The case report was published in Northern Medical Journal. Those who need to have reference can download from here and use thereby. An acknowledgement to me is appreciated.

2. 101
Northern Medical Journal 2009; 18(2): I01-105
PENETRATING ABDOMINAL TRAUMA
CAUSING INFERIOR VENA CAVAL INJURY
- A CASE REPORT
Hriday Hanjan Royl, SM Abu Taleb2, Bimal Chandra Roy3, MA Basuniaa
Abstract:
lnfenor vena cava injury is a grave condition. Patient present with severe shock and become reluctant
to the procedure of resuscitation. We performed an emergency operation of inferior vena cava injurywho had non recordable blood pressure, ieeble pulse and scanty urine output even after resuscitation
by l/V fluid and blood transfusion. The patient was rescued. However, due to associated pancreatic
injury, an embarrassing pancreatic pseudo cyst developed later on. A second operation was done 2
months later; patient recovered completely and at present leading a normal life. Nofthern Medical
Journal 2009; 18 (2): 101-105
lndexing words: Penetrating abdominal trauma, lnferior vena caval injury, Pancreatic injury.
lntroduction:
The incidence of injuries to major abdominal
vessels in a patient sustaining penetrating
abdominal trauma is 1A/.1. Most abdominal
vascular injuries result from penetrating trauma
and are associated with other abdominal injuries
2.
lnferior vena cava (lVC) is themost frequently
injured vessel in the abdomen ". The mortality
o.
rate for this type
o{ injury is 37% The high
mortality is due to blood loss either from the
vena cava or from associated vascular injuries
resulting
in multiple organ f ailure caused
1. Junior Consultant (Surgery) &
2. Senior Consultant (Surgery)
5
by
delayed resuscitation and surgical intervention 6.
Clinically the patient will present either as free
intra peritoneal hemorrhage or As a contained
retro peritoneal haematoma.''o
Penetrating
wounds of the vena cava are usuallV fatal either
before any aid can be rendered e or later. despite
surgical treatmentl0. Knowledge of
the
anatomical location of the major vessels and the
course
of the
penetrating object brings into
a major vascular
injury '. However, the definite diagnosis of vena
caval injury is usually established only at
laparotomy, b"ing no, inf requently an
consid,eration the possibility of
unexpected f inding.e'1 0,,,
J.
Rangpur Medical College Hospital
Consultant (Surgery)
Sadar Hospital, Lalmonirhat
Case Report:
4
Asst. Prof. Dept. of Surgery &
A 28 years young male hailing from Gangachara.
Rangpur Medical College
Rangpur was admitted into this hospital havrng

3. 102
Roy, Taleb, RoY, Basunia
history of stab injury on right upper abdomen'
Assault on him was occurred at 10 am and he
'1.30 pm on the same day'
reached hospital at
On admission, he was restlessness and his
cloths were stained with profuse blood' There
was continuous oozing of blood through the
wound and omentum came out through it'
Examination findings on admission were,
Fig-1 : rncrough ar: thorough injur'.'
''
r'1:'
-' '
appearance- restlessness, anemic, urine
output- scanty, pulse- rapid, thready and
feeble, B.P- non recordable'
RaPid
resuscitation was tried by l/V fluid and blood
transfusion. But the result of resuscitation was
failed. So, the patient was submitted for urgent
laparotomy with double risk bond consent At
7.30 pm, abdomen was opened by a generous
right paramedian incision. The whole peritoneal
civity was full of clotted and f resh blood' lt was
sucked out and mopped out rapidly (about 2/3
liters). But continuous severe exsanguinations
of blood made the field so ditficult to identify the
injury. An injury on stomach at its antral part
anO UtooO stained lesser sac - which was full of
blood, draw the attention' So, lesser sac was
accessed rapidly by opening the gaslrocolic
ligament. There was terrible bleeding like an
igneous of volcano through an inlury at the site
of OoOy and head of the pancreas medial to
duodenal C-cap. Pressure by mop failed to
control the bleeding. So, manual finger
pressure (introducing finger into the injury) was
applied and it was controlled' Keeping it
controlled by an assistant, duodenum was
kocherized from laterally and the IVC was
explored. The injury was found extended up to
vertebral column injuring both anterior and
posterior wall of IVC (Fig-1)' Meticulous
dissection of IVC was done and control taken
by rubber catheter both above and below of the
injury (Fig-1).
There was about 1 inch linear longitudinal tnlui-,'
in both anterior and posterior aspect o{ IVC in its
infrararenal part. Both were repaired
prolene (Fig-2).
Fig-2: After- r'epair of posterior wali of IVC
by
5/0

4. 103
Penetrating abdominal trauma
causing inferior vena cavai
injury-Acasereport
Control was removed. During this procedure, only
carotid pulse was recorded by the anesthesiologist.
After removal of control, pulse, B.P and urine output
began to reappear. Oozing from pre-vedebral area
was controlled by cauterization. The renal and
gonadal veins were found to be intact. There was
also associated injury to the stomach injuring both
anterior and posterior wall near its antral pafi. Both
An ultrasonogram report reveals huge encysted
thick (inf ected) collection in upper abdomen.
Patrent also had respiratory distress. Aspiration
was done by wide bore needle by which the
patient felt comfort. The aspirate was clear
pancreatic flurd. Later on a folley catheter was
inserted into the cyst by local anesthesia.
lnitially, about 1 to 1112liter of collection per 24
were repaired by double layered suture, Nothing was
done for the associated pancreatic rnjury. Ti;o drain:
hours was there. But it was gradually decreasing
day by day. Later on, the catheter was removed
and he was discharged from the hospital.
one in pelvis and anoiher in lesser sac (through
foramen of Winslow; were inserled. Closure of
incision wound and stab wound was done
accordingly. Recovery f rom anesthesia was
uneventful. Four units of fresh blood were given peroperatively. lnjection calcium gluconate and sodi bi
carb was also given. Postoperative period was
uneventful.
At Sth post operative day, a cystic swelling began to
appear in left hypochondriac region which was
gradually enlarging occupying the left hypochondriac,
epigastria, umbilicaland left lumber region (Fig-3).
Fig-3: Cysl c sr,relllng in upper abdomen
After about 11/, months (>2months f rom initial
operation), he again admitted into surgery unit
with the complaints of huge swellrng over the
upper abdomen which typically became enlarged
and painful during meal. lt made him discomfort
and dyspnoeic. Repeat ultrasonogram revealed
the same picture as before. Repeated aspiration
by wide bore needle (clear fluid) made
him
temporary comfort, but the problem remain to be
continued. At Iast, the decision of laparotomy
was taken for a cysto-jejunostomy with roux-enY reconstruction. Abdomen was opened through
the previous incision line excising the scar of
previous operation. There was a huge swelling
behind the stomach, aspiration f rom which
revealed clear fluid. Lesser sac could not be
accessed due to huge adhesions. So, after
opening of the anterior wall of stomach, it was
reached by incising the posterror wall of stomach
and a cysto-gastrostomy was constructed.
Recovery from anesthesia was smooth and
postoperative period was uneventful. He was
discharged from hospital on 8th postoperative
day. Further follow up was done after one month
and he had no more complaints and was leading
completely normal life.
Discussion:
lnferior vena caval injury is a serious and rare
condition more oftei" encountered
with
penetrating than with blur,t traumass. Despite the

5. Roy, Taleb, Roy, Basunia
progress
in
104
surgery and preoperative care
technique, the mortality rate for IVC injury is still
high". Thirty six per cent patients die before
reaching hospital.s The factors, which play
significant role in mortality, are presence of
shock on admission, suprarenal IVC injury and
bleeding without retroperitoneal haematoma6.
Survival was best when the-injury was located in
the infrarenal IVC (68%)." ln a study, it was
shown that the patients with IVC injury with
shock had a 286-fold increase in the risk oJ
death8. For patients whose hemorrhage through
IVC is stopped by the
retroperitoneal
haematoma the mortalitv rate is 26% and those
without iI is 74"/..8 ln a siudy,t3 91% survival rate
with
retroperitoneal temponade f rankly
contrasted to 93% mortalrty rate without
temponade. ln our case, the patient was in
severe shock and there was no temponade
ef{ect by haematoma, rather severe continuous
bleeding was present. The only favorable
situation was that the injury was infrarenal. The
early intervention with appropriate technique
made the patient
safe.
About 100 cases have
been published in the Enqlish literature with
successful surgical treatmeni.e'11'14'15'16'17'18 Gunshot wounds are the main cause of penetrating
caval injuries and half of the patients are dead
on arrival at hospital.l' Of those still alive, half
will die in spite of therapy.lo Our case was a
victim of stab injury by a sword.
Upon admission, most show signs of severe
blood loss and_ peritonitis, suggesting a major
vascular injury." ln our case, signs of severe
shock and continuous oozing of blood through
the stab was present. We guessed about the
major vascular injury, but the definite site was
uncertain. A number, however, do not appear
gravely injured and the presence of a major
vascular injury is . pre-operatively not even
remotely suspected.'" The patient who had an
abdominal penetrating trauma with shock should
be operated immediatelyo. We also performed
urgent surgery despite unstable haemodynamic
condition, reluctant to resuscitation procedures.
During operation, control of hemorrhage is the
first step of intervention.o The determination of
the pathway of the
penetrating wound
is
essential Jor the diagnosis.s Any haematoma
in
Zone '1 of
retroperitoneum
(Midline
lnframesocolic Area which includes infrarenal
abdominal aorta and inferior vena cava) should
be explored.le lf inf ramesocolic haematoma
appears to be more extensive on the right side of
abdomen than left and if there is active
haemorrhage coming through base of mesentery
of ascending colon or hepatic flexure of colon,
injury
to IVC below the liver should be
suspected.ls
Survival rates for patrents with injury to IVC
depend on location of injury.ls The average
survival rates for 515 patients with injuries to
infrahepatic IVC was 72.2/o20'2t'22. When injury
to infrarenal IVC alone are included the averaoe
survival for 318 patients was 70.1"/o.zo'zt'zz'z{2s
Ours was a case of infrarenal IVC injury.
The reported articles cited here did not show any
associated pancreatic injury. We had fetched it
with a severe postoperative complication" After
about two and half months, by which the cyst
wall matured, a second operation of
cystogastrostomy was done. The question is, whether
the pancreatic injury could be handled safely at
the first time with
a
pancreatico-enterostomy
reconstruction. During first operation, the patient
was in critical condition and duration of surgery
and anesthesia was a factor. Should we go to
handle
the
pancreatic injury during
f
irst
operation, in this situation?
Conclusion:
Penetrating injury of IVC remains a challenging
problem. The key to effective management
includes early diagnosis, resuscitation and
prompt surgical intervention. Associated solid or
hollow visceral injuries negatively affect survival.
ln case of haemodynamic instability, sometimes,

6. 't05
Penetrating abdominal trauma
causing inferior vena caval
injury-Acase report
a technically simpler procedure is more
beneficial than a complex, time consuming
reconstruction. ln our patient, the early
recognition, prompt intervention culminated in
satisfactory outcome. The associated pancreatic
injury made
a
problem for us, though
it was
managed successfully at a later time.
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