Tips & tricks for managing caval and retrohepatic injuries

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Karim

I try to keep it simple:
If the cava is ruptured below the liver and the renals, with a simple
repair after simple compression possible (I also use the Langenbeck or
Morris to compress - I find the swab-sticks clumsy!) and the patient is
stable - repair with running suture, otherwise I ligate the cava - done
this 5 times in the last few years with only one of the patients demising
from other injuries.

For the retro-hepatic cava: Once you know it is the cava and not the
liver, PACK and get out - especially in blunt injury. Thereafter speak to
your endovascular colleagues for intervention post-stabilisation. They can
occlude the arterial branches and then go back with experienced HPB
surgeons to do the repair under controlled circumstances, on some form of
bypass / liver exclusion. The Belasegaram clamp may also be useful if the
liver surface is bleeding badly! Access is important - don't be scared to
use a T-incision and have thoracic control of the intra-pericardial IVC.

As far as the Shrock shunt is concerned - no success and I feel it is a
overused but unsuccessful option.

Regards
Tim
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Senior Lecturer UKZN Dept Surgery
Deputy Director - IALCH Trauma Service
Durban, South Africa


> The list has been a bit quiet recently so here's a quickie - I'm
> giving a talk tomorrow at the Australasian Surgical Congress on the
> management of inferior vena cava and retrohepatic venous injuries and
> it seems to me that this is one area in particular where surgeons have
> developed their own tips, tricks or techniques to manage thiese
> injuries.  So does anyone have any golden nuggets of tools or
> manoevres or anyting that gets them out of trouble, makes venous
> control/repair easier, etc?
>
> I have a couple - here's one of mine: I was always taught to use
> spongesticks to control bleeding from a caval injury by pressing down
> on the cava proximally and distally.  I find langenbeck retractors are
> much more effective (the flat bit pressing down against the spine) for
> this purpose.
>
> I have more - but you'll need to show me yours first!
>
> Karim
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