Portal triad injuries.

OBJECTIVE: Injuries to the portal triad are a rare and complex challenge in trauma surgery. The purpose of this review is to better characterize the incidence, lethality, and successful management schemes used to treat these injuries.
DESIGN: A retrospective review of the experience of eight academic level I trauma centers over a combined 62 years.
RESULTS: A retrospective review of the experience of eight anatomical structures of the portal hepatis: 118 injuries to the anatomical structures of the portal hepatis: 55 extrahepatic portal vein injuries, 28 extrahepatic arterial injuries, and 35 injuries to the extrahepatic biliary tree. Sixty-nine percent of the injuries were by penetrating mechanism and 31% were by blunt mechanism. All patients had associated injuries with a mean Injury Severity Score of 34 in blunt trauma patients. Overall mortality was 51%, rising to 80% in patients with combination injuries. Sixty-six percent of deaths occurred in the operating room, primarily from exsanguination; 18% of deaths occurred within 48 hours of injury from refractory shock, coagulopathy, or cardiac arrest; 16% occurred late. Ten percent of patients undergoing portal vein ligation survived, compared to 58% managed by primary repair. Survival after hepatic artery ligation was 42%, compared to 14% after primary repair. Survival after biliary-enteric anastomosis as treatment of extrahepatic bile duct injury was 89%, compared to 50% after primary repair and 100% after ligation of lobar bile duct injuries. Missed bile duct injuries had a high (75%) severe complication rate.
CONCLUSIONS: Injuries to the anatomical structures of the portal triad are rare and often lethal. Intraoperative exsanguination is the primary cause of death, and hemorrhage control should be the first priority. Bile duct injuries should be identified by intraoperative cholangiography and repaired primarily or by enteric anastomosis; lobar bile ducts can be managed by ligation.