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Damage Control Surgery

Organ-Specific Techniques

Damage Control Surgery

Metabolic failure
Damage control laparotomy
Organ-specific techniques
Critical Care
Abdominal Compartment Syndrome

The basic damage control technique for control of hepatic haemorrhage is peri-hepatic packing. This manoeuver, when performed properly, will arrest most haemorrhage except for major arterial bleeding.

Major hepatic bleeding may be partially controlled with a soft vascular clamp on the portal triad (Pringle's manoeuver). Further vascular isolation (inferior vena cava above and below the liver) may be hazardous and is generally unnecessary in a damage control setting. Full hepatic mobilization and extension into the chest either through a median sternotomy or left thoracotomy may be required to achieve this.

The liver parenchyma can be compressed manually initially, followed by ordered packing. To adequately pack the liver requires compression in the antero-posterior plane. This can only be achieved by mobilization of the right hepatic ligament and systematic placement of packs posterior and anterior to this, as well as one or two in the hepato-renal space. Even retrohepatic venous and inferior vena cava injuries may be controlled in this manner.

Only major arterial bleeds from the liver parenchyma will require further attention. In this case the liver injury can be extended using a finger-fracture technique and the bleeding vessels identified and tied or clipped. In some cases, where the injury is not deep and easily accessible, rapid resectional debridement may be possible by placing large clamps along the wound edges, performing a rapid debridement and the underrunning the clamp with suture to include all the raw surface.

The patient who undergoes hepatic packing should be transferred to the angiography suite immediately after the operation to identify any ongoing arterial haemorrhage which may be controlled with selective angiographic embolization.


Critical Care