Hepatic vein and retrohepatic vena caval injuries in children. Sternotomy first?
S. L. Moulton, F. P. Lynch, T. G. Canty, D. L. Collins and D. B. Hoyt
Division of Trauma, Children's Hospital, San Diego, CA 92123.
Major hepatic vein and retrohepatic vena caval injuries are often fatal
because of massive uncontrollable hemorrhage. Children with these injuries
can be identified by their unique and dramatic clinical presentation and
the selective use of computed tomographic imaging. Volume resuscitation
promotes abdominal wall tamponade and hemodynamic stability until the
abdomen is opened, at which point there may be sudden exsanguination before
vascular control can be obtained. An alternative approach is to open the
sternum before opening the abdomen. Management in this sequence provides
rapid vascular control and improves the efficiency of hepatic exclusion. To
date, five children with major hepatic vascular injuries have been treated
with the sternotomy-first approach and four have survived; an atriocaval
shunt was used on two occasions. Although sternotomy before laparotomy
improves the efficiency of hepatic exclusion and may offer improved
survival, accurate preoperative case selection limits its routine use.
