Successful management of severe blunt hepatic trauma by angiographic embolization

Systematic Review of the Management of Retro-Hepatic Inferior Vena Cava Injuries

Background

Retro-hepatic inferior vena cava (RHIVC) injuries resulting from blunt or penetrating abdominal trauma are rare but devastating events that remain a considerable challenge to even the most experienced doctors, which continue to carry a considerable mortality.

Aim

To establish a better understanding of the management of RHIVC injuries and to identify any adjuncts or operative methods that were associated with an increased survival.

Methods

A systematic review of the MEDLINE database was conducted using Medical Search Headings and exploded keywords and phrases. Studies were screened and subjected to inclusion/exclusion criteria. Data were extracted in a methodical manner collecting population demographics, morbidity, mortality and operative intervention, where provided. Operative strategies were compared and discussed.

Results

An initial search identified 483 articles. Following duplicate removal and abstract screening, 85 full-text articles were assessed with 25 meeting the desired criteria and were, therefore, included in the systematic review. Key operative strategies and complications were identified and discussed.

Conclusion

The wide variety of operative interventions in the management of RHIVC liver injuries described attest to the increased efforts to improve outcomes. The overall improvement in mortality can be noted since the earlier descriptions reported mortality approaching 100% compared to the 52% reported in this review. An algorithm has been proposed based on these findings and our experiences for the management of RHIVC injuries.

Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery

We present the case of a 22-year-old man transferred to the regional major trauma centre following a fall of ~15 m. He remained consistently haemodynamically stable for over 10 hours of observation until he deteriorated suddenly with major haemorrhagic shock requiring immediate trauma laparotomy. At laparotomy, 2 L of blood was drained from the abdomen but no source of active bleeding identified. 30 minutes after closure of the abdomen, 500 mL of fresh blood was noted in the drain so he was returned to the theatre where the bleeding source was found to be-after manual compression of a mildly bruised hepatoduodenal ligament-the proper hepatic artery (PHA). This case describes an unusual finding at relaparotomy and shows that even when there is no active bleeding from abdominal organs or classified vessels, it is possible to have isolated injury to PHA.

Management of blunt liver injury: what is new?

Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach

INTRODUCTION

Posterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury.

PRESENTATION OF CASE

A 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful.

DISCUSSION

Incisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries.

CONCLUSION

Thoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.