Because the pancreas doesn’t shout when it’s injured, it whispers, waits, and then destroys.
The Lie of First Impressions
Pancreatic trauma rarely looks bad at first glance.
Minimal bleeding. A bruise here. A tear there.
The liver hogs the attention. The spleen throws a tantrum.
The pancreas just… sits there.
And that’s the trap.
The pancreas doesn’t bleed to kill, it leaks to kill.
Enzymes dissolve tissue.
Ductal leaks create sepsis time bombs.
Retroperitoneal hematomas become necrotizing pancreatitis.
By the time the patient shows you they’re sick,
the window to help has often slammed shut.
Anatomy is Destiny
The pancreas lives in the worst possible neighbourhood:
Surrounded by:
- Portal vein
- Superior mesenteric vein (SMV)
- Superior mesenteric artery (SMA)
- Hepatic artery
- Bile duct
- Duodenum
One wrong move, one injured duct, suddenly damage control becomes a war zone.
Head. Body. Tail. Three Injuries, Three Different Fights.
Injury to the Head
This is where trauma gets ugly, fast.
The pancreatic head’s relationships:
- Wrapped around the duodenum
- Hugging the portal triad
- Neighbours with SMA/SMV
A blow to this area means:
- Check the duodenum, ALWAYS (Kocher manoeuvre or you’ll miss a hole)
- Check the bile duct, subtle injuries ruin lives
- Check the portal vessels, bleeding here is a bad day in slow motion
Duct Intact?
→ Drain + watch
(A well-placed cavity drain is worth gold)
Duct Disrupted?
→ Minimal options:
- Roux-en-Y Pancreaticojejunostomy if stable
- Pancreatic head resection is rarely survivable in trauma without support, call hepatopancreatobiliary surgery early
Vascular involvement?
If SMA or portal vein is shredded:
- Packing + tamponade → get out
- IR or staged repair once physiology returns
Pancreatic head injuries are not a place for lone-hero surgery.
Injury to the Body
Middle ground, literally and figuratively.
- Bleeding is manageable
- Exposure is better
- Duct injuries more obvious
If duct intact → drain
If duct compromised → distal pancreatectomy with splenectomy if stable
Tip: preserve spleen in low-grade trauma only if patient is not borderline.
If there’s hypotension, take the spleen, move on.
The body gives you options.
Take them without overthinking.
Injury to the Tail
Tail trauma seems harmless, until the pancreas tail kisses the splenic hilum.
- High association with splenic injuries
- Vascular proximity means sudden bleeding
- Duct injury here loves to form pancreatic fistulas
Management:
- Distal pancreatectomy usually the move
- Drains if small, contained injury and duct appears intact
The tail bleeds and leaks, pick your poison and drain what you fear.
The Duct Is Everything
A pancreatic laceration without duct injury is an inconvenience.
A laceration with duct injury is a crisis.
You must know: is the duct in or out?
Tools for the truth:
- Intraoperative inspection (don’t be shy, open the lesser sac)
- HIDA rarely helpful in acute trauma
- ERCP if stable and time exists (stent early → better outcomes)
- MRCP in slower burn cases
If you leave a duct leak behind, it will come looking for you later, as a fistula, abscess, sepsis, or all three.
Associated Vascular Injury Around the Head
This is where trauma becomes a nightmare:
Vessels at stake:
- Gastroduodenal artery
- SMA
- SMV
- Portal vein
- Hepatic artery
If these are involved:
- Bleeding is deep, dark, and hard to see
- Suction lies to you
- Packing becomes your best friend
- Consider aortic control or REBOA just to get breathing space
You don’t reconstruct SMA with lactate 10 and a MAP of 40.
You pack, drain, get out, and come back when they’re human again.
Damage Control Wisdom (Earned the Hard Way)
- Drain every pancreatic cavity you’re unsure of
- Never miss a duodenal injury, do a Kocher every time
- If in doubt about the duct, assume it’s injured
- Stents early save lives later
- Pancreatic head trauma is team surgery, call for help
- Don’t close fascia tight if retroperitoneum is swollen, ACS will punish you
- Plan a relook before things fall apart
Pancreas trauma won’t kill them today.
It kills them next week if you ignore it.
The Long Tail of Pancreatic Trauma
Survival isn’t the end.
Complications define the aftermath:
- Pancreatic fistulas
- Necrosis
- Sepsis
- Late biliary stricture
- Portal vein thrombosis
Follow-up is a marathon, and each clinic visit is a reminder that trauma isn’t a single moment.
And From Behind the Drapes…
They’ll remember the crash. The fall. The weapon.
But they’ll never know the organ that nearly took them weeks later with a leak they never felt, a duct they never knew existed.
We guard them from the complications they cannot see.
Because for them, the danger ended the day they survived.
For us, that’s when the real fight began.
