Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique

Abstract

We evaluated 35 consecutive patients treated with temporary intraabdominal packing for control of bleeding to determine factors that could improve hemorrhage control, morbidity from infection, and mortality. Twelve patients could not be resuscitated from hemorrhagic shock and died in the operating or recovery room. Bleeding was controlled in the remaining 23 patients; however, five (22%) died of complications other than hemorrhage. Intra-abdominal abscesses occurred in seven of the 21 patients who survived longer than 5 days and were more frequent in patients who had gastrointestinal perforation (50% versus 27%) and selective hepatic artery ligation (80% versus 19%). Four patients with either retrohepatic vena cava injury, hepatic vein injury, or both, were packed without attempted repair; three underwent delayed repair and survived. Coagulopathy occurred in 55% of patients who received greater than 15 units of blood before packing but in only 17% who received less than 15 units. The abdomens of ten patients were closed with a prosthetic mesh which did not prevent hemorrhage control, and only one patient developed a wound infection compared to 42% of patients with primary suture closure. We therefore conclude: 1) packing is more effective if instituted early (when less than 15 units of blood have been transfused) and is not contraindicated before either repair of retrohepatic vena cava injury, hepatic vein injury, or both; 2) selective hepatic artery ligation should be avoided if packing alone stops bleeding; 3) abdominal closure with a synthetic mesh decreases the incidence of wound infection; and 4) patients should be returned to the operating room for repacking if 24-hour postoperative blood requirements exceed 10 units.