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Operative Management Of Penetrating Ivc Injury
Catherine Kilada, MD, Mina Guerges, MD, Katherine McKenzie, MD.
Jamaica Hospital Medical Center, Jamaica, NY, USA.
DEMOGRAPHICS: Patient is a 24-year-old Male with a medical history of Anxiety.
HISTORY:A 24-year-old male presented as a Level 1 trauma for stab wound to the mid back embedded paramidline at the L1 region, with the retained blade projecting 4-5cm externally. The patient was transported and remained in prone positioning. He was hemodynamically stable, with a GCS of 15, intact motor function in all extremities, and positive distal pulses bilaterally. CT confirmed penetration of the blade through the IVC with a retroperitoneal hematoma containing active extravasation near the anterior aspect of the L1 vertebrae.
PLAN:Two operating room tables were arranged side by side with a 5-6 inch gap. The patient was transported onto one of the operating room tables, maintaining a prone position and preservation of the lodged knife. He was then rotated supine straddling the two operating room tables to allow the external portion of the knife to project downwards between the tables. Midline laparotomy was performed, A Zone 1 retroperitoneal hematoma was noted and the knife was found projecting anteriorly through the IVC in the subhepatic and suprarenal region with ~2cm of the knife tip projecting anteriorly past the level of the IVC with active bleeding which was controlled through proximal and distal compression of the IVC with sponge sticks. The IVC was primarily repaired with prolene sutures and the knife was withdrawn in stages from the posterior aspect of the patient. The IVC was unclamped after hemostasis. A venogram confirmed IVC patency. Cavogram confirmed a patent suprahepatic IVC and a patent repair.
DISCUSSION: IVC injuries occur in 0.5-5% of cases of penetrating abdominal injury with a prehospital mortality of 30-50% and in-hospital mortality of 20-60%. While studies have shown a decrease in mortality for blunt vascular trauma due to the advancement of endovascular techniques, mortality rates have increased in the setting of penetrating vascular trauma. Outcomes depend on hemodynamic status, the extent of injury, and the presence of associated injuries requiring innovative operative approaches and clear intraoperative communication between teams for definitive repair to be tailored to the patient and type of injury.
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