Cadaveric training of total hepatic vascular exclusion for juxtahepatic venous injury: a technical study

Retrohepatic inferior vena cava (IVC) injury is a rare but frequently fatal challenge in trauma surgery. This study describes a structured cadaveric training sequence for total hepatic vascular exclusion (THVE), including transdiaphragmatic intrapericardial IVC exposure as an alternative escalation route for suprahepatic venous control.

A structured cadaveric dissection study was performed on nine adult cadavers by a multidisciplinary team of vascular and pediatric surgeons. The motivation was derived from an index pediatric blunt trauma case involving life-threatening retrohepatic caval bleeding. Five anatomical exposure steps relevant to THVE were rehearsed sequentially: hepatoduodenal ligament control, infrahepatic IVC exposure above the renal veins, access to the suprahepatic IVC via infradiaphragmatic and transdiaphragmatic intrapericardial IVC exposure and optional supracoeliac aortic exposure. The exposure steps were performed in a fixed sequence that was identical in all nine donors; the sequence was not randomized. After each dissection, procedural difficulty for each anatomical landmark was graded using a five-point scale: 1 = very easy, 2 = easy, 3 = moderate, 4 = difficult, and 5 = very difficult.

Hepatoduodenal ligament control received the lowest difficulty ratings. Perceived difficulty of infrahepatic IVC and supracoeliac aortic exposure decreased after repeated dissections. Infradiaphragmatic suprahepatic IVC exposure remained technically demanding, whereas transdiaphragmatic intrapericardial IVC exposure received significantly lower ratings of perceived difficulty (p = .004), with lower ratings after the initial dissections.

In this cadaveric training model, transdiaphragmatic intrapericardial IVC exposure received significantly lower ratings of perceived difficulty than infradiaphragmatic suprahepatic IVC exposure. Because the order of the two approaches was fixed and difficulty was assessed by team consensus, this finding does not establish that the transdiaphragmatic route is objectively easier, safer, or clinically superior.