Management of blunt and penetrating injuries to the porta hepatis

Injuries to the porta hepatis pose difficult problems in management, and transection of the bile ducts, portal vein and hepatic artery is among the most challenging. Twenty-one patients with severe injuries to the porta hepatis were treated over a 10 yr period. Ages ranged from 13 to 56 yr, and follow-up was up to 9 yr. Among the 14 patients with bile duct injury, 8 were found to have complete transection, and 5 suffered a tangential laceration or incomplete disruption with a portion of a duct wall remaining intact. Five of the 8 patients who had complete transection underwent primary end-to-end repair with T-tube splinting, while 3 were treated with primary Roux-en-Y choledocojejunostomy. All patients with incomplete disruption underwent primary repair with or without T-tube splinting. Of the 5 patients with complete disruption who were treated with primary end-to-end anastomosis of the bile duct in conjunction with T-tube splinting, all required secondary biliary tract reconstruction of some type. No patient with complete transection that was treated with primary Roux-en-Y biliary enteric anastomosis required reoperation. Partial transections were successfully treated with primary repair. Portal vein injury was encountered in 10 patients. Injury was successfully managed by primary closure, interposition of a vein, or splenic-mesenteric vein bypass. Associated injuries to liver, pancreas, kidney and duodenum were common. In 4 patients there was injury to the main or left or right hepatic artery which was managed successfully by repair or ligation, with or without hepatic lobectomy. By adhering to the principles of management to be outlined, many patients with injury to the porta hepatis will survive, and the long term outcome can be gratifying.