If packing fails to control hemorrhage in complex liver injuries, the Pringle maneuver allows hemorrhage control from the hepatic artery and portal venous system. The technique also helps to rule out other sources of bleeding such as retrohepatic veins and the vena cava. If this does not lead to control of the bleeding (grade VI lesions), total vascular exclusion of the liver is performed by clamping the supradiaphragmatic IVC after sternotomy and the infradiaphragmatic IVC (see chapter "Techniques of Vascular Exclusion and Caval Resection"). The appropriate and early use of vascular control allows for accurate identification of the injury and the control of hemorrhage.
In case of a retrohepatic caval injury, an atrial-caval shunt to the superior vena cava or a hepatic venovenous bypass should be employed additionally to the Pringle maneuver early in the operation to preserve venous return while repairing the retrohepatic caval injury. An atrial-caval shunt can be performed with a large chest tube through the right atrial appendage placed and advanced into the IVC distal to the renal veins. Additional side holes are cut in the tube at the atrial level. Tourniquets are tightened around the vena cava at the level of the supradiaphragmatic and suprarenal cava levels and the atrial appendage.
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