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Major truncal venous structures include the inferior vena cava (IVC), the portal venous system (i.e., the portal vein, the superior mesenteric vein [SMV], the splenic vein, and the inferior mesenteric vein), the hepatic veins, the iliac veins, and the renal veins. Renal venous injuries are addressed in Chapter 13, “Mesenteric and Renal Artery Injuries” and are not discussed in this chapter. The portal venous system and hepatic venous vein tributaries are located within the peritoneal cavity. As such, injuries to these structures manifest as bleeding within the peritoneum. The remaining major truncal venous structures are within the retroperitoneum. Injuries to the major truncal venous injuries traditionally encompass four zones in the retroperitoneum that have been used for trauma and that can be from penetrating or blunt trauma (Fig. 16-1). These zones are divided into Zone 1 (IVC and abdominal aorta), Zone 2 (renal veins and arteries), Zone 3 (pelvis with iliac vasculature), and Zone 4 (retrohepatic IVC and hepatic veins). Note: Zone 4 is not shown in Fig. 16-1 but lies within the retrohepatic region encompassing the right upper quadrant of Zones 1 and 2. Grades of injury have been studied, developed, and used to categorize truncal venous structures based on the American Association for the Surgery of Trauma (AAST)—and Organ Injury Scale for Abdominal Vascular Injury (Table 16-1).1


Vascular zones in the retroperitoneum. Zone 4 of the retrohepatic IVC and hepatic veins is not shown.

TABLE 16-1American Association for the Surgery of Trauma—Organ Injury Scale for Abdominal Vascular Injury*

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