Injury to the retrohepatic inferior vena cava can have a poor prognosis due to the difficulty in surgical access.
The retrohepatic inferior vena cava is 8-10 cm in length.
Presentation: retrohepatic hematoma
The initial intervention is to attempt packing.
If initial packing controls the hemorrhage, then:
(1) admit to the ICU
(2) return to OR in 24-48 hours to remove the packing.
(3) if bleeding is controlled then remove packs and perform definitive repairs.
(4) if bleeding is uncontrolled then either repeat packing or consider exposure and repair.
If initial packing does not control the hemorrhage, then:
(1) extend the laparotomy with right subcostal incision
(2) mobilize the hepatic attachments to visualize the vena cava
(3) if the injury can be controlled, then perform either a primary repair or patch repair.
(4) if the injury cannot be controlled, then perform a total hepatic vascular isolation
(4a) if there is a pre-existing right thoracotomy, then extend the laparotomy to the right thoracotomy
(4b) if there is not a pre-existing right thoracotomy, then extend the laparotomy to median sternotomy
(4c) consider an atriocaval shunt
Complication:
(1) air embolism
(2) severe hemorrhage with hemodynamic collapse
