Injuries of the retrohepatic inferior vena cava and the liver

Abstract

Beckground. Injuries of the retrohepatic inferior vena cava, and the liver have mortality rate up to 71-78%. We presented a patient with combined injury of the retrohepatic inferior vena cava, liver, craniocerebral and thoracic traumas, inflicted in a traffic accident. Case report. Man, 20 years old has been injured in a traffic accident. At admission, 20 minutes after the injury, the patient was comatose and hypotensive. Bloody content was obtained by abdominal tracer. The patient underwent emergent laparotomy, utilizing trifurcated incision and cell saver device. Abdominal exploration revealed two liters of free blood and massive retroperitoneal hematoma. Manual compression of the liver was done, as well as perihepatic packing, complete hepatic vascular exclusion and mobilization of the right liver lobe. Due to impressive chemodynamic instability supraceliac aortic clamping was performed. Upon exposure of the retrohepatic inferior vena cava and right liver lobe, multiple lacerations of retrohepatic inferior vena cava and right hepatic vein, and right hepatic vein avulsion were found. We also identified an injury of VII and VIII segments of the liver (grade V according to the Moore's classification). Nonexpansive hepatoduodenal ligament hematoma and the injury of II and III segments of the liver group II/III according to Moore were found. Venorrhaphy of the inferior vena cava was done in the area of circumference of the right hepatic vein, a portion of which served as autologous vein patch. Continuous prolene 3/0 venorrhaphy of the distal caval laceration was done. Total caval and aorta clamping time of the inferior vena cava was 41 minutes. Atypical resection, debridment, of hepatic segments was done by using a harmonic scalpel. Hepatoduodenal ligament was declamped after 65 minutes. Fibrin glue was applied on the resectioned area of liver. The patient received 3.2 l of autologuos blood transfusion with 5 units of packed red blood cells, 6 units of fresh frozen plasma, 13 units of concentrated thrombocytes and 15 units of cryoprecipitates. Due to coagulopathy, factor rVIIa was administered. Bilateral toracal drainage was done. Small bilateral contusions of the frontal part of the brain were noticed but the patient successfully recovered and was dismissed after three weeks. Conclusion. Combined injuries of the inferior vena cava and the liver befall into the most complex vascular traumas, thus representing a challenge for any complete medical team to manage them. The patient presented in our study was urgently transported to the hospital, immediately operated on applying modern doctrines of anesthesiology, transfusiology and vascular surgery that, all together, resulted into favorable treatment outcome with no distant complications.Uvod. Tupe povrede retrohepatickog dela donje suplje vene (vena cava interior - VCI) i jetre imaju mortalitet od 71-78%. U radu je prikazano zbrinjavanje bolesnika sa kombinovanom povredom retrohepatickog dela donje suplje vene, povredama jetre, kraniocerebralnim povredama i povredama toraksa zadobijenim u saobracajnoj nesreci. Prikaz bolesnika. Muskarac, star 20 godina, povredjen je u saobracajnom udesu. Na prijemu, 20 minuta posle povrede, bolesnik je bio komatozan i hipotenzivan. Punkcijom abdomena dobijen je krvav sadrzaj. Povredjeni je hitno operisan, uz upotrebu cell saver aparata. U abdomenu je nadjeno oko dva litra krvi i veliki retroperitoneumski hematom. Ucinjena je manuelna kompresija jetre, perihepaticka tamponada, kompletna vaskularna ekskluzija i mobilizacija desnog lobusa jetre. Zbog izrazite hemodinamske nestabilnosti aorta je klemovana supracelijacno. Eksploracijom su uoceni visestruki rascepi retrohepatickog dela donje suplje vene, desne hepaticke vene i njena avulziju od usca. Povreda VII i VIII segmenta jetre pripadala je grupi V po Moore klasifikaciji. Nadjen je i neekspanzivni hematom hepatoduodenumskog ligamenta i povreda II i III segmenta jetre grupe II/III po Mooreu. Ucinjena je venorafija donje suplje vene u podrucju usca desne hepaticke vene ciji je deo iskoriscen kao autologni venski pac. Distalna lezija donje suplje vene zbrinuta je direktnom venorafijom. Vreme klemovanja donje suplje vene i aorte trajalo je 41 minut. Ultraharmonicnim skalpelom ucinjen je resekcioni debridman destruisanog tkiva VII i VIII segmenta jetre. Hepatoduodenumski ligament bio je deklemovan nakon 65 minuta. Na resekcionu povrsinu jetre aplikovan je fibrinski lepak. Bilo je autotrasfundovano 3,2 l krvi, uz pet jedinica deplazmatisanih eritrocita, sest doza sveze smrznute plazme, 13 jedinica koncentrovanih trombocita i 15 jedinica krioprecipitata. Zbog stecene koagulopatije ordiniran je rekombinantni faktor VIIa. Obostrano je ucinjena drenaza toraksa. Dijagnostikovane su manje bilateralne kontuzione lezije frontalnog reznja mozga. Bolesnik se uspesno oporavio i nakon tri nedelje otpusten je iz bolnice. Zakljucak. Udruzene povrede VCI i jetre spadaju u najkompleksnije vaskularne traume i predstavljaju izazov za kompletan medicinski tim koji ucestvuje u njihovom zbrinjavanju. U prikazanom slucaju bolesnik je bio brzo transportovan do bolnice, hitno operisan uz primenu savremene anestezioloske, transfuzioloske i vaskularne hirurske doktrine sto je rezultovalo povoljnim ishodom lecenja bez udaljenih komplikacija.