RETROPERITONEAL HEMATOMASPatrick Dolan

PGY-1 3/30/2015

OUTLINE

Definition Incidence Etiology of hematomas Classification systems Diagnosis Management

DEFINITION

Injuries to structures that can cause retroperitoneal hematomas: GI: distal esophagus, 2nd, 3rd, and 4th portions of

the duodenum, pancreas, posterior ascending and descending colon (and flexures), rectum

GU: kidneys, adrenals, ureters, bladder Vascular: abdominal aorta, IVC and their

branches, branches of the portal vein Musculoskeletal: psoas major, quadratus

lumborum, iliacus muscles, diaphragm, vertebral bodies, or pelvic bones

INCIDENCE

Etiology: Blunt 67-80% vs. penetrating 20-33% 44% of patients admitted after blunt trauma

(documented at laparotomy or autopsy, based on a series of 171 patients)

Location of retroperitoneal hematoma after blunt trauma: One series: 45% perirenal, 29% pelvic, 26% “other” Pelvic (zone 3) 70.2%, flank or lateral (zone 2)

22.8%, upper to mid-central (zone 1) 7%. Incidence w/ penetrating abdominal wounds is

less clear 1966 paper: 5.9% incidence of retroperitoneal

hematoma at laparotomy

ETIOLOGY OF HEMATOMAS

Pelvic retroperitoneal hematoma: Blood loss from fracture sites Disruption of veins in the posterior pelvis Deep pelvic arteries (branches of the internal iliac)

Perirenal hematomas Direct contact: contusions, lacerations, polar

avulsion, or rupture Deceleration: avulse the renal vein or disrupt the

intima of the renal artery w/ secondary thrombosis Midline retroperitoneal hematomas:

Deceleration w/ avulsion of small branches of the aorta, IVC, SMA, or portal vein

Midline transection of the pancreas over the spine

CLASSIFICATION SYSTEMS

DIAGNOSIS: CLINICAL

Clinical Pain: anterior abdomen, flank, back, pelvis Hypovolemic shock Grey-Turner’s Sign (typically not present during

the first day after injury) Hematuria Elevated amylase

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961943-1/fulltext

DIAGNOSIS: RADIOLOGIC

Blunt Trauma Plain film

obliteration of psaos muscle shadow Displacement of gas-filled organs by a mass Pelvic, lumbar, or lower rib fractures Air in the RUQ outlining the lateral aspect of the

duodenum, or air in front of the first lumbar vertebrae on a lateral abdominal film

CT Scan w/ PO and IV contrast

DIAGNOSIS: RADIOLOGY

Penetrating Trauma Plain film:

Can localize projectile, giving some indication of which retroperitoneal structure is injured

Triple contrast CT Asymptomatic patients w/ penetrating wounds to the

back Hemorrhage can be tamponaded by retroperitoneum,

symptoms of organ penetration can be minimal for days or weeks

Evaluates posterior surface of duodenum, ascending and descending colon

MANAGEMENT

Nonoperative Management after Blunt Trauma Laparotomy is necessary in patients with signs of

significant blood loss or peritonitis Perirenal:

Superficial lacerations: however, continued hematuria has been reported, and delayed renal surgery rate is between 13 and 68%.

Delayed renal operation as high as 53% in more severe renal injury.

Medullary laceration, extensive urinary extravasation, polar avulsion w/ more than 20% of the kidney nonviable, kidney rupture, or renovascular injury should undergo renal exploration

Pelvic: Pneumatic Anti-Shock Garment (PASG) Therapeutic embolization (deep pelvic arterial bleeder)

MANAGEMENT

Operative Management after Blunt Trauma Midline Supramesocolic:

Should be opened after proximal and, if possible, distal vascular control.

Blunt suprarenal aorta injury is rare, however avulsion of the SMA is reported. Avulsion of small posterior branches of the suprarenal aorta are more common.

Medial mobilization of left-sided intra-abdominal viscera. Left radial phrenotomy incision and dissection of the distal

thoracic aorta or abdominal aorta in the hiatus superior to the celiac nerve plexus.

Aortic clamp applied to supraceliac aorta before the hematoma is opened.

Must visualize the origin of the SMA and left renal artery. Avulsed SMA:

vascular clamp or insert Fogarty catheter to control back-bleeding.

Reimplant, ligation with dependence on collateral flow, or bypass grafting

MANAGEMENT

Midline Inframesocolic: Avulsion of posterior lumbar branches of the infrarenal

abdominal aorta or IVC Mandatory exploration to ensure a lumbar artery is not

bleeding Infrarenal aorta exposed inferior to the base of the

mesocolon for proximal control Kocher maneuver to allow visualization of entire

infrahepatic IVC

MANAGEMENT

Lateral Perirenal: Exploration favored if preop imaging suggests severe

degree of renal injury, or if there is rapid expansion, a pulsatile nature, or a free rupture of the hematoma

Opened only after renovascular control obtained at the midline for left-sided, or at the midline and after a Kocher maneuver for the right-sided vessels.

Rarely, can be caused by an avulsed right adrenal vein. IVC should be repaired w/ 5-0 or 6-0 polypropylene

Lateral paraduodenal: Should be opened to evaluate for perforation or

blowout of the 2nd or 3rd portion of the duodenum (may have palpable crepitus or visible bile staining under the hematoma).

MANAGEMENT Lateral pericolonic:

Often are pelvic hematomas that extend superiorly, these are not opened if the colon itself shows no signs of injury.

If not, open to inspect the colonic wall Pelvic:

Not opened in the presence of pelvic fracture, a slow rate of expansion, intact arterial pulses in the groin, and no preop radiographic evidence of bladder or urethra injury.

Ruptured, pulsatile, or rapidly expanding: Proximal control of the infrarenal aorta and IVC Small bowel pulled to the R, sigmoid to the L, midline

retroperitoneum opened proximal to the sacral promontory.

Distal vascular control of iliac vessels just proximal to the inguinal ligament.

Careful dissection of major arteries and veins to search for vascular injury

MANAGEMENT

Pelvic (cont’d) If no major vascular injury is seen and bleeding is

thought to be venous or bony, pelvis is packed. Bleeding slows and blood pressure stabilizes: immediate external fixation of pelvic fractures

If it seems to be arterial, can do intraop arteriography through hypogastric arteries w/ proximal ligation and passage of Fogarty balloon catheter, or by intraop embolization.

Portal and retrohepatic: Should be opened: evaluate for CBD, common hepatic

duct, or portal vein injury. If portal vein injury is suspected, Pringle maneuver

(proximal vascular clamp to all structures in the hepaticoduodenal ligament) and repair by lateral venorrhaphy, transversely, using 5-0 or 6-0 polypropylene.

MANAGEMENT

Nonoperative management after penetrating trauma Laparotomy necessary if there are signs of significant intra-

abdominal blood loss, peritonitis, hematemesis, or proctorrhagia

Triple contrast CT Observation and serial abdominal exams

Operative management Midline supramesocolic:

Open after obtaining proximal and, if possible, distal vascular control Similar maneuvers to expose the suprarenal aorta as with blunt

trauma Exposure for distal vascular control of an injury to the suprarenal

aorta is improved by ligation and division of the celiac axis Can repair with lateral aortorrhapy, patch aortoplasty, end-to-end

anastomosis, or interposition grafting with 12- or 14-mm Dacron Injuries to suprarenal aorta and IVC yield a 100% mortality rate Rarely can get penetrating SMV injury beneath the pancreas, possibly

requiring division of the pancreas.

MANAGEMENT Midline inframesocolic:

Exposure as previously described, repairs to the infrarenal aorta the same as with the suprarenal

Survival is slightly higher in infrarenal aorta injuries, 45% compared to 36%

Exposure of infrahepatic IVC best with Kocher. Place partial occlusion clamp, however may need a complete cross-clamp around the perforation. Hypotension associated with this can be alleviated by simultaneously cross-clamping the infrarenal aorta.

Survival after penetrating IVC injury is 83%, however this drops to 36% with injury to the retrohepatic IVC.

Most other locations necessitating opening, obtaining proximal and lateral vascular control, and repair of associated injured vessels.

Exception: pericolonic, however sometimes need to reoperate due to steady bleeding from lumbar vessels or muscle

SUMMARY TABLES

SOURCE Management of Traumatic Retroperitoneal hematoma. Feliciano.

Annals of Surgery, Vol 211, Number 2. Feb1990