Hepatic vein and retrohepatic vena caval injury.

Retrohepatic venous injury presents as a rare but frequently lethal complication of trauma. The anatomic arrangement makes management of these injuries difficult at best. Operative exposure and isolation techniques ranging from cross-clamping the aorta, portal triad, suprarenal vena cava, and suprahepatic vena cava to the use of internal shunts are described in this report. Our experience from 1968 to 1987 with internal shunting techniques includes 27 patients. We have successfully resuscitated 12 patients for an acute mortality of 55%. We believe that this figure is high but compares favorably with published results. Late deaths from sepsis, disseminated intravascular coagulation, or multiple systems organ failure remain as significant causes of overall mortality. Many techniques have been successfully employed over the years in achieving vascular isolation of the liver. The methods all have their own merits, but the key factor in each is the recognition that they need to be employed. Conservative selection of patients is undoubtedly justified, but aggressive approaches should not be delayed until they are the methods of last resort.