The liver is the most frequently damaged organ in abdominal trauma [4], and the most widely used classification system for liver injury is the AAST-OIS [5]. Grade I or II injuries are relatively inconsequential, such as minor capsular tears, that do not require operative treatments. Grade III includes vascular injury associated with a hematoma or parenchymal laceration. Injuries greater than grade III are severe and often require operative management. Grade IV injuries are characterized by major parenchymal disruption, and Grade V injuries are the most severe, involving juxtahepatic venous injuries. High-grade liver injuries are associated with poorer prognosis, and thus, an appropriate management strategy should be developed in each emergency hospital [6]. Lin et al. [7] showed their treatment algorism for liver injury and presented 58 patients with blunt liver injury equal to or greater than AAST-OIS grade III. The patients with 14 grade V injuries were mainly managed with debridement hepatectomy and venous repair. Four patients underwent IVC repair and only one survived after IVC repair, although the precise method used in the IVC repair was not reported.
Injury to the retrohepatic vena cava accounts for only a small proportion of all liver injuries. However, it has been described as the most technically difficult and most deadly form of liver trauma [8]. Its mortality remains high, ranging between 50 and 80% [9]. The three major operative methods for hepatic veins or retrohepatic vena caval injuries include (a) direct suture repair of the bleeding vessels with or without vascular isolation, (b) lobar resection, and (c) intraparenchymal or perihepatic packing [8]. If hemorrhage control is not achieved by the major operative methods, then a definitive surgery to repair the hepatic vein or retrohepatic IVC using TVE, atrial-caval shunt, or bio pump, is required [10]. Of these, TVE might be especially useful, since it does not require extracorporeal circulation and can be performed in the surgical site.
In reported series, most institutions preferred direct exposure and suture repair of the hepatic vein or retrohepatic caval wounds, regardless of injury patterns [11]. In a large multicenter series, Cogbill et al. reported a mortality rate of 90% for patients with main hepatic vein or caval injuries in whom atriocaval shunting had been used [12]. Gao et al. reported 7 cases of retrohepatic IVC injury repair with hepatectomy by total vascular exclusion and the mortality rate was 77.8% (7/9) [10]. Others have reported similar horrendous results [2, 3]. In more recent years, a smaller retrospective study was conducted by Hansen and colleagues [13]. They investigated 47 patients with abdominal vena caval injuries and examined the type of repair performed with respect to the outcome. The repair methods included suturing, ligation, vein patch, and graft patch, and the most common repair of IVC injury was suturing (72%). Of the 47 patients, there were 9 cases of retrohepatic IVC injury with a mortality rate of 66% (6/9).
Although different operative methods and associated mortality for major venous injuries have been reported, there have been few reports focusing on the detailed procedure of vena caval suture repair. In the present report, we present a hemodynamically unstable patient with grade V liver injury who required emergency laparotomy at the ER. The laceration reached the retrohepatic IVC, and hemostasis was achieved by suturing the injured IVC following left hemihepatectomy and TVE. In a deep stab wound to the liver suspected of retrohepatic IVC injury, it is essential to obtain an adequate operation field to thoroughly observe the extent of injury. As there are various patterns and degrees of seriousness of IVC injuries, different and individualized case-oriented approaches to repair the injured IVC must be considered, and these methods should be more precisely investigated in future studies.