Temporary hemostasis
Temporary hemostasis is used directly during surgical intervention so that the operating surgeon can quickly assess the extent of damage and prepare the surgical field for definitive manipulations. Basic techniques include direct digital compression of the liver tissue and the application of specialized elastic clamps to bleeding areas.
A special place in emergency surgery is occupied by compression of the hepatoduodenal ligament, widely known as the Pringle maneuver. The surgeon performs this manipulation either with the fingers of the left hand or using a specialized soft clamp. The main rule of the Pringle maneuver is strict time control. The clamping limit for the ligament is no more than 15 minutes. Exceeding this interval leads to severe systemic and local complications: liver tissue necrosis develops, acute venous stasis occurs in the gastrointestinal organs, which can ultimately trigger vascular collapse.
Definitive hemostasis: mechanical methods
Mechanical methods are recognized as the most reliable for definitive hemostasis. This group includes wound packing, the application of specific hepatic sutures, and isolated ligation of vessels directly within the wound (the latter is most often used as a necessary adjunct to the primary suture).
Hepatic sutures are divided into two main types:
- Kuznetsov-Pensky suture. This is a complex but extremely effective technique. The liver tissue is transfixed through its entire thickness using a double ligature, which is passed exclusively with a blunt needle to minimize trauma. The threads are brought out onto the upper and lower surfaces of the organ but are not tied immediately. Then, one of the threads is cut at the exit sites. The ends of adjacent threads are tied together and pulled tight. As a result of this transfixation, the liver tissue is reliably compressed in separate areas, forming characteristic «bolsters» over the liver capsule.
- Mattress sutures. Characterized by technical simplicity and a high degree of reliability. The main problem when suturing the liver is the high risk of threads cutting through the fragile parenchyma. To avoid this, mattress sutures are often passed through the omentum. A strand of omentum on a pedicle is carefully wrapped around the damaged area of the liver, and it takes on the mechanical load, preventing tissue destruction.
Physical, biological, and chemical methods
If mechanical methods cannot be applied in isolation or if it is necessary to enhance their effect, surgeons resort to additional techniques:
- Physical methods. These include the use of hot compresses: a gauze wipe generously moistened with a hot isotonic NaCl solution is pressed firmly against the wound. Exposure time ranges from 5 to 10 minutes. Electrocoagulation is also sometimes used. However, its use is strictly limited due to a serious risk: the formed thermal eschar may eventually slough off, inevitably causing dangerous secondary bleeding.
- Biological methods. The most frequent and physiological method in this category is omental packing. The greater omentum possesses powerful natural hemostatic properties. When placed in the wound, it adheres extremely rapidly to the damaged liver surface, reliably blocking the bleeding.
- Hemostatic agents. In modern practice, local agents—special fibrin and collagen films, as well as hemostatic sponges—are actively used to stop parenchymal bleeding and are applied directly to the damage zone.
Briefly: answers to topical questions
What anatomical structures run within the hepatoduodenal ligament?
The hepatoduodenal ligament (lig. hepatoduodenale) contains the elements of the portal triad, additional blood vessels, lymph nodes, and nerve plexuses.
- Proper hepatic artery (a. hepatica propria) — located on the left, gives off the left and right branches.
- Bile ducts — located on the right, include the common bile duct (ductus choledochus), as well as the common hepatic (ductus hepaticus communis) and cystic (ductus cysticus) ducts that form it.
- Portal vein (v. portae) — located between them and posteriorly.
- Additional vessels — right gastric (a. et v. gastricae dextrae) and gastroduodenal (a. et v. gastroduodenales) vessels in the lower section.
- Nerve plexuses (plexus hepaticus) — anterior and posterior hepatic plexuses.
What types of hemostatic sutures exist for closing liver wounds?
Special hemostatic sutures are used to close liver wounds, ensuring reliable hemostasis and approximation of the wound edges.
- Kuznetsov-Pensky suture — liver tissue is transfixed through the entire thickness with a double ligature using a blunt needle. The threads are brought out to the surfaces, one is cut, and the ends of adjacent threads are tied in a U-shape. The tissue is compressed in separate areas.
- Mattress sutures — simple and reliable sutures. Often passed through an omental flap on a pedicle, which is wrapped around the liver to prevent suture cutout.
- Oppel suture — used as an alternative option to interrupted or mattress sutures with tissue entrapment.
What autologous tissues, besides the greater omentum, can be used for biological packing of liver wounds?
For biological packing in hemorrhages from parenchymal organs, which include the liver, the patient's muscle tissue can be used in addition to the omentum.
- Muscle tissue — used as an autologous tissue to stop capillary and parenchymal bleeding.
- Omentum — used as a free graft or a pedicled flap.
Other types of the patient's own tissues for hemostasis are not described in sources. Additionally, biological products such as fibrin film, collagen or gelatin sponges can be used, but they are not autologous tissues.
For quick memorization of the Pringle maneuver restrictions, use the "Three P's Rule": Pringle maneuver — Fifteen minutes — Protection for the Parenchyma (Liver).
Class and exam questions
What is the essence of the Pringle maneuver and why is it dangerous?
This is a method of temporary hemostasis by clamping the hepatoduodenal ligament with fingers or a clamp. The danger lies in ischemia: if the ligament is kept clamped for longer than 15 minutes, liver necrosis, vascular collapse, and venous stasis in the GI organs may occur.
Why is the omentum used when applying mattress sutures?
Liver tissue is very fragile and tears easily. An omental flap on a pedicle acts as a biological cushion that prevents surgical threads from cutting through the parenchyma and additionally stimulates the hemostatic process.
Why is electrocoagulation used with caution in liver trauma?
The thermal effect of the current forms an eschar on the wound. In the postoperative period, this eschar can unexpectedly slough off, leading to the development of life-threatening secondary bleeding from damaged vessels.
What kind of needle is needed to perform the Kuznetsov-Pensky suture?
A special blunt needle is used to pass a double ligature through the entire thickness of the liver tissue. This is necessary to push the tissues apart, minimizing additional trauma to blood vessels and bile ducts.
What else to study on this topic
- Topographic anatomy of the hepatoduodenal ligament and its elements.
- Step-by-step technique for forming «bolsters» when applying the Kuznetsov-Pensky suture.
- Properties of the greater omentum and the mechanism of its adhesion to damaged tissues.
- Pathophysiology of venous stasis in GI organs during prolonged vascular clamping.
- Mechanism of action of fibrin and collagen films at the cellular level.
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