Zones of Injury

Most major vascular structures within the abdomen are retroperitoneal, and therefore the retroperitoneal zone that contains them can also aid in understanding basic management paradigms. There are three retroperitoneal zones (Figure 1).

Zone I extends from the aortic hiatus to the sacral promontory and includes the midline vascular structures (aorta and vena cava). Zone II includes the retroperitoneal structures within the paracolic gutters (kidneys, renal artery, renal vein), and zone III includes the pelvic retroperitoneum (iliac arteries and veins). If major vascular injury occurs within zone I, as evidenced by active bleeding or large hematoma, the injury should be explored and repaired regardless of whether it resulted from a blunt or penetrating mechanism. For retroperitoneal hematomas in zones II and III, typical management includes operative exploration if the mechanism is penetrating and nonexploratory management if the mechanism is blunt, including observation, urologic evaluation, or angioembolization. Pelvic fixation for unstable fractures is a critical component for safe management of zone III trauma to limit hematoma expansion or a worsening of the vascular injury.

Vena Cava Injuries

Major injury to the inferior vena cava (IVC) is a highly lethal event, especially when involving the retrohepatic region. Surgical treatment has primarily involved open techniques. Compression of the vena cava proximally and distally is an important part of hemorrhage control, with sponge-sticks being a useful adjunct in this regard (Figure 2). Even with adequate compression, hemorrhage can be significant as a result of renal and lumbar venous bleeding. The surgeon must be ready to make the initial repair the definitive repair, because suture laceration of the vein can easily convert a manageable injury to one that is complex or stellate.

Allis clamps can aid in the repair of linear caval injuries and facilitate suture placement in a relatively bloodless field (Figure 3). Lacerations and puncture wounds should be sutured using permanent monofilament suture. The author recommends 4–0 nonabsorbably polypropylene monofilament (Prolene) suture on an SH needle, which may be manually straightened to lengthen the throw on the needle and enhance control. Using Teflon felt or skeletal muscle pledgets can aid in hemostasis if the vein wall is friable or if initial suture attempts pull through the vein wall.

Retrohepatic injury presents a unique clinical problem that is one of the most lethal encountered by vascular and trauma surgeons. Total vascular isolation in this setting was described by Heaney and colleagues and is specifically designed for this injury pattern. The steps in this strategy for controlling retrohepatic IVC injuries consist of clamping the aorta just below the diaphragmatic hiatus; encircling the hepatic artery, portal vein, and common bile duct with an umbilical tape for en-mass clamping; encircling the IVC just above the renal veins with an umbilical tape; and controlling the suprahepatic IVC, just above the diaphragm in children and intrapericardially in adults.

Endovascular control of IVC injuries has been relegated to case reports. Nevertheless, in the setting of major venous bleeding from the IVC, transfemoral venous sheath placement with subsequent inflation of a large vessel-occlusion balloon such as the CODA (Cook Medical, Bloomington, IN) or Reliant (Medtronic, Fridley, MN) below or across the region of IVC injury can aid in hemorrhage control. Adequate accessible endovascular inventory, radiolucent surgical table, and imaging capabilities with either a fixed system or C-arm are essential for using these adjuncts.