Major Hepatic Hemorrhage from Complex Hepatic Injury — When Initial Bleeding Control Has Failed
This protocol addresses patients with blunt liver trauma who present with major hepatic hemorrhage arising from complex hepatic injury — a high-stakes operative situation in which bleeding has not been controlled by the initial management approach.
The first step in the management of patients with major hepatic hemorrhage is manual compression. When the initial operative approach — encompassing manual compression of the hepatic parenchyma, perihepatic packing with laparotomy pads, blood component therapy, activation of a massive transfusion protocol, damage control laparotomy, and consideration of angiography — has not achieved the critical goal of:
Control of hepatic bleeding (hemostasis)…a defined next-line operative strategy is required.
The next-line protocol centers on structured vascular inflow control at the hepatic hilum, followed by systematic operative management of the injured parenchyma — the full sequence, including which steps apply and in what order, is contained in the structured protocol.
Control of hepatic bleeding (hemostasis).
- The first step in the management of patients with major hepatic hemorrhage is manual compression.
- The first step entails a Pringle maneuver, with placement of a vascular clamp on the porta hepatis to control portal vein and hepatic artery bleeding.
- If not already performed, takedown of the falciform, coronary, and triangular ligaments should be undertaken.
- Once bleeding is controlled by the Pringle, actively bleeding vessels and injured bile ducts should be ligated.
- For hepatic parenchymal devascularization or destruction, resectional debridement along nonsegmental planes should be performed.
- Placement of a viable piece of omentum can fill in dead space and aid in hemostasis.