Operative Management of Portal Vein/SMV Trauma: Can We Just Ligate
Case Scenario:
A 21-year-old male presented to the emergency department after he was stabbed in the abdomen. On examination, his vital signs were significant for a systolic blood pressure of 70 mmHg, heart rate of 120 beats per minute, and a right upper quadrant stab wound. Given the concern for intra-abdominal bleeding, he was taken to operating room for exploratory laparotomy. The patient had a large right zone 1 retroperitoneal hematoma. The hematoma was entered after obtaining supraceliac aortic control. There was a traumatic transection of the body of pancreas and laceration of the mid-portal vein in the hepatoduodenal ligament.
Portal Vein Injury
The portal vein is …show more content…
The portal triad is typically approached from the right. A wide Kocher maneuver is performed to mobilize the duodenum and head of the pancreas. The ascending colon and hepatic flexure are mobilized with right medial visceral rotation. The duodenum and right colon are reflected to the left to expose the retro-pancreatic or supra-pancreatic portal vein. Occasionally, we enter the lesser sac and divide the neck of pancreas if exposure of more distal portal vein is required. Control of bleeding from portal vein can be technically challenging. Pringle maneuver with compression of the portal triad is usually helpful to allow temporary control of bleeding. Supraceliac aortic control might be necessary if there is significant bleeding despite the occlusion of the portal triad. Direct control of bleeding with manual compression or sponge stick is also useful to allow visualization. The vein edges can be carefully grasped with Judd-Allis clamp if visualization is possible. Indiscriminate clamping should be avoided due to risk of injury to other portal triad structures. If the injury is at the mid-portal vein in the hepatoduodenal ligament, clamps can be placed on the vein proximal and distal to the
Case Scenario:
A 21-year-old male presented to the emergency department after he was stabbed in the abdomen. On examination, his vital signs were significant for a systolic blood pressure of 70 mmHg, heart rate of 120 beats per minute, and a right upper quadrant stab wound. Given the concern for intra-abdominal bleeding, he was taken to operating room for exploratory laparotomy. The patient had a large right zone 1 retroperitoneal hematoma. The hematoma was entered after obtaining supraceliac aortic control. There was a traumatic transection of the body of pancreas and laceration of the mid-portal vein in the hepatoduodenal ligament.
Portal Vein Injury
The portal vein is …show more content…
The portal triad is typically approached from the right. A wide Kocher maneuver is performed to mobilize the duodenum and head of the pancreas. The ascending colon and hepatic flexure are mobilized with right medial visceral rotation. The duodenum and right colon are reflected to the left to expose the retro-pancreatic or supra-pancreatic portal vein. Occasionally, we enter the lesser sac and divide the neck of pancreas if exposure of more distal portal vein is required. Control of bleeding from portal vein can be technically challenging. Pringle maneuver with compression of the portal triad is usually helpful to allow temporary control of bleeding. Supraceliac aortic control might be necessary if there is significant bleeding despite the occlusion of the portal triad. Direct control of bleeding with manual compression or sponge stick is also useful to allow visualization. The vein edges can be carefully grasped with Judd-Allis clamp if visualization is possible. Indiscriminate clamping should be avoided due to risk of injury to other portal triad structures. If the injury is at the mid-portal vein in the hepatoduodenal ligament, clamps can be placed on the vein proximal and distal to the