Clinical Challenges in Trauma Surgery - Retrieval to Survival
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[00:00:00] Welcome back to the Behind the Knife Trauma Subspecialty podcast series. Thanks to all who have listened so far and given feedback on our first two episodes. First one was a challenging junctional injury and then a journal review in pre-hospital resuscitative thoracotomy. Today, we're going to focus a little bit more on how a resuscitative trauma surgeon might be able to pick up the skills to confidently perform challenging operative steps in resuscitative trauma surgery.

How does a general surgeon who may have laparoscopic elective practice develop the ability to rapidly open the chest, cross-clamp the aorta in a trauma case? In today's episode, we're going to explore organ retrieval surgery and the opportunities it holds to expose a surgeon to the operative steps that they might need to execute quickly and correctly, but are likely infrequently performed by the general surgeon.

As a reminder, I'm Prash Ramaratch. I'm a ST5 general surgery trainee in Edinburgh, similar to PGY4 for those in America. I've just come to the end of a rotation in [00:01:00] vascular and transplant surgery, and I've just headed off for a year of trauma surgery training in South Africa. So to reintroduce the team, firstly, we have Roisin, a former junior trauma fellow at the Royal London Hospital Major Trauma Centre, who's currently working in Sydney, Australia, prior to specialty training similar to PGY3.

Thanks, Prash. Also looking forward to today's discussions. I'll be introducing some challenging trauma cases as a stem for discussion about challenging operative steps that have a role in both trauma and retrieval surgery. I'd like to reintroduce Mr. Max Marsden, who is a consultant trauma and upper GI surgeon at the Royal London Hospital Major Trauma Centre and British Army.

Thanks, Roisin. Uh, I think today's discussion will be really helpful especially for those budding trauma surgeons who are out there wondering how they're gonna master, uh, those trauma resuscitation moves they need to manage things like non-compressible hemorrhage while trying to balance learning [00:02:00] their elective skills that may be, uh, laparoscopic and, and even robotic.

And I'll be discussing those operative steps in the challenging cases that Roisin introduces and their purpose in resuscitating the severely injured trauma patient. And so lastly, I'm very, uh, excited to introduce, joining us now for the first time on Behind the Knife, is Mr. Chris Johnson. Mr.

Chris Johnson is a consultant liver transplant surgeon at the Royal Infirmary of Edinburgh, and he is the fellowship director for transplant surgery in Edinburgh.

Thanks, Max. It's a pleasure to join you and the team today talking about organ retrieval and how it might help the resuscitative trauma surgeon.

Uh, in organ retrieval, as you know, we frequently perform operative steps that are really found nowhere else in elective surgery, and that really could be very helpful to the trauma surgeon in a time-critical intervention. I'll go through some of the, the operative steps and discuss also how we train our trainees in performing these steps in a, in a controlled [00:03:00] but time-critical environment.

So thanks all for the introductions. Having just come to the end of a transplant rotation, I'm very aware that there'll be a large group of surgical listeners who will never have been exposed to organ retrieval or transplant surgery. But broadly, there are two types of retrieval that I came across.

Firstly, in patients who are deceased due to brain stem death or DBD, and secondly, those who are deceased due to circulatory arrest, DCD. Importantly, the operatively distinguishing feature is that a DBD retrieval, the heart is still beating, there's normal blood pressure maintained, and the donor remains on a ventilator.

In today's episode, we'll be avoiding the topic of normothermic regional perfusion, which is essentially establishing an ECMO limited to the abdomen and/or chest but needs sort of a master's degree of its own to understand it fully. We'll mostly be referring to the operative steps in DBD and standard DCD retrieval performed by a general surgical trainee with a transplant surgeon oversight to [00:04:00] retrieve the liver, pancreas, kidneys, iliac vessels.

Chris, would you mind briefly going over the steps of a DBD retrieval for the listeners who may not have ever heard of one or seen one before? Could you also tell us a little bit about what the time pressures are in retrieval surgery?

Sure. Th-thanks, Prash. So, as you said, a, a DBD retrieval starts essentially like a normal operation.

The donor is ventilated, blood pressure is maintained, hemostasis is equally important as for any other operation. And for around twenty percent of the donors, a cardiothoracic team will attend and operate simultaneously to retrieve the heart and/or lungs. That means eighty percent of the time, the abdominal team will open the chest to clamp the aorta and often retrieve the heart for valves in addition to retrieving the, the abdominal organs For surgeons new to transplant surgery for training, we generally in the first six months focus on the DBD donor with three main objectives.

First is a fast but safe [00:05:00] thoracotomy to confidently open the pericardium and cross clamp the descending thoracic aorta without causing any injury. Second is a, a comprehensive laparotomy with cattle brash, so essentially right medial visceral rotation to access the aorta and, and cava and full coccyzation of, of the duodenum.

And the, the last thing then for the new trainee is, is a suprasiliac aortic clamp, and this is something that is not particularly difficult procedure, definitely benefits from having some experience of doing that exposure, dividing the left triangular ligament, getting access and confidently placing a clamp there again without injuring the esophagus.

And we're very... It, it's very helpful, this type of surgery that we do have the two types of donors because it's very different. So in the DBD setting, we spend about sixty to ninety minutes of dissection to mobilize the liver, dissect out the portal structures and get... prepare all of the vessels before cannulating the aorta [00:06:00] and exchanging warm circulating blood for cold preservation fluid.

And this allows time to, to be taken to demonstrate the anatomy and increase the confidence of, of more junior trainees. And then we proceed to remove the abdominal organs and that, that part of the procedure is quite time pressured, so it takes about thirty minutes to remove the, the liver, kidneys and pancreas.

And it's an unusual procedure in that there's always a balance against time and injury, unlike you would have in any other operation. So time is really, really important. And just very briefly, DCD procedure is very different. So in this setting once death is confirmed, about five minutes after asystole, the donor is rushed into theater and we aim for timings of door of theater to knife to skin of around one minute and knife to skin to clamping the aorta in the chest, cannulating the aorta in the abdomen within three minutes.

So that's clearly very different. It requires a bit more experience, [00:07:00] but it's equally of significant value to the potential trauma surgeon in doing these procedures at a much higher, higher speed, more akin to what you might need to do in a cardiac arrest situation.

Yeah, thanks very much for the explanation, Chris.

Um, I completely agree. In my sort of six months of, uh, retrieval, uh, exposure it was one of the only places I've come across where as a trainee actually you really have that time pressure element as well that you're sort of bearing in the back of your mind and almost the license to operate quickly as well.

So hopefully that gives listeners a bit of a overview of the procedure and a taster of how some of these steps might help a trauma surgeon. So let's see how this might help us tackle some of Roisin's cases.

Yes, thanks, Prash. This brings us perfectly to our case discussions. I've brought three classic resuscitated trauma scenarios today, and I'm going to use these as a scaffold to discuss difficult operative steps with Max and how retrieval surgery might [00:08:00] expose a surgeon to these steps with Chris, and explore how Prash learned these transferable skills during his transplant rotation.

So let's start with case one. Um, this is a twenty-four-year-old male who was brought into the emergency department with a single stab wound to the left parasternal edge. He loses output in the resuscitation bay, undergoes an emergency clamshell thoracotomy. Max, once that chest is open, what is the immediate priority and the primary challenge?

Uh, thanks, Roisin. So, this feels a bit like our previous podcast. So, um, you know, the immediate priorities we discussed then, uh, was that we've got to relieve the cardiac tamponade. So we've got to swiftly, safely open the chest. In this case, uh, as is standard in UK practice, we talked about a bilateral anterolateral thoracotomy or a clamshell thoracotomy.

Once we've done that safely, we need to relieve the tamponade and [00:09:00] essentially ensure that the heart can fill again in diastole creating some cardiac output.

So once we open the pericardium, we would evacuate the

pericardial blood, which was causing the tamponade, and then repair the cardiac stab injury with prolene sutures and pledgets.

Now, depending on your time from traumatic cardiac arrest to evacuating the tamponade, the cardiac contractility may be sufficient, or it may need some encouragement to get a good cardiac output again. So to do that and to encourage coronary artery filling and return of spontaneous circulation, we need to occlude the thoracic aorta.

You can do that manually. You can just compress the thoracic aorta in the chest, but that tends to get quite tight in terms of space for the operators. So you've got one hand in there manually compressing the thoracic aorta and, um, two hands doing internal cardiac massage. [00:10:00] So I find it's advantageous to use a clamp across the thoracic aorta rather than have that, uh, extra pair of hands in the chest, which it can all get a bit tight

Okay, thank you, Max.

And Chris, how, uh, does this clinical scenario mirror organ retrieval?

Uh, thanks, Roisin. Yes, so this is a, a routine step in retrieval, which, you know, would be performed by the team 15 to 20 times a month. And as we've discussed, the, there's a difference for DBD and DCD, that in the, the DBD setting there's time, so sternotomy is performed, pericardium, we can demonstrate how to do that, to open the pericardium safely, mobilize the, the, the left lung and get it-- lift it right up out of the chest so that you can see exactly where the aorta is and the pleura over it, and put a clamp on confidently.

We can do that a number of times to, to increase the [00:11:00] confidence of, of the trainees. When it comes to the DCD setting, things are much quicker. So we would generally look at opening the chest and putting a clamp on the, on the aorta in under a minute. And to do that, we would teach the trainees that as you reach in on the left side and run your fingers along the ribs at the back, immediately coming from lateral to medial, the first thing that you'll come to is the aorta.

And you can generally punch through the pleura with your thumb and forefinger and reach right the way around and the descending thoracic aorta has no branches there. So generally, that, that is quite a safe thing to do, and it gets it away from the esophagus. So you can gently lift the, the aorta laterally with your thumb and forefinger right the way around it and place a clamp, ideally a centimeter or two centimeters across, so it's literally cross-clamping.

And then once your clamp is on, you're confident it's completely occluding the blood flow there, and you can move on to the next steps. We would see [00:12:00] frequently where a surgeon that isn't confident at the beginning, it's very easy to, to put a clamp partially across the aorta, or it's not fully on, or you're not 100% certain.

And clearly, in a resuscitation scenario, as blood pressure hopefully increases and pressure increases, that, that puts a risk of moving a clamp off it.

Yes. And Prash, how did you learn this specific step over your six months rotation?

Uh, so exactly as sort of Chris has just, uh, described I'd sort of fortunately done some cardiothoracics before, so I was relatively happy getting into the chest and to do a sternotomy, um, but hadn't really had the reason to cross-clamp the descending thoracic aorta.

Sort of having that confidence to be able to punch your finger and thumb across the pleura that covers the descending aorta and sort of being able to grab the aorta. I remember having a trainer saying, "Take a good look at it, you know? Look and see exactly what you're picking up." And I sort of just took, I don't know, [00:13:00] one second to, having gone through the pleura, look at it and go, "Oh, yeah, that's the aorta," and then sort of look and see as I'm putting the clamp down across the aorta.

Of course, you know, in a trauma scenario, you may not have that luxury if it's dark or if there's blood in the, in the cavity as well. But I think almost sort of slowing down and taking a second to make sure you're doing the correct thing actually sort of helped me to avoid that potential mistake of either clamping the wrong thing or, um, of avulsing anything off the aorta.

Similarly, you know, having that confidence to pick up the left lung, pull it over towards myself, deflating it slightly, and getting a good view of the left pleural cavity. I thought those were sort of maybe the, the commonly mistaken bits or the areas that might lead to, to error. Um, and it was good to have sort of an experienced trainer telling me, "This is the way to troubleshoot that issue."

Yes, and Chris, what's going through your mind as the trainer when Prash is doing this, and I guess the common pitfalls and what you're trying to do to keep Prash on the right track?

So, [00:14:00] uh, I, I guess the, the, the thing with this is that the repetitions make a big difference, that, you know, this kind of scenario would very infrequently be encountered anywhere else, whereas it's a routine part of the procedure that's performed week in, week out.

And as a trainer, it's actually relatively straightforward to, to supervise these for new trainees getting, getting going, even in a time-critical way. So we tend to have a, a brief and discussion beforehand, talk through the steps. We have video footage of previous procedures so that we can show exactly what's planned and what's gonna need to be done before we start.

And then once we start off, in general the trainee would be the lead surgeon for 90% of these, even for the NRP retrieval SMEs, uh, Prash touched on earlier. And in general, when we talk through, we will discuss and, and the, the trainee is the first surgeon. We'll put the clamp on. In the f- in the [00:15:00] beginning it's very easy for the trainer to, to have a look and, and check.

And as Prash said, if, if we're making adequate exposure, you can just lift the lung out of the way and check that the clamp is on or reach around and, and feel that. So that, that's not particularly difficult actually and, um, I think Prash's experience with was like that, that the first six months he was up and running straight away.

Thank you. And Max, I know you s- also did some retrieval training as part of your training. Um, and outside of retrievals, have you come across any other specialties in which you can learn and practice this essential trauma skill frequently in such a controlled setting? And how did you become comfortable at this skill?

So thanks, uh, Rasheen. So, uh, I think just answer that second question first. So how do you become comfortable in a skill such as this? Um, for me, I think it's a stepwise [00:16:00] approach, and, um, Mr. Johnson, you know, touched on a lot of this, uh, in, in his response just now. But for me, the first step is understanding why.

Why do we need to do this, particularly in respect to the, uh, trauma resuscitation? Uh, and then how, and how is a stepwise approach. So how is starts with textbooks for me, so I'm gonna read something like you know, Top Knife and, and just understand their approach to how it's done. Then I'm gonna look at the anatomy textbooks, uh, and then courses, cadaveric courses I think have been incredibly helpful.

Um, so in the UK, that's the Royal College of Surgeons, uh, definitive surgical tr- uh, trauma skills, DSTS. In the US I think Asset course is a, is a close equivalent. Uh, and then I think this, what we're talking about now, and organ retrieval is the absolute pinnacle, uh, i-in terms of training. It, it sits for me at the top of that hierarchy.

And that is [00:17:00] understanding the three-dimensional anatomy, the the real you know, haptic feedback of when you run your fingers down the back of the, the ribs and you, and you walk onto the aorta before you hit the vertebra. Uh, those kind of sensations, uh, you only get from, from doing in, in this. Uh, and then I think when you're in that trauma case, that's when that experiential learning really comes to the fore because what you don't want to do, I don't think, is try and learn these steps, and particularly as we talk about some of the, the other cases, uh, you don't really want to be learning these steps in a hurry at three o'clock in the morning when the anatomy is distorted and the patient is you know, critically unwell.

Max, may- maybe I could just make a brief, uh, comment on that, that, um, we've certainly had c- concerns mentioned in the past about, you know, is this ethically appropriate, uh, for training or practicing for a different reason than for an organ for [00:18:00] transplant? And certainly that's not my experience, that having spoken with donor families in the past specifically about video recordings for training it was very positive responses to that, and it was discussed as a way of leveraging the gift that was being given, that it's not just for an individual transplant but for training other surgeons.

And in most cases, a donor family feels very positive about that, that there are more things coming out of it and potentially multiple lives that'll be saved in the future rather than just, you know, of those individual transplants that are being performed as a result of this one donation.

Thank you, Max and Chris.

Some really interesting insights and discussions there. And so let's move on to case two. In this case, it's a 45-year-old female who was involved in a high-speed road traffic collision, and she arrives in with massive abdominal distension. So Max, you do a trauma laparotomy and find a massive expanding zone one retroperitoneal hematoma [00:19:00] above the transverse mesocolon.

What is going through your mind?

Yeah. Uh, so this is a worrying presentation, right? And I think the important thing to say is that, uh, so I'm just coming up to a year of being a consultant or a-attending practice, and, um, for me, this is ringing alarm bells and, uh, I'm gonna wanna ph-phone a friend, uh, and probably get another experienced surgical pair of hands into to this case to manage this 'cause I'm expecting, I'm expecting trouble here.

And, uh, you know, I work at the Royal London Trauma Center. Uh, I think operatively we're the probably the busiest trauma center in the UK and we would expect to see a, a big case like this, you know, probably not more than once a month. Uh, so this is not something I'm super comfortable with if I'm really honest.

Uh, so if we've got a supramesocolic, uh, zone one hematoma, then I'm worried about injuries to the great vessels. So, uh, the supra-celiac aorta, [00:20:00] uh, or the origin of the, the major visceral vessels either that's the, um, celiac trunk or the SMA. And I can't just cut into this hematoma, you know, it's a fundamental strategy of, of trauma training or trauma surgery is that we need proximal and distal control before you dive into the, um, the zone of the hematoma.

Uh, 'cause if we don't have control and I open that hematoma, which is probably being contained by the retroperitoneum, uh, then there's a, a decent risk gonna completely lose control and, uh, the patient may exsanguinate. So I, I need to get proximal control. I'm gonna do that probably at the level of the diaphragmatic, uh, hiatus.

And to do that, I'm gonna likely perform a left medial visceral rotation otherwise known as the Maddox maneuver after Ken Maddox. So to do that, I'm gonna mobilize the left colon, the spleen bring up the, the pancreas, uh, sweeping them up to the right with or without the, uh, the kidney, and we'll talk about that in a second.

And that's gonna give me access to [00:21:00] the, uh, abdominal aorta from, uh, from the diaphragm down to where it bifurcates into the iliacs. The reality is, you know, I haven't done this a thousand times. There aren't that many opportunities to practice this move in elective surgery, uh, in, in general surgery and which is my training.

And that can be you know, potentially a, a, a scary thing to do with that time pressure and a critically unwell patient.

Thank you, Max. And Chris, is this a commonly performed step in retrieval surgery?

S-so I'd say yes and no. Essentially for retrieving the pancreas, you're essentially doing a large step of the Massock's maneuver of lifting the, the spleen directly up out of the abdomen and dissecting back and protecting the pancreas across to the level of the aorta and exposing the aorta.

We generally leave the, the kidney where it is, and you can... As you lift the spleen up, you get a, an avascular plane that [00:22:00] will take you lateral to medial down to the to, to the left renal vein. But I would say this is a, a much more difficult procedure than a right medial visceral resi- rotation. You know, a cattle brush maneuver you can do quickly, relatively bloodlessly, and you can access quite a significant aspect of the aorta.

When you coccyx the duodenum fully, you can expose the level of SMA, and I would generally say that's something that's done as a sort of starting step routinely by the more junior surgeon and will usually give you s-very, you know, perhaps surprisingly, uh, impressive exposure to, to the abdominal aorta, and it's, it's much easier to achieve.

The, uh, uh, in this kind of scenario, I think as, as Max mentioned, the, the first priority is really getting access for a supraceliac cross-clamp. And one of the reasons in, uh, retrieval surgery, if we're [00:23:00] even if we're only retrieving the abdominal orga-organs, we'll routinely open the chest, and one of the reasons for that is access.

That it's much easier to access the liver and access the aorta if the s- the chest is open. If you haven't opened the chest, in this scenario, standard things apply that having adequate lighting having a headlight and having a, we would use a Thompson retractor if you have that available, makes this a much, much easier procedure.

A table-mounted retractor will make a, a suprasiliac cross-clamp a straightforward procedure with easy access and good visibility compared to in a, in a thin donor, in a thin patient it can be a real challenge

Thank you for, for talking us through that. And Prash, the Maddox maneuver is often described in textbooks, but it's notoriously difficult to learn because we rarely do it in elective surgery.

How did your experience with retrieval surgery help?

Uh, yeah, you're entirely right. And Max, thanks for mentioning Top Knife. I've actually got [00:24:00] it right in front of me, having just arrived in South Africa as well, which has some beautiful diagrams of the Maddox maneuver with one of the authors, of course, being Dr.

Maddox. Um, I think in terms of you know, trauma operative steps, uh, every trainee sort of knows about it but will probably realistically never have the opportunity to do it through their training, probably even more rare to be performing these steps regularly. As Chris was saying, you know, i- in the cold phase of organ retrieval usually you'd start with a Caudal-Brash maneuver and then move over to completely mobilize the transverse colon, free the spleen up from its diaphragmatic, uh, lateral peritoneal attachments, set free the splenic fracture, uh, and the lienorenal ligament, and then rather than sort of getting behind the left kidney like in a true Maddox maneuver when we're over on the left-hand side, you'd mobilize the left colon off Gerota's fascia like almost a, an open left hemicolectomy or a, a Hartmann procedure all the way down to the distal sigmoid, uh, rectosigmoid junction.

And in retrieval [00:25:00] surgery, um, this is done to get the bowel out of the way and to expose the retroperitoneum. Um, but it also means that you have the entire abdominal aorta out, uh, the left renal vein exposed, the sple- the spleen and the pancreatic tail mobilized and you've already done a Caudal-Brash before you move over to the left-hand side, and you have the IVC out in front of you as well.

The only other time that I'd, uh, seen a Maddox maneuver performed electively was in a type IV TAAA exposure, um, in vascular surgery, uh, and that was very much sort of watching, being, you know, a fourth pair of hands, whereas in retrieval surgery because it's quite a commonly performed step especially the Caudal-Brash side of things and getting the, um, entire length of the abdominal aorta out on display, I've probably been either doing it or involved in it maybe five to 10 times in a six-month period.

Okay. And Max, this might be possibly a slightly difficult question but how often do you think you'd have to perform a Maddox maneuver in your trauma practice? And outside of retrieval training, did you find a way to [00:26:00] gain exposure to it?

Thanks, Rasheen. So, outside of trauma practice, uh, the only time I've seen these, uh, this Mattox maneuver done is in, uh, vascular surgery of the, of the aorta, and particularly those thoracoabdominal aortic aneurysms that, that Prash mentioned.

In terms of how many times I do this in my trauma practice, I haven't done it yet, uh, in a year. And I remember a case that really sticks with me with colleagues at King's, Duncan Bew and, uh, Umar Wali. We, uh, were looking after a motorcyclist, uh, that came off at high speed and had this really awkward injury of his, uh, aorta across, uh, the diaphragm.

So we needed to do the Mattox maneuver to try and get control but also open the chest. And, you know, it was really challenging. The anatomy was distorted by, um, a big central hematoma. It was bleeding from either sides of, um, you know, the, the diaphragm, which yeah, I'm certainly, [00:27:00] um, have been previously sort of, um Uh, guilty of compartmentalising the anatomy into cavities that, that injuries don't respect.

Um, so you know, that was a real head scratcher, and, and that was a very, very challenging case, uh, where we needed to perform the Maddox maneuver. But yeah, to answer your question i-i-in my practice, y- significantly fewer times than Prash experienced during his retrieval training.

Chris, one of the key takeaways from my retrieval training has been learning to operate quickly.

In a Hartmann's, it might have taken me a few minutes to mobilize the left colon, the splenic flexure, but in a retrieval it takes seconds. Of course the scenario and types of complications are very different. But how do you train a trainee to operate quickly but to avoid injuries?

Thanks, Prash. Well, I think the, the, the first thing is it, it can't be at the expense of quality, and retrieval surgery is fairly unique in that it's one of the most audited procedures [00:28:00] that, that is performed.

So every organ that is retrieved is typically sent to another center, and the first thing that happens when it's taken out of the box is an assessment for any injuries at all, and all of that is recorded alongside recording of all of the timings that goes to implanting centers. And that, obviously that has, uh, you know, parallel with, with your trauma scenario that it's-- you could very quickly have multiple problems at once rather than one in attempting to perform a Maddox maneuver if, uh, if you're not confident with that.

But there's a lot of things that we can do. So we mentioned about the operative video. I think that's very helpful. We have a number of masterclasses that take place on a, on a regular basis throughout the year. There's a, a virtual masterclass that shows a lot of the video exposure, and certainly trauma trainees are w- are welcome to attend that.

That's in November. There are cadaveric, uh, masterclasses as well. And a lot of that is not just the operating, and it's certainly [00:29:00] not each step being performed more quickly. It's, it's the, I think the, the gaps between steps and preparation. You know, what way you can stand, what... where you can have your equipment ready, discussion with the scrub nurse, clarity of communication, clarity of instructions.

That is where it improves. And the video is for the trainees, but it's also for us as surgeons that watching the video back, you really see the, you see where areas could be improved. And again, the audio is really important that you see some of the instructions and the time that is lost is in asking for things and getting the wrong instrument And as you sometimes see this there are some really good examples of this.

So some of our cardiothoracic colleagues when they started DCD heart programs, this is retrieving a non-beating heart, restarting it and transplanting it, and it is really one of the most time-critical [00:30:00] operations that can be performed. And you see for that they have a plan of surgeon one is, you know, knife to open the chest, surgeon two saw, surgeon one again retractor, and it moves in a very smooth and in a way that it doesn't look rushed, it just looks smooth.

Uh, so preparation like that makes a big difference. Preparing your tray, discussing with the scrub nurse which instruments you're gonna need in which order if you can. And the final thing is a large part of the training when it comes to the actual operating is confidence around, around the anatomy. And when we look at where time marches on, it's usually because of the lack of confidence about where you are and what plane you're in.

And a large part is identifying landmark, landmark, this part's safe, cut and move on. And that's where the, the time gradually comes down, and it doesn't cause any expense to the organ quality or encountering [00:31:00] additional bleeding, which becomes really important when you start the NRP retrievals, where you've got 80,000 units of heparin circulating for two hours.

So you need, as you've seen Prash, that's a, you know, different setting of clipping any vessels, moving quickly, but keeping to bloodless planes and preventing any unnecessary bleeding that's gonna cause problems for you

I think having that, um, mental rehearsal as well beforehand where, as you said, Chris, um, you know, in the back of the ambulance when you're heading over, uh, watching that video with you and having it fresh in your memory and also when it's sort of the two surgeons and the scrub nurse while you're waiting for the donor to be ready, going through all of the steps, what instruments you're going to use, what the steps are going to be.

Actually, I found as a, you know, relatively junior trainee that it was really useful to mentally rehearse that, you know, visualize what I'm going to do and have that discussion, you know, a few minutes before the case as well. So I thought that really helped in terms of having a plan in my mind and then sharing that sort of mental model both with [00:32:00] the consultant and the trainer, but also with the scrub nurse as well who's going to be handing you those bits of kit.

So I thought that was something that was, um, really useful and might be translatable into trauma, you know, when you're, uh, practicing scenarios beforehand, which relies on you having the same scrub team every time as well.

I, I, I think so, and I think it's something that hasn't really been in the culture of surgery, certainly in the UK, which I find very surprising.

You know, professional golfers and dancers have had video-based feedback and training for 20 years, but it's only really gradually coming in. And it's not just for the junior trainee. For consultants as well, it's helpful. I find doing a brief with the trainee and the scrub nurse is helpful for procedures, particularly if you're not going out that often or if it's a procedure.

We, we have shortened videos for procedures that we perhaps wouldn't do all that often that we can share with consultant colleagues of femoral access, ten ECMO lines, that kind of thing, that these are not difficult [00:33:00] procedures, but they involve maybe 20 or more steps and need to be done reasonably quickly.

So having that, uh, really, uh, just avoids simple errors that take up time.

Next on to case three, where we'll transition to the other side of the abdomen. A 19-year-old male presents with a gunshot wound to the right upper quadrant. Max, you open the abdomen, and there is torrential venous bleeding from behind a shattered liver.

Yeah. So this is a really difficult scenario. And you know, it's, it's potentially very problematic. So we're gonna start with the simple steps, uh, that we do routinely for every trauma laparotomy, and I'm gonna try and pack this liver as, as we would when I open the abdomen for quadrant packing. Uh, if I think the bleeding's particularly coming from one area of the abdomen, I'm gonna concentrate my packing there to begin with and see if that controls the bleeding.

If it doesn't, I'm then gonna [00:34:00] escalate through my ladder of hemorrhage control for the liver. And that's going to include a Pringle maneuver. And if that's not helping then I potentially have got a bleed from behind the liver. Uh, so if we've controlled the inflow to the liver via occlusion of the, uh, hepatic artery in Pringle, uh, and we've still got a load of dark red bleeding welling up, then, you know, I'm worried now that I've got either hepatic vein injury or a retrohepatic IVC.

Again, this is phone call to a friend, hopefully before the point of realization so that they're on their way in because you, I, I think, need two, uh, experienced surgeons to, to manage this well. We're gonna need to try and get proximal and distal control of the bleeding point, uh, if that's possible.

Uh, and that may require, uh, total hepatic isolation, so total, uh, control of the liver inflow and outflow So to do that, um, we're [00:35:00] looking at the cattle brash again to, to get onto the infrahepatic IVC but we're also going to need to mobilize the liver superiorly, laterally, and medially to get control of the suprahepatic IVC.

I'm gonna be thinking about whether I need to do that from the abdomen or potentially, uh, from the very short segment of suprahepatic IVC that's in the chest and in the pericardium. And this is clearly a, a very significant injury if we've got bleeding, uh, from the either the retrohepatic IVC or hepatic vein and this carries a, a significant mortality risk to it.

So, uh, this is, this is challenging, uh, for, uh, for even the most experienced trauma surgeons in the world.

Thank you, Max, for talking us through those steps and I guess your real ti-time thought process. Chris, your background in liver retrieval and your implant practice must be the perfect exposure for this clinical [00:36:00] scenario if you were to come across it as a traumatic injury.

Uh, yes. Thanks, uh, Roisin. So I th- I think, uh, what Max has said, preparation, usually if you're going into something like this, you'll have a good idea that there's potential for, for trouble beforehand, and as we mentioned before, the standard things, access and visibility proximal distal control is the, the really key here.

The surprising thing I think for a lot of people the, the infrahepatic cava, so the IVC below the liver, is relatively easily accessed, certainly compared to the cava above the liver, and as Max said, it's, it's sometimes if that's necessary, it's sometimes easier to clamp it in the chest inside the pericardium.

Uh, getting around the cava above the liver in a trauma scenario would be a real challenge and risky as well. Whereas getting below the liver and you know, dissecting that out is relatively straightforward or even just compressing [00:37:00] it to begin with I would say 80% of the blood flow is coming from the cava below the liver and above the liver it's almost negative pressure going into the heart so above the liver, more difficult, less benefit.

If you're able to compress or ideally go around with a vascular tourniquet the, the cava below the liver and put your pringle, again, we tend to use a, a vascular tourniquet that can be put on gently. You're really just trying to compress the, the portal veins. It's not high pressure. That will generally get you control and certainly buy enough time to, to get some, some help.

For mobilizing the, the liver, I think for packing the liver, taking down the falciform ligament is important. It's difficult to pack the liver and get adequate pressure on it without taking down the falciform and mobilizing it slightly at the back. But again, there are problems with that, that if you think there is a, a significant vascular injury behind the liver, I generally, if you're able to get [00:38:00] control of the cava at least below the liver I would do that before venturing to mobilize it because even for any liver transplant, what we would predict to be a straightforward transplant, we would have two cell savers and be prepared for significant bleeding, 10 to 20 liters is not unusual.

Uh, which you wouldn't tend to get thankfully in other elective practice. So in the trauma setting, uh, I would advise caution. And if you have to, if you have to get it in there, then yes, a transplant experience even six to 12 months, as Prash mentioned, would, would be helpful if you're unfortunate enough to end up in this scenario.

Thank you, Chris. And Prash, how did you handle the complexity of the portal triad and liver mobilization when you started on transplant?

Yeah, so you're about to hear essentially the exact opposite of the voice of experience that Chris clearly is in, uh, what he's just mentioned. My, um, surgical training, I hadn't done an HPB [00:39:00] rotation and haven't done one yet, so it was pretty much liver surgery to me equals dissecting the gallbladder off the gallbladder fossa, and that was about it.

So to go from that to, uh, describing, you know, what Max and Chris have just talked about seems an entire world away. But I'm sure, you know, my next, um, three to four years of surgical training will hopefully start to bridge that gap a bit. In retrievals and implants, um, learning to cut to fully mobilize the liver was really helpful.

But the thing that I wanted to talk about mostly was actually the advantage of, uh, sort of back table dissection. So in Edinburgh, the retrievals are mostly, um, en bloc retrievals of the liver, pancreas, duodenum, spleen all together, which I think is the most straightforward way of getting the organs out of the abdominal cavity, and they're then split up on the back table.

And the back table is probably where I've actually learned the most in terms of anatomy and, uh, especially the vascular anatomy of how the liver, pancreas, spleen are all connected up. I've not really had any other opportunity anywhere else [00:40:00] to, um, relative... with relative comfort and a bit of time and, you know, good lighting, be able to dissect out the portal triad inspect it and expect aberrant anatomy, uh, and learn vascular reconstructions as well.

So I thought while we're, you know, having a, a podcast episode about the advantages of retrieval surgery, uh, as an exposure to potential trauma surgery, actually, I, I thought, you know, we should mention, um, the back table, which is where you're able to, um, figure out exactly where the arteries are, how they're connected up, uh, and be able to dissect them free or indeed reconstruct them if you need to.

Um, that was a really invaluable skill to pick up as well. Uh, knowing how they're sat on the back table then helps me, uh, sort of visualize where they might be especially aberrant or replaced left and right hepatic arteries, um, in situ as well.

Yeah, and, and I can't emphasize enough how rare that, that skill is, Prash, and I think that's a really good point.

Uh, and I think that gets to a lot of what we've [00:41:00] been saying, which is, you know, you need to have an understanding of the three-dimensional anatomy. Uh, you need to have the time and space mentally to, to appreciate, learn, understand, uh, how that anatomy relates to, uh, each other. And y- I think that's a, a great point.

You know, the back table is, is is a really useful place to do this. I think most general surgeons in the UK will finish their training without mobilizing a liver or exposing the, the retrohepatic IVC. These are you know, these are sort of fellowship, uh, for the majority of surgeons, uh, fellowship plus, you know, early consultant career, uh, skills.

I try and spend a bit of time with my HPB colleagues, again, because I think that i- it's useful to see this anatomy in elective settings, in that slightly calmer environment where the anatomy isn't distorted by an injury, uh, so that at 3:00 in the morning, invariably [00:42:00] when it comes in you have some understanding of where things should be.

Uh, one other thing just to mention about the specific injury is that, uh, we did a, a recent M&M, and I went away and looked at the literature of retrohepatic IVC injuries and, um, found some really beautiful diagrams demonstrating a to cable jumps. Uh, and the sort of older and bolder surgeons in the, um, in the audience in the M&M, We're very much of the opinion that that practice is, is not useful and, and, um, this is the idea of trying to shunt the, an IVC from the abdomen into the, uh, atrium using often, uh, something like, um, a chest drain.

But the feeling was that in most hands th- this isn't going to be successful. Uh, so that had gone. That was quite an important learning realization for me. Um, and I wonder while we've got Mr. Johnson, uh, with us today, whether there are any other sort of top tips Chris, sorry to put you on the spot, that you [00:43:00] might, um, be able to share with us, uh, about managing such an injury.

You mentioned having that set up on table, so table-mounted, uh, retractors. Any, any other sort of top tips that y- you could share with us from this, you know, really awful injury pattern?

Yeah. So, so I mean, it, it's, it's one of those things to, to not come across as too conservative, but in general, doing the, the least that is necessary to achieve a, a safe environment and waiting for some additional support because things can go south very quickly.

One of the things for the portal dissection, you know, Prash mentioned about 20% of patients will have variant arterial anatomy, and that's often getting to grips with that is the, the final step before our fellows go out independently for, for retrieving liver and, and pancreas. But I think the, the key things in a trauma scenario, portal vein is obviously, is say, one of the only [00:44:00] vessels that you can't tie off.

You know, so you can tie off aorta, you can tie off cava if you had to. Not advisable, but possible. Uh, but portal vein, uh, you won't manage for more than a few hours without it. And so big sutures in that area are frequently very problematic, particularly as they can take out portal vein and, and artery and result in liver infarction.

Whereas getting around for Pringle tape and occluding the, the portal vein is relatively straightforward and relatively safe. So I think, you know, I would say complete portal, complete liver occlusion It's quite a challenging procedure, particularly in a, a trauma scenario where you've already got significant bleeding.

But compressing the cava below the liver and putting a, a Pringle tape on, and that can be on, you know, you, you can have it 45 minutes, absolutely no problem. Uh, if necessary, enough time to take down the falciform ligament mobilize the, the liver a little bit if you [00:45:00] have to. And I mean that of just dividing superficial attachments a-a-around the side and the back of the liver so that you can pack anterior, posterior, and just compress the liver together.

And most of the time, that will get out of a completely critical scenario through to a degree of stability that will allow for your anesthetic team to, to catch up. And often, that would be the, the, the first step of getting in, getting packed, correcting clotting, and enough to get back to a bit of intensive care support and then plan definitive management in a more controlled setting.

So thanks, Roisin, for guiding us through those cases. They were really great in highlighting trauma exposures, operative steps, and how a trauma surgeon might be exposed to these steps that actually could be done relatively frequently in transplant in a controlled but time-pressured environment.

Max, through your training and now in your consultant practice are there any key operative steps that you'd [00:46:00] have ex- you'd be expected to perform in trauma that you may have struggled to gain regular exposure to whilst training?

Thanks, Prash. I think that's a really good question, and it's definitely something that I tried to think about during my training.

And, and in the UK we, I think, have an advantage of having or, or at least training is deliberately broad to begin with. And, uh, there's a tension here, and I think that tension is being sufficiently rounded that you can use those skills for, for trauma. And, you know, trauma is a broad specialty where, uh, you may need to do a vascular anastomosis.

Uh, you may have to, you know, rarely do something extreme like a perimortem hysterostomy. In, in the military world, you know, we need to be able to do burr holes if we're on our own. There are plenty of specialties in a, in a busy hospital where you can, uh, be exposed to those procedures and I think, you know, making [00:47:00] friends with colleagues around the hospital and, uh, seeing what they do, uh, either, you know, ad hoc when you're, when you're free, uh, what's coming up on the emergency list or, or more formal than doing a rotation in a specialty that's outside your main, uh, goal.

So cardiothoracics, for example, like you mentioned earlier, is, is really, really useful. But the tension then is that you do still need to pass all of the prerequisites, um, that in the UK that the Joint Committee on Surgical Training mandates for you to become a subspecialty general surgeon in, you know, for me, for example, upper GI surgery.

So there is a bit of a tension there. There is a recognition now that, uh, trauma surgery in the UK is a training path in its own right, but that is a very new thing, and I think takes some thought and a lot of collaboration with the training program [00:48:00] director to make sure that you are getting exposure to those jobs such as transplant that are gonna be helpful for, for trauma training

I completely agree, Max, with, um, you know, everything that you, you mentioned.

And I think being the most junior member o-on this team, it is important to, I guess, have that consideration. Whilst you're doing training, at times it can be quite easy to have tunnel vision on the end goal and focusing on, as you mentioned, the prerequisites that you need to get through your years of training.

But sometimes exploring rotations in complementary specialties overall when you're a senior specialist will stand to you, and there'll be opportunities that you necessarily wouldn't be afforded further down the line. So I think really just looking at the, the whole picture rather than the end goal is really important to remember whilst completing training.

I,

[00:49:00] I very much agree with that. And I think looking at, at transferable skills and skills that you can pick up in areas that you might not expect. So in our setting, HPB very much helps retrieval. Retrieval h-helps HPB. Renal transplant, arteriovenous fistulas are fantastic vascular anastomoses for trainees to, to do.

And similarly, often a renal vein for a kidney can be more challenging than a, a portal vein anastomosis, and you can rack up significant experience in that context. And I'll just say very briefly that for our transplant fellowship program, we very much try to curate, if you like, a group of trainees with differing subspecialty interests and different levels of experience.

So we have some that are HPB, getting a bit of transplant experience, some liver transplants, some kidney transplant, and increasingly other trainees who, like we've mentioned here, are in a different specialty but coming for six months or a [00:50:00] year of additional exposure to areas that they wouldn't get elsewhere.

And we very much benefit from a, as a program, from having enthusiastic and, and keen, uh, surgeons coming to join us from varied, uh, areas that we wouldn't normally see. So very much welcome supporting the, the trauma surgeons around the UK and elsewhere and, uh, encourage them to get in touch if they're interested.

Chris, that, that's really wonderful to hear. And, uh, certainly our military, uh, senior leadership are, are very keen that we as surgeons just approaching consultant practice, uh, and even consultants looking to maintain their skills, uh, do undertake organ retrieval, um, for all the reasons we've discussed today.

But also, you know, the, that reproducible opportunity to operate under time pressure and, and go into areas of the body that, that are you know, uncommon in, in most elective practice. So, that's, [00:51:00] that's great to hear.

So all that's left to say is thank you very much to the whole team, Chris, Max, and Roisin.

We look forward to joining you again in a few months' time for our next installment, which will be a journal review in trauma surgery. Um, but up until that time, all that's left to say is to our US listeners, dominate the day, and to our British listeners, cheerio