Packing is the mainstay of damage control. The principle is to perform a compression of the liver against the diaphragm (upper and posterior direction), which works very well for venous bleeding. Gauze swabs are placed around the liver - not inside the lesion -in order to compress the fracture and keep the compression against the diaphragm. However, no pack should be placed between the liver and the diaphragm to avoid a compression of portal veins and vena cava compromising venous return and resulting in decreased cardiac inflow and a portal venous thrombosis. However, the elevation of the diaphragm leads to a high peak airway pressure with hypoventilation which needs to be taken into account in the postoperative care.
The abdomen is closed under tension without drainage to maintain pressure on the packs. The increased intra-abdominal pressure represents a major risk for an abdominal compartment syndrome and therefore needs to be checked regularly.
If the hemorrhage is not controlled, manual compression is performed again and the liver is packed one more time. If this does not lead to control of the bleeding, partial or total vascular exclusion of the liver needs to be performed (Step 10).
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