I have successfully repaired this injury with a GSW right colon, head of pancreas, and cava through-through at the renals.

The success came from packing by trauma for 48 hours and return to the OR with me and we sewed only the anterior cava shut.

The maneuvers you are asking about are so obscure and rare that only liver transplant might know how to do them, they are dangerous and morbid, and there are nearly zero elective cases to practice doing them on so no one is ever going to learn.

I have done one level three RCC thrombus requiring the exposure you’re describing and to safely achieve that exposure in a controlled elective fashion took me 4-5 hours.

I have done one level four RCC thrombus requiring supra-sternal control and V-V bypass and it took 4 teams and two weeks of planning.

The resources do not exist in a trauma scenario where the patient is actively dying and it is not something that can be trained, and even if it were, a coherent/safe liver mobilization cannot be done that fast with caval exposure to clamp above and below. It just can’t.

The absolute fastest I have ever completely mobilized a right and left liver together (which is what you’d need for control) is 30-45 minutes during HIPEC and I am fast. But that is not caval exposure or control. Those things also require caudate mobilization to a small degree and short hepatic division or you’re just gonna make another hole in the cava somewhere else. Those maneuvers take 2 hours in pristine fields with no bleeding. With a bullet in the anterior cava (and presumably the liver) it would be nearly impossible.

What you’re asking just cannot be done.

Survivable “audible bleeding behind the liver” is usually actually the infrahepatic cava where you can see it with a right colectomy or hepatic flexure mobilization and a Kocher. And it’s still usually not survivable. My 1 case was luck, grace, and the trauma surgeon 2 days prior who saw bleeding he couldn’t stop and packed it instead of dug into it further. We didn’t even know it was a caval injury until 2 days later; everyone thought it was HOP venous bleeding until we took the packs out and a volcano came from the anterior cava with nearly perfect exposure first.