Hepatobiliary Splenic Or Pancreatic Injury

Hepatic and splenic injury may result from Veress needle passage, initial trocar insertion, or an unmonitored auxiliary instrument.

Organomegaly noted on computed tomography imaging before laparoscopy should prompt lower abdominal or umbilical primary trocar placement. As haptic feedback is limited with laparoscopy, retraction injuries to organs, which are outside the surgeon's field of vision, are a common source of laparoscopic liver and splenic injury. Retraction injuries can be minimized by application of a mechanical self-retaining retraction system that is connected at one end to the side rails of the operating room table and at the other end, to the shaft of the retracting instrument. The retractor can then be placed in position under direct vision and then locked in position. Unlike an assistant who may fatigue, the fixed retraction systems are indefatigable, reliable, and safe.

Minor injuries to the liver or spleen may be controlled by compression onto the bleeding site with a rolled surgical gauze, or hemostatic cellulose gauze. Surgical hemostatic agents such as fibrin glue or FlosealĀ®c are also very useful for superficial injuries to the liver and spleen. If these measures fail, open surgical repair of a liver injury or splenectomy may be necessary.

Injury to gall bladder can occur due to perforation. Laparoscopic cholecystectomy after general surgical consultation is appropriate.

Pancreatic injury can occur during left-sided renal or adrenal surgery.

Preoperative evaluation of the computed tomography scan help the surgeon identify a long tail of pancreas, which may drape over the adrenal gland or over a portion of Gerota'a fascia. Careful dissection of the plane between the tail of pancreas and the Gerota's fascia should prevent trauma to the pancreas.

In all cases of suspected pancreatic injury, an intra-abdominal suction drain is left in the left renal bed, and postoperatively, fluid from the drain is sent for amylase levels for evidence of pancreatic injury.

If there is superficial injury to the pancreas, general surgical consultation is obtained and usually a drain in the region for few days should suffice. A major pancreatic duct injury may necessitate distal pancreatectomy by laparoscopic stapling technique or by an open conversion. If the laparoscopic technique is employed, a tissue load should be applied on the tail of the pancreas. If an open pancreatic duct is identified, this structure should be closed with a figure of eight suture to minimize the risk of leakage. In all cases of suspected pancreatic injury, a suction drain should be left in position.

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