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