Abdominal Vascular Injuries

Retroperitoneal Hematomas

1. Zones of the Retroperitoneum
• injury to retroperitoneal structures may result in the rapid expansion of a hematoma through the areolar tissues
• multiple injuries are common and > 40% of intraabdominal vascular injuries involve 2 or more major vascular structures
• location of the hematoma and the mechanism of injury are the 2 most important criteria to guide evaluation and treatment



1. Zone I
• boundaries include the diaphragmatic hiatus superiorly, sacral promontory inferiorly, and the psoas muscle laterally
• includes the aorta, vena cava, superior mesenteric artery and vein, celiac axis, and portal vein
• aortic injuries have a 40% to 80% mortality; caval injuries have a 10% to 40% mortality
• injuries in the suprarenal location have a higher mortality than infrarenal injuries


2. Zone II
• lateral to the psoas muscles
• important structures include the renal artery and vein, kidney and ureter, ascending and descending colons


3. Zone III
• bordered by the space of Retzius anteriorly, sacrum posteriorly, and iliac crests laterally
• important structures include the iliac artery and vein, bladder, and rectum


2. Diagnosis
• the unstable penetrating trauma patient needs no diagnostic studies and should have an immediate laparotomy
• the unstable blunt trauma patient should have a FAST exam or DPL to diagnose intraperitoneal bleeding
• occasionally, the hemodynamically stable blunt trauma patient will have a retroperitoneal hematoma diagnosed on CT scan


3. Management
1. Zone I Injuries (Central)
• mandatory exploration for both penetrating and blunt injuries
• patient is prepped from the chin to the midthighs
• if available, an auto transfusion device should be used


1. Suprarenal Hematoma



• injury to the aorta, celiac axis, superior mesenteric vessels, or vena cava is usually responsible
• associated gastric, duodenal, colon, and pancreatic injuries are the rule
• initial maneuver with free intraperitoneal bleeding is to pack all 4 quadrants
• proximal control of the aorta may be obtained through a left anterolateral thoracotomy or through the lesser sac at the hiatus (retract the esophagus and stomach, divide the overlying crural fibers)







• after proximal control has been obtained, the next challenge is to obtain adequate exposure to repair the injury
• injuries to the vena cava and right renal vessels are best exposed by the Cattell maneuver (right medial visceral rotation with a wide Kocher maneuver)
• injury to the suprarenal aorta and left renal vessels is best exposed by the Mattox maneuver (left medial visceral rotation)







• after the injury has been exposed, the vessel should be debrided and repaired
• lateral repair of the aorta and vena cava is often possible
• if lateral repair is not possible, then patch angioplasty is the next option
• a limited resection with anastomosis is usually not technically feasible because of excessive tension


1. Celiac Axis Injuries
• splenic and left gastric arteries are best treated with ligation
• hepatic artery injuries proximal to the gastroduodenal may be ligated, but repair is the first choice if possible


2. SMA Injuries
• partial transections may be closed primarily
• since mobilization of the SMA is difficult, complete transections may require an aorta-SMA bypass with saphenous vein or PTFE
• saphenous vein is preferred if there is enteric contamination
• ligation is not tolerated since it results in small bowel and colonic ischemia
• in damage control mode, insertion of a temporary intraluminal shunt is appropriate



3. SMV Injuries
• may be ligated if primary repair is not feasible
• post op bowel edema usually resolves without sequelae
• patients will require fluid resuscitation for the resulting systemic hypovolemia


4. Portal Vein Injuries
• exposure of the retropancreatic portion requires transection of the neck of the pancreas
• primary repair is the first and best option
• end to end repair with saphenous or jugular vein interposition is necessary if primary repair is not possible
• in damage control mode, ligation is possible
2. Infrarenal Hematoma
• exposure of the infrarenal aorta and vena cava may be obtained through the retroperitoneum by retracting the small bowel and its mesentery to the right and the transverse colon superiorly
• left renal vein may be ligated to gain additional exposure
• the proximal clamp is placed at the level of the renal vein; the distal clamps are placed on the common iliacs (avoid the ureter)
• for wounds involving only one wall, a partially occluding clamp (Satinsky) may be used
• through and through injuries to the vena cava may be repaired by enlarging the anterior wound so that the posterior wound may be fixed through the anterior wound
• if the vena cava is extensively damaged, it may be ligated


2. Zone II Injuries (Lateral)
• managed differently for penetrating and blunt trauma
• usually indicates injury to the renal vessels


1. Penetrating Zone II Hematomas
• all zone II hematomas must be explored
• on table IVP should be performed to document the presence and function of the contralateral kidney
• before opening Gerota’s fascia, renal vascular control must be obtained
• injury to the renal artery or vein should be repaired if possible
• for kidney injuries, the guiding principle is to preserve as much renal parenchyma as possible


2. Blunt Zone II Hematomas
• managed nonoperatively if the kidney is well-perfused, there is no urine leak, and the hematoma is not expanding
• if the kidney does not visualize on CT scan or IVP, then prompt exploration should be performed because of the high risk of major vascular injury


3. Zone III Injuries (Pelvic)
• managed differently for penetrating and blunt trauma


1. Penetrating Zone III Hematomas
• usually caused by injuries to the iliac vessels
• initial control is obtained by direct pressure
• proximal control is obtained by retracting the small bowel to the right and incising the retroperitoneum over the aortic bifurcation and common iliacs
• distal control is obtained just proximal to the inguinal ligament
• injuries to the common iliac and external iliac arteries should be repaired if possible
• the internal iliac artery may be ligated without sequelae



1. Iliac Artery Injuries
• in damage control mode, a temporary shunt can be placed
• if there is extensive contamination, primary anastomosis or synthetic conduit repair can lead to pseudoaneurysm formation and anastomotic blow out
• a safe approach to this problem is ligation of the common iliac artery, abdominal closure, and extra-anatomic femorofemoral bypass


2. Iliac Vein Injuries
• confluence of the iliac veins lies behind the right common iliac artery
• right common iliac artery may need to be divided to expose this area
• primary repair of the vein is usually possible
• ligation of an iliac vein is possible if primary repair is not feasible
• the divided iliac artery must be repaired after the venous injury is repaired


2. Blunt Zone III Hematomas
• caused by pelvic fractures
• no role for operative exploration of the hematoma
• 15% caused by arterial bleeding, the rest by venous bleeding
• placement of an external pelvic fixation device will control much of the venous bleeding
• if the patient remains hemodynamically unstable after pelvic bone fixation, then pelvic angiography is indicated to rule out an arterial source
• if an arterial source is identified, then transcatheter embolization may be performed
• if a rectal injury is identified on rectal exam or proctoscopy, then a diverting colostomy must be performed in order to avoid pelvic sepsis