Do We Need a Relaparotomy to Remove the Perihepatic Packs Used to Control Bleeding? Case Series

Case Report

Abstract

Introduction: Liver injuries, often resulting from trauma, present a significant challenge in surgical management. Perihepatic packing has emerged as a critical technique in controlling bleeding and stabilising patients with severe liver injuries. This study aims to evaluate the outcomes of perihepatic packing and removing packs without relaparotomy in a cohort of eleven patients treated over two years.
Methods: We conducted a retrospective study of 11 patients with liver injuries identified at laparotomy at General Hospital Kuliyapitiya from May 2020 to June 2022. Excluded were patients who managed without packing. Data were collected from operating theatre records and medical charts, including age, sex, injury mechanism, vital signs, FAST scan results, intraoperative findings, estimated blood loss, blood transfused in the first 24 hours, associated injuries, liver complications, time to pack removal, and incidence of rebleeding.
Perihepatic packing has been used for persistent hepatic haemorrhage post-suturing, unsaturable injuries, and hemodynamically unstable patients. Packs have been brought outside the abdomen through a separate incision and sutured to each other if multiple packs were used. A G28 intercostal tube has placed for drainage. Packs have been removed between 48 and 72 hours. The drain has kept for more than 48 hours post-removal to monitor rebleeding. In cases of uncontrollable haemorrhage during pack removal, plans included reopening and repacking if necessary.
Results: The study included eleven patients aged 24 to 74 years, with three female patients. The causes of liver injuries were identified as follows: road traffic accidents (63.6%), assault (18.2%), stab injuries (9.1%), and falls from height (9.1%). Pre-operative ultrasound correctly identified liver injuries in 54.6% of patients. Intraoperative findings showed right liver lobe involvement in 63.6% of cases, bilobar involvement in 27.3%, and left lobe involvement in 9.1%. Additionally, 63.6% of patients had other organ injuries. The timing of pack removal was within 48 hours for seven patients (63.6%) and within 48-72 hours for the remaining patients. Drains were removed on the fifth day in 54.50% of patients and on the sixth day in the rest. There were no cases of rebleeding and post of complications were able to be managed conservatively. There was one death with sepsis and multi organ disfunction.
Conclusion: Perihepatic packing is a valuable technique in the management of liver injuries, demonstrating high efficacy in controlling haemorrhage and low complication rates. Removal of the pack through the pre-placed incision avoids the relaparotomy and thereby reduces the second trauma to the patient. Further studies with larger cohorts are recommended to validate these findings.