FIGURE 26 Pelvic Packing for Grade 5 Fracture With Retroperitoneal Bleeding

A–B. Through a low midline incision, the area of the extraperitoneal bladder is approached, taking care to stay outside the peritoneal cavity

C. Any free blood is removed, and the sides of the bladder are retracted

D. Three laparotomy pads are placed on each side, lateral and posterior to the bladder. The laparotomy pads are left in place as a damage control tactic (to be removed later), and the lower midline incision is closed. Some surgeons also ligate the internal iliac arteries bilaterally. Others recommend leaving these vessels intact to provide a route for embolization should bleeding continue

FIGURE 27 Liver and Biliary Anatomy

A. This drawing depicts the anatomy of the gallbladder and porta hepatis. Although many variations may exist, review of this area can be helpful prior to operating on an injury in this location

B. This drawing illustrates the vascular anatomy of the liver

FIGURE 28 Hepatorrhaphy

Using a large, special “liver” needle on an absorbable suture, a deep figure-of-eight suture can stop troublesome bleeding. Sutures should be tied loosely, rather than snug and tight, since the liver swells postoperatively, and tight sutures can cause liver necrosis

FIGURE 29 Tractotomy

Gross, large ligatures to the liver may cause liver necrosis and postoperative fever. The injury is unroofed by performing a tractomy, with direct ligation of the biliary and vascular structures

FIGURE 30 Liver Omental Packing

The left side of the omentum is mobilized off of the transverse colon mesentery, preserving a vascular pedicle from the right side of the transverse mesocolon. The sutures attaching the omentum to the liver are loosely applied, so as not to strangulate the omentum

FIGURE 31 Hepatic Balloon Tamponade

A custom, temporary balloon is fashioned using a Penrose catheter and a rubber catheter, sealing off the ends of the Penrose drain placed over the catheter. After insertion into the body of the liver, the catheter is then filled with saline. Over time, the pressure on the “balloon” can be lost, so that reinflation or a secondary procedure might be necessary following this temporary “damage control” tactic

FIGURE 32 Liver Packing

Temporary packing of a bleeding liver is the prime example of damage control. Laparotomy packs are placed above and below a bleeding area in the liver, making a “liver sandwich.” Care is taken not to obstruct the inferior vena cava or to produce too much constriction, leading to liver necrosis

FIGURE 33 Pancreaticoduodenal Biliary Anatomy

The normal anatomy in the gastroduodenal-pancreatic area of the abdomen is very compact, with many adjacent structures. The superior mesenteric vein is usually to the right of the superior mesenteric artery, and the splenic artery is usually near the superior border of the pancreas, while the splenic vein is posterior to the pancreas and covered by this organ. Note, the collateral arterial circulation in the head of the pancreas, which can be a significant source of bleeding

FIGURE 34 The Pringle Maneuver

Using a noncrushing (vascular) clamp, the entire porta hepatis can be occluded to decrease bleeding from an injured liver. This is a temporary occlusion of the portal vein, hepatic artery, and bile duct. It is accomplished by palpating the Foramen of Winslow and precisely placing the clamp on only the desired structures

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