Endovascular adjuncts for hybrid liver surgery

L iver trauma is often associated with major hemorrhage. Despite frequent and successful nonoperative management of liver injury, hemodynamic instability mandates emergent exploration for hemorrhage control. The operative principles of liver trauma are well established, including packing, the Pringle maneuver, hepatorraphy, and resection. Repair, however, comes at a variable cost that is highly contingent upon the anatomy of the injury, with some injuries, such as retrohepatic caval injury, still carrying high rates of morbidity and mortality. Endovascular techniques have the advantage of being able to access all regions of an organ, provided a conduit and an access point. Traditionally, endovascular techniques have been used separate from open surgical methods, frequently in an interventional radiology suite. This geographical obstacle has largely limited these techniques to patients stable enough for transport; however, with the advent of hybrid operating rooms, procedures can more often be performed concomitantly. In our institution, we have developed and refined several endovascular techniques designed to control bleeding from arterial, portal venous and hepatic venous hemorrhage for use in conjunction with operative surgery. Crucially, these techniques are delivered by vascular trauma surgeons in a hybrid operating room located adjacent to the trauma receiving bay and with the full availability of operative and resuscitative capability. These procedures and techniques are reviewed below.