- Initially compress right and left lobes together then push backwards for compressive effect
- i.e. Push, Pack, Pringle, then Total Vascular Isolation
- Options
- Packing
- Pringle’s
- Liver clamp
- Diathermy
- Haemostatic agents/glue
- Hepatic suture
- Hepatorrhaphy and non-anatomic resection
- Packing
- Dry, folded packs with radioopaque marker
- Remove within 1-3 days - Can cause infection
- Complications
- Reduced CO - Too tight, compress IVC
- Respiratory deterioration - increased pressures from diaphragm reduced compliance
- Other options
- Hepatic tourniquet
- Tract tamponade balloon - with Sengstaken Blakemore tube is ideal
- Pringle’s
- Diagnostic - Hepatic Artery/Portal Vein vs Hepatic Vein/Caval bleeding
- Therapeutic
- Timing
- 1 hr max
- Less ischaemia with 10 mins on 5 mins off
- Sometimes need to finger fracture to get access to deeper bleeders within parenchyma
- Can staple off or ligasure bleeding segments along anatomical planes
- Anatomical lobectomy acutely has high mortality
- Situations where anatomical lobectomy is needed
- Left lateral segment extensive injury - can’t pack
- Non-viable liver segment post-packing
- Almost free segment
- Devitalized liver at pack removal
- Seldom have to mobilise the liver fully, acutely and without specialist help
- Hepatic isolation
- Inflow - Pringle
- Outflow - Clamp IVC infrahepatic and suprahepatic
- Thoracic or abdominal approach
- Complications of severe liver injuries
- Perihepatic infection
- Biloma
- Biliary fistulae