Retroperitoneal Injury

All mesenteric / visceral haematomas need to be explored
- they may be hiding significant injuries.

Whether retroperitoneal haematomas need to be explored is more complex, based largely on the location of the haematoma, mechanism and appearance (eg expanding or not).
The abdomen should be considered in zones:

image
1 = central / media
- from diaphragm to aorta / IVC bifurcations and bilaterally to renal hila
; 2 = lateral; 3 = pelvic

Zone 1 haematomas
Must be explored (esp if expanding); high incidence of major vascular / duodenal / pancreatic injury.
- vascular control of the aorta is first mandatory to avoid massive life-threatening bleeding.
- at the diaphragmatic hiatus ideally; best initial instrument to do this is your fingers.
- expose left and right abdomens as below

Zone 2 haematomas

Controversial, but all agree blunt non-expanding perirenal injuries should not be explored.
- more kidneys lost than saved by exploration.
- explore expanding zone 2 haematomas
Controversy about stable penetrating renal injuries
- but any penetrating non-renal injury with rapid expansion or pulsatile haematoma should be explored.

Zone 3 haematomas

Associated with pelvic fractures should not be explored.
Better to go for orthopaedic stabilisation and angiography / embolisation.
- else you may convert a serious injury into a lethal event.
A penetrating pelvic haematoma that is pulsatile or expanding may well need exploration.


Retroperitoneal exploration

In general any retroperitoneal haematoma with penetrating injury requires exploration

In blunt trauma only haematomas in the central area (Zone I) require exploration.

Haematoma in left flank/perinephric area:

· Left medial visceral rotation – Mattox Maneuver. I incise along the line of Toldt and go behind the left kidney anterior to Psoas. This allows access to the aorta and its proximal branches.

If the suspect organ is the kidney or ureter then find the plane between colon and kidney.

Haematoma in right flank or perinephric area: three stages

1.     Start with Kocher manaeuvre. If exposure is insufficient then mobilize the hepatic flexure. This exposes the posterior aspect of D2, the right renal hilum and superior IVC.

2.     Divide the line of Toldt to expose the entire IVC, right kidney and renal hilum and right iliac vessels.

3.     Cattell-Braasch maneuver: incise the posterior peritoneal attachment from medial side of caecum to the ligament to Treitz. Swing the colon and small bowel onto the chest. Exposes the IVC, infra-renal aorta, both renal arteries and veins, both iliac vessels

Now decide on damage control vs. definitive repair

If damage control is necessary I leave the abdomen open and manage the laparostomy using either propriety VAC system or a home made sandwich.

· I place a sterile polyurethane sheet between the viscera and the posterior surface of the abdominal wall.

· I place laparotomy sponges on the sheet, just tucked under the fascia and then palce two JP drains (brought out through inferior stab incisions) on top of the sponges either side of the wound.

· I then clean and dry the wound edges and cover the entire arranagemnet with Ioban.

· The drains are connected to low wall suction via a Y connector