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Hepatic vein and retrohepatic vena caval injuries in children. Sternotomy first?
S L Moulton1, F P Lynch, T G Canty
1Division of Trauma, Children's Hospital, San Diego, CA 92123.
Insights
Sternotomy before laparotomy improves survival in children with severe liver vascular injuries by enabling faster vascular control. This approach enhances hepatic exclusion efficiency but requires careful patient selection for optimal outcomes.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Vascular Injury
Background:
- Major hepatic vein and retrohepatic vena cava injuries in children often lead to fatal hemorrhage.
- Prompt identification through clinical presentation and CT imaging is crucial.
- Traditional volume resuscitation can stabilize patients until laparotomy, risking exsanguination upon abdominal entry.
Purpose of the Study:
- To evaluate the efficacy of a sternotomy-first approach in managing pediatric major hepatic vascular injuries.
- To assess the impact of this approach on vascular control, hepatic exclusion, and survival rates.
Main Methods:
- A sternotomy-first approach, preceding laparotomy, was employed in pediatric patients with severe hepatic vascular injuries.
- Computed tomographic imaging was used for selective case identification.
- An atriocaval shunt was utilized in specific cases.
Main Results:
- Five children with major hepatic vascular injuries were treated using the sternotomy-first strategy.
- Four out of five patients survived, demonstrating improved outcomes.
- The sternotomy-first approach facilitated rapid vascular control and enhanced the efficiency of hepatic exclusion.
Conclusions:
- The sternotomy-first approach offers improved survival and efficiency in managing pediatric hepatic vascular injuries.
- Careful preoperative case selection is essential for the successful routine application of this technique.
- This strategy represents a potentially life-saving intervention for critical pediatric trauma cases.
Abstract:
Major hepatic vein and retrohepatic vena caval injuries are often fatal because of massive uncontrollable hemorrhage. Children with these injuries can be identified by their unique and dramatic clinical presentation and the selective use of computed tomographic imaging. Volume resuscitation promotes abdominal wall tamponade and hemodynamic stability until the abdomen is opened, at which point there may be sudden exsanguination before vascular control can be obtained. An alternative approach is to open the sternum before opening the abdomen. Management in this sequence provides rapid vascular control and improves the efficiency of hepatic exclusion. To date, five children with major hepatic vascular injuries have been treated with the sternotomy-first approach and four have survived; an atriocaval shunt was used on two occasions. Although sternotomy before laparotomy improves the efficiency of hepatic exclusion and may offer improved survival, accurate preoperative case selection limits its routine use.