Repair of inferior vena cava injury below renal vein level

Inferior vena cava injury repair below the renal vein plane for surgical treatment of inferior vena cava injury. Although the inferior vena cava injury is rare, it is the highest venous system damage. In the wartime, the firearm injuries involving the inferior vena cava almost died without being rescued; usually, the inferior vena cava damage, even in large cities with good transportation and emergency conditions, about 40% of the wounded died before arriving at the hospital. The wounded can be sent to a large hospital or trauma center alive, and the mortality rate is as high as 50%. In normal times, the common causes of injury are gunshot wounds, stab wounds and blunt injuries (such as traffic accidents). The area of the wound is mostly below the plane of the renal vein, accounting for about 3/4, and the injury in the posterior segment of the liver is about 1/4. In addition to the transport efficiency of the wounded, the degree of blood loss and the quality of the resuscitation, the prognosis of the inferior vena cava injury is closely related to the location of the injury and the severity of the combined injury. Inferior vena cava damage above the renal vein plane is difficult to treat, the mortality rate is above 50% to 60%, and the lower segment injury is around 30%. In the combined injury, the most significant impact on the prognosis is abdominal vascular injury, followed by abdominal organ injury. Among the injury factors, the prognosis of the stab wound is the best (the mortality rate is about 10%), the second is the bullet injury (30% to 40%), and the worst is the blunt injury (60% to 70%). Diagnosis of intra-abdominal hemorrhage is not difficult, but it is difficult to determine inferior vena cava damage. Because laparotomy to stop bleeding can not be delayed, it is not appropriate to perform a directional examination such as angiography before surgery to avoid delay. After laparotomy, the blood in the abdominal cavity was quickly removed and the cause of bleeding was ascertained. There is still fierce bleeding after blocking the abdominal aorta under the diaphragm, suggesting damage to the inferior vena cava system. Regarding the principle of treatment, in the past, the injury below the renal vein plane was often performed as an inferior vena cava ligation, but most of them caused long-term lower extremity edema; the upper inferior segment of the inferior vena cava was more than 90%. At present, ligation is only used for the injury of the lower kidney and the vital indications are unstable and cannot tolerate the repair surgery. Some authors have suggested that thrombosis and pulmonary embolism can occur after venous repair, which is not as safe as ligation. A large number of clinical reports in recent years have shown that this is not the case, but there may be more opportunities for thrombosis after ligation. Therefore, whenever possible, the vein should be repaired while hemostasis, and blood flow should be restored. Treatment of diseases: pediatric inferior vena cava obstruction syndrome Indication Inferior vena cava injury repair below the renal vein plane is suitable for inferior vena cava damage below the renal vein plane. Preoperative preparation At the same time of strong resuscitation, the chest and abdomen are prepared from the skin to the sternal notch, down to the middle of the thigh; systemic application of antibiotics to prevent infection; preparation of blood and preparation of their own blood transfusion device. Surgical procedure 1. The midline incision is fast into the abdomen. 2. Quickly remove the blood in the abdominal cavity, and then control the bleeding by hand pressure after finding the bleeding site, then open the peritoneal and peritoneal ligament of the ascending colon, and lift the right colon to the medial side to reveal the inferior vena cava. Instead of hand pressure, a gauze ball is clamped by two oval pliers respectively to press the lower and lower end inferior vena cava of the wound. 3. Lift the wound edge with a non-invasive vasospasm and use a Satinsky forceps to remove the two oval pliers. 4. No injury 5-0 single-strand non-absorption line continuous suture wound. Open Satinsky forceps. 5. The penetrating injury of the anterior and posterior walls of the vein needs better exposure. The upper and lower ends of the injury can be clamped with a vascular blocking forceps to improve the exposure, but care must be taken because the vein wall is fragile and easy to tear. A safer method is to use a fine latex tube around the vein and tighten it through a rubber tube to block blood flow. There are two kinds of repair methods. One is to ligature and cut 1 or 2 lumbar veins, free the posterior wall of the inferior vena cava, and then suture it directly after suturing. Second, when the inversion suture cannot be completed, the back wall is repaired through the anterior wall rupture (if appropriate, if necessary), and the anterior wall is repaired. 6. If the vein wall defect is too large, simple suture will cause stenosis and increase the chance of thrombosis. The autologous great saphenous vein patch can be used for repair. The whole segment can also be transplanted by using the internal jugular vein or the large saphenous vein that is cut open and spliced. 7. There are two ways to splicing veins: 1 vertical stitching method. 2 Spiral vein graft, with a corresponding caliber rubber tube as a temporary pad. 8. Close the posterior peritoneum and properly cover the repaired inferior vena cava. complication Direct complications include repair bleeding and thrombosis, which leads to inferior vena cava obstruction or even pulmonary embolism. As long as it is handled properly, the incidence is not high. More common complications are related to stress or organ injury, such as ARDS, pulmonary infection, renal failure, abdominal abscess, and spasm.