Abdominal packing for surgically uncontrollable haemorrhage.

Background: Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82 % due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible. Patients and methods: Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years) . The risk factors for mortality were analyzed. The reasons for uncontrollable bleed were : liver trauma (8), liver tumours (3), following liver transplantation (4), pancreatic necrosectomy (17) and miscellaneous causes (17). Results: There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <340C, metabolic acidosis and sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality. Conclusion: A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.

Liver hemangioma mimicking cholangiocarcinoma - a diagnostic dilemma.

A 55-year-old man presented with a liver mass that had been diagnosed on ultrasonography, carried out in response to the patient’s complaint of non-specific abdominal pain. Triphasic computed tomography (CT) revealed a lesion involving segments 1, 4, 5 and 8 of the liver. It was centrally hypodense with peripheral enhancement in the arterial phase suggesting a cholangiocarcinoma. The middle hepatic vein was encased and the tumour was present near the junction of the left hepatic and middle hepatic veins. We planned a right hepatic trisegmentectomy including resection of the caudate lobe but since the estimated volume of the liver remnant was only 17% of the total, we first embolised the right portal vein. CT scan repeated 5 weeks later revealed that the lesion was still resectable and that the left lateral segment had hypertrophied to 27% of the liver volume. We performed a right trisegmentectomy including caudate lobe resection using intra-operative ultrasonography to establish that the left hepatic vein was not involved. The removed lesion was hard with ill-defined margins. Histopathological examination revealed a hemangioma.