Hepatic Packing: Procedure and Management

Indications for Hepatic Packing

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, according to the World Journal of Emergency Surgery 1, 2
The American College of Surgeons recommends hepatic packing for major hemorrhage from liver trauma that cannot be controlled by simple compression, electrocautery, or topical hemostatic agents 3, 2
Hepatic packing is indicated for retrohepatic caval or hepatic vein injuries where direct repair carries prohibitively high mortality rates, as stated by the Eastern Association for the Surgery of Trauma 1, 4
The Society of Critical Care Medicine recommends hepatic packing for patients developing the lethal triad (hypothermia, acidosis, coagulopathy) requiring damage control surgery 3, 1

The World Journal of Emergency Surgery recommends beginning with manual compression of the liver to temporarily control hemorrhage, followed by mobilization of the liver and simultaneous intensive resuscitation with early massive transfusion protocol to maintain organ perfusion and reverse physiological derangements 3, 2
The American College of Surgeons suggests providing simultaneous intensive resuscitation with early massive transfusion protocol to maintain organ perfusion and reverse physiological derangements 2, 4
Temporary abdominal closure with synthetic mesh is recommended to reduce wound infection rates and prevent abdominal compartment syndrome, according to the World Journal of Emergency Surgery 3, 5

The Eastern Association for the Surgery of Trauma recommends performing Pringle maneuver (hepatic pedicle clamping) as a fundamental initial maneuver alongside packing 3, 5
The Society of Interventional Radiology suggests considering post-operative angioembolization for persistent arterial bleeding after packing, which allows hemorrhage control while reducing complications 1, 2
The American College of Surgeons recommends avoiding anatomic hepatic resection in unstable patients during damage control—defer to staged procedures by experienced surgeons 6, 2

The World Journal of Emergency Surgery recommends close ICU monitoring with serial hemoglobin measurements and maintaining low central venous pressure to decrease ongoing blood loss 2, 4
The Society of Critical Care Medicine suggests using restrictive transfusion strategy to avoid increasing portal pressure, with a target hemoglobin level of 7-9 g/dL 7
The Eastern Association for the Surgery of Trauma recommends monitoring for complications such as hepatic necrosis or ischemia, biloma formation, and rebleeding upon pack removal 1, 4