101 Northern Medical Journal 2009; 18(2): I01-105

PENETRATING ABDOMINAL TRAUMACAUSING INFERIOR VENA CAVAL INJURY

- A CASE REPORTHriday Hanjan Royl, SM Abu Taleb2, Bimal Chandra Roy3, MA Basuniaa

Abstract:lnfenor vena cava injury is a grave condition. Patient present with severe shock and become reluctantto the procedure of resuscitation. We performed an emergency operation of inferior vena cava injury-who had non recordable blood pressure, ieeble pulse and scanty urine output even after resuscitationby l/V fluid and blood transfusion. The patient was rescued. However, due to associated pancreaticinjury, an embarrassing pancreatic pseudo cyst developed later on. A second operation was done 2months later; patient recovered completely and at present leading a normal life. Nofthern MedicalJournal 2009; 18 (2): 101-105

lndexing words: Penetrating abdominal trauma, lnferior vena caval injury, Pancreatic injury.

lntroduction:The incidence of injuries to major abdominalvessels in a patient sustaining penetratingabdominal trauma is 1A/.1. Most abdominalvascular injuries result from penetrating traumaand are associated with other abdominal injuries2. lnferior vena cava (lVC) is themost frequentlyinjured vessel in the abdomen ". The mortalityrate for this type o{ injury is 37% o. The highmortality is due to blood loss either from thevena cava or from associated vascular injuries 5

resulting in multiple organ f ailure caused by

1. Junior Consultant (Surgery) &

2. Senior Consultant (Surgery)Rangpur Medical College HospitalConsultant (Surgery)Sadar Hospital, LalmonirhatAsst. Prof. Dept. of Surgery &

Rangpur Medical College

delayed resuscitation and surgical intervention 6.

Clinically the patient will present either as freeintra peritoneal hemorrhage or As a containedretro peritoneal haematoma.''o Penetratingwounds of the vena cava are usuallV fatal eitherbefore any aid can be rendered e or later. despitesurgical treatmentl0. Knowledge of theanatomical location of the major vessels and thecourse of the penetrating object brings intoconsid,eration the possibility of a major vascularinjury '. However, the definite diagnosis of venacaval injury is usually established only atlaparotomy, b"ing

0,,, no, inf requently an

unexpected f inding.e'1

Case Report:

A 28 years young male hailing from Gangachara.Rangpur was admitted into this hospital havrng

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Roy, Taleb, RoY, Basunia102

There was about 1 inch linear longitudinal tnlui-,'

in both anterior and posterior aspect o{ IVC in its

infrararenal part. Both were repaired by 5/0

prolene (Fig-2).

Fig-2: After- r'epair of posterior wali of IVC

history of stab injury on right upper abdomen'

Assault on him was occurred at 10 am and he

reached hospital at '1.30 pm on the same day'

On admission, he was restlessness and his

cloths were stained with profuse blood' There

was continuous oozing of blood through the

wound and omentum came out through it'Examination findings on admission were,

appearance- restlessness, anemic, urine

output- scanty, pulse- rapid, thready and

feeble, B.P- non recordable' RaPid

resuscitation was tried by l/V fluid and blood

transfusion. But the result of resuscitation was

failed. So, the patient was submitted for urgent

laparotomy with double risk bond consent At

7.30 pm, abdomen was opened by a generous

right paramedian incision. The whole peritoneal

civity was full of clotted and f resh blood' lt was

sucked out and mopped out rapidly (about 2/3

liters). But continuous severe exsanguinations

of blood made the field so ditficult to identify the

injury. An injury on stomach at its antral part

anO UtooO stained lesser sac - which was full of

blood, draw the attention' So, lesser sac was

accessed rapidly by opening the gaslrocolic

ligament. There was terrible bleeding like an

igneous of volcano through an inlury at the site

of OoOy and head of the pancreas medial to

duodenal C-cap. Pressure by mop failed to

control the bleeding. So, manual finger

pressure (introducing finger into the injury) was

applied and it was controlled' Keeping it

controlled by an assistant, duodenum was

kocherized from laterally and the IVC was

explored. The injury was found extended up to

vertebral column injuring both anterior and

posterior wall of IVC (Fig-1)' Meticulous

dissection of IVC was done and control taken

by rubber catheter both above and below of the

injury (Fig-1).

Fig-1 : rncrough ar: thorough injur'.' '' r'1:' -' '

103

Control was removed. During this procedure, onlycarotid pulse was recorded by the anesthesiologist.After removal of control, pulse, B.P and urine outputbegan to reappear. Oozing from pre-vedebral areawas controlled by cauterization. The renal andgonadal veins were found to be intact. There wasalso associated injury to the stomach injuring bothanterior and posterior wall near its antral pafi. Bothwere repaired by double layered suture, Nothing wasdone for the associated pancreatic rnjury. Ti;o drain:one in pelvis and anoiher in lesser sac (throughforamen of Winslow; were inserled. Closure ofincision wound and stab wound was doneaccordingly. Recovery f rom anesthesia wasuneventful. Four units of fresh blood were given per-operatively. lnjection calcium gluconate and sodi bicarb was also given. Postoperative period wasuneventful.At Sth post operative day, a cystic swelling began toappear in left hypochondriac region which wasgradually enlarging occupying the left hypochondriac,epigastria, umbilicaland left lumber region (Fig-3).

Fig-3: Cysl c sr,relllng in upper abdomen

Penetrating abdominal traumacausing inferior vena cavai

injury-Acasereport

An ultrasonogram report reveals huge encystedthick (inf ected) collection in upper abdomen.Patrent also had respiratory distress. Aspirationwas done by wide bore needle by which thepatient felt comfort. The aspirate was clearpancreatic flurd. Later on a folley catheter wasinserted into the cyst by local anesthesia.lnitially, about 1 to 1112liter of collection per 24hours was there. But it was gradually decreasingday by day. Later on, the catheter was removedand he was discharged from the hospital.After about 11/, months (>2months f rom initialoperation), he again admitted into surgery unitwith the complaints of huge swellrng over theupper abdomen which typically became enlargedand painful during meal. lt made him discomfortand dyspnoeic. Repeat ultrasonogram revealedthe same picture as before. Repeated aspirationby wide bore needle (clear fluid) made himtemporary comfort, but the problem remain to becontinued. At Iast, the decision of laparotomywas taken for a cysto-jejunostomy with roux-en-Y reconstruction. Abdomen was opened throughthe previous incision line excising the scar ofprevious operation. There was a huge swellingbehind the stomach, aspiration f rom whichrevealed clear fluid. Lesser sac could not beaccessed due to huge adhesions. So, afteropening of the anterior wall of stomach, it wasreached by incising the posterror wall of stomachand a cysto-gastrostomy was constructed.

Recovery from anesthesia was smooth andpostoperative period was uneventful. He wasdischarged from hospital on 8th postoperativeday. Further follow up was done after one monthand he had no more complaints and was leadingcompletely normal life.

Discussion:

lnferior vena caval injury is a serious and rarecondition more oftei" encountered withpenetrating than with blur,t traumass. Despite the

Roy, Taleb, Roy, Basunia

progress in surgery and preoperative caretechnique, the mortality rate for IVC injury is stillhigh". Thirty six per cent patients die beforereaching hospital.s The factors, which playsignificant role in mortality, are presence ofshock on admission, suprarenal IVC injury andbleeding without retroperitoneal haematoma6.Survival was best when the-injury was located inthe infrarenal IVC (68%)." ln a study, it wasshown that the patients with IVC injury withshock had a 286-fold increase in the risk oJ

death8. For patients whose hemorrhage throughIVC is stopped by the retroperitonealhaematoma the mortalitv rate is 26% and thosewithout iI is 74"/..8 ln a siudy,t3 91% survival ratewith retroperitoneal temponade f ranklycontrasted to 93% mortalrty rate withouttemponade. ln our case, the patient was in

severe shock and there was no temponadeef{ect by haematoma, rather severe continuousbleeding was present. The only favorablesituation was that the injury was infrarenal. Theearly intervention with appropriate techniquemade the patient safe. About 100 cases havebeen published in the Enqlish literature withsuccessful surgical treatmeni.e'11'14'15'16'17'18 Gun-shot wounds are the main cause of penetratingcaval injuries and half of the patients are deadon arrival at hospital.l' Of those still alive, halfwill die in spite of therapy.lo Our case was avictim of stab injury by a sword.Upon admission, most show signs of severeblood loss and_ peritonitis, suggesting a majorvascular injury." ln our case, signs of severeshock and continuous oozing of blood throughthe stab was present. We guessed about themajor vascular injury, but the definite site wasuncertain. A number, however, do not appeargravely injured and the presence of a majorvascular injury is

. pre-operatively not evenremotely suspected.'" The patient who had anabdominal penetrating trauma with shock shouldbe operated immediatelyo. We also performed

urgent surgery despite unstable haemodynamiccondition, reluctant to resuscitation procedures.During operation, control of hemorrhage is thefirst step of intervention.o The determination ofthe pathway of the penetrating wound isessential Jor the diagnosis.s Any haematoma inZone '1 of retroperitoneum (Midlinelnframesocolic Area which includes infrarenalabdominal aorta and inferior vena cava) shouldbe explored.le lf inf ramesocolic haematomaappears to be more extensive on the right side ofabdomen than left and if there is activehaemorrhage coming through base of mesenteryof ascending colon or hepatic flexure of colon,injury to IVC below the liver should besuspected.lsSurvival rates for patrents with injury to IVCdepend on location of injury.ls The averagesurvival rates for 515 patients with injuries toinfrahepatic IVC was 72.2/o20'2t'22. When injuryto infrarenal IVC alone are included the averaoesurvival for 318 patients was 70.1"/o.zo'zt'zz'z{2sOurs was a case of infrarenal IVC injury.The reported articles cited here did not show anyassociated pancreatic injury. We had fetched itwith a severe postoperative complication" Afterabout two and half months, by which the cystwall matured, a second operation of cysto-gastrostomy was done. The question is, whetherthe pancreatic injury could be handled safely atthe first time with a pancreatico-enterostomyreconstruction. During first operation, the patientwas in critical condition and duration of surgeryand anesthesia was a factor. Should we go tohandle the pancreatic injury during f irstoperation, in this situation?

Conclusion:Penetrating injury of IVC remains a challengingproblem. The key to effective managementincludes early diagnosis, resuscitation andprompt surgical intervention. Associated solid orhollow visceral injuries negatively affect survival.ln case of haemodynamic instability, sometimes,

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a technically simpler procedure is morebeneficial than a complex, time consumingreconstruction. ln our patient, the earlyrecognition, prompt intervention culminated insatisfactory outcome. The associated pancreaticinjury made a problem for us, though it wasmanaged successfully at a later time.

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