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.