Inferior vena cava interruption and plication

Inferior vena cava interruption and plication
  • The inferior vena cava may also be exposed retroperitoneally with relative ease through a right paramedian right rectus muscle-retracting incision. The in­cision should extend from the pubis to 3 or 4 cm. above the umbilicus. The peri­toneum is easily retracted at the distal part of the incision. The rectus muscle is re­tracted to expose the posterior rectus sheath. This is carefully dissected away from the peritoneum with wide, blunt-pointed scissors, then divided to permit fur­ther retraction of the peritoneum and the abdominal viscera.
  • The retroperitoneal area has been opened up to show the bifurcation of the aorta and the distal portion of the inferior vena cava with its bifurcation behind the aorta and right common iliac artery. The right ureter (1) is shown pulled to the right of the operative field by the large retractor. A small constant tributary of the vena cava is shown, care having been taken to ligate and divide it as it arises distal to the level at which the inferior vena cava is ligated. The inferior vena cava is ligated with two nonabsorbable ligatures placed approximately 1 cm. apart. The proximal one is placed close to but not occluding the lumbar veins just proximal to it. The incision can then be closed in the routine method used for a right paramedian rectus-retracting incision. In female patients who have developed septic pulmonary emboli from a source in the pelvis, this incision is recommended for performing the interruption of the vena cava transperitoneally rather than ex – traperitoneally so that at the same time interruption of the ovarian veins can be performed, a necessity under these conditions. This incision has the advantage that it interrupts fewer of the collateral veins in the abdominal wall for the return of venous blood from the limb than does the transverse flank incision.
  • Various methods of partial occlusion of the inferior vena cava have been devised. The one in favor at this time is some form of clip that is placed around the inferior vena cava, dividing its large lumen into four small ones after the clip is tied into place. This figure shows the plastic DeWeese type.
  • This shows the extraperitoneal exposure of the infrarenal portion of the infe­rior vena cava through a right flank incision and the application of a clip. This usually requires a little more adequate exposure than for ligation of the vein. It is recommended that the clip be placed close to the proximal lumbar veins in case thrombosis of the vena cava distal to the clip should occur; this will help to reduce the formation of a proximal thrombosis as a source of pulmonary embolism.
  • The clip has been applied and the two limbs of it tied together. It shows how the large caval lumen has been changed to four small lumina. This method may prevent a massive pulmonary embolus, but small emboli do occur in a higher per­centage than when total occlusion by ligation has been performed. It is also not known what percentage of clipped inferior venae cavae become completely occluded. It seems therefore that each surgeon must decide for himself which method he wishes to use, then follow his patients closely so that he may take care of any late sequelae that develop.


Inferior vena cava interruption and plication



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