Abbreviated laparotomy or damage control laparotomy: Why, when and how to do it?

The goal of abbreviated laparotomy is to treat severely injured patients whose condition requires an immediate surgical operation but for whom a prolonged procedure would worsen physiological impairment and metabolic failure. Indeed, in severely injured patients, blood loss and tissue injuries enhance the onset of the "bloody vicious circle", triggered by the triad of acidosis-hypothermia-coagulopathy. Abbreviated laparotomy is a surgical strategy that forgoes the completeness of operation in favor of a physiological approach, the overriding preference going to rapidity and limiting the procedure to control the injuries. Management is based on sequential association of the shortest possible preoperative resuscitation with surgery limited to essential steps to control injury (stop the bleeding and contamination), without definitive repair. The latter will be ensured during a scheduled re-operation after a period of resuscitation aiming to correct physiological abnormalities induced by the trauma and its treatment. This strategy necessitates a pre-defined plan and involvement of the entire medical and nursing staff to reduce time loss to a strict minimum.

Management of pancreatic trauma

INTRODUCTION

Pancreatic trauma (PT) is associated with high morbidity and mortality; the therapeutic options remain debated.

MATERIAL AND METHODS

Retrospective study of PT treated in the University Hospital of Grenoble over a 22-year span. The decision for initial laparotomy depended on hemodynamic status as well as on associated lesions. Main pancreatic duct lesions were always searched for. PT lesions were graded according to the AAST classification.

RESULTS

Of a total of 46 PT, 34 were grades II or I. Hemodynamic instability led to immediate laparotomy in 18 patients, for whom treatment was always drainage of the pancreatic bed; morbidity was 30%. Eight patients had grade III injuries, six of whom underwent immediate operation: three underwent splenopancreatectomy without any major complications while the other three who had simple drainage required re-operation for peritonitis, with one death related to pancreatic complications. Four patients had grades IV or V PT: two pancreatoduodenectomies were performed, with no major complication, while one patient underwent duodenal reconstruction with pancreatic drainage, complicated by pancreatic and duodenal fistula requiring a hospital stay of two months. The post-trauma course was complicated for all patients with main pancreatic duct involvement. Our outcomes were similar to those found in the literature.

CONCLUSION

In patients with distal PT and main pancreatic duct involvement, simple drainage is associated with high morbidity and mortality. For proximal PT, the therapeutic options of drainage versus pancreatoduodenectomy must be weighed; pancreatoduodenectomy may be unavoidable when the duodenum is injured as well. Two-stage (resection first, reconstruction later) could be an effective alternative in the emergency setting when there are other associated traumatic lesions.

Hepatic artery ligation for arterial rupture following liver transplantation: a reasonable option

Hepatic artery (HA) rupture after liver transplantation is a rare complication with high mortality. This study aimed to review the different managements of HA rupture and their results. From 1997 to 2007, data from six transplant centers were reviewed. Of 2649 recipients, 17 (0.64%) presented with HA rupture 29 days (2-92) after transplantation. Initial management was HA ligation in 10 patients, reanastomosis in three, aorto-hepatic grafting in two and percutaneous arterial embolization in one. One patient died before any treatment could be initiated. Concomitant biliary leak was present in seven patients and could be subsequently treated by percutaneous and/or endoscopic approaches in four patients. Early mortality was not observed in patients with HA ligation and occurred in 83% of patients receiving any other treatment. After a median follow-up of 70 months, 10 patients died (4 after retransplantation), and 7 patients were alive without retransplantation (including 6 with HA ligation). HA ligation was associated with better 3-year survival (80% vs. 14%; p=0.002). Despite its potential consequences on the biliary tract, HA ligation should be considered as a reasonable option in the initial management for HA rupture after liver transplantation. Unexpectedly, retransplantation was not always necessary after HA ligation in this series.

La laparotomie écourtée pour le traitement des traumatismes abdominaux sévères

On critically injured patient the decision to perform a damage control laparotomy is based on the volume of transfusion and shock. The aim of the surgery which is to obtain as fast as possible the best hemostasis to limit the peritoneal thermal loss and to perform as soon as possible physiologic restoration in the Intensive Care Unit.

Traumatismes du pancréas

If an emergency laparotomy is necessary, a damage control laparotomy may be useful. If during the laparotomy the hemodynamic is stabilised, the severity is depending on the existence of a ductal injury and an associated duodenal lesion. Surgical indications and techniques are described in these different cases. If no laparotomy, the location and type of injury is assessed by CT scan, magnetic resonance cholangiopancreatography or ERCP. Injury of the pancreatic duct is the main part of prognosis and indications. The non operative treatment in case of ductal injury remains controversial.

Nonoperative management of blunt hepatic trauma

Over the past 15 years, there have been dramatic changes in the management of blunt hepatic trauma, specifically in the imaging techniques, and in the non-operative management. Actually, in more than 80% of blunt hepatic trauma, non operative management is used. In the last 20% the surgical option has to be taken without delay, sometimes in extreme emergency, using the adapted surgical techniques. In this article the author describes the nonoperative management of blunt hepatic trauma: classification, presentation, initial decision, treatment, possible complications and results.

[Radiofrequency ablation of malignant hepatic tumors. Preliminary experience apropos of 25 cases]

STUDY AIM

Radiofrequency (RF) ablation of malignant hepatic tumors is an interesting and recent technique which offers new treatment possibilities. In this study, the preliminary findings have been reported on 25 patients with hepatic tumors who received RF treatment between January 1998 and February 2000.

PATIENTS AND METHODS

Twenty-five patients (11 cases of hepatocellular carcinoma, HCC; and 14 cases of liver metastases, LM) underwent RF treatment. Thirty tumors (range: 10 to 54 mm in diameter) out of a total of 63 were destroyed by RF: 13 HCC (average diameter: 32 mm) and 17 LM (average diameter: 26 mm). Treatment consisted of six percutaneous and 19 surgical RF procedures. In the surgical group, there were 11 cases of hepatectomy: right hepatectomy in five patients with segment IV enlargement in one case, and sub-segmentectomy in six other patients. In all cases, hepatic tomodensitometry was performed at one month post-treatment and then every three months.

RESULTS

Postoperative portal thrombosis occurred in two patients, one of whom died. Other postoperative complications were observed in five patients. During the mean follow-up period of 14 months (range: 2 to 28 months), two patients died (carcinosis, ascitic decompensation), two and four months respectively after RF treatment. In situ recurrence occurred in four HCC and two LM patients. Three HCC and four LM patients developed new hepatic or extra-hepatic lesions.

CONCLUSION

RF is a particularly interesting technique for the treatment of bilobar or unresectable metastases. It appears to be equally as efficient as other local treatments for small-sized HCC. However, technical improvements remain necessary to increase the destructive field covered by RF. A more important follow-up is needed so that the long-term efficacy and specific role of this new therapy can be accurately assessed.

[Abbreviated laparotomy]

The decision to perform damage control laparotomy in a critically injured patients depends on the risk of life-threatening coagulopathy. The main decision criteria are: presence of concomitant injuries, patient history, shock, transfusion volume, hypothermia and acidosis. The aim of surgery is to achieve satisfactory hemostasis, limit peritoneal thermal loss, and perform physiological restoration as rapidly as possible in the intensive care unit. This includes gauze packing of major liver or retroperitoneal injuries and ligation of injured blood vessels. Injuries to the intestine and the urinary tract are sutures, stapled or drained. If the skin borders cannot be reapproximated because of excessive abdominal tension, a wall prosthesis should be used to avoid abdominal compartment syndrome. Reoperation is a dangerous procedure in the immediate postoperative period but must be proposed later for reexploration or damage repair.

[Is it useful to maintain specific scores for the early determination of the severity of acute pancreatitis?]

STUDY AIM

Acute pancreatitis (AP) is a potentially life-threatening disease in which specific severity scoring system has been developed. The aim of this prospective study was to compare efficiency of the general severity of illness scoring system and the most widely used specific scoring system of AP in order to simplify the initial monitoring of AP at the time of admission.

PATIENTS AND METHODS

Eighty-seven patients with AP were hospitalized in the same center. There were 47 men and 40 women (mean age: 57 +/- 16 years). Specific scores (Ranson, Imrie, Blarney) and general severity of illness scores (SAPSI, SAPS II, Apache II) were calculated for each patient. Radiological scores (Hill, Balthazar) were also calculated when TDM was early performed (80%). Each scoring system was correlated with severity, morbidity and mortality of AP and its predictive value evaluated by the area under the ROC curve.

RESULTS

Aetiology of AP was predominantly biliary (20%) and alcoholic (70%). Eight per cent of the patients died and 29% of AP were classified as severe according to the Atlanta Congress Score. Morbidity rate was 40%. All the scoring systems were significantly correlated with mortality and exhibit ROC curve area between 0.77 and 0.84, resulting in a similar prediction of death.

CONCLUSION

Specific scoring system and general severity of illness scoring system have the same predictive efficiency in acute pancreatitis. The use of the specificity scoring system seems to be no more justified in acute pancreatitis.

[Liver transplantation with a graft taken from a heart transplant patient who was brain-dead]

The shortage of organ donors has led to progressive softening of selection criteria for organ donation. We report on hepatic transplantation in a 55-year-old woman with primary biliary cirrhosis, whose donor was a 50-year-old heart transplant recipient who became brain stem dead, due to cerebral bleeding 8 months after transplantation. An orthotopic liver transplantation was performed. The postoperative course was uneventful and the recipient was alive and had normal liver function after a 42-month follow-up. Analysis of the literature included ethical consideration, potential hepatotoxic effects of immunosuppressive drugs and modification of the graft immunogenicity. It confirms that transplanted patients should not be a priori excluded from organ donation.

[Self-expandable metal stent in the treatment of obstructive cancer of the left colon. Preliminary results and review of the literature]

AIM

To report our preliminary experience with self-expandable metal stent in the treatment of acute malignant obstruction of the left colon and to review the literature on this specific subject.

PATIENTS AND METHODS

From March to September 1999, 8 consecutive patients with a mean age 71 were admitted as an emergency for acute malignant obstruction of the left colon. A self-expandable metal stent was inserted under radioscopic and, in 4 cases, endoscopic guidance. The patients then underwent bowel preparation before operation, if required.

RESULTS

There was no mortality. Bowel preparation was satisfactory in 6 cases. Complications occurred in 1 patient, who was operated on day one for peritonitis due to perforation of the tumour by the prosthesis inserted after dilatation. Another six patients were operated: 2 had resection followed by anastomosis; 3 had resection and anastomosis protected by ileostomy; 2 had Hartmann's procedure. The last patient retained the prosthesis as palliation. In the literature, self-expandable metal stent application in obstructed carcinoma of the left colon gives satisfactory results.

CONCLUSION

Based on our experience and a review of the literature, we provide practical recommendations when inserting self-expandable metal stents for acute malignant left colonic obstruction.

[Treatment of blunt trauma to the liver]

Management of Blunt hepatic injuries is dramatically modified since early 80's. Non operative management is presently used in over 80% of all cases, irrespective of haemoperitoneum and grade of injury. Close observation of the patient is requested. Laparotomy or laparoscopy must be decided in any case of suspected missed injury. Laparotomy is used for worse hemodynamic status. Peroperative mortality is mainly attributed to haemorrhage. Aggressive surgery has progressively given place to more conservative techniques. Understanding of coagulopathy related to massive transfusions, acidosis and hypothermia led to enhance efficacy of manual compression of the injured liver and of perihepatic packing and planned reoperation. In survivors this abbreviated laparotomy has pitfalls and complications which must be known, mainly rebleeding and abdominal compartment syndrome. Decision of very early reoperation is most difficult to take.

[Surgical treatment of acute cholecystitis. A retrospective study of a series of 192 patients operated on over a period of 3 years]

Emergency conditions make laparoscopic treatment of acute cholecystitis challenging. The aim of this study is to retrospectively analyse our experience of cholecystectomy for acute cholecystitis performed between January 1995 and December 1997. In order to be included, patients had to present (i) symptoms of acute cholecystitis correlated with laboratory blood tests and ultrasonographic studies (ii) evidence of acute inflammation during the operation and (iii) histological confirmation of acute or subacute inflammation of the excised gallbladder. 192 patients were treated: 62 were totally managed laparoscopically (group CCN), 33 managed laparoscopically but required conversion to open cholecystectomy (group CCC) and 97 were managed conventionally by laparotomy (group CL). Mean age was significantly different between the three groups, (CCN: 55.6 +/- 15 years, CCC: 64.2 +/- 13 years, CL: 66.5 +/- 17 years), as was ASA score (CCN: ASA 3 and ASA 4: 16%, CCC: ASA 3 and ASA 4: 48%, CL: ASA 3 and ASA 4: 46%), and initial infectious signs (temp. > or = 38 degrees C: CCN: 35%, CCC: 39%, CL: 63%). Mean operative delay was significantly higher in the converted group [8.7 +/- 13 days (CCC) vs 4.5 +/- 8 days (CCN) and 5.4 +/- 8 days (CL)]. There were two (1%) bile duct injuries, one in the CCC group, the other in the CL group. Operative mortality was 2% (CCC: 0%, CCN: 0%, CL: 4%) and operative morbidity was 40% (CCN: 21%, CCC: 24%, CL: 57%). The mean postoperative hospital stay was shorter in the CCN group (6.5 +/- 3.5 days) and CCC group (9.6 +/- 4.4 days) vs the mean stay in the CL group (14.7 +/- 11.6 days). Appears to be beneficial for selected patients with low surgical risk to conclude laparoscopic cholecystectomy. It has yet to be shown whether this benefit can be extended to patients with a high surgical risk.

Large inferior right hepatic vein. Clinical implications

The right middle and inferior hepatic vv. are very frequent, indeed constant, but usually of small caliber. The presence of an extra-wide right inferior hepatic v., usually solitary, produces a variation in the venous drainage of the right lobe of the liver. The right inferior hepatic vv. reaching or exceeding a caliber of 0.5 cm were investigated in 125 anatomic liver specimens: 70 injection-corrosion specimens, 32 formolised livers and frontal or frontal-oblique sections of the trunk made in 23 cadavers. The incidence of such vv. was estimated at 9% in the injection-corrosion specimens, 13% in the sections and 16% in the formolised livers. The incidence of these vv. in the literature varies from 10% to 24% according to the method used to demonstrate them. Usually, there is a balance between the right superior and inferior hepatic vv. Rarely, the right inferior hepatic v. predominates compared with the right superior hepatic v. The position of an extra-wide right inferior hepatic v. is constant, close to the visceral aspect of the liver. Its appropriate territory is segment VI, but it may encroach somewhat on adjacent segments. Clinically, the existence of an extrawide right inferior hepatic v. as detected by MRI and, especially, located by intraoperative ultrasonography, allows performance of a subtotal hepatectomy leaving only segment VI. In certain pathologic conditions, thanks to the development of anastomoses between the hepatic vv., an extra-wide right inferior hepatic v. may contribute to a compensatory circulation towards the right atrium.

The cystohepatic ducts: surgical implications

The cystohepatic ducts (CHDs) drain the entirety of a hepatic territory of variable extent into the cystic duct or gallbladder (cholecystohepatic ducts). Certain very rare patterns of the CHDs constitute anomalies but as a rule a CHD represents one of the numerous variants of division of the extrahepatic bile-ducts. Their existence is explained by the normal anatomic development of the bile-ducts. They are usually discovered during peroperative cholangiography performed during cholecystectomy for gallstones. Their actual incidence is small: 1-2% of cases. A CHD was found by the authors on 12 occasions in a total of 1410 cholecystectomies (0.9%). The CHDs are always bile ducts of the right lobe of the liver and may drain a subsegment or segment, a sector or, exceptionally, the whole of the right lobe of the liver. Peroperative cholangiography does not always allow distinction of the CHDs from other and equally rare variants of division of the extrahepatic bile-ducts, whose existence carries the same practical implications. The existence of the CHDs is unpredictable. Their position renders them particularly vulnerable during cholecystectomy and the seriousness of an accidental injury of a CHD depends on the extent of the hepatic territory it drains. Strict observance of the rules of biliary surgery and routine peroperative cholangiography should preserve the integrity of CHDs draining an extensive hepatic territory.

Magnetic resonance imaging of the liver by frontal (coronal) sections

In general, frontal sections of the liver in magnetic resonance imaging are used less than sections passing through other planes of space. Frontal sections of the trunk in magnetic resonance imaging involving the liver, performed in over 80 patients for various reasons, were compared with frontal sections of the trunk made in 10 cadavers. A general schema was established of the anatomy of the liver studied in the frontal plane. Frontal sections in magnetic resonance imaging make it possible to form a very good estimate of the structure and size of the liver, and to recognize individual variations. They clearly show certain inferior relations of the liver. In particular, frontal sections in magnetic resonance imaging make it possible to identify most of the main veins of the liver, the main lobar veins and branches of the portal vein, and to properly study the entire retrohepatic portion of the inferior vena cava. Some of the vascular images were found almost constantly in the sections of the various subjects. The right lobe of the liver is more accessible to such study than the left by reason of its structure and its venous arrangements. Frontal sections of the liver in magnetic resonance imaging constitute a preferential method for studying the anatomy of the liver. Together with transverse sections, they make it possible to specify the site and venous relations of a pathologic process within the liver, with a view to hepatectomy.

A general review of anomalies of hepatic morphology and their clinical implications

Anomalies of hepatic morphology, as opposed to anatomical variations, are rare. Nevertheless, knowledge of such anomalies is important since they do not always remain clinically latent. Four case studies of different types of anomalies encountered in surgical practice in the adult are reported herein. A general review of hepatic anomalies can be divided into two categories, i.e. anomalies due to defective development and anomalies due to excessive development of the liver. Such disturbances are sometimes associated with malformations of other structures, especially the diaphragm and suspensory apparatus of the liver. Defective development of the left lobe of the liver can lead to gastric volvulus. Conservely, defective development of the right lobe either remains clinically latent or leads to portal hypertension. Anomalies related to excessive development of the liver lead to formation of accessory lobes annexed to the liver. Despite their diversity of shape, size and location, such accessory lobes have common features allowing them to be considered as an entity. In most cases the accessory lobe is found in the infra-hepatic position. Riedel's lobe is the best known example of a sessile accessory lobe. Accessory lobes may also stimulate tumor. In cases where the accessory lobe has a pedicle, torsion is a common event leading to discovery of the abnormal mass. The origin of the anomalies of hepatic morphology occurring in the course of organogenesis remains to be elucidated. The use of ultrasonography should now allow identification of such anomalies prior to the occurrence of an acute complication and in the future to possibly detect them in the fetus.