Overview

Definition:
-Liver packing is a critical surgical technique employed to control massive, life-threatening hepatic hemorrhage when other hemostatic measures have failed
-It involves strategically placing sterile surgical sponges or gauze within the liver parenchyma, porta hepatis, or subdiaphragmatic space to provide direct external compression and tamponade the bleeding vessels.
Epidemiology:
-Severe hepatic hemorrhage is a leading cause of death in patients with blunt or penetrating abdominal trauma
-It can also occur in the context of major hepatic resections, hepaticojejunostomy, or rupture of hepatic tumors
-The incidence of requiring liver packing is relatively low, typically reserved for uncontrollable bleeding.
Clinical Significance:
-The ability to effectively manage severe hepatic hemorrhage through techniques like liver packing is paramount for surgical residents preparing for DNB and NEET SS examinations
-Rapid and appropriate intervention can be lifesaving, significantly impacting patient outcomes and demonstrating critical surgical skill under pressure.

Clinical Presentation

Symptoms:
-Hypotension refractory to initial resuscitation
-Tachycardia
-Signs of hemorrhagic shock
-Abdominal distension and tenderness
-Palpable pulsatile mass in severe cases of vascular injury
-Hematemesis or melena if associated with gastrointestinal bleeding.
Signs:
-Signs of hypovolemic shock including pallor, diaphoresis, altered mental status, and weak peripheral pulses
-Abdominal examination may reveal distension, bruising (Cullen's or Grey-Turner's sign in severe retroperitoneal extension), rigidity, or guarding
-Auscultation may reveal absent bowel sounds.
Diagnostic Criteria:
-There are no specific diagnostic criteria for liver packing itself
-it is an interventional procedure
-However, the indication for packing is based on the clinical presentation of severe, uncontrollable hepatic hemorrhage during laparotomy, typically following trauma or complex hepatic surgery, despite attempts at direct ligation, electrocautery, or topical hemostatic agents.

Diagnostic Approach

History Taking:
-Detailed history of trauma mechanism (blunt vs
-penetrating)
-Previous abdominal surgeries or liver disease
-Medications (anticoagulants, antiplatelets)
-Time of last meal if emergency surgery is contemplated
-Rapid assessment of hemodynamic stability.
Physical Examination:
-Focused abdominal examination for signs of peritonitis, distension, ecchymosis, and masses
-Assess for signs of shock
-A thorough cardiovascular and respiratory assessment to evaluate the patient's overall stability.
Investigations:
-FAST scan (Focused Assessment with Sonography for Trauma) for rapid fluid detection
-CT abdomen with contrast is crucial for identifying the source and extent of hepatic injury, vascular disruption, and active bleeding (if hemodynamically stable)
-Laboratory investigations include complete blood count (Hb, platelets), coagulation profile (PT, INR, aPTT), liver function tests, and cross-matching for blood products.
Differential Diagnosis:
-Other intra-abdominal sources of hemorrhage (spleen, kidneys, mesentery, bowel)
-Aortic or IVC injury
-Diaphragmatic rupture with hemothorax
-Ruptured ectopic pregnancy in females of reproductive age
-Spontaneous rupture of hepatic adenoma or hepatocellular carcinoma.

Management

Initial Management:
-Immediate resuscitation with crystalloids and colloids
-Early initiation of blood product transfusion (packed red blood cells, fresh frozen plasma, platelets in a 1:1:1 ratio)
-Correction of coagulopathy
-Rapid sequence intubation and mechanical ventilation if indicated
-Hemodynamic monitoring (arterial line, central venous pressure).
Medical Management:
-While not a primary treatment for active hemorrhage, medical management focuses on resuscitation and support
-This includes aggressive fluid resuscitation, blood component therapy, reversal of anticoagulation if applicable, and correction of metabolic derangements
-Inotropic support may be required for persistent hypotension.
Surgical Management:
-Laparotomy is indicated for patients with hemodynamic instability and suspected intra-abdominal bleeding
-The surgical approach involves identifying the source of bleeding
-Initial attempts at hemostasis include direct ligation of visible vessels, bipolar electrocautery, topical hemostatic agents (e.g., oxidized regenerated cellulose, gelatin sponges, fibrin sealants), and sutures
-If bleeding remains uncontrollable, liver packing is performed
-This may involve: 1
-Pringle maneuver (occlusion of the porta hepatis) to temporarily reduce inflow
-2
-Placement of large laparotomy pads (sponges) into the liver substance, particularly in lacerations
-3
-Placement of packs around the liver hilum and beneath the diaphragm to provide external compression
-4
-Definitive surgical control may involve hepatic resection, hepatic artery ligation (rarely), or hemostatic suturing techniques
-Packing is typically a temporizing measure, with re-exploration planned within 24-48 hours.
Supportive Care:
-Intensive care unit (ICU) admission postoperatively
-Continuous hemodynamic monitoring
-Mechanical ventilation and respiratory support
-Strict fluid and electrolyte balance
-Nutritional support via nasogastric or parenteral feeding
-Early mobilization as tolerated
-Close monitoring for signs of re-bleeding, infection, or organ dysfunction.

Complications

Early Complications:
-Re-hemorrhage after pack removal
-Compartment syndrome of the abdomen leading to abdominal hypertension and organ ischemia
-Biliary leakage or fistula
-Post-operative coagulopathy
-Acute kidney injury
-Respiratory distress syndrome
-Sepsis.
Late Complications:
-Biliary strictures
-Liver abscess formation
-Adhesions leading to bowel obstruction
-Chronic pain
-Hepatic dysfunction or failure in cases of extensive parenchymal injury
-Pseudoaneurysm formation.
Prevention Strategies:
-Judicious use of packing, removing it as soon as definitive hemostasis is achieved
-Careful packing to avoid excessive pressure
-Prompt re-exploration to remove packs to prevent complications
-Aggressive perioperative fluid management and blood product resuscitation
-Prophylactic antibiotics
-Early recognition and management of coagulopathy.

Prognosis

Factors Affecting Prognosis:
-Severity and extent of liver injury
-Hemodynamic stability at presentation
-Time to definitive surgical control
-Number of units of blood transfused
-Development of complications (e.g., sepsis, ARDS, MOF)
-Patient's underlying comorbidities.
Outcomes:
-Liver packing is a lifesaving procedure, but associated with significant morbidity and mortality
-Survival rates vary widely depending on the underlying cause of hemorrhage and patient factors, but can be as high as 70-80% in selected trauma cases
-Morbidity remains high due to the severity of the initial insult and the potential for complications.
Follow Up:
-Close follow-up is essential
-This includes serial abdominal examinations, laboratory monitoring (Hb, LFTs), and imaging (ultrasound or CT scan) to assess for complications such as abscesses, bilomas, or strictures
-Long-term follow-up may be required for patients with significant hepatic dysfunction.

Key Points

Exam Focus:
-Liver packing is a temporizing measure for uncontrollable hepatic hemorrhage
-Indications: refractory shock despite resuscitation and direct hemostasis
-Technique: placement of sponges to tamponade bleeding
-Re-exploration is mandatory within 24-48 hours
-Complications include re-bleeding, abdominal compartment syndrome, and biliary issues.
Clinical Pearls:
-Always consider Pringle maneuver before packing if possible to reduce inflow
-Use appropriately sized sponges and avoid excessive force
-Pack not just the laceration but also the surrounding areas for maximal compression
-Document the number of sponges placed for accurate removal.
Common Mistakes:
-Delaying laparotomy in hemodynamically unstable patients
-Inadequate resuscitation before surgery
-Failure to identify the exact source of bleeding before packing
-Leaving packs in situ for too long without re-exploration
-Insufficient compression or improper placement of sponges.