Interruption of the inferior vena cava

Interruption of the inferior vena cava
    • This shows the position of the patient on the operating table for the extraperi­toneal exposure of the infrarenal portion of the inferior vena cava through a right flank incision. The patient lies supine with the right side elevated approximately 15 degrees by blanket rolls under the right chest, hip and thigh.
    • The inferior vena cava has been exposed through a right flank incision. In some cases the procedure is made easier by partial excision of the twelfth rib. The external and internal oblique muscles are partially divided. The transversalis muscle and lumbodorsal fascia are next divided in the line of their fibers to expose the retroperitoneal area. The retroperitoneal tissues, the kidney and the ureter are displaced forward and medialward with a large Deaver retractor over gauze packs. The psoas muscle is retracted posteriorly. These steps expose the inferior vena cava distal to the renal veins shown at the level of the proximal edge of the incision. Distal to them two sets of lumbar veins are seen with two ligatures being placed around the inferior vena cava with a right-angle clamp.
    • There is some difference of opinion in regard to which type of inferior vena cava interruption is the best and results in the fewest postoperative complications. It is believed the most effective method for prevention of further pulmonary emboli is to interrupt the inferior vena cava completely with two nonabsorbable ligatures a centimeter apart placed just distal and flush with a set of lumbar veins. This will permit blood to flow into the proximal end of the inferior vena cava to help to prevent the formation of a secondary thrombus that might result in a pul­monary embolism. Some surgeons prefer to place the ligatures just distal to the renal veins to permit blood to flow into the proximal end of the inferior vena cava and prevent a secondary thrombus. This site of interruption also permits more outflow channels from the distal vena cava through the lumbar veins, but from experience it does not seem to make a great deal of difference. Anticoagulant therapy should be started following the operation as an additional measure to help in prevention of proximal thrombosis in the inferior vena cava. One of the criticisms of ligation is that it results in sequelae that are not so frequently seen with partial occlusion. It has been observed that with adequate elastic support to the lower leg these sequelae are not too serious and usually can be controlled, so that for the additional safety from secondary embolism the complete inter­ruption is the preferred method.


Interruption of the inferior vena cava



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