Name:
17 IVC Med
Description:
17 IVC Med
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/8db1c706-d270-4504-a31b-954c9db04702/thumbnails/8db1c706-d270-4504-a31b-954c9db04702.jpg?sv=2019-02-02&sr=c&sig=zJCdhHPA5bLAK%2BJMuIar93pZVcobio8Q%2FzZxUDiCVLM%3D&st=2024-12-22T06%3A24%3A23Z&se=2024-12-22T10%3A29%3A23Z&sp=r
Duration:
T00H08M30S
Embed URL:
https://stream.cadmore.media/player/8db1c706-d270-4504-a31b-954c9db04702
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/8db1c706-d270-4504-a31b-954c9db04702/1720IVC20Med.mov?sv=2019-02-02&sr=c&sig=Kv%2FXgoQsTmkguOv4gLs8lvjhkiEnkbhGcSFFvs%2Bzo64%3D&st=2024-12-22T06%3A24%3A23Z&se=2024-12-22T08%3A29%3A23Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, we will discuss the proper technique for exposure of the inferior vena cava.
Segment:1 Objectives.
We will begin by discussing the relevant anatomy, the instruments and positioning, exposure and techniques, and, finally, the tips and pitfalls of this exposure.
Segment:2 Anatomy.
The inferior vena cava is formed through the confluence of the common iliac veins at the level of the fifth lumbar vertebra and courses cephalad. Along with retroperitoneal course, it receives tributaries from several paired lumbar veins, the right gonadal vein, the renal veins, and the right adrenal vein.
It then travels in a retrohepatic fashion, receiving the hepatic veins. There is a short segment of suprahepatic IVC, approximately one centimetre in length, prior to passing through the diaphragm and into the mediastinum and right atrium. At the level of the renal veins, the inferior vena cava lies in the retroperitoneum, covered by the second portion of the duodenum and the pancreatic head. A Kocher maneuver must be performed in order to gain exposure of the inferior vena cava and the renal veins at this level.
The inferior vena cava lies to the right of the aorta. The right renal vein is fairly short, while the left renal vein is significantly longer in length. Note that the superior mesenteric artery crosses over the left renal vein during its course. The right gonadal vein joins the inferior vena cava directly, while the left gonadal vein joins the left renal vein. At the level of the fifth lumbar vertebra, the common iliac veins join to form the inferior vena cava.
Note that the confluence is crossed superficially by the right common iliac artery. There are four to five lumbar veins, which join the inferior vena cava between the confluence and the renal veins. Note the easily accessible right lumbar veins, and the less accessible left lumbar veins as they travel posterior to the aorta.
Segment:3 Instruments and Positioning.
The patient should be positioned supine and the preparation should include the chest and abdomen to the knees. The instruments required include a standard laparotomy tray, an abdominal retractor such as a Bookwalter, a vascular tray and a sternotomy tray, should exposure of the retrohepatic inferior vena cava be required.
A midline laparotomy incision is made in the skin from the xiphoid process to the pubis symphysis, using a scalpel. Upon entry to the peritoneal cavity, a fixed self-retaining retractor, such as the Bookwalter, is helpful. In order to expose the inferior vena cava at the level of the renal veins, first the hepatic flexure of the colon must be mobilized. Next, a Kocher maneuver is performed by incising the lateral attachments of the second portion of the duodenum, and retracting the pancreatic duodenal complex medially.
With the duodenum and pancreatic head retracted medially, the inferior vena cava and right renal vein are easily identified and dissected. The distal most extent of the Kocher manoeuvre is identified by the left renal vein. Recall that the superior mesenteric artery crosses over the left renal vein, preventing further medial dissection. Further exposure to the abdominal inferior vena cava requires access to the retroperitoneum.
This is achieved with a right visceral medial rotation or Cattel-Braasch maneuver. The right colon is retracted medially, and the white line of Toldt is incised. Mobilization is continued around the cecum and to the ileocecal junction. Once the colon is mobilized, the small bowels are retracted to the right side, exposing the base of the mesentery from the ileocecal junction to the ligament of Treitz. The base of the mesentery is then divided along this line.
The right colon and small bowel are now able to be retracted towards the patient's left chest, providing wide exposure of the inferior vena cava and retroperitoneal structures. Care must be taken when retracting the bowel once medial rotation has been completed, as the bowel is attached only by the mesenteric vessels. The inferior vena cava, right gonadal vein, and both renal veins, as well as the aorta, are now easily visible.
Note the location of the superior mesenteric artery after mobilization, as it no longer crosses the left renal vein. During dissection of the infrarenal inferior vena cava, recall that there are four to five paired lumbar veins which can easily be injured during dissection. As dissection of the inferior vena cava is continued to the bifurcation, note that the right common iliac artery crosses superficially over the bifurcation.
With this exposure, the abdominal aorta is also easily exposed to the left of the inferior vena cava. In order to expose the bifurcation of the inferior vena cava and the common iliac veins, the right common iliac artery is carefully dissected and mobilized to the left. A vessel loop is then used to encircle the right common iliac vein. Similarly, the left common iliac vein is exposed by retracting the right common iliac artery and, again, the left common iliac vein is encircled using a vessel loop.
If an injury's identified in the inferior vena cava, the bleeding can easily be controlled with either direct manual pressure, a vascular clamp, or with sponge sticks. With posterior injuries to the inferior vena cava, identify and repair the posterior injury through the anterior venotomy in order to avoid mobilization and avulsion of the lumbar veins. The anterior venotomy is extended to facilitate exposure and the posterior injury is repaired with a 4-0 non-absorbable monofilament suture.
The anterior venotomy, or injury, can then be repaired similarly with a 4-0 non-absorbable monofilament suture. As previously stated, posterior injuries can be repaired via an anterior venotomy. If an injury is too large to be repaired with a stenosis greater than 50%, a vein or prosthetic patch may be utilized. If there is a destructive injury with a loss of a segment, an interposition graft may be utilized.
These techniques are particularly useful in the vicinity of the renal veins as ligation of the inferior vena cava here will result in renal failure. In a damage control situation, where the patient is in extremis with a destructive injury to the inferior vena cava, a temporary shunt using a chest tube is an option. Umbilical tapes are used to encircle the inferior vena cava and a chest tube is inserted into the lumen. If the injury is juxtarenal, be sure to orient the side holes near the renal veins.
The chest tube is then secured using the umbilical tapes and the patient may be brought to the ICU for further resuscitation and eventual reconstruction.
Segment:4 Tips and Pitfalls.
With suspected abdominal vascular injuries, the femoral veins should be avoided for venous access. Contained retrohepatic IVC injuries should not be exposed. Avoid injury to the lumbar veins during mobilization of the infrarenal IVC. Early control of exposed IVC injuries will decrease the risk of air embolism.
Primary repairs of the IVC should not result in stenosis greater than 50%. Juxtarenal and suprarenal IVC injuries should always be repaired if technically possible. Ligation of the infrarenal IVC is an option during damage control. If ligation of the IVC is performed, always monitor for compartment syndrome of the leg post-operatively. Thank you.
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