Tae JOURNAL OF ‘TRAUMA Copseaghtn 1 by The Wins & Wilkins Co, Printed in OS A Intra-abdominal Packing for Control of Hepatic Hemorrhag A Reappraisal DAVID V. FELICIANO, M.D., KENNETH L. MATTOX, M.D., anv GEORGE L. JORDAN, JR., M.D, Presently available techniques for control of hepatic hemorrhage in patients with extensive parenchymal injuries include direct suture, agents, hepatotomy or resectional debridement with lobectomy, and selective hepatic artery ligation. In many topical hemostatic lective vascular ligation, rrauma centers the placement of intra-abdominal packing for hepatic tamponade has been an infrequently used technique in recent years, From 1 July I 978 to 1 September 1980, ten patients with continued hepatic parenchymal oozing following all attempts at surgical control of extensive injuries were treated by the insertion of intra-abdominal packing around the liver as a last desps Pacl erate maneuver. ing was removed at reluparotomy in four patients and through abdominal sites in five patients. Nine of ten patients survived, and thet e were no. instances of rebleeding following removal of the packing. Four patients developed postoperative perihepatic collections and two of the four patients underwent reoperation for drainage. Based on the recent experience at the Ben ‘Taub General Hospital, intra-abdominal packing for contr: hepatic hemorrhage appears to be a lifesaving mancuver i patients in whom coagulopathies, hypothermi surgical efforts likely to increase hemorrhage. ol of exsanguinating in highly selected , and acidosis make further ‘Trauma to the abdomen produces injury to the liver more commonly than to any other intra-abdominal or- gan. With recent improvements in prehospital transport and techniques for emergency center resuscitation, more patients with extensive hepatic injuries now undergo operation, yet mortality rates less than 15% for all liver injuries have been reported from several urban trauma centers (7, 21, 22) Parenchymal hemorrhage remains the major cause of death in patients with extensive hepatic injuries (10). Although historical (23, 33, 36, 37) and presently available (32, 38) surgical techniques control most parenchymal hepatic hemorrhage and hemorrhage from the porta hepatis, hepatic veins, or retrohepatic vena cava (3, 4,17, 42), nonmechanical hemorrhage (coagulopathies), ruptured subcapsular hematomas, and extensive bilobar injuries remain unsolved problems (5, 16, 31). Our increasing exposure to such problems at the Ben ‘Taub General Hospital prompted a reappraisal of the use of intra-abdominal packing for extensive hepatic injuries From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine, and the Ben Taub General Hospital, Houston, Texas Presented at the Fortieth Annual Session of the American Associ tion for the Surgery of Trauma, Phoenix, Arizona, 18-20 September 1960, ‘Address for reprints: David V. Feliciano, MD. Department of Surgery, Bavlor College of Medicine, 1200 Moursund Avenue, Houston, Tx TT, 25, in which reasonable attempts at surgical control of hem- orthage were unsuccessful. CLINICAL MATERIAL From 1 July 1978 until 1 September 1980, 1,642 pa- tients with penetrating or blunt abdominal trauma un- derwent exploratory laparotomy at the Ben Taub Ger eral Hospital. In this group were 465 patients who suf- fered injury to the liver, including 403 with penetrating wounds and 62 with blunt injuries. Forty-one patients (8.8%) with liver injuries expired, including 29 (71%) in whom hemorrhage was the major cause. MANAGEMENT Patients with abdominal trauma are admitted to a Shock Room in the Emergency Center of the Ben Taub Hospital, where resuscitation is performed in the stan- dard fashion, In patients with penetrating abdominal wounds and profound hypotension, lower extremity in- travenous lines are avoided. Patients with blunt abdominal trauma or stab wounds to the anterior abdomen or flanks who present without signs of overt peritonitis or blood loss are evaluated by the technique of peritoneal lavage (11, 19, 39). In patients who present near death with a massively distended ab- domen secondary to hemoperitoneum, either emergency center or operating room thoracotomy may be performed in an attempt to prevent cardiac arrest before release of286 The Journal of Trauma peritoneal tamponade (20, 34). Emergency center lapa- rotomy has not improved salvage in patients with mas- sive hepatic trauma in our experience (25) In the operating room the patient's anterior trunk is, prepared and draped from the chin to the knees as the Cell Saver (Haemonetics Corp., Natick, MA) autotrans- fusion apparatus is readied. An upper midline incision from the xyphoid to 2 inches below the umbilicus is made, and a self-retaining retractor inserted after ligation of the round ligament. All free blood is aspirated with Cell Saver suction while clots are manually extracted. If rapid exploration reveals an extensive hepatic injury, a Pringle maneuver (33) is performed and the faleiform ligament is divided to the diaphragm. Laparotomy pads are placed around the liver to allow for temporary com- pression while the anesthesiologist arranges for further blood replacement and transfusions of fresh frozen plasma and platelets. The involved lobe is then mobilized by division of the respective triangular and anterior and posterior coronary ligaments (2), and the magnitude of the injury assessed (Fig. 1). Laparotomy pads are left behind the injured lobe to elevate the lobe into the incision. In this series extensive blunt injuries were usually treated with hepatorrhaphy utilizing 0-chromic sutures applied in a horizontal mattress fashion or resectional debridement of devitalized tissue. In gunshot wounds when a Pringle maneuver failed to stop exsanguinating hemorrhage, the tracts were generally opened by blunt dissection using silver clips on large vessels and ducts and mattress sutures on either side of the tract (hepato- tomy) to obtain hemostasis (Fig. 2). With deep paren- chymal injuries near the hepatic veins, application of a vascular clamp to the respective hepatic vein above the liver was occasionally necessary to prevent retrograde hemorrhage, and then selective vascular ligation in the bullet tract was performed. Following hepatotomy, he- Fic. 1. Division of the triangular and coronary ligaments to free the right hepatic lobe. April 1981 Fic. 2. Hepatotomy with selective vascular ligation, patorthaphy of the bullet tract or resectional debride- ment of the liver lateral to the tract was done. When precise vascular ligation was not successful in controlling parenchymal hemorrhage, selective hepatic artery ligation was performed if the Pringle maneuver appeared to slow the rate of hemorrhage. When deep parenchymal injuries required extensive resectional de- bridement, ligation of the respective hepatic vein was occasionally necessary to control further retrograde hem- orrhage (8). Atriocaval shunting was used on rare occa: sions (six patients) for control of hemorrhage from the hepatic veins or retrohepatic vena cava. The recent 26- month experience (one survivor) is not as successful as that previously reported from this hospital (3), but is comparable to available data from other institutions (41). Patients Requiring Packing. In ten patients (2.2%) with continuing hemorrhage following all attempts at surgical control, the technique of intra-abdominal pack- ing to the liver was then applied as a last desperate maneuver to control exsanguinating hepatic hemorrhage. Alllten patients who required intra-abdominal packing to the liver were males, with an average age of 27 years ‘There were three patients with blunt hepatic trauma and seven patients with penetrating wounds to the liver (four Bunshot wounds, two stab wounds, and one shotgun wound). All patients arrived in the Emergency Center with a systolic blood pressure less than 80 mm He, including five patients with a systolic blood pressure less than 50 mm Hg and two patients who had no palpable blood pressure. After rapid resuscitation in the Emer- gency Center all patients underwent exploratory laparot- omy utilizing the techniques described. Four patients were found to have extensive liver injury as the only intra-abdominal injury; six patients had other intra-ab- dominal injuries (three kidney, two spleen, one vascular) which were readily controlled. Hemorthage from the liver injury was massive in nineVol. 21, No.4 of ten patients. Multiple operations to control this hem- orrhage were necessary in 60% of the patients (‘Table I). Blood replacement ranged from four units to 60 units, with an average replacement of 31 units through all operations to control hemorrhage. Intraoperative auto- transfusion was a useful adjunct in five patients. After application of a clamp for temporary occlusion of the portal vessels multiple intraoperative maneuvers were attempted in all ten patients to control hepatic hemorrhage (Table II). One example was a patient with a gunshot wound of the diaphragm, right lobe of the liver, right hepatic vein, and retrohepatic vena cava; 12 sepa- rate maneuvers were performed before control of hepatic hemorrhage was considered satisfactory (Table III). At the completion of all mechanical attempts to control hepatic hemorrhage, eight patients were found to have significantly altered coagulation studies with partial thromboplastin times at least two times greater than normal and prothrombin times 1.5 times greater than normal. Platelet counts were not routinely measured during operation. All patients had significant oozing, ruptured subcapsular hematomas, or bilobar injuries which prompted the application of tamponading intra- abdominal packing to the liver. The type of packing utilized depended on the operating surgeon. Multiple TABLET Operations necessary to control hepatic hemorrhage ‘No. of Operations ' 4 t TABLET Operative maneuvers utilized in an attempt to control ing hepatic hemorrhage before packing, Patienie Hepatorrhaphy 0 Hepatotomy 5 Resect, debril 4 Hepatic a. tigation Hepatic v. ligation 2 Atriocaval shunt 1 TABLE TIT Procedures performed in a patient requir! abdominal packing following a gunshot wound to the liver Xcclamp abd, aorta ‘Retrohepatic v.cavorrhaphy Pringle maneuver Partial r, hepatic lobectomy Hepatotomy "Tourniquet abd. aorta Sternotomy’ Intea-abstorsinal packs ‘Atriocaval shunt OR & SICU autoteansfusion ation r hepatic ¥ ‘ sond look’ operation Intra-Abdominal Packing for Hepatic Hemorrhage 287 laparotomy pads were used in six patients, vaginal packs in two patients, and Kerlix rolls (Kendall, Boston, MA) in two patients. Suction drains were usually placed be- neath the packs to allow for continued autotransfusion in the surgical intensive care unit. Intra-abdominal packing was removed when the pa- tient’s hemodynamic status was satisfactory, bleeding appeared to be under control, and other systemic prob- lems did not preclude another general anesthetic if this was necessary. Packing was removed from 8 hours to 10 days (average, 5.2 days) following the last operation to control hepatic hemorrhage. Four patients required re- operation for removal of intra-abdominal packing; five patients had gradual removal of packing in the surgical intensive care unit through abdominal drain sites; one patient expired before removal of packing. RESULTS Nine of ten patients with extensive hepatic injuries survived to leave the hospital at an average of 37 days following injury. One patient with a gunshot wound to the right lobe of the liver expired on the eighth day following injury. This patient required two operations to control hepatic hemorrhage, including an extensive hepatotomy with selective intrahepatic vascular ligation. At autopsy extensive hepatic necrosis and necrotizing pneumonia were found. Dissection of the bullet tract through the liver at autopsy suggested that atriocaval shunting or right hepatic lobectomy should probably have been performed rather than intra-abdominal pack- ing. Intra-abdominal complications following removal of packing required reoperation in two patients, including ‘one patient with a late subphrenic abscess following an incomplete drainage through an old drain tract and one patient with a small infected subhepatic hematoma. Two other patients had late purulent perihepatic collections drained through old drain tracts under general anaes- thesia. There were no instances of rebleeding following removal of packing (Table IV) Systemic complications were notable in this critically injured group of patients and included four instances of ‘TABLE IV intra-abdominal complications following removal of packing Cena Na Paton Rebleeding ° Other Abacos Reoperation Open drain tract, Hematoma Re ‘One patient subsequently required reoperation,288 = The Journal of Trauma respiratory failure requiring prolonged intubation and two instances of acute renal failure requiring hemodi- alysis, DISCUSSION ‘The management of hepatic trauma is relatively stan- dardized in most trauma centers. Approximately 80 to 85% of injuries to the liver can be handled by simple surgical techniques, including compression for 5 to 10 minutes, direct sutures, or topical hemostatic agents such as Avitene (Arnar-Stone Laboratories, McGaw Park, IL) (27, 28). Drainage of minor injuries is controversial (12), but we continue to drain most hepatic injuries at the present time. More extensive blunt hepatic injuries include avul- sions, deep lobar lacerations, or burst injuries. Penetrat- ing wounds which pose difficult. technical problems in- lude stab wound or gunshot wound tracts with extensive capsular disruption or involvement of intraparenchymal vessels near the porta or retrohepatic vena cava and close-range shotgun wounds. Such injuries usually de- mand advanced techniques for control of hepatic hem- orthage such as hepatotomy (14), resectional debride- ment (1), anatomic lobectomy (9, 13), or selective hepatic artery ligation (15, Packing for severe injuries to the liver is not a new technique. At the turn of the century hepatic lacerations were frequently filled with either absorbable or nonab- sorbable materials and sutures applied over this to create a tampon (36). Increasing experience with primary repair of hepatic injuries during World War II led to general condemnation of intrahepatic packing by most authori ties (6, 23, 24, 29, 40) because of the problems of rebleed- ing with pack removal and late sepsis. ‘The experience with intrahepatic packing at the Ben ‘Taub General Hospital was not dissimilar to that at other centers, and packing was not performed from 1974 to 1978. In recent years, however, we have encountered a small group of patients (less than 2.5%) with extensive hepatic injuries who have developed either coagulopa- thies following liver repair or who have irreparable sub- capsular hematomas or bilobar injuries. All patients in this series were victims of significant hepatic trauma and required massive rapid transfusion to sustain life. This transfusion coupled with intermittent hypotension, hypothermia, and metabolic acidosis was responsible for diffuse oozing in eight patients and ex- panding subcapsular hematomas in two patients, Further intraoperative attempts to control such bleeding prob- lems in these patients would clearly have precipitated further hemorthage with eventual exsanguination. The use of intra-abdominal packing around the liver to tamponade diffuse hepatic oozing was a last desperate maneuver. Laparotomy pads appeared to be the most effective tamponading agent. Reoperation is necessary for their April 1981 removal, but a ‘second look’ operation is valuable in the care of certain patients with hepatic trauma since it allows for further debridement of nonviable tissue, irri- gation of the subphrenic and subhepatie spaces, and the insertion of clean perihepatic drains. ‘The timing for removal of intra-abdominal packing did not appear to be critical in this patient review. When patients were normotensive, with no further bleeding from abdominal drains, and had no immediate life- threatening problems, pack removal was accomplished in the operating room if relaparotomy was required or in the surgical intensive care unit if packs were to be re- moved through abdominal drain sites. The type and number of intra-abdominal compliea- tions after removal of intra-abdominal packing was not excessive for patients with such extensive hepatic inju: ries. Increased use of suction drains and extensive de. bridement at the first operation and vigorous irrigation at reoperation may account for this. Innovative and somewhat heroic techniques for control of hepatic hemorrhage in both elective and trauma sur- gery have been described in recent years (18, 30, 32, 38) No one technique appears to be applicable to all patients, with extensive hepatic injury. Intra-abdominal packing around the traumatized liver has proved to be lifesaving in nine of ten patients at the Ben Taub General Hospital with continuing hepatic hemorrhage following failure of mechanical attempts at control during a recent 26-month period (Fig. 3). Packing appears to be a valuable adjunct for control of hepatic hemorrhage in highly selected patients with the following injuries: 1) coagulopathy post- hepatotomy or selective hepatic artery ligation; 2) coag: ulopathy before a needed lobectomy can be performed; 3) extensive subcapsular hematoma; 4) extensive bilobar injuries, ‘Trauma surgeons who regularly encounter patients Bre. tntea-ubdloni ing tenen the injured vee packing applied to tamponade diftase owsVol. 21, No. 4 with extensive hepatic injury should consider the addi- tion of intra-abdominal packing to their armamentarium. A. J, Walt has stated it best: “I have no wish to revivily the idea of the pack as a desirable standard practice. On the other hand, the judicious surgeon who chooses this method should in no way fear the whispered loss of his surgical manhood” (41). Acknowledgment We acknowledge the technical assistance of Mrs, Barbara Feliciano, B.S.N., and Mrs. Ellen Ford and the illustrations by Patrick McDonnell, Medical Illustrator, Baylor College of Med. REFERENCES 1. Balasegaram, M: The surgical management of hepatic trauma “Traum, 18: 141-148, 1976, 2, Bethea, M. CA simplified approach to hepatic vein injuries. Surg. (Gynecol. Obstet, 145: 78-8), 197 4, Bricker, D. L, Morton, J. R, Okies, J. K., et al Surgical manage went of injuries to the vena cava Changing patterns of injury and newer techniques of repair J. Trauma, 11? 725-735, 1971 4. Busuttil, RW, Kitahama, A. Cerise, E, et al: Management of blunt and penetrating injuries to the porta hepatis. Ann. Surg, 191; 642-648, 1980, 5, Clagett, G. P, Olsen, W, Re Non-mechanical hemorrhage in severe Liver injury. An. Surg., ABT: 969-574, 1978, 6. Crosthwait, ROW. Allen, J. K., Murga, F,, et als ‘The surgical ‘management of 640 consecutive liver injuries in civilian practice Surg. Gsnecol. Obstet, 114: 630-654, 1962 Defure, W.W., Je, Mattox, KL, Jordan, G. LJ. et al: Manage. ‘ment of 1,590 consecutive cases of liver trauma, Arch. Surg, 121! 9-497, 1976 1. DePinto, D. J. Mucha, 8.4, Powers, B. C2 Major hepatic vein ligation necessitated by blunt abdominal trauma. Ann, Surg AB: 243-246, 1976, 8, Donovan, A.J, Michaelian, M. Yellin, A, E.: Anatomical hepatie Tobectomy in trauma to the iver. Surgery, 13: 833-847, 1973 ding, S.C, Aragon, G. K., Moore ‘age following trauma. Am. J. Surg., 138: 843-AN8, 197 11, Kngrav, LHL, Benjamin, C. 1, Strate, R. G., et al: Diagnostic ‘Peritoneal lavage in blunt abdominal trauma. J. Trauma, 15: 51-859, 1975, 12, Fischer, K. P., O'Farrell, K. A. Perry, J. F,, Jr: The value of Peritoneal drains in the treatment of liver injuries, J. Trauma, 1a: 305-98, 1978, 1, Fischer, KL P., Stremple, J. F MeNamara, J.J. et al: The rapid Tight hepatectomy. J. Trauma, 11: 142-748, 1971 14 Flint, L. M, Jr: Managing hepatic trauma. Surg. Rounds, 3: 14 20, 1980. 15, Flint, Lo M, Jr Polk, H.C. Je lctive hepatic artery ligation: 9-823, 1979 IC. M. Mackenzie, RJ, MacDonald, G. A. et als The ‘mechanism of impaired coagulation after partial hepatectomy in the dog. Surg. Gynecol Obstet 143: 81-86, 1976 17. Heaney. J. P, Jacobson, A: Simplified control of upper abdominal Ihemorthage from the vena cava. Surgery, 78: VI8-141, 1975, 18, Huguet, C., Nordlinger, B. Bloch, P., et al: Tolerance of the human liver to prolonged normothermic ischemia, Arch. Surg., 113: Tah 1451, 19 19, Jackson, G.'L, Thal, E. Re Management of stab wounds of the back and flank. J. Trauma, 19: 660-664, 1979, 20. Ledgerwood, A. M., Kazmets, M., Lucas, C.F. The role of thoracie ‘aortic occlusion for massive hemoperitoneum. J. Trauma, 16: 10-615, 1976 21, Levin, A. Gover, P,, Nance, F. C2 Surgical restraint in the man: ‘agement of hepatic injury: A review of Charity Hospital experi hee Trauma, 18: 3A-404, 178 22 Laas, C. E. Ledgerwood, A. M: Prospective evaluation of hemo: static techniques for liver injuries. J. Trauma, 16: 442-451, 1976. Intra-Abdominal Packing for Hepatic Hemorrhage 289 23, Madding, G. Ps Injuries of the liver. Arch. Surg, 70: 748-756, 1965. 24, Madding. G. F.: Wounds of the liver. Surg. Clin. No, Amer, 38: 619-1629, 1958, 25, Mattox, K. L.. Allen. M. K., Feliciano, D. V.: Laparotomy in the emergency department, FA.CE.P. 8: 180-185, 1979 Mays. f. T:, Conti, S. Pallahzadeh, H., et al: Hepatic artery Tigation. Surgery, 86: 585-543, 1979. Melnnis, W. D. Richardson, J D., Aust, J B: Hepatic trauma: Pitfalls in management. Arch. Surg, 112: 157-161, 1977 28, Morganstern, L, Michel, S. L., Austin, Ky: Control of hepatic bleeding with microfibrilar collagen, Arch, Surg. 12: 941-943, Ws 29, Morton, J. R., Rays, G. D., Bricker, D. Le: ‘The treatment of liver juries. Surg. Gynecol. Obstet, 124i 298-102, 1972 W0. Murray, D. Hinde, Borge, J. D., Pouteau, G.G.: Tourniquet control of liver bleeding. J. Trauma, 18: 771-773, 1978 BI. Nilehn. JE. Nilsson, LM. Aronsen, K.F.,et al: Studies on blood clotting factors in man after massive lier resection. Acta Chir Sean, 133: 189-195, 1967 82. Pachter, H.L., Spencer, F.C.: Recent concepts in the treatment of hepatic trauma, Facts and fallacies, Ann, Surg, 190: 423-428, 1979, 4. Pringle, J. HL: Notes on the arrest of hepatic hemorshage due to ‘trauma. Ann, Sure. 48: 541-549, 1908 4 Sankaran, 8, Lucan C., Wall, A. i: Thoracie aortic clamping for prophvlaxis against sudden cardiac arrest during laparotomy for Acute massive hemoperitoneum. J. Trauma, 18: 200-296, 1975, 138, Schrock, Blaisdell, F. W., Mathewson, C., Jr: Management of ‘blunt trauma to the liver and hepatic veins. Arch, Surg. 96: 698 Tos, 1968, 38, Schroeder, W. K, teases (resection 1906, parkman, R. S., Fogelman, M. J: Wounds ofthe liver: Review of 100 cases. An. Surg, 138: 690-719, 1954 38, Stone, H. HL, Lamb, 4. Mz Use of pedicled omentum as an autog ‘enous pack for control of hemorrhage in major injuries of the liver. Ann, Surg.. 141: 92-94, 1975, 39, ‘Thal, B. R: Evaluation of peritoneal lavage and local exploration in tower chest and abdominal stab wounds, of. Trauma, 17: 642 6548, 1977, 40, Walt, A. J: The surgical management of hepatic trauma and its ‘complications, Ann. Roy. Coll Surg, Eng., 45: 319-339, 196. 441, Walt, AJ: The mythology of hepatic rauma-—Or Babel revisited. ‘Aim. J. Sur 1B: 12-18, 1978 42, Yellin, AE. Chaffee, C. B., Donovan, A. J: Vascular isolation in treatment ofjustahepatic venous injuries. Arch. Surg., 102: 565- 574, 1971 The progress of liver hemostasis—Reports of sutures, ete). Surg. Gynecol. Obstet, 2 DISCUSSION Dx. J. Davip RICHARDSON (Department of Surgery, Univer sity of Louisville, Ambulatory Care Bldg., Louisville 40202); Once again the trauma unit from Ben Taub is to be congratu- lated on another fine paper reflective of a large experience with, a very difficult group of patients. In this case they have re- minded us of the use of intra-abdominal packing as a means of salvaging a desperately injured patient, which was initially described by Pringle in 1908, Much of the literature on hepatic trauma in the past two decades has centered on the role of newer procedures that have ‘come and gone, such as hepatic lobectomy, atrio-caval shunting, and hepatic artery ligation, which once was extremely popular in our institution in Louisville, We have often found that on careful scrutiny these procedures have not fulfilled the promise they initially held in the management of liver injuries. T quickly reviewed our experience with our last 220 cases of liver injuries over 20 months in Louisville, and found that we have actually done only five hepatic artery ligations, with three survivors, during that period of time, We had three hepatic lobectomies, with one survivor. We have done four atrio-caval shunting procedures, with no survivors. Two patients had pack-290 ‘The Journal of Trauma ing, similar to what the authors have recommended today, with tone survivor and one death due to late sepsis, I think the message is clearly that most patients with liver injuries can be managed with the time-honored techniques of direct suture, hepatorthaphy, resectional debridement when necessary, direct compression, and the like. If patients do not stop bleeding with these maneuvers, then we may need to rely con hepatic artery ligation, hepatic lobectomy, or liver packing, and all of these certainly should be a part of the trauma surgeon's armamentarium, On the two patients whom we packed, we performed a reoperation in 48 hours to remove the packs, debride devitalized tissue if their clotting studies were normal, and then carefully place drains. I prefer this approach conceptually to removing. packs through drainage sites in the intensive care unit, but certainly our experience is not large enough to argue that point strongly. [believe the authors have clearly stated the indications for intra-abdominal packing in this highly selected group of pa: tients. They are: 1) patients who have had coagulopathy after other more standard procedures have been tried and failed; 2) patients who would require lobectomy in the face of ongoing. coagulopathy: 3) extensive injuries such asa continuing subcap- sular hematoma; 4) extensive bilobar injuries. We certainly would agree with those indications My only concern about this paper, which I expressed to Doctor Feliciano, is that some who read it may not follow the very careful dictums that they have used in terms of carefully selecting patients, and that they may return to the indiserimi: nate use of packing as a primary treatment for liver injuries. I believe this would be a great step backward and must be guarded against. Dr. Kirk V. CaMMack (Desert Springs Plaza #218, Las ‘Vegas, NV 89109): When I was a volunteer surgeon in Vietnam working in the provincial hospitals, the only blood we had came from outdated blood that the Air Force would give us, and we had poor anesthesia. The first five liver trauma patients oper- ated on as you would in the United States died on the table, mostly with high-velocity missile injuries. They could not sur- vive prolonged surgery even under the best conditions. After that I decided to pack them all. Some of them died, but som of them did live. I also learned that if you left the pack in more than 2 to 3 days, they all got abscesses. Dk. Ricuanp J, Fist (Field Clinic, Centreville, MS 39631): 1 rise to express appreciation to the Ben Taub Emergency Unit for another excellent paper which presents a very important point. They are focusing our attention on what I believe to be the correct perspective in our treatment of liver lacerations. ‘They have presented good evidence that there are still cases in April 1981 which packing of the liver wound is prudent. As you know, during the last several years, as Doctor Alex Walt has succinctly put it it was a demonstration of our ‘surgical manhood! to do a lobectomy on a liver laceration if it were of any magnitude. 1 think it is important for us to be reminded that there are ‘occasions when liver laceration packing should be done. We are particularly interested in trauma in the rural areas of our country and I suspect that with the pendulum of liver trauma therapy recently swinging entirely toward lobectomy, that there were some surgeons who were not properly prepared, either by blood bank oF technical training, who attempted to do this. I feel that this modality may have produced some unwarranted deaths and some of these people might well have been saved had the traditional packing of the laceration been accomplished, ‘Thank you again for reminding us that in a carefully chosen cease, packing of the liver laceration is the thing to do and ix something we need not be ashamed of. Dx. Crantes E. Lucas (Department of Surgery, Wayne State University, Detroit, MI 48201): I would like to support the Houston revivification of the liver pack in very selected instances. Since 1968 I have done this five times, with the last three instances being an intrahepatic pack rather than a para- hhepatic pack. When using this technique, itis important to stop the very active bleeding before resorting to the pack. This may be achieved by a hepatotomy and direct ligation of the larger vessels within the depth of the wound. After that has been achieved one can place a Raytec® within the liver and close the liver over it. This necessitates reoperation at about 3 (0 5 days. I like to wait about 3 days. When the packs are removed debridement should be minimal, although irrigation is helpful. ‘The cavity from which the packs were taken, however, should be drained by way of soft rubber Penrose drains which are brought out through a large abdominal wall stab wound, Dx. Davin V. Fetictano (Closing): I would like to thank Doctors Richardson, Cammack, Field, and Lucas for their com: ments. Doctor Cammack, we do redebridement at our second operation and take out all devitalized tissue. Doctor Lucas, we irrigate extensively, as if it were a primary operation, and we change all our abdominal drain sites. I think this is probably ‘one of the reasons our sepsis rate has been acceptable. Also, Doctor Lucas, we certainly agree with the concept of hepatotomy, and we do it in most of our gunshot wound tracts now, We have been fooled several times at Ben Taub in the last ‘couple of months with what would appear to be slowly bleeding bullet tracts in hypotensive patients which, if they are oversewn, suddenly let loose in the S.LC.U. thank you,