Unilateral pringle manoeuvre and packing for haemostasis in severe liver trauma

Abstract

Major haemorrhage from liver trauma is a difficult surgical problem. Basic haemostatic techniques such as direct suture of bleeding points and peri-hepatic packing are often sufficient. If these fail, temporary control can usually be obtained by instituting total vascular inflow occlusion (the Pringle manoeuvre) [1]. The Pringle manoeuvre then allows the surgeon to gain better exposure and visualisation of the injury whilst the anaesthetist works to restore circulatory volume. Although inflow occlusion can be safely applied for an hour or more in elective situations [2,3], this period may be considerably shorter in the presence of hypovolaemia and shock. Following restoration of hepatic inflow, re-bleeding that cannot controlled by peri-hepatic packing presents a dilemma. Such situations are usually accompanied by coagulopathy, acidosis, and hypothermia. Major liver resection, when attempted in this setting, usually has a fatal outcome. Survival is much more likely if bleeding can be controlled sufficiently for coagulation and other physiological parameters to be restored before definitive surgery is attempted. The concept of ‘damage control’ has gained considerable popularity in the last 10 years [4,5]. Where coagulopathy, acidosis, hypothermia, or urgent extra-abdominal priorites (e.g. extradural haematoma) exist, termination of laparotomy following temporary heamostasis and control of enteric leakage is recommended. While peri-hepatic packing is often sufficient to gain temporary haemostasis, in some situations it fails because hepatic inflow persists and ongoing bleeding then compromises the ability to warm the patient and correct coagulopathy. The damage control philosophy has seen many recommendations for temporary or permanent major arterial ligation [5] but unilateral hepatic inflow occlusion has been reported infrequently [6]. This procedure commits the patient to subsequent hepatic lobectomy. It should, therefore, be reserved for unilateral liver trauma severe enough to warrant its consideration, and be backed up by the availability of an experienced liver team for subsequent resection. We describe four patients (summarised in Table 1) with major liver injuries in whom unilateral inflow occlusion, combined with peri-hepatic packing, was employed to control bleeding that could not be arrested by any other means. Bleeding was arrested in three patients and partially arrested in the fourth. Three underwent subsequent right hepatectomy and survived. The other patient died of concurrent pulmonary injuries, despite complete control of haemorrhage from the liver.