In a stable patient, management of a complete transection of the common bile duct distal to the insertion of the cystic duct would be optimally performed with a
|C||Primary end to end anastomosis of the transected bile duct|
a. Penetrating trauma is the most frequent mechanism associated with porta hepatis injuries, although 30% of porta hepatis injuries in the aforementioned study followed blunt trauma.
b. Isolated injuries to the porta hepatis are uncommon. Because of the proximity of other organs, porta hepatis injuries are usually associated with hepatic, duodenal, gastric, colonic, and other major vascular injuries.
c. The overall mortality rate is 50%, but it increases to 80% in patients with associated injuries.
d. Management is difficult because of life-threatening hemorrhage and associated organ injury.
e. If the patient survives the operation, complications such as biliary fistula, portal vein thrombosis, and hepatic ischemia may contribute to morbidity.
f. Management of portal vein and hepatic artery injuries is discussed later under major abdominal vascular injuries.
g. Management of common bile duct injury is challenging. Primary repair and placement of a T-tube should be attempted for partial or minor injuries involving less than 50% of the duct's circumference.
h. Major injuries or complete transection of the common bile duct are best managed by choledochoenteric anastomosis. This procedure significantly reduces the incidence of late postoperative complications, in particular, the development of strictures.
i. Missed extrahepatic bile duct injuries occurred in nine patients in a multicenter review, with a 75% complication rate in those who survived.
j. Gallbladder injury is also an uncommon injury after both blunt and penetrating trauma. Cholecystectomy is the procedure of choice.