Overview
Definition:
Segmental hepatic packing involves localized packing within specific liver segments to control bleeding, often in conjunction with a Pringle maneuver
The Pringle maneuver is transient occlusion of the hepatic artery and portal vein inflow to the liver, typically performed to reduce intraoperative blood loss during hepatic resections or in cases of severe hepatic trauma
The addition of shunts (e.g., portovenous or cavoportal shunts) may be employed in specific scenarios to maintain organ perfusion or facilitate de-arterialization of segments.
Epidemiology:
Indications for these techniques arise in complex liver surgeries, trauma management, and cases of uncontrollable hepatic bleeding
The incidence of severe hepatic bleeding requiring such interventions is variable and depends on the surgical context and patient population
Trauma accounts for a significant portion of emergent hepatic packing scenarios.
Clinical Significance:
These techniques are critical for surgeons managing major hepatic bleeding, especially during oncologic resections of vascular tumors or trauma management where standard hemostatic methods may be insufficient
Understanding their application is vital for reducing perioperative morbidity and mortality, and for resident preparedness for complex surgical scenarios.
Indications
Major Hepatic Resection:
Control of significant bleeding from major vessels within the liver parenchyma during extensive resections, particularly for tumors involving major vascular structures.
Hepatic Trauma:
Management of severe, life-threatening hemorrhage from liver lacerations, particularly in the context of blunt or penetrating abdominal trauma where damage control is paramount.
Vascular Liver Tumors:
Facilitating oncologic resection of hypervascular tumors like hepatocellular carcinoma or metastases, where meticulous hemostasis is crucial.
Rare Indications:
Management of intraoperative rupture of aneurysms of hepatic vessels or severe post-operative bleeding not controlled by other means.
Preoperative Preparation
Detailed Imaging:
Comprehensive CT angiography or MR angiography to delineate tumor vascularity, venous drainage, and relationship to major vessels, guiding planned resection and Pringle strategy.
Blood Products Availability:
Ensuring adequate availability of packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate
Advanced bleeding management protocols should be in place.
Anesthetic Considerations:
Careful hemodynamic monitoring, including arterial line and central venous access
Anesthesiologists must be prepared for rapid fluid resuscitation and potential coagulopathy management.
Surgical Team Briefing:
Clear discussion of the surgical plan, including the extent of resection, anticipated bleeding sites, and the precise timing and duration of the Pringle maneuver and use of shunts.
Procedure Steps
Pringle Maneuver:
Dissection of the hepatoduodenal ligament to identify and isolate the common hepatic artery and portal vein
Temporary occlusion is achieved using a vascular tape or vessel loop, with careful monitoring of duration to prevent ischemic injury.
Segmental Packing:
Once inflow is controlled, bleeding segments are identified
Packing is performed using sterile gauzes or sponges, meticulously placed within the specific segment to achieve direct tamponade effect on bleeding vessels
Packing is done from periphery inwards.
Shunt Placement If Indicated:
In selected cases, shunts may be placed
A portovenous shunt might be used to maintain portal flow to non-ischemic segments or to divert flow
A temporary cavoportal shunt can be used to maintain systemic circulation if liver failure is a concern during prolonged ischemia.
Completion Of Resection And Hemostasis:
The hepatic resection is completed, with meticulous attention to hemostasis of the resected surface
The liver bed is irrigated and checked for any residual bleeding points
Packing is removed incrementally after confirming hemostasis.
Postoperative Care
Intensive Monitoring:
Close monitoring of hemodynamic status, urine output, and coagulation profile in an intensive care unit setting
Serial hemoglobin and hematocrit levels are essential.
Fluid And Electrolyte Management:
Aggressive fluid resuscitation may be required, with careful attention to electrolyte balance and acid-base status
Management of potential dilutional coagulopathy.
Liver Function Tests:
Serial assessment of liver function tests (bilirubin, ALT, AST, albumin, INR) to detect evidence of hepatic ischemia or dysfunction.
Antibiotic Prophylaxis:
Broad-spectrum antibiotic prophylaxis is crucial to prevent infection, especially given the use of packing and the surgical manipulation of the liver
Fever is investigated promptly.
Complications
Ischemic Hepatitis:
Prolonged or repeated Pringle maneuvers can lead to ischemic injury to the liver parenchyma, manifesting as elevated liver enzymes, coagulopathy, and potentially liver failure.
Postoperative Hemorrhage:
Inadequate packing or failure to secure hemostasis can lead to significant postoperative bleeding requiring re-exploration.
Bile Leak:
Injury to bile ducts during packing or resection can result in bile leaks, requiring drainage and potentially further intervention.
Infection:
The presence of packing material increases the risk of intra-abdominal infection, abscess formation, and sepsis
Early removal of packing is important once hemostasis is assured.
Shunt Related Complications:
If shunts are used, potential complications include thrombosis, infection, and malposition, necessitating careful monitoring and management.
Key Points
Exam Focus:
Understanding the indications for Pringle maneuver and segmental packing, contraindications, potential complications, and critical monitoring parameters are high-yield for exams.
Clinical Pearls:
Limit Pringle maneuver duration to <15-20 minutes per cycle, with reperfusion periods of 5-10 minutes to minimize ischemic injury
Meticulous gauze placement is key for effective segmental packing
Consider the risk-benefit of shunts carefully.
Common Mistakes:
Overly prolonged Pringle maneuver without reperfusion, inadequate packing leading to persistent hemorrhage, failure to recognize and manage ischemic hepatitis, and delayed diagnosis of infection or bile leaks.