The American Journal of Surgery (2011) 201, e5– e14

How I Do It

Refinement in the technique of perihepatic packing: a safe

and effective surgical hemostasis and multidisciplinary
approach can improve the outcome in severe liver trauma

Franco Baldoni, M.D.a, Salomone Di Saverio, M.D.a,*, Nicola Antonacci, M.D.a,

Carlo Coniglio, M.D.b, Aimone Giugni, M.D.b, Nicola Montanari, M.D.c,
Andrea Biscardi, M.D.a, Silvia Villani, M.D.a, Giovanni Gordini, M.D.b,
Gregorio Tugnoli, M.D.a

a
Emergency and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy; bDepartment of Emergency,
Trauma ICU, Maggiore Hospital Trauma Center, Bologna, Italy; cDepartment of Radiology, Interventional Radiology
Unit, Maggiore Hospital, Bologna, Italy

KEYWORDS: Abstract
Liver trauma; BACKGROUND: Since 2005, we refined the technique of perihepatic packing including complete
Perihepatic packing; mobilization of the right lobe and packing around the posterior paracaval surface, lateral right side, and
Damage-control anterior and posteroinferior surfaces.
surgery; METHODS: Two groups of patients with grade IV/V liver trauma underwent perihepatic packing
Operative technique; before and after 2005. The study group included 12 patients treated with the new technique. The control
Trauma intensive care group included 23 patients treated with the old technique.
unit; RESULTS: All 13 patients except one who died within 24 hours were treated with the old technique.
Rebleeding; The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P ⬍ .02);
Repacking; the liver-related mortality was 8.3% versus 34.8% (P ⫽ not significant). The mean survival time in the
Hemostasis; intensive care unit was longer in the latest group (39.4 vs 22.3 days, P ⫽ not significant). The incidence
Survival; of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5%
Complications; in the patient who were treated with the old technique (P ⫽ not significant). The overall (81.8% vs
Trauma center 100%, P ⫽ not significant) and liver-related morbidity rate (18.2% vs 41.7%, P ⫽ not significant) and
the incidence of abdominal sepsis (9.1% vs 41.7%, P ⫽ not significant) decreased.
CONCLUSIONS: Our refined technique of perihepatic packing seems to be safe and effective.
© 2011 Elsevier Inc. All rights reserved.

Major liver trauma, when associated with extensive pa-
renchymal injury and uncontrollable bleeding, may rapidly
and “irreversibly” evolve toward the development of the
* Corresponding author. Tel.: ⫹39-34-8600-7338; fax: ⫹390516478585.
E-mail address: salo75@inwind.it
Manuscript received January 22, 2010; revised manuscript May 24,
2010
lethal triad of death (acidosis, hypothermia, and coagulopa-
thy). These situations are challenging for the trauma sur-
geon. In the last decades, temporary packing with gauzes
has been extensively used since its reintroduction in the
1970s by some trauma surgeons, becoming a safer and more
effective alternative to liver resections.1 This strategic ap-
proach has been defined by Rotondo et al2 in 1993. This
concept and its definition have been derived from the mil-

0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2010.05.015
e6 The American Journal of Surgery, Vol 201, No 1, January 2011

itary strategy adopted by the US Navy in order to perform

quickly the necessary, essential repairs to a ship for absorb-
ing damages and maintaining mission integrity.3 Those re-
pairs should be just sufficient for navigating the ship back to
its own native harbor for definitive repairs. This concept to
bail out surgery and reoperate for definitive surgery after
appropriate intensive care unit (ICU) resuscitation and an-
giography with embolization when indicated has been in-
troduced for severely injured trauma patients4 and massive
liver trauma. The first described surgical approach to un-
controllable traumatic liver hemorrhage, based on the con-
cept of gaining temporary control by packing and occlusion
of the porta hepatis, has been the “Pringle Maneuver.”5 As
early as 1900s, abbreviated laparotomy and planned reex-
ploration for hepatic trauma have been proposed.6,7 Packing
as a method to control hemorrhage from liver injuries was Figure 2 Step 1: complete mobilization of the right lobe by
also described by Halsted in 1903.8 Based on the experience sharp dissection of the falciform and right triangular and coronary
in World War I, the Medical Department of the US Army ligament.
recommended intrahepatic packing or sutures to be used for
large liver wounds with or without active hemorrhage.9 The
first pioneer experiences in packing of liver injuries were ing.18 Major hepatic resections had become rare ever since
discouraged after experiencing serious complications in 1982.19 –21 Perihepatic packing is currently used in 4% to
World War II and the Vietnam War.10 Observations from 25% of patients requiring operative management for liver
the 2nd Auxiliary Surgical Group in the Mediterranean and injury.9,22 A careful selection of the patients for perihepatic
Southern European Campaigns suggested alternative ap- packing (massive liver injuries with uncontrollable hemor-
proaches to liver wounds.11 Because of the potential for late rhage associated to hemodynamic instability and lethal
complications from these experiences, such as sepsis and triad), together with appropriate timing of packs removal,
recurrent hemorrhage after the removal of packs, packing could guarantee low morbidity and mortality rates.6,12,23
for liver injures was almost abandoned for nearly 2 de- Several techniques of perihepatic packing have been pro-
cades.12 Nevertheless, during the 1970s and 1980s, perihe- posed to achieve an effective hemostasis with a low inci-
patic packing was reestablished as safe and effective in dence of rebleeding after its removal.12,24 –26 Nonetheless, it
managing liver injuries.13–17 In fact, in the 1970s, the results is unclear which one of these techniques guaranteed the best
of the aggressive surgical strategies that were preferred results. Hence, we attempted to systematize and standardize
during the previous decade were disappointing. Ironically, the number and location of packs to be used and the direc-
after adopting these aggressive surgical procedures, oc- tion of the compression forces. In our level I trauma center
curred the same complications (even more frequently and in Bologna, Italy, we started a dedicated surgical activity
worse) that previously led the surgeons to abandon pack- focused on trauma surgery in 1989. We had an initial ex-

Figure 1 Step 1: complete mobilization of the right lobe by

sharp dissection of the falciform and right triangular and coronary Figure 3 Folded gauze laparotomy sponges coated with topical
ligament. hemostatic agents.
F. Baldoni et al. Perihepatic packing
Figure 4 Folded gauze laparotomy sponges coated with topical
hemostatic agents.
perience of perihepatic packing in the earlier years consist-
ing in the placement of a variable number of gauze laparot-
omy sponges compressing the posteroinferior and anterior
surface of the liver as well as over the injured site and
elsewhere at the surgeon’s discretion. Since 2005, we im-
proved and systematized our perihepatic packing technique
(see attached educational video), starting with the complete
mobilization of the right lobe accomplished by sharp dis-
section of the falciform and right triangular and coronary
ligament (step 1, Figs. 1 and 2), carefully avoiding any
intrahepatic packing. We do use a total number of 8 folded
gauze laparotomy sponges coated with topical hemostatic
agents (Figs. 3 and 4). We then proceed to pack them in
pairs all around the posterior paracaval surface (avoiding
IVC compromise27) (step 2, Figs. 5 and 6), the lateral right
side (step 3, Figs. 7 and 8), the anterior surface (step 4; Figs.
9 and 10), and the posteroinferior visceral surface of the
liver (step 5; Figs. 11 and 12). The diaphragmatic surface
remains free (Fig. 13) to avoid unduly elevation and respi-
Figure 5 Step 2: the sponges placed all around the posterior
paracaval surface (avoiding IVC compromise).
e7
Figure 6 Step 2: the sponges placed all around the posterior
paracaval surface (avoiding IVC compromise).
ratory compromise. In fact, the diaphragm itself and the rib
cage provide sufficient rigidity, which allows the gauzes
(placed in this sequence) to obtain a focused and centripetal
compression. The compression is directed toward an ideal
center located on the confluence of the hepatic veins into the
IVC (Figs. 13–15). This technique allows approximation of
the injured parenchyma and achievement of an effective
hemostasis.
Methods
In our level I trauma center in Bologna, Italy, 2,921
polytrauma patients have been admitted to the trauma ICU
and recorded in a dedicated trauma registry database (pro-
spectively collecting all the prehospital and in-hospital, both
intraoperative and postoperative data) in the period between
1996 and 2008. Of them, 272 patients sustained a liver
Figure 7 Step 3: the sponges placed over the lateral right side of
the liver.
e8
Figure 8 Step 3: the sponges placed over the lateral right side of
the liver.
trauma. 84 (31%) patients sustained a grade IV-V American
Association for the Surgery of Trauma (AAST) liver injury,
whereas 39% of the lesions were grade III. The design of the
study was a retrospective comparative analysis of the pro-
spectively collected data. Two separate groups of patients
underwent perihepatic packing with the old (23 patients)
and new technique (12 patients), respectively, before and
after 2005. The study group included the records (prospec-
tively collected) of 12 patients treated with the new refined
packing technique after 2005. The control group consisted
of 23 patients treated with the old technique in the period
before 2005.
All these 35 patients had a grade IV-V liver injury and
were treated with perihepatic packing. All the data available
from our ICU trauma registry were included in the analysis.
The patients’ baseline, clinical, and laboratory characteris-
tics; trauma scores and AAST grade of injuries; changes in
treatment and therapeutic management; and outcome (over-
all and early mortality, repacking rate, average ICU stay and
Figure 9 Step 4: the sponges placed over the anterior surface of
the liver.
The American Journal of Surgery, Vol 201, No 1, January 2011
Figure 10 Step 4: the sponges placed over the anterior surface
of the liver.
survival time, and complication rate) of the 2 groups are
calculated and reported in comparison (Table 1). The mor-
bidity and mortality of the 2 groups in comparison have also
been calculated, and all the clinical, laboratory, and thera-
peutic factors available from our ICU trauma registry were
included in the univariate and multivariate analysis of their
prognostic value. The statistical analysis was conducted
using the statistical software package SPSS 13.0 (SPSS Inc,
Chicago, IL). Data are expressed as numbers (%) and means
(standard deviation). The results were analyzed using the
chi-square test and the Fisher exact test, as appropriate, for
proportions in case of discrete data. For means in case of
continuous numeric data, we used the independent samples
t test and the Mann-Whitney U test, respectively, for data
normally and nonnormally distributed; the data were previ-
ously tested for normality by the Kolmogorov-Smirnov test.
Kaplan-Meier curves were used for overall survival and
liver hemorrhage-specific survival analysis, and its compar-
ison significance has been tested using the log-rank (Mantel
Figure 11 Step 5: the sponges placed on the posteroinferior
visceral surface of the liver.
F. Baldoni et al. Perihepatic packing
Figure 12 Step 5: the sponges placed on the posteroinferior
visceral surface of the liver.
Cox) test. Overall and liver injury-specific morbidity rates,
early mortality, rebleeding incidence, and intra-abdominal
septic complications were calculated and compared as well.
A P value of ⬍.05 was considered statistically significant.
Results
Age, sex distribution, and body surface area values were
not significantly different between the 2 groups of patients.
The AAST classification of the liver injury did not show any
significant change in the severity of injury in the latest
period. The percentage of patients hemodynamically unsta-
ble was 78% versus 83% (P ⫽ not significant) in the 2
groups, respectively, and 26% versus 33% of the patients in
each group presented hypothermia, whereas GCS (Glasgow
Coma Scale) at presentation was significantly higher in the
patients treated in the latest period (9.4 vs 13.6 in the last 3
years). ISS (Injury Severity Score) and NISS (New Injury
Figure 13 An overview of our refined perihepatic packing
technique.
e9
Figure 14 An overview of our refined perihepatic packing
technique.
Severity Score) scores did not change significantly, but RTS
(Revised Trauma Score) was significantly higher in the
latest group (5.35 vs 6.78, P ⫽ .01). The respiratory rate at
arrival did not differ significantly between the groups of
patients; the mean systolic blood pressure and the values of
pH and BE (Base Excess) at arrival were lower in the first
group although they did not reach any statistically signifi-
cant difference (77 vs 86 mm Hg, 7.18 vs 7.24 mm Hg, and
⫺10.7 vs ⫺8 mm Hg, respectively; P ⫽ not significant).
The therapeutic resuscitative measures adopted in the pre-
hospital setting, European Review, and within the first 24
hours were not significantly different between the 2 groups.
Nonetheless, a wider use of angiographic embolization
(17.4% vs 25%, P ⫽ not significant) and a decreased need
for aggressive fluid resuscitation (3,000 mL vs 2,400 mL)
and multiple transfusions (21.3 vs 11.7 U) were noted in
recent years. The massive transfusion policy in our trauma
center and trauma ICU is based on the following ratio: red
blood cells (RBCs):fresh frozen plasma (FFP):platelets pack
2.5:2:1. This policy has not changed over the years of the
Figure 15 An overview of our refined perihepatic packing
technique.
e10 The American Journal of Surgery, Vol 201, No 1, January 2011

Table 1 Comparison of the results in 2 groups of patients treated with the old and new perihepatic packing technique
Old technique New technique
(period 1996–2004) (23 patients) (period 2005–2008) (12 patients) p
Demographics
Sex (M/F) (%) 56.5/43.5 83/17 .113†
Age 40.8 (SD ⫽ 16.7) 43.4 (SD ⫽ 20.33) .694‡
Body surface area 1.83 1.88 .423‡
Clinical characteristics of trauma
patients (%)
Injury Grade IV-V AAST 16–7 (69.6⫺30.4) 9–3 (75⫺25) .260†
Hemodynamically unstable 78.3 83.3 .722†
Hypothermia 26.1 33.3 .652†
GCS 9.4 13.6 ⬍0.01‡
ISS 39.5 31.5 .080‡
NISS 45.8 39.1 .095‡
RTS 5.35 6.78 ⬍.05‡
Systolic blood pressure (arrival) (mmHg) 77 86.2 .336‡
Respiratory rate/min (arrival) 20.8 19.1 .687‡
BE (arrival) ⫺10.7 ⫺8 .200‡
pH 7.18 7.24 .319‡
Therapeutic measures
PRBCs transfused (within first 24 h) (U) 21.3 11.7 .146‡
FFP transfused (within first 24 h) (mL) 2,770 1,190 .775‡
Prehospital fluid infusion (mL) 1,440 990 ⬍0.05‡
Emergency room fluid infusion (mL) 1,590 1,410 .245‡
Total fluids infusion (prehospital and 3,030 2,410 .164‡
emergency room) (mL)
Angiographic embolization (%) 17.4 25 .593†
Time to ICU admission (min) 263 (SD ⫽ 179, SEM ⫽ 37) 248 (SD ⫽ 203, SEM ⫽ 59) .981‡
Results
ICU stay (d) 11.3 (SD ⫽ 20, SEM ⫽ 4.3) 16.5 (SD ⫽ 14.5, SEM ⫽ 4.2) .439‡
Early deaths (within 24 h) (%) 52.2 8.3 0.01† OR 0.77
Overall survival (%) 30.4 75 0.015† OR ⫽ 1.58
Mean overall survival time (d) 22.3 (SEM ⫽ 7.7) 95% CI, 7, 1–37, 4 38.5 (SEM ⫽ 6.6) 95% CI, 25, 5–51, 5 0.022储
Mean time to death (d) 2.8 (SE mean 1.7) 95% CI 0–6, 2 5.8 (SE mean 5.6) 95% CI 0–16, 7 .759储
Liver hemorrhage–related survival (%) 65.2 91.7 .089† OR ⫽ 1.11
Rebleeding at depacking and need for 45.5 16.7 .134† OR ⫽ 0.9
repacking (%)
Complications (%)
Overall complications rate (all types) 100 81.8 .122† OR ⫽ 0.93
Liver-related complications rate 41.7 18.2 .221† OR ⫽ 0.97
Intra-abdominal sepsis 41.7 9.1 .076† OR ⫽ 0.89
Data are mean (standard deviation) or number of patients (%).
SD, standard deviation; SEM, standard error of the mean; CI, confidence interval; OR, odds ratio; GCS, ; ISS, ; NISS, ; RTS, ; BE, .
†Fisher exact test.
‡Independent samples t test.
储Log-rank (Mantel-Cox) test.

study, and both groups underwent the same damage-control
resuscitation protocol adopted in the early 1990s by our
Bologna Trauma Center Blood Bank. The crystalloids are
used for resuscitation in the prehospital setting and in the
emergency room until urgent uncross-matched RBCs and
FFP are available; crystalloids are minimized, giving prior-
ity to FFPs and packed red blood cells (PRBCs) with a ratio
of 1:1.25 and the adjunct of 1 platelet pack every 1:1.25
FFP:RBC. Factor VIIa has not been used in any of the
patients included in this study whether they were treated
with the old or the new packing technique. The patients
were transferred to the trauma ICU after an average time of
261 minutes, and a slight trend in reduction of this time has
been recorded in the period 2005-2008 (263 vs 248 minutes,
P ⫽ not significant). The AAST grade of the liver injury
was IV in 71% of the cases and V in 29% without signifi-
cantly different changes in the 2 periods (30.4% vs 25% of
grade V injuries). All 31 patients were taken to the operating
room and treated with perihepatic packing. The length of
ICU stay did not significantly differ between the groups of
the study (11.3 vs 16.5 days). Thirteen patients died early
within 24 hours of admission. Surprisingly, all the patients,
except one, who died within the first 24 hours were treated
with the old packing technique in the period before 2005.
The early (within 24 hours) mortality decreased significantly
in the latest period (8.3% vs 52.2%, P ⫽ .01). The overall
survival rate was 75% for the patients treated in the last 3
years with the new technique and 30.4% in the previous
group (P ⬍ .02), whereas the liver injury–related mortality
decreased to 8.3% in the second period (vs 34.8%, P ⫽ not
significant). The mean survival time in the ICU was longer
in the patients who underwent the new packing technique
F. Baldoni et al. Perihepatic packing
One Minus Survival Functions
1,0
0,8
One Minus Cum Survival
0,6
0,4
0,2
0,0
0 20
ICUstay
Figure 16 A comparison of the overall mortality curve and between the 2 study groups. One minus survival is expression of the
probability of failure of survival (mortality). P ⬍ .05. Coding of the Period: 0 – 1996 –2004; 1 – 2005– 08.
(22.3 vs 38.5 days, P ⬍ .05), and the nonsurvivor patients
from the group treated in the second period with the refined
technique seemed to have a later occurrence of death (2.8 vs
5.8 days, P ⫽ not significant). The incidence of rebleeding
requiring repacking at the second-look laparotomy was
16.7% in the patients who underwent the new packing
versus 45.5% of patients who were treated with the previous
technique (P ⫽ not significant). The overall and liver-
related morbidity rate decreased after the adoption of new
technique although it was not statistically significant (100%
vs 81.8% and 41.7% vs 18.2%, respectively; P ⫽ not
significant). The overall incidence of abdominal sepsis after
packing was 26%, showing a trend in the reduction of its
incidence after the introduction of the new technique, al-
though not reaching statistical significance (41.7% vs 9.1%,
P ⫽ not significant). The comparative analysis of the mor-
tality curves and the cumulative hazard function of death
between the 2 study groups (periods 1996 –2004 vs 2005–
2008) (Figs. 16 and 17) revealed a significant reduction of
the overall mortality in the latest period. There was a sig-
nificantly lower risk of death in the new technique–treated
group, which was even lower in the early period (24 hours)
of ICU stay (P ⬍ .05). The liver hemorrhage mortality and
hazard function, although nonstatistically different, de-
creased after the introduction of the new technique (Figs. 18
and 19), and only 1 patient (out of 12) in the latest group
treated with the refined packing technique died for liver-
related hemorrhage versus 8 (out of 23) from the previous
period.
e11
period2005
0
1
0-censored
1-censored
40 60 80
Comments
The previously described refined technique of perihe-
patic packing seems to be safe and effective in achieving a
fast and reliable hemostasis. Some surgeons are actually still
reluctant to mobilize the right lobe, especially in trauma
situations and a damage-control setting. Nonetheless, in our
experience, a fast but complete mobilization of the right
liver lobe seemed to have significantly contributed to ac-
complish an efficacious packing “all around” the liver. This
compression following the lines of force centripetally ori-
ented toward an ideal center located at the confluence of
supraehapatic veins into the IVC (Inferior Vena Cava) al-
lows the clinician to achieve an anatomic parenchymal
approximation and, consequently, a better hemostasis. In
our series, a trend toward a decrease in the amount of
resuscitative fluids as well as in the PRBC and FFP trans-
fusions required was observed although it did not reach a
statistically significant degree. The new technique might
have contributed to the reduction of the incidence of re-
bleeding and the need for repacking, prolonging the survival
time period. Helping in decreasing the operative time and
the overall time needed before ICU admission, the new
technique seemed to have contributed in reducing mortality
(ie, a significant reduction of early and overall mortality and
nonsignificant reduction of liver-related morality, P ⫽
.089). A decreased but not statistically significant morbidity
(overall and liver-related) as well a reduced incidence of
abdominal sepsis (nearly significant, P ⫽ .076) have also
been observed. These improvements of the outcomes cannot
e12 The American Journal of Surgery, Vol 201, No 1, January 2011

Hazard Function

1,50 period2005
0
1
0-censored
1,25
1-censored

1,00
Cum Hazard

0,75

0,50

0,25

0,00

0 20 40 60 80

ICUstay

Figure 17 A comparison of the overall cumulative hazard function of death between the 2 study groups. Hazard function is expression
of the risk of death during the time interval. P ⬍ .05. Coding of the Period: 0 – 1996 –2004; 1 – 2005– 08.

be solely attributed to the improved surgical technique. tive efforts, angiographic embolization, and changes in the
They most probably may be interpreted and explained with severity of injuries that occurred in recent years. A de-
a more effective surgical technique in conjunction with creased severity of road traffic accidents (eg, restrained
improvements in the prehospital and in-hospital resuscita- passengers, increased use of airbags, and other safety is-

One Minus Survival Functions

1,0 period2005
0
1
0-censored
0,8 1-censored
One Minus Cum Survival

0,6

0,4

0,2

0,0

0 20 40 60 80

ICUstay

Figure 18 A comparison of Liver Hemorrhage-related mortality curve between the 2 study groups. One minus survival is the expression
of the probability of the failure of survival (mortality). P ⫽ ns (0.08). Coding of the period: 0 – 1996 –2004 and 1 – 2005–2008.
F. Baldoni et al. Perihepatic packing
Hazard Function
0,5
0,4
Cum Hazard
0,3
0,2
0,1
0,0
0 20 40
ICUstay
Figure 19 A comparison of Liver Hemorrhage-related cumulative hazard function of death between the 2 study groups. Hazard function
is the expression of the risk of death during the time interval. P ⫽ ns (0.08). Coding of the period: 0 – 1996 –2004 and 1 – 2005–2008.
sues) might also have contributed in decreasing the early
and overall mortality as well as the improvements in the
prehospital and overall intensive trauma care in recent
years. The small size of our sample probably affected the
statistical significance of our results, but further experience
with a greater number of patients is needed to better confirm
the efficacy of this refined surgical technique. In conclusion,
damage control for major liver injuries with perihepatic
packing is best and effectively applied if associated with
appropriate additional strategies for hemorrhage control
such as an effective fluids resuscitation/transfusion proto-
col, a timely damage-control surgery, a carefully selected
angioembolization, and an accurate trauma ICU critical
care.
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