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.