¶ Intro / Opening
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¶ Welcome & Initial Liver Trauma Management
Welcome to the Trauma Podcast. I'm John Maddox. I'm one of the trauma surgery and critical care fellows here at the R. Adams Cali Shock Trauma Center, University of Maryland. We are joined today by Dr. Thomas Scalea, the physician in chief for the R. Adams California. Adams Cali Shock Trauma Center and Professor of Surgery at the University of Maryland. Dr. Scalea, thank you for taking time to talk with me today.
My pleasure.
Sir, liver injuries are particularly daunting to me as a young surgeon. I would like to take advantage of this opportunity to learn from your years of experience by going through a few clinical scenarios and questions. So to start. At laparotomy, for a grossly unstable blunt trauma patient with a positive fast, you encounter a large volume hemoperitoneum with high grade right lobe hepatic injury. How do you approach damage control surgery for the liver?
Yeah, I think that um The older I get, the fewer the number of operations I do, and I do'em more often. I I think if you you have a bunch of years of experience that A good look and a feel of the liver tells you a huge amount. People talk about a Pringle and I think that's fine.
operate on somebody with a high grade blunt injury to the right lobe of the liver, the pringle is not gonna work. It may reduce the volume of hemorrhage, but those people always have a hepatic vein injury or some component of the Vein injury and so the idea that you're gonna do the Pringle and the field's gonna be dry in in my mind is just unrealistic. I think it's okay you get a little bit of bang out of it. I think the first thing that it's wise to do is peck the liver.
A and packing to me is a surgical operation. It's not taking thirty lap pads and shoving them up and saying it I hope it's okay. So you take the falsiform down. I don't take the uh triangular ligaments down at that point. I put a couple of laps above uh the right lobe, a couple above the left lobe, I put a couple three below um the liver and I push the liver up into the diaphragm. It's eight or ten lapses, not a million. And it's a diagnostic test as well as a therapeutic maneuver.
If that stops the bleeding, I think that it's uh time to let the anesthesia guys catch up and then decide what if anything else you want to do. For somebody with uh a deep liver injury, I think it's a great time to ask whether you're gonna use endovascular care. Because once you stick your finger in it, it's hard to make that go away and rewind and a and make that bleeding stop. And so I pack And if I've used a Pringle, I come off the Pringle, and if that seems to control the hemorrhage.
Thank you.
Maybe I get the endo guys in or if I'm was wise enough to be in the hybrid room, right, you can just now's a great time to get the catheter in and and do a um Diagnostic and therapeutic test slash maneuver.
¶ Definitive Surgical Techniques for Liver
If it doesn't stop then you have to do something. And to me the next um decision is is based on where is it because I'm always thinking about what's my fallback position. If you do this well In my mind, you're mentally two steps ahead of your hands. And it's always what am I gonna do when this doesn't work?
Altyazı M.K.
People talk about finger fracture and I don't think that's a great maneuver most of the time and I you know at conference at least a few times a year I laugh at this point and say this there's a reason that every time you see it it's a line drawing. because it's i it's not so simple. You don't just open it up and say, Oh yeah, that's what's bleeding particularly with blood trauma. Lots of stuff is bleeding and you have to divide if you have to divide a lot of liver Then that's gonna be
It's gonna be a problem. It's gonna make the bleeding worse when you do that. Now The next issue comes down to what can you do for definitive hemostasis and if you're lucky And this is a relatively peripheral injury, and I mean not in the middle of the liver. I think that the next move is the breben hepatectomy. And to me that is the best. It's the op liver operation I do the most often now for almost forty years into this. And that's based on on a realization that I came to about eight
Or ten years ago. The blood comes up in the porta, it goes through the liver, and there's a bridge of liver that's still intact. So it goes across that bridge and it bleeds from both. sides of the injured segment. If you take out the injured segment and lateral, then there's only one surface from which the liver can bleed. It's a lot easier to see it then. And for me then What I do is I put the Pringle on, I note the time.
And then I take out the right lobe or the I mean the left lobe is relatively straightforward. I take out the lateral portion of the damaged liver. And I I do that We I do it these days mostly with staplers. Though I don't think you actually need to use the staplers. What uh i in the past what I did is I just put my hands on medial to the injury and pushed down. That could that's your Pringle out that includes the hepatic vein, right? Then you just take, frankly, a pair of
Scissors, or you take the cautery, or the argon, or anything, and you divide the liver, and now you only have one surface from which the liver is going to bleed. And I can push with my hands harder than the liver can bleed. If that's true, then I'll ease up a little bit, and the big thing in the back that starts to bleed is the hepatic vein. Put a stitch in it. The rest of it now is the more central hepatic artery.
and um portal vein branches, which and you should get some help with the with the Pringle with that. And then you can those are a little easier to see. Control those.
Do you approach those just over sewing or do you have any other tricks for taking care of the the raw edge of that leaf?
Yeah, I will, um... The main the named vessels need to And you guys have operated with me enough to know that I don't actually care what suture you use. The only thing I care about is the needle. And I want something on a big semicircle needle. And I don't know who teaches young surgeons to sew these days, but everybody that teaches you guys to sew teaches you to take a long skimpy bite and that'll kill you here. You need to turn the needle at once.
right angles, go into the substance of the liver, and turn your hand over so you use the whole surface of the of the available length of needle. And that'll get you a substantial substantial bite of liver and then you can tie it down. If you take that skimpy bite it'll tear and just keep bleeding. And then you've just taken that and made and made it worse.
The last thing I do, or not the last, but one of the other tricks I have for that raw surface bleeding, is I take a zero chromic On the blood liver tip needle and I straighten the liver uh the needle out and I go through the liver top to bottom or bottom to top and I put a mattress suture in and then that's going to compress the edge of the liver.
You the capsule's intact so you get a little help from that. And instead of tying it down, I set the tension with a hemoclip, medium clip usually, and that'll compress the surface of the liver. And will take care of a frankly a lot of relatively annoying level, but some relatively high volume hemorrhage. And then I throw a couple of stitches onto So when the hemoclip falls off The suture is still effective. And we invented that maybe about fifteen years ago. And I I think it's a great trick.
¶ Pringle Maneuver and Necrosis Management
Well, you've mentioned the Pringle maneuver a couple of times as sort of an initial stop gap. Do you have any tips and tricks on how to get that quickly and efficiently and not mess around with it?
Yeah, I don't think uh I actually think if you know the anatomy this is pretty easy. Now one thing that's important is to uh Remember that young surgeons who are not d haven't grown up doing a lot of liver surgery may not be as familiar. And I had this almost uh heart attack moment a few years ago.
ago when I told the young surgeon to put through the Pringle and I turned around and he was getting ready to put a coker clamp on the porter, which I thought would be a bad idea. So he y you have to use a vascular clamp.
And if you slide your finger back behind the porter, it's really a a a a reasonably easy maneuver. I then carefully I usually use uh some um relatively uh uh a Satinski and just open the jaws wide, slide the jaw posterior in, you can f guide it with your finger and then just come down out. Well
the debrement hepatectomy. Is that always something you do at initial operation? And would there be a reason to do a delayed resection?
I if you're doing it for hemostasis, you gotta get the bleeding to stop. Now sometimes, you know, you're sort of in the soup and you've got other issues going on and maybe you just take some of those big sutures and
Just
Sew the crab out of the liver. Just get big deep sutures cause you got other fish you need to fry and if that stops the hemorrhage for a while, so be it. And then when you come back later maybe you're gonna do the the breedman. Now the other thing of course is we observed uh ten years ago I guess. that uh hepatic necrosis was a common complication of embolization
And of course if the liver dies then you're going to do the debrievement, which is usually a formal right hepatoclobectomy, later. Early still, but later than the first operation.
When you're managing a patient with that post-embolectomy hepatic necrosis, What do you need to worry about? What should I worry about?
¶ Thresholds and Seeking Senior Guidance
Yeah, I I think when we realized how common it was, um, we began looking for it and guess what? We found it. Because those people with the bad lymjury injuries are kinda sick. And so They all have abnormalities of their liver functions, they all have fever, they all have why count, they all have, they all have. And so in my mind, if you embolize the liver, Um I say okay. I'm gonna That's first on my mind for complications and
And if there's any issue, and there usually is, about three days post-embolization I get a CT scan. And if there's a bunch of dead liver with air in it, we put them on the schedule for the next day and we do a lobe. Say that I think it's less common now than it used to be, and I think at least in this institution it is, and I think that's because we do better embolization. And this was one of a thousand advantages to having our own endovascular surgery team.
Because when you have people that do trauma for a living doing the embolizations They know what the problems are and they avoid those problems. And I think we were doing um much wider embolization than we do now. We're much more selective and I think that's why uh we don't see so much apasto necrosis anyway. anymore. Still see some, but very much less.
Is there a threshold or I guess sort of what is your threshold of when to go and debris? Where is that cut off?
I I think um A lot of this is comfort level. And I think that young surgeons should take advantage of a couple of um opportunities and they hate doing it. The first is a bad liver injury is really a good time to call a senior friend early. And people s don't want to need help. Most people in their training either do zero bad livers or two or three or four and that's just not enough.
And those of us that grew up doing these things still are Yeah, I get back and I look at that and I go, Oh, I wish this wasn't true. uh I have a pretty fair idea of what to do, but it's not a great feeling to see the sh a shattered right lobe of the liver. And it's one of the few things that may gives me some anxiety when I when I see it. And so to utilize um
Senior help I I think makes a huge amount of sense. It's better for the patient and it's frankly better for you because you will then learn the tips. And when you're old like me, you can teach them to your young partners. I think the other thing, and this is hard to do. in a RVU atmosphere is to go sc and it's hard to do because the liver transplant guys are five of them in every liver transplant. But if you could go scrub
with somebody that does a lot of livers. The cancer guys, maybe not the transplant guys, but the cancer guys or go help go scrub on the procurements. So you really learn your way around that anatomy, it's inordinately helpful. And I I gotta tell ya, I was pretty far into my career when we started doing these hepatoclobectomies, we would do it me or Either me and Dr. Stein or me or Dr. Stein and one of the liver guys. And I learned.
Yeah, I was probably in my fifties at that point. I got better. I got like a lot better. And'cause I got a lot more comfort. comfortable with the retro hepatic cava and how you get there and just how much of the triangular ligament you can take and how you g take the falciform down all the way. I mean the first time I saw somebody do it I
it was Ben Philisov and he took the cautery and he exposed the caver, taking the uh the valciform ligament down. Wow. Guess what? I figured it out. Now I can do that. And so The more of these you get to do, the more at-bats you get, the better your banning average.
¶ Retrohepatic Bleeding and Balloon Tamponade
With that being said I remember a a case I did with you a couple of years ago when I was a resident.
Did I do okay?
It did, sir, but it it's one of those things that scares the hell out of me. And I'd just like your take on this. It was a a brisk retrohepatic bleed. How do you approach that?
Yeah, I d I think I approach him differently now than I did then, John, because I think this bridge balloon is a complete game changer. And you know that is a percutaneous balloon you can I mean femoral vein is the easiest way to do it. And then particularly if you're in the hybrid operating room And you can get this longer, softer than the Reboa balloon up in position behind. The liver It makes life Much, much easier. And I so now I would probably use that. Back then I'm sure we didn't.
A and what you have to do is have enough intestinal fortitude to go find it. It's a heart injury to expose and the anesthesia guys really need to um hustle a and I Just look over the drapes and go, We're gonna lose a lot of blood. Sorry. And then you go. And if they can't keep up with you, then uh the patient doesn't survive. But if you don't have Um the courage of your convictions to go expose it and get control of it. You know, it's one of those things every time you try to mobilize
the liver and it bleeds, you lose a couple, three units of blood and you do that four or five times and you've lost fifteen, twenty units of blood. It's game set and match by then. Now you've got no option.
When trying to get control of that, what is the role of a shrock shru shunt? Have you done it? And it is e is it useful?
Yeah, I don't think there is a role for a shot shunt anymore. Um it's another one of those things, it's always a line drawing in the book. It's complicated and you gotta open the sternum, you gotta get into the heart. You know, you're trying to hustle. I'm doing one thing and I the last time I did this, whoever, my chief resident, my fellow, whoever it was, put the purse string suture in the atrium and then went to tie it down and broke it. So now you got a hole in the heart.
You got a hole in the cava.
🔊 Rapping
And the second is a bridge balloon and then explosion.
When you say exposure, how much of the triangular ligament?
All of it. I take it all the way down to the um to the cava. And we just d did this guy two nights ago. You get your hand behind the liver, you deliver the right lob ups. Somebody's that's usually me. I expose it and then my chief resident or my fellow you have enough retraction so you can see it and then it's a relatively straightforward, relatively rapid, but exposure is is I think hundred percent of getting that opera that part of the operation done.
Are there any pitfalls to that exposure?
You make a hole in the cave and that's bad. Um, you rip the liver by yanking on it. You gotta get your hand back all the way behind the right lobe. And then you've got to really deliver the right lobe up. And once you start dividing the ligament. That gets easier. It's the first three or four inches of trying to get that mobile.
That makes it more complicated. I think the other thing that I use for this that I find extraordinarily helpful is a sponge on a stick that'll just push the ligament out of your way, then you divide some more. and you push on it and you divide the ligament some more and then you divide it up quickly. The other thing I I think that you can do to get down to the cava quickly is open the right chest and take the the diaphragm down all the way to the cable. Now you can see everything.
¶ Deep Parenchymal Gunshot & Poghetti Balloon
Well there's another thing that I wanted to talk to you about, and that's the deep paranchimal gunshot track. It's a challenging woman. What is the pajeti balloon? Have you used it and what tips do you have for making it successful?
successful. I love it. I think it's a great it's a great tool. We we just uh wrote up the last three or four cases. And you take a stiff Red rubber catheter. You put it into a one-inch Penrose drain. The hard thing is to find the damn Penrose drain because most operating rooms don't use them. But because we we have some around just for this. And you tie off the um
You tie off the uh Penrose drain around the catheter and then at the very end. The hardest thing about using this is getting it through the tract. And what I usually do then is take a long tonsil clamp, thin tonsil clamp, and gently put it through the um the parenchymal missile tract and you can either grab The Penrose drain itself or Grab a heavy silk tie and then use the silk tie to introduce it through. You gotta get some Penrose drain out the other side. So you've got the whole tract full.
Uh blow up. the pen rose into a balloon. And um It'll give you great tamponon. It won't stop it'll stop almost all venous bleeding and it'll stop some decent-sized arterial bleeding, and this was uh reported on by Renato Poghetti when he was in Denver as Gene Moore's research fellow. And a b the story goes
You know, it's it's a story. It's either true or it's not true. That doctor Poghetti was persistent one night when Dr. Moore was in the operating room trying to handle one of these and said, Let me show ya, let me show ya. took apparently several times to convince Dr. Mortem to listen and and it worked great. Renato from Brazil and those guys They see a lot of stuff and they Renato brought that trick with him from Brazil and
So I think it's a great. I think the other option, this is a great place for a superficial, relatively superficial for tractotomy. Open the tract and look, now you can see what's bleeding. And and that's nice because You c it you can do that as one and done. You open the tract, you stop the hemorrhage and and you're done. You don't need to go back and deflate the balloon and stuff.
¶ Extreme Liver Injury and MARS System
Well before we get into our final questions. What important liver topic should I have asked you about, but haven't?
What do you do when no matter what you do it keeps bleeding? And when you've exhausted all of your resources, I mean in the sense that you've done everything you can do.
Terima kasih.
um and they're just bleeding, twice in my life I've done a total hepatectomy. The only good piece of news is nobody's h higher on the transplant list than the guy that has no liver. Um, and what we did was we did total hepatectomy. This guy had been crushed in the epigastrium with a wrecking ball. His friends played a trick on him and didn't tell him that the the building was gonna be demolished.
So he's in the building, the wrecking ball comes through the uh the wall and hits him square in that Pegasum inus and took his liver off his cavo. He still had some hepatic flow from his hepatic artery, but his hepatic veins were all avulsed. He was. shockingly not dead when he got here. And uh but when I put my fing my hand behind the liver to mobilize the liver, it came off. Came off the cable.
So we took his whole liver out. I didn't know what else to do and did a a uh temporary porta caval shunt, I guess. and listed them and we got a liver and we the transplant guys put it in. We actually also he had a crush injury to the head of his pancreas and we did a whipple. A whipple antitotal hepatey. And he lived through. We got a a liver. We got it plugged in. It started to work. He woke up.
And then sadly, we got his abdomen closed and reconstructed, and then he died of sepsis two or three weeks later. And so I think we have I don't think that we have embraced Yeah, that's obviously a crazy case. But the liver transplants are really good operation these days and and their time
Which I think when we um play with the liver, when maybe the the better answer would be Mars, right? Now that we have the Mars circuit. Mars is a bridge to transplant. Instead of trying to support what's left of this liver, which is not very much and not very and not working very well.
So you mentioned Mars, which is the molecular absorbent recirculating system, described as uh dialysis for the
Yeah.
Um are there any other instances where you'd use that?
Yeah, we used it. I mean we published what was, you know, by Mars standards, a pretty big series, thirty people and Um we use it i it's it's FDA approved for toxic ingestion. We have used it off label as a bridge to transplant. We've used it for severe hepatic insufficiency following in injury. What what it doesn't work is a patient f with liver failure and multiple organ failure. And it's not a cure like roboa or many things. It's a bridge, right? It it keeps you going.
So you can do something else. For toxins I I guess it it it it can be. cure, right in because it once their liver recovers then they're well but it's a great tool.
¶ Personal Insights and Career Advice
Well sir, thank you for answering the easy questions. Now we're gonna move on to the hard questions. So if a turtle does not have its shell, is it nude or just homeless?
It is both.
All right. It is commonly described that Albert Einstein, one of the great minds of our age, had problems tying his own shoes. What are you strangely bad at?
That's why I wear loafers. Fair enough, sir. I am strangely bad at turning the computer on or doing anything with the computer. Anyone that knows me knows that uh I type with two fingers, I'm up to four now, and that if Stevie isn't Yeah. I'm helpless.
your passion outside of trauma.
It's a great question. Eating really good food. And drinking really good wine.
Terima kasih.
And your rare time when you're not here. And you're kicking back with some good food and good wine. What music do you listen to?
White boy rock and roll.
And sir, the final question. What advice would you give a young doctor scaled just starting his career in surgery?
I think Then you shouldn't let the system put you in a box. And the system wants you in a box. You know, I was lucky enough to grow up with the one in the box. Now you need permission from the nurse in charge of this or the doctor in charge of that to take care of your patients and I I hate it because most of the time they know something about something but it isn't about trauma.
a or critical illness of of any kind. And the rules uh uh in the clinic don't apply to the TRU or the ICU here and so I think that um We have Protected young surgeons in a that robs them of their the opportunity to do what I did when I was a kid. And I think we stifle creative thought. by s s saying, Oh, you're not allowed to do that. Why not? And um it's not that I think that we were so much smarter, but we were less constrained. And some of the best work we did.
was um thinking outside that box. It's a ter I hated that term, but I can't think of a better one right now. Thinking outside the norm and saying what if what do you think will happen if we do this? And some of the best work we did when I was in New York and when I first got here. was the crazy ideas that turned out weren't so crazy.
Dr. Squaya, thank you so much for taking time to
That's great. Had a good time.
to the podcast. So this is John Maddox concluding another trauma podcast. On behalf of Dr. Joe DeBoze, Dr. Rishi Kundi, and the trauma podcast. Team. I would like to thank Dr. Thomas Scalaya for his time today and invite you, our listeners, to check out all the rest of our content.
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