What is the proper procedure and management for hepatic (liver) packing?

Hepatic Packing: Procedure and Management

Hepatic packing is the most successful and least risky method for managing severe liver hemorrhage, particularly for retrohepatic caval and hepatic vein injuries, and should be employed as a first-line damage control technique in the presence of major hemorrhage. 1

Indications for Hepatic Packing

When to pack:

• Major hemorrhage from liver trauma that cannot be controlled by simple compression, electrocautery, or topical hemostatic agents 1
• Retrohepatic caval or hepatic vein injuries where direct repair carries prohibitively high mortality rates 1
• Failure of Pringle maneuver or arterial control to stop bleeding 1
• Patients developing the lethal triad (hypothermia, acidosis, coagulopathy) requiring damage control surgery 1
• When blood transfusion requirements approach 15 units—packing is more effective if instituted early before massive transfusion 2

Packing Technique

Initial maneuvers:

• Begin with manual compression of the liver to temporarily control hemorrhage 1
• Mobilize the liver as much as possible to access the injury site 3
• Provide simultaneous intensive resuscitation with early massive transfusion protocol to maintain organ perfusion and reverse physiological derangements 1

Optimal packing method:

• Place a non-stick bowel bag or OpSite sheet directly on the disrupted liver surface to prevent rebleeding upon pack removal 4, 3
• Position laparotomy pads on top of the protective layer, extending coverage beyond the injury site 4, 3
• Pack systematically to achieve tamponade without causing additional parenchymal injury 3
• Avoid packing in patients with ruptured hollow viscus or large extrahepatic vessel injuries 5

Abdominal closure:

• Use temporary abdominal closure with synthetic mesh rather than primary suture closure to reduce wound infection rates (42% vs single-digit percentages) and prevent abdominal compartment syndrome 1, 2
• Temporary closure is indicated when risk of abdominal compartment syndrome is high or when second-look operation is planned 1

Timing of Pack Removal

Planned reoperation:

• Return to operating room for pack removal after 24-72 hours once hemodynamic stability is achieved 5, 6, 3
• Optimal timing is when patients are normothermic, have corrected coagulopathy (PT >30%, platelets >45 g/L), restored acid-base balance, and no longer require high-dose vasopressor support 6
• For prolonged packing in severe cases, removal can be delayed 7-10 days with low infection and mortality rates 5
• If 24-hour postoperative blood requirements exceed 10 units, return to operating room for repacking rather than waiting 2

Adjunctive Measures

When packing alone is insufficient:

• Perform Pringle maneuver (hepatic pedicle clamping) as a fundamental initial maneuver alongside packing 1
• Consider post-operative angioembolization for persistent arterial bleeding after packing, which allows hemorrhage control while reducing complications 1
• REBOA (resuscitative endovascular balloon occlusion of the aorta) in zone I may be used as a bridge to definitive hemorrhage control if bleeding persists despite damage control procedures 1

Avoid these pitfalls:

• Do not perform selective hepatic artery ligation if packing alone stops bleeding, as ligation increases infection risk (80% abscess rate with ligation vs 19% without) 2
• Avoid anatomic hepatic resection in unstable patients during damage control—defer to staged procedures by experienced surgeons 1
• Do not ligate portal vein branches, as this causes liver necrosis or massive bowel edema; packing or resection are preferable 1

Post-Packing Management

Monitoring requirements:

• Close ICU monitoring with serial hemoglobin measurements 1
• Maintain low central venous pressure (below 5 cm H2O) to decrease ongoing blood loss 7
• Use restrictive transfusion strategy (transfuse when hemoglobin <7 g/dL, target 7-9 g/dL) to avoid increasing portal pressure 7

Complications to monitor:

• Hepatic necrosis or ischemia (increased risk after hepatic artery ligation) 1
• Intra-abdominal abscesses (occur in approximately 22-27% of cases, higher with gastrointestinal perforation) 2
• Biloma formation 1
• Rebleeding upon pack removal (significantly reduced with non-stick barrier technique: 66 mL vs 152 mL average blood loss) 3

Follow-up imaging:

• Perform CT or ultrasound to assess for rebleeding or development of complications 1