1. Recognize popliteal artery injury as early as possible.

2. Describe the options for hepatic vein and vena cava injuries.

3. Review the operative management of grade III to V liver injuries.

4. Elaborate on the various cellular wound dressings and their applications.

5. List the indications for laparoscopy in penetrating thoracoabdominal injuries.

Management of Peripheral Vascular Injuries
A. Brent Eastman, MD, Associate Clinical Professor of Surgery and Trauma, University of California, San Diego, School of Medicine; Chief Medical Officer and N. Paul Whittier Chair of Trauma, Scripps Health, San Diego

Introduction: data from war in Iraq (and how data applied) one of greatest sources of evidence-based literature

Popliteal artery injuries: study by Hoyt et al (1990)—108 cases; limb preservation rate 88%; amputation rate 12%; 76 blunt traumas and 32 penetrating traumas; included injuries from fracture dislocations to high-velocity gunshot wounds; if spasm present, do not delay treatment; amputations can be categorized as preventable, potentially preventable, and nonpreventable; preventable amputations unfortunate, but provide learning about errors in diagnosis, judgment, and technique; in another study, amputation rate 18% in 65 injured extremities with blunt trauma (3 times that of penetrating injury); all patients who underwent amputation presented with severe signs of ischemia; delay in recognition of popliteal artery injury recurring cause for litigation; most failures and errors occur after midnight; conclusions—4-compartment fasciotomy should be performed early and to completion; early constructive management of soft tissue injuries beneficial; perform tension-free arterial repair expeditiously; decrease ischemia time, using shunts if necessary; utilize aggressive multidisciplinary approach; strive for functional outcome (do not be afraid to perform life-saving amputation)

Computed tomographic arteriography (CTA): has role, particularly in patient with multiple injuries; excellent resolution with 64-slice CT

Fasciotomy: shunts minimize ischemia time; temporary vascular shunts common when managing wartime vascular injury because of need to remove patient from austere environment to more protective one; done to prevent compartment syndrome; physical diagnosis unreliable; presence of pulse does not rule out compartment syndrome; role of prophylactic fasciotomy in high-risk extremity trauma extremely important; patients undergoing delayed fasciotomies had twice rate of major amputations and 3-fold higher mortality rates; fasciotomy revision associated with 4-fold increase in mortality; always all 4 compartments

Vacuum-assisted closure (VAC) of wounds: Class 1 evidence not yet available; clear salutary effect at molecular level

The Myth of Nonoperative Management of Liver Trauma
Donald D. Trunkey, MD, Professor and Past Chair of Surgery, Oregon Health Sciences University Medical School, Portland

Introduction: from 1872 to 1965, dramatic decrease in mortality from rupture of liver; before World War II— treatment included sutures, packs, cautery, and drains; during World War II—significant changes; landmark paper by Madding and Kennedy (assigned to Second Auxiliary Surgical Group); for first 23 mo of war, gauze packing and drains used; from 1944 to 1954, 829 wounds treated, with only 53 deaths; resectional debridement and hepatectomies performed; between World War II and 1965—penetrating liver injuries top problem; mortality different depending on whether trauma blunt or penetrating; 1965 pivotal year, because possible to diagnose previously undiagnosed liver injuries, with great majority grade I to III; surgeons were unknowingly performing nonoperative liver management; diagnostic peritoneal lavage (DPL) introduced (problem of being overly sensitive); 25% to 30% of celiotomies unnecessary because bleeding already stopped; first myth that nonoperative management of liver injuries not new concept; after 1965—more penetrating injuries than blunt injuries; mortality high; in speaker’s series from Parkland Hospital, of 106 deaths, 72 unrelated to liver injury and almost one- third due to liver injury; 1981 another pivotal year due to introduction of CT; made it possible to determine whether surgery necessary, but had to correlate with physiology; essentially eliminated unnecessary celiotomies; defining problem—before 1965, 40% to 50% of liver injuries not diagnosed; after 1981, unnecessary celiotomies almost completely eliminated; hollow viscus injuries became problem, because in some institutions, CT inaccurate; surgeons not trained in liver surgery

Contemporary management: since 1981, due to grading of liver injuries, almost possible to eliminate grade I and II as major problem; patients with grades III to V injuries at higher risk for shock and instability; nonoperative complications include bilomas; study by Strong—13-yr period; 287 patients with liver injuries; of 37 patients with severe liver injuries who underwent anatomic resection, 75% experienced shock; 25 patients referred from other centers; 3 deaths; concluded that role of resection should be reevaluated; wide condemnation of anatomic resection for severe liver injuries inappropriate; transfer of patients with severe liver injury should be considered if surgeon not comfortable with procedure; American Board of Surgery requires only 4 cases/yr (liver surgery) for training; segmental anatomy critical; myth that inferior vena cava (IVC) intrahepatic vein (actually not; has 2 investing envelopes of fibrous tissue around it); if spleen and liver bleeding, remove spleen; clamp porta hepatis to determine whether bleeding controlled; if controlled, indicates hepatic arterial or portal venous bleeding; never clamp descending thoracic aorta, unless associated aortic injury present; clamping aorta results in removal of blood supply to liver and intestines, contributing to acidosis; in “bear claw” injury of liver, assisting medical personnel key; assistant must get behind liver with hand and compress liver; allows surgeon to open up liver and individually suture- ligate (usually) branches of middle hepatic vein that have been avulsed; remove ligaments when performing liver surgery to allow exposure to hepatic vein; middle hepatic vein joins left hepatic vein 85% of time; removing ligaments brings liver to midline from right side so that surgeon can access veins from segment 1; speaker not in favor of staples in liver; since liver moves 15 times/min postoperatively (due to ventilation), staples dislodged; speaker prefers baby Satinsky clamps and vascular silk 3.0 suture

Options for hepatic vein and vena cava injuries: Schrock shunt—speaker’s success rate 35%; failure due to late use; must use before patient becomes coagulopathic; speaker no longer uses; veno-veno bypass—22-French catheter placed into femoral vein and another into axillary vein and blood run through Bio-Medicus centrifugal pump; able to return 1500 to 1800 mL blood to circulation; must have suprahepatic and suprarenal caval isolation and perform Pringle maneuver; time available to repair problem in liver ≈30 min

Contemporary operative management: includes compression, tractotomy and suture ligation, fibrin sealants, omentum, resectional debridement, lobectomy, temporary packs (in damage control), and embolization (if patient stable after CT; otherwise, take patient to operating room [OR] and embolize after); hemostatic agents include sterile compressed sponge (Gelfoam), oxidized cellulose (Surgicel), chitosan, and fibrin sealants

Management: if patient presents as hemodynamically stable (blood pressure [BP] >80 mm Hg), perform CT; if injury grade I or II, treat nonoperatively; however, must rule out hollow viscus injuries or other indications for laparotomy; if injury grade III to V and BP >80 mm Hg, consider angiography if “blush” present and embolize if necessary; if BP <80 mm Hg, operate; if minimal blood present in peritoneum, patient stable, and no hollow viscus injury, trial of nonoperative management preferable

Summary: concept of nonoperative management of liver injuries is “mirage”; 65% to 75% of grade III to V liver injuries require operative management; operative mortality from severe liver injuries has decreased, while morbidity and liver-related complications have increased; prudent surgeon should know when and how to operate

Burn Wound Excision
David N. Herndon, MD, Jesse H. Jones Distinguished Chair in Burn Surgery and Professor of Surgery, University of Texas Medical Branch, and Chief of Staff, Shriners Burns Hospital, Galveston, TX

Treatment: early excision and grafting largely responsible for reduction in mortality; decrease in metabolic rate seen if burn wound excised within 48 hr after injury; also, marked decrease in infection, weight loss through hospital course, amount of bacteria in burn wounds, and incidence of sepsis (50% less); burn wound should be treated on day of occurrence; biosynthetic wound dressing—second-degree burn easily covered with pigskin or plastic (eg, Biobrane), which decreases length of hospital stay, pain, and suffering, allowing discharge of patient night after burn injury; less use of antibiotics and less frequent occurrence of purulence under plastic collagen bilaminate closure of burn wounds in hand, back, chest, and leg than with topical antimicrobial agents; in deeper skin injuries, other skin substitutes include, eg, cadaver skin without epidermis (Alloderm) to improve cosmetic results; artificial dermis (Integra)—used in extensive burns; dermal matrix comprised of bovine collagen cross-linked with short chondroitin sulfate with plastic layer placed on top to replicate epithelium; wound excised, artificial dermis applied and left for 3 wk, then peeled off; thin graft then taken and applied over it, with good cosmetic results; when hole of burn wound covered with artificial dermis immediately after injury in burns covering >70% of total body surface, resting energy expenditure decreased, and bone mineral content and strength improved at 18 mo and 24 mo after injury (compared to traditional skin grafting techniques); in randomized study, use of Integra led to markedly improved cosmetic results (less scarring) 2 yr after injury, compared to traditional techniques; human fibroblast-derived temporary skin substitute (TransCyte; formerly, Dermagraft-TC)—substance which combines Biobrane with tissue culture technology; currently off market; amnion—used for second-degree burns; first described in 1913; frozen and delivered for application in difficult areas, eg, face, hands; applied on wound on night of occurrence and allowed to lie on wound until wound heals; decreases pain and dressing changes and improves scar results; third-degree burn wound should be excised night of occurrence and autograft placed on it; larger burns require artificial dermis (eg, Integra) approach or cadaver skin (used night of occurrence); second-degree burns not excised; deep third-degree burns excised to level of punctate bleeding, then cadaver skin applied; decreases length of stay, pain, and infection, compared to using topical antimicrobial treatment; study showed that early excision and grafting decreased mortality in burns encompassing >40% of total body surface; blood loss less if wound excised within first 24 hr of injury, compared to 48 hr; to excise massive third-degree burns, traditional approach to tangentially excise punctate bleeding in areas least deeply injured; for wounds down to (or close to) level of muscle, excision to level of fascia acceptable (cosmetically acceptable for chest and back)

Techniques for more widely expanding skin: Meek’s methodology—developed in 1960s; small postage stamp-size patch of skin expanded via cotton application techniques or reversed on bottom of cadaver skin, allowing 12:1 expansion when limited donor sites available; tissue culture allows small biopsy to expand sufficiently to cover whole patient; not as durable as traditional technique; individuals with burns on >80% of total body surface covered with cultured epidermal autograft (CEA), compared to traditional widely expanded “sandwich” technique, have longer length of hospital stay and higher cost; with subsequent mobility of patients, adherence of tissue culture cells to underlying beds poor; blisters occur, and areas of open wound recur; combination of artificial dermis (eg, Integra) and tissue culture technologies allows better results; tissue culture cells grown over Integra-like substance in laboratory; cells adhere better when grown in that fashion and applied on top of wound (costly); more durable than tissue culture cells placed on top of wounds, and lower incidence of blisters; previously, mortality ≈30% when burns over >60% of total body surface (presently, mortality <18%); 10 to 15 reconstruction operations required for patients with burns >60% of total body surface; ongoing psychosocial assistance necessary over many years and at adolescence and periods of adult stress

Cavitary Endoscopy in Trauma
L.D. Britt, MD, MPH, Brickhouse Professor of Surgery and Chair, Department of General Surgery, Eastern Virginia Medical School, Norfolk

Introduction: from nipple to costal margin considered thoracoabdominal region; lower part of cardiac box in this region; incidence of diaphragmatic injuries high; speaker believes thoracoabdominal region should not be probed; no diagnostic study can conclusively rule out diaphragmatic injury; diaphragmatic injury should be diagnosed and managed, particularly on left side; before laparoscopy, surgery performed on patients

Laparoscopy: part of armamentarium for penetrating thoracoabdominal injury, particularly on left side; management of choice; therapeutic laparoscopy “not ready for prime time” in trauma; with operative approach, plan to control hemorrhage and gross spillage and to perform thorough exploration; no financial advantage in trauma patients; in gunshot wound to abdomen, exploration management option of choice; if stab wound present and peritoneal signs, evisceration, and hemodynamic instability absent, no blood from natural orifice, and no impaled object present, speaker recommends observation; also has possible role in blunt trauma

Thoracostomy: indicated in patient with retained hematoma; no role in penetrating thoracoabdominal injury; role of endoscopy clear in neck injuries; bronchoscopy has role in blunt trauma, with sustained leak of chest tube; in thoracic aortic rupture, high mortality rate (>90%)seen; still not standard of care