HEMATOMA

RETROPERITONEAL
ANDY MALEACHI
INTRODUCTION

Abdominal cavity is like a temple, it is full of

mistery.

The retroperitoneum has remained a source

of missed injuries and etiology of both early
and late morbidity and mortality in the
trauma patient
Injuries in the retroperitoneum challenge the
surgeons as diagnosticians and can present
therapeutic challenges too to them when
confronted with these difficult - to - expose
injuries.
God put the pancreas in the back
because he did not want surgeons messing
with it
The retroperitonel can be looked as a
separate and distinc entity in the care of the
trauma patients
Some feature that are importants to be
understood

Retroperitoneal anatomy
The mechanisms of injury
The diagnostic tools
The surgical techniques for proper exposure
of injuries.
The surgical management of injury for each
organ system
Mechanism of injury

Blunt
Penetrating
Blunt trauma

Shearing injury (acceleration-deceleration)

Compressive injury
Both
Blunt trauma

Frontal impact
Lateral impact
Rear impact
Rotation
Multiple vehicle collision
A pedestrian being struck by a motor vehicle
from the side.

What can be happen?

Frontal impact, car versus car.

What can be happen?

The pancreas has a unique location. Its
adherence to the posterior abdominal wall, and
its lack of a vascular pedicle, reduce its
susceptibility to shear injury but increase
the probability of compressive injury.
In a frontal impact, there is continued motion
of the unrestrained occupant in a forward
direction against the reduced motion of the
vehicle. Impacts of the anterior abdominal
wall against the steering column or
dashboard rapidly stops the motion of the
anterior abdominal wall.
Continued motion of the vertebral column
from behind compresses the center part
of the pancreas
The diagnostic tools

The most common means of diagnosing

retroperitoneal trauma is via exploratory
laparatomy for associated in the abdominal
injuries. For this type of patient, DPL is an
excellent test.

For isolated retroperitonel injury?

The diagnostic tools

Duodenum

Duodenal perforation :
Water soluble contrast medium
Intramural hematoma :
barium
The diagnostic tools

Rectum

Rectal perforation :
Rectoscopy
Water soluble contrast
The diagnostic tools

Kidney

IVP (regular)
One shot IVP
CT Scan
The diagnostic tools

Pelvic fracture, retroperitoneal hematoma

zone 3
Arteriography
diagnostic
embolization
Retroperitoneal Hematomas

Hematomas present in the retroperitoneum

carry the potential of different problems, they
do not carry the same risk of injury to vital
structures. Depending on the anatomic
location, predictions may be made as to the
possibility of which, if any, vital structures
may be injured.
 The decision tree confronted intraoperatively
will involve which retroperitoneal
hematomas should be explored and which
maybe safely left intact, because exploration
raises the mortality rate (i.e. those associated
with pelvic fractures).
Zones of retroperitoneal
hematoma

Zone 1. Upper central portion

Zone 2. Right and left flanks
Zone 3. Lower retroperitoneum
Zone 1

Hiatus oesophagei promontorium

medial to the kidneys.

Included : aorta abdominalis, v. cava inferior,

vena renalis, v. portae, pancreas and
duodenum
Zone 2

Lateral retroperitoneum :

kidneys, suprapelvic ureters, colon

ascendens, colon desendens
Zone 3

Incorporates the pelvis :

rectum, vesica urinaria, pelvic ureters,

vasa iliaca, colon sigmoid
 The necessity of exploring retroperitoneal
hematoma is determined by the method
of injury (blunt versus penetrating), the
zone, and the expansion of the
hematoma during the course of the
operation.
Blunt trauma

Not often the cause of major vascular injuries

Exploration is usually based on the location
and the expansile nature of the hematoma
Penetrating trauma

High incidence of major vascular injuries.

All zones 1 and 3 hematomas should be
opened and explored
Zone 2 maybe selectively explored
Zone 1 injuries

Carry the highest morbidity and mortality

Always warrant exploration
Surgical exposure

Mattox maneuver
Kocher maneuver
Cattell maneuver
Zone 2 injuries

May be managed nonoperatively :

Approximately :
95% of blunt trauma
50% of stab wounds
15% of gunshot wounds
Before entering the hematoma

Preoperative CT scan or IVP

One shot IVP on the operating table :
1. Presence or absence of bilateral
renal function
2. Extravasasion of contrast material from a
renal unit
Criteria for exploration

1. Expanding or pulsatile hematoma

2. Evidence of extravasation on
pyelography
3. Pyelogram demonstrating loss of
function on the side of the hematoma
Important :
Vascular control of the kidney be
obtained prior to opening the
hematoma
Zone 3 injuries

Penetrating trauma :
Should be explored
Blunt trauma :
do not explored
associated with pelvic fracture
Pelvic veins, branches of the iliac
arteries, cancellous bone
Zone 3 injuries

A severe pelvic fracture is to be

respected there is little a surgeon can do
to stop the bleeding, but much that can
be done to make the bleeding worse
Zone 3 injuries

External stabilization
Bedsheet reduction
Pelvic gridles
MAST
Pelvic clamp
External fixation

Selective embolization
External stabilization
Effective splint
Raising intra abdominal pressure above that
of venous pressure (MAST, double edged
sword)
Tamponade bleeding from bone edged as well
as venous bleeding by reducing fracture
fragments and decreasing the geometry of the
pelvis
Stabilize the clot
Summary
Type of Penetrating Blunt injury
hematoma injury
Zone 1 Explore Explore

Zone 2 Usually explore Usually do not

explore
Zone 3 Explore Do not explore
After exploring, before closing :

When the abdomen is open you

control it when closed, it controls
You.
THANK YOU
REFERENCES
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In Moose EE, Feliciano DV, Mattox
KL,Eds. Trauma. McGraw-Hill
Co,Inc.New York,2004
2. Mackersie RC. Abdominal trauma. In
Norton JA. et all.Eds.Surgery. Basic
science and clinical Evidence. Springer-
Verlag New York, Inc.2001
3. Mc Swain NE. Kinematics of
retroperitoneal trauma. In Frame B, Mc
Swain NE. Eds. Retroperitoneal
Trauma.Thieme Madical Publishers, Inc.
New York.1993
4. Nathens AB. Blunt abdominal trauma, in
Schein M, Rogers PN. Eds. Scheins
Common Sense Emergency abdominal
Surgery. Springer-Verlag Berlin
Heidelberg,2005
5. Scalea TM, Burgess AR. Pelvic
Fracture. In Moore EE, Feliciano DV,
Mattox KL. Eds. Trauma. Mc Graw. Hill
Co, Inc. New York, 2004