Retroperitoneal Hematoma

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Resuscitate first (ATLS).  If unstable, proceed to OR immediately.

 Thoracic Vascular Control

Left anterolateral thoracotomy if patient in extremis.  Extend trans-sternally for clamshell if cardiac or right-sided injuries. 

Abdominal Vascular Injuries

Abdominal Vascular Injury incidence:  blunt – 5-10%, stab wound – 10%, gunshot wound – 25%

Zone 1:  midline retroperitoneum

• Supramesocolic – suprarenal abdominal aorta, celiac axis, proximal SMA, proximal renal artery, SMV
• Inframesocolic – infrarenal abdominal aorta, infrahepatic IVC

Zone 2:  upper lateral retroperitoneum, renal artery/vein

Zone 3:  pelvic retroperitoneum, iliac artery/vein

• Portal-retrohepatic: portal vein, hepatic artery, retrohepatic IVC

Explore – Zone I Central RP Hematoma, Expanding, or Penetrating Hematomas Do Not Explore – retrohepatic, blunt or nonexpanding Zone 2/3 hematomas (consider endovascular)

 

Exposure

• Supramesocolic and Zone 2 left:
  • ? left thoracotomy and cross-clamp aorta (unstable pt with suprarenal injury)
  • Divide peritoneal reflection left of colon along splenic flexure
  • Rotate fundus of stomach, spleen, and tail of pancreas (and L kidney if necessary)
• IVC, and Zone 2 right:
  • Divide peritoneal reflection right of colon along hepatic flexure
  • Kocher mobilization of duodenum and pancreas
• Inframesocolic and pelvis:
  • Reflect mesocolon cephalad and eviscerate small bowel to right
  • Open midline retroperitoneum cephalad until L renal vein exposed (proximal control) and caudad to bifurcation (avoid IMA origin)
  • ? compartment fasciotomies