case: splenoportal confluence trauma

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A question for surgeons;
Suppose you recieve MVA with vasculopathic lady in shock, thoracic trauma with pneumothorax and flail chest(drain), at laparotomy bleeding liver, multiple cracks (packed), more than one liter of blood lost right there, zone II hematoma expanding at left, small zone I hematoma, and because someone else ordered a CT beforehand in another smaller hospital (believe me, if this story was true, it would not be in my hospital, and I would not have asked for it, I know better), you know you have a blush at the splenoportal confluence as well as on the left renal vein. Pancreas looks really bad. Proximal jejunum blown after angle of Treitz. 


Do you have any other ideas beside what I would do next in this crashing patient while the anasthaesiologist has fun with  the blood bank (remember this case is fiction, we're on the net!):
Staple jejunum, left medial visceral rotation, huge hematoma, left nephrectomy, spleen is OK, aorta OK,opening of the lesser sac, pancreas looks bad but in one piece (not sure), and splenic vein seen from the back-left looks OK... don't want to do a Cattell-Braasch manoeuver because the liver is packed... and don't want to try to get to the (maybe bleeding) splenoportal confluence from the left because I would not have control if it bleeds, and if it does'nt bleed I don't need to get there!  


And no angio, by the way. Anyway patient is acidotic.  Lost 2500 cc blood just in surgery. Not bleeding anymore, from what I see.


Would you do a on-table angio from the splenic vein with a C-arm? I would take the spleen out to at least reduce blood flow to the confluence, pack and go away putting a peripancreatic drain and temporary abdominal closure.


Your ideas are welcome for this (theoretic, remember?) case.  On second look, if no bleeding, do you think the image is VOMIT, ignore it and just unpack, anastomosis on jejunum, and go away? Or angio through what is left of the splenic vein, or Cattell-Braasch, Kocher and explore from the right?

Do you try to do a pancreatography through tail of the funny-looking pancreas? I don't think so but welcome any good ideas and/or new evidence on this.


JPA
rural community surgeon

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