCS given the high incidence of rebleeding which is three times higher than those patients in which packing was removed after the first 24 hours from their initial laparotomy 22 , 23 .

REBOA has emerged as a useful tool to temporarily stop the bleeding in cases of Non-Compressible Torso Hemorrhage (NCTH). The REBOA allows not only proximal control of the source of hemorrhage but also promotes the perfusion of vital organs including the heart and brain 24 . The concomitant use of REBOVC along with a REBOA and a Pringle Maneuver has been previously described in the literature to facilitate a combined endovascular and open isolation of the liver in cases of severe penetrating liver injuries with ongoing hemorrhage 21 , 15 - 27 . Recently, this proposal of penetrating liver trauma was included in the guideline of liver trauma by the World Society of Emergency Surgery (WSES) 27 . Colombia has evolved to become one of the world leaders in the use of REBOA especially regarding its use in penetrating trauma 28 - 31 .

Conclusion

It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional MTP, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Acknowledge:

Thanks for the illustrations and the design of the cover to the Anatomical Draftsman Fabian R. Cabrera P. Professor of the Design Department of the Faculty of Integrated Arts of the Universidad del Valle

References

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Colomb Med (Cali). 2020 Dec 30;51(4):e4134365. [Article in Spanish]

Control de Daños en Trauma Hepático Penetrante: El Miedo a Lo Desconocido

Contribución del estudio

1) ¿Por qué se realizó este estudio?
El hígado es el órgano solido más comúnmente lesionado en casos de trauma abdominal. El objetivo de este artículo es proponer un algoritmo de manejo acerca del abordaje de los pacientes hemodinámicamente inestables con trauma hepático penetrante.
2) ¿Cuáles fueron los resultados más relevantes del estudio?
El manejo debe ser por parte de un equipo multidisciplinario que comienza desde la evaluación inicial de los pacientes, la activación temprana de protocolo de transfusión masiva y el control temprano de la hemorragia, siendo estos aspectos esenciales para disminuir la mortalidad
3¿Qué aportan estos resultados?
El miedo a lo desconocido es el dilema quirúrgico donde existen pocas opciones y es imperante decisiones rápidas y oportunas; por esta razón, se propone dar una luz de guía sobre lo desconocido respecto al manejo del paciente con trauma hepático severo.
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Introducción

En los casos de trauma abdominal penetrante, el hígado es el órgano más frecuentemente lesionado, y su manejo un dilema para el cirujano de trauma 1. La introducción de nuevas técnicas quirúrgicas y los avances en las imágenes diagnósticas se han implementado en los nuevos algoritmos para el manejo de este grupo de pacientes. El uso de la tomografía axial computarizada (TAC) en pacientes hemodinámicamente estables permite una adecuada estratificación de las heridas hepáticas con el fin de determinar los pacientes que se beneficiarían de un manejo no quirúrgico 2,3. Los pacientes hemodinámicamente inestables requieren de intervenciones quirúrgicas inmediatas para controlar el sangrado y disminuir la morbimortalidad 4,5. Sin embargo, el trauma hepático severo crea una sensación de miedo entre el equipo quirúrgico basado en su propia experiencia: “El miedo a lo desconocido”. Es por esto por lo que el objetivo de este artículo es proponer un algoritmo de manejo para pacientes con trauma hepático penetrante e inestabilidad hemodinámica.

El presente artículo es un consenso que sintetiza la experiencia adquirida durante los últimos 30 años en el manejo de la cirugía de trauma y emergencias, cirugía general y cuidado crítico del grupo de cirugía de Trauma y Emergencias (CTE) de Cali, Colombia conformado por expertos de Hospital Universitario Fundación Valle del Lili y el Hospital Universitario del Valle “Evaristo García”, con la Universidad del Valle y la Universidad Icesi, en colaboración con la Asociación Colombiana de Cirugía y la Sociedad Panamericana de Trauma y en conjunto con especialistas nacionales e internacionales de Estados Unidos.

Trauma hepático

El trauma hepático es más frecuente en hombres menores de 40 años asociado a un trauma cerrado 6-8. En América Latina, el mecanismo de trauma penetrante tiene una prevalencia hasta el 62% de los casos. De estas, el trauma penetrante como heridas por arma de fuego tienen una proporción del 89% y las heridas por arma cortopunzante, el y 11%, Las lesiones complejas del hígado Grado III y IV según la clasificación de la Asociación Americana de Cirugía de Trauma (American Association for the Surgery of Trauma - AAST) (Tabla 1) 9,10. Se estima que el 86% de los pacientes con trauma penetrante a hígado presentan heridas de otros organos intra-abdominales concomitantes: colon (34%), estómago y duodeno (30%), con una mortalidad global del 22 al 66% 1,6,8,11.

Tabla 1. Clasificación de la asociación americana de cirugía de trauma (American Association for the Surgery of Trauma - AAST) de las lesiones hepáticas 10 .

Grado Descripción
I Hematoma subcapsular < 10% del área de superficie
Laceración del parénquima < 1 cm de profundidad
Desgarro Capsular
II Hematoma subcapsular 10-50% del área de superficie; hematoma intraparenquimatoso < 10 cm de diámetro
Laceración de 1-3 cm de profundidad y ≤ 10 cm de largo
III Hematoma subcapsular >50% del área de superficie; ruptura subcapsular o hematoma intraparenquimatoso
Hematoma intraparenquimatoso >10 cm
Laceración >3 cm de profundidad, con sangrado activo
IV Desgarro del parénquima del 25-75% del lóbulo hepático. 1-3 segmentos, con sangrado activo.
V Desgarro del parénquima >75% del lóbulo hepático. Mas de tres segmentos
Lesiones venosas juxtahepáticas incluyendo la vena cava retrohepática y las venas hepáticas centrales
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La frecuencia de las lesiones hepáticas en casos de trauma abdominal puede explicarse debido a la localización y el tamaño de este órgano. Las heridas penetrantes de hígado pueden ocasionar hemorragias severas que desencadenan el rombo de la muerte, hipotermia, coagulopatía, acidosis e hipocalcemia culminando en la muerte 12,13. Razón por la cual, a la llegada del paciente al servicio de urgencias es de vital importancia iniciar inmediatamente la resucitación de control de daños seguida a una intervención quirúrgica temprana donde se busca lograr un rápido control del sangrado.

Abordaje inicial y diagnóstico

el manejo no quirúrgico es la técnica estándar en pacientes con trauma hepático penetrante y estabilidad hemodinámica, que alcanza más del 33% de evolución clínica satisfactoria 3,7. Sin embargo, en pacientes con inestabilidad hemodinámica (presión arterial sistólica < 90 mmHg) y/o con signos de irritación peritoneal se deben aplicar los principios del manual de soporte vital avanzado en trauma (Advanced Trauma Life Support - ATLS) y de la resucitación de control de daños requiriendo una intervención quirúrgica temprana 14.

Manejo quirúrgico del trauma hepático penetrante con inestabilidad hemodinámica

La cirugía de control de daños ha sido propuesta como el estándar de manejo quirúrgico en casos de trauma hepático con inestabilidad hemodinámica e indicación de intervención quirúrgica inicial. La cirugía de control de daños consiste en la realización de una laparotomía abreviada con empaquetamiento perihepático, maniobra de Pringle (clampaje completo y en bloque del hilio hepático) y ligadura selectiva de vasos intrahepáticos. Posteriormente, el paciente debe ser llevado a angiografía con disponibilidad de embolización y finalmente se traslada a la unidad de cuidados intensivos para continuar con la corrección de los parámetros fisiológicos por medio de la resucitación de control de daños 15,16. En un estudio prospectivo que incluyeron pacientes con trauma hepático penetrante e inestabilidad hemodinámica, se halló que el 77% (68) requirieron cirugía de control de daños con una mortalidad global del 15.9%. Con este estudio se observó la necesidad de un algoritmo para el enfoque de este grupo de pacientes 9,17; por lo que, basados en nuestra experiencia y en el consenso realizado entre expertos del área, proponemos un nuevo algoritmo para el manejo de trauma hepático penetrante asociado a inestabilidad hemodinámica (Figura 1).

Figura 1. Algoritmo de manejo del trauma hepático penetrante con inestabilidad hemodinámica.

Figura 1

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  • PASO 1: Activar el protocolo de transfusión masiva institucional e insertar un introductor en la arteria femoral común y un catéter venoso de alto flujo en la vena femoral común. Esto puede realizarse en el servicio de urgencias o en el quirófano.

  • PASO 2: Se debe realizar de forma inmediata una laparotomía exploratoria, en la cual se evacúa el hemoperitoneo, con cuantificación y autotransfusión, cuando que sea posible, y posterior empaquetamiento sistemático de los cuatro cuadrantes. Esta medida le dará tiempo para que el anestesiólogo continúe con la resucitación de control de daños previamente iniciada. En seguida se realiza el desempaquetamiento de los cuatro cuadrantes, dejando por último el cuadrante superior derecho para una evaluación directa del hígado con el fin de lograr una adecuada clasificación de la lesión: simple (Grado I-II AAST) o compleja (Grado III-V AAST) (Tabla 1). Si la lesión hepática es simple y no presenta sangrado activo, se hace compresión directa, se aplican agentes hemostáticos directamente en la lesión y/o se realiza reparo primario de la herida con sutura simple (hepatorrafia). Algunas de estas laceraciones pueden requerir de la ligadura selectiva de los vasos intrahepáticos y/o de los conductos biliares periféricos.

  • PASO 3: Si la lesión hepática es compleja y se presenta con sangrado activo, se requiere empaquetamiento perihepático y directo de la lesión. Cuando el sangrado se detenga se debe completar la cirugía de control de daños y se realiza una angiografía con el fin de identificar cualquier fuente de sangrado activo para hacer una embolización endovascular selectiva en el mismo procedimiento. Posteriormente, el paciente se trasladará a la unidad de cuidados intensivos para continuar con la resucitación de control de daños con medidas de corrección de la acidosis, la coagulopatía, la hipotermia y la hipocalcemia.

  • PASO 4: Si el sangrado persiste se debe realizar la maniobra de Pringle.
    • Cuando el sangrado se detenga y se logre estabilizar hemodinámicamente, el paciente se desempaqueta y se ligan selectivamente los vasos intrahepáticos y/o los conductos biliares periféricos. Se suspende la maniobra de Pringle y se verifica el control del sangrado.
    • En el caso de persistir el sangrado, se realiza nuevamente la maniobra de Pringle seguido de la ligadura del vaso sangrante. Este paso puede ser repetido cuantas veces sea necesario, teniendo en cuenta que la maniobra de Pringle no debe instaurarse por más de 30 minutos continuos. Si el sangrado se detiene, se re-empaqueta y se completa la cirugía de control de daños. Se debe realizar una angiografía como se describe en el paso 3

  • PASO 5: Cuando el sangrado persiste a pesar del uso del empaquetamiento intra y perihepático y de la maniobra de Pringle, se debe considerar la colocación de un balón de reanimación endovascular de aorta (Resuscitative Balloon Occlusion of the Aorta - REBOA) en la zona I. Simultáneamente, el catéter de alto flujo venoso debe ser cambiado por un introductor con el fin de avanzar un balón de reanimación endovascular de la vena cava (REBOVC) a nivel retrohepático. (Figura 2) El objetivo es disminuir el flujo vascular proximal y distal controlando el sangrado y permitiendo la exploración de los vasos retro o suprahépaticos para descartar lesión

  • PASO 6: Una vez colocado el REBOA y el REBOVC, se desempaqueta y se ligan selectivamente los vasos intra y/o suprahepáticos. Si el sangrado se detiene, se reempaqueta, se retira el REBOA y el REBOVC, se verifica la hemostasia y se completa la cirugía de control de daños. Se debe realizar una angiografía, igual que lo descrito en el paso 3.

  • PASO 7: Si persiste el sangrado, se debe considerar que la fuente está en la vena cava retro-hepática. Se debe realizar una rotación medial del hígado para exponer y reparar cualquier lesión. Si el sangrado se detiene, se re-empaqueta, se retira el REBOA yel REBOVC, se verifica el control del sangrado y se completa la cirugía de control de daños. Se debe realizar una angiografía, igual que lo descrito en el paso 3.

  • PASO 8: Entre 24 a 72 horas posteriores, una vez en el paciente se hayan corregido los parámetros fisiológicos por medio de la resucitación de control de daños, en el quirófano se desempaqueta, se hace lavado abdominal y cierre definitivo de la pared abdominal. Si el paciente sufrió lesiones intestinales asociadas que inicialmente fueron resecadas y dejadas en discontinuidad, se busca reestablecer su continuidad en lo posible. Si persiste el sangrado, se repiten los pasos 1 a 7 hasta lograr el control.

Figura 2. (A) Trauma hepático penetrante complejo; (B) Aislamiento hepático endovascular y abierto con REBOA, REBOVC y maniobra de Pringle. El aislamiento hepático endovascular y abierto se logra inflando el REBOA en la Zona 1 entre la arteria subclavia izquierda y el tronco celiaco y el REBOVC debe desplegarse por encima del origen de la vena suprahepática. El aislamiento abierto se logra realizando la maniobra de Pringle realizando un clampeo del hilio hepático. Esta maniobra no puede superar más de 30 minutos por el riesgo de lesión por isquemia.

Figura 2

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Discusión

Un consenso sobre el manejo de trauma hepático penetrante con inestabilidad hemodinámica es necesario debido a la alta mortalidad y a los posibles abordajes entre cirujanos alrededor del mundo 18,19. Nuestro objetivo es proponer un nuevo algoritmo de manejo para este grupo de pacientes, en que se incluyan los principios de control de daños conjunto con el uso del REBOA, del REBOVC y de la maniobra de Pringle. Las heridas complejas de hígado alcanzan una mortalidad hasta del 70% y sus principales determinantes son el pH sanguíneo inicial, el déficit de la base, la pérdida de sangre intraoperatoria y la coagulopatía postraumática 11,16,20. Por esta razón, a la llegada del paciente al servicio de urgencias se debe activar inmediatamente el protocolo de transfusión masiva institucional con el objetivo de iniciar la resucitación de control de daños y lograr una adecuada estabilización. En la actualidad, el enfoque de manejo quirúrgico para este grupo de pacientes incluye solamente la compresión directa de la herida con empaquetamiento, maniobra de Pringle, hepatorrafía, ligadura selectiva de vasos intrahepáticos, abdomen abierto y resucitación de control de daños en la unidad de cuidados intensivos 21. El empaquetamiento abdominal debe permanecer durante por lo menos 24 horas después de la primera intervención quirúrgica, de lo contrario puede aumentar hasta tres veces el riesgo del resangrado 22,23.

El REBOA ha surgido como una técnica útil que permite temporalmente el control proximal de la hemorragia y simultáneamente promueve la perfusión de órganos vitales como corazón y cerebro 24. El uso concomitante del REBOA,el REBOVC y la maniobra de Pringle ya ha sido descrito en el manejo de pacientes con lesiones complejas del hígado y sangrado quirúrgico activo logrando un aislamiento hepático endovascular y abierto 21,25-27. Nuestro grupo de Cali, Colombia decide entonces incluir estas estrategias en un algoritmo de manejo basado en nuestra experiencia sobre el uso del REBOA en el trauma penetrante 28-31.

Conclusión

Es importante establecer un enfoque multidisciplinario en el manejo de los pacientes con trauma hepático penetrante asociado a inestabilidad hemodinámica entre los equipos de anestesiología, cuidado intensivo, radiología y cirugía de trauma y emergencias. Una evaluación inicial cuidadosa, la activación temprana del protocolo de transfusión masiva institucional y un rápido control de la hemorragia son medidas esenciales para disminuir la mortalidad en este grupo de pacientes., por lo tanto, con el algoritmo propuesto buscamos crear un camino dentro del manejo de pacientes con trauma hepático complejo para disminuir el miedo a lo desconocido.

Agradecimientos:

Por las ilustraciones y el diseño de la portada al Dibujante Anatómico Fabian R. Cabrera P. Docente del Dpto de Diseño de la Facultad de Artes Integradas de la Universidad del Valle

Articles from Colombia Médica : CM are provided here courtesy of Universidad del Valle

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