1. RETROPERITONEAL HEMATOMA - ZONES - APPROACH
k.s. sanju

2. HISTORY……
Retroperitoneal zones were described by Monson

3. RETROPERITONEAL ZONES

4. ZONE 1 (MIDLINE RETROPERITONEUM)
Extends from diaphragmatic hiatus to sacral promontory
Contents-
Aorta
vena cava
duodenum
pancreas

5. ZONE 2 (PERINEPHRIC SPACE)
Both abdominal flanks
Contents -kidney
ureters
colon

6. ZONE 3 (PELVIC RETROPERITONEUM)
Confined to pelvis
Contents-rectum
bladder
ureter
iliac vessel

7. Causes of injury BLUNT TRAUMA PENETRATING TRAUMA crush injury blast
seatbelt injury
PENETRATING TRAUMA
stab
gunshot wounds

8. Clinical features Abdominal tenderness flank mass
discoloration of flanks(grey turner’s sign)with or with out features of shock

9. APPROACH HEMATOMAS DUE TO PENETERATING INJURY ARE EXPLORED
ALL RETROPERITONEAL
HEMATOMAS
DUE TO
PENETERATING INJURY ARE EXPLORED

10. APPROACH IN ZONE 1 (central hematoma)
ALL CENTRAL HEMATOMAS MUST BE EXPLORED
WHY???
Due to major abdominal vascular injury

11. ZONE 2 (lateral hematomas)
Associated with injuries to genitourinary tract
KIDNEY is the
MOST COMMONLY
INJURED organ
Colon injuries

12. MANAGEMENT
Treatment is individualised
conservative
exploratory

13. exploration??? Penetrating injury
Hematoma is adjacent to colon,concealing an occult colonic injury
Expanding hematoma
Major renal injury

14. Conservative??? Hematoma not expanding IVU or CT SCAN normal
Critically injured patient with a stable renal hematoma from penetrating injury

15. Zone 3 (pelvic retroperitoneal hematoma)
PELVIC FRACTURE IS MOST OFTEN PRESENT AND IS THE MAJOR CAUSE OF RETROPERITONEAL HEMATOMA
Treatment
exploratory
conservative

16. exploration??? Penetrating trauma to exclude iliac vessel injury
Rapidly expanding hematoma

17. Conservative??? Pelvic fracture effective management is
-external fixation
-angiographic
embolisation

18. Investigations Blood –group,hemoglobin,hematocrit Urine-hematuria
Serum amylase
Plain Xray abdomen
- pelvic #
- obliterated psoas
shadow

19. Investigations…….contd
Plain xray abdomen contd…
-gas bubbles in right upper quadrant
-Abdominal mass displacing bowel loops
-Site of missile in penetrating injury
CT SCAN is the PREFERRED INVESTIGATION
Arteriography
IVU
DPL
USG-FAST

20. RENAL INJURY Most common causes Blunt trauma Penetrating trauma
Motor vehicle accidents
deceleration injuries
Fall from heights
Assaults
Penetrating trauma
Gun shot
Stab wounds

21. INDICATOR.. HEMATURIA –best indicator
Microscopic-5 red blood cells per high power field
Macroscopic-visible blood

22. GRADING GRADE 1- Contusion,subcapsular hematoma without parenchymal
laceration

23. Grading…. GRADE 2- Non expanding perirenal hematoma,cortical
laceration<1cm

24. Grading…. GRADE 3- Parenchymal laceration more than
1cm deep, no urinary
extravasation

25. Grading… GRADE 4- Parenchymal Laceration extending into the collecting
system or thrombosis of a
segment of renal artery

26. Grading… GRADE 5- thrombosis of a renal artery, avulsion of the
renal vessels OR
a shattered kidney

27. Indications for imaging
Penetrating injuries with any
degree of hematuria
All blunt trauma patients with
gross hematuria
Microscopic hematuria and
shock(SBP <90 mm hg)
suspicion of renal injury on basis
of history or examination
To visualise the un injured kidney

28. IMAGING STUDIES Preferred imaging study for renal trauma is
CONTRAST-ENHANCED CT
Spiral CT
Excretory urography
USG
Arteriography

29. MANAGEMENT
1 Non operative
2 Operative

30. NON OPERATIVE- indications
HEMODYNAMICALY STABLE patient with injury well staged by CT Scan
98% of renal injuries can be managed
High grade injuries that are WELL STAGED
Penetrating trauma if carefully staged with CT

31. OPERATIVE- indications….
ABSOLUTE
Evidence of persisting renal bleeding
Expanding perirenal hematoma
pulsatile perirenal hematoma
RELATIVE
Urinary extravasation
Non viable tissue
Delayed diagnosis of arterial injury
Segmental arterial injury
incomplete staging

32. RENAL EXPLORATION….. TRANSABDOMINAL APPROACH
Renal vessels are isolated before exploration- may bleeds once gerota’s fascia is opened
Injured kidney is completely dissected from the surrounding hematoma

33. RENAL RECONSTRUCTION….
Complete renal exposure
Debridement of non viable tissue
Hemostasis by individual suture ligation of bleeding vessels
Water tight closure of collecting system
Coverage or approximation of parenchymal defect

34. Renovascular injuries
Occlusion of involved vessel with vascular clamps
Injured renal vessels repaired with 5 -0 non absorbable vascular suture
Renal artery thrombosis need immediate renal exploration

35. NEPHRECTOMY ?? Extensive parenchymal vascular or combined injury
Hemodynamic instability
Shattered kidney

36. COLONIC INJURIES… Majority due to penetrating or perforating trauma
Relatively refractory to blunt injury(5%)
Peritoneal irritation ,tenderness

37. Investigations..
CT scan(triple contrast-iv,oral ,rectal)-free extraluminal air,retroperitoneal free fluids,bowel wall hematoma,intramural air
DIGITAL EXAMINATION-blood
XRAY-free air in peritoneal cavity
Proctoscopy,sigmoidoscopy
Lab studies not helpful
DPL not useful in extraperitoneal injury

38. MANAGEMENT Prophylactic antibiotics IV ALWAYS OPERATIVE
-Primary repair
-Resection and colostomy

39. Criteria –primary repair
<6 hours interval from injury
<2 assctd intraperitoneal inuries
Absence of hemorrhagic shock
Otherwise stable patient

40. Criteria-resection and colostomy
Pre-operative hypotension
Intraperitoneal hemorrhage exceeding 1 litre
>2 assctd injuries(hepatic ,splenic,pancreatic)
Significant fecal spillage
>6 hours since injury

41. SPLEEN COMMONEST ORGAN INJURED in blunt abdominal trauma
Penetrating injuries uncommon due to its small size
History helpful in diagnosis

42. Clinical features Left upper quadrant pain
Pain in left shoulder(kehr’s sign)
Fixed dullness in left upp quad(Ballance’s sign)
Palpable mass
Signs of blood loss

43. INVESTIGATIONS HEMATOCRIT shows a fall LEUCOCYTOSIS >15000/cu mm
PLAIN XRAY
fracture of lower ribs,
elevation of the left hemidiaphragm
medial displacement of gastric bubble
loss of splenic outline…

44. Investigations contd….
CT SCAN IS THE MAIN STAY OF
DIAGNOSIS
-show blood around spleen
-show active bleeding sites

45. GRADING… GRADE 1 subcapsular hematoma <10% surface area,
capsular tear <1cm parenchymal depth

46. Grading…. GRADE 2 subcapsular haem 10-50% surface area.
intraparenchymal haem <5cm in
diam,laceration extending 1-3cm
into parenchyma

47. Grading… GRADE 3 subcapsular hematoma >50% surface area
intraparenchymal hematoma
>=5cm or expanding
laceration >3cm into paenchyma

48. Grading…
GRADE 4
ruptured intraparenchymal hematoma with active bleeding
laceration involving hilar vessel

49. Grading..
GRADE 5
completely
shattered,devascularised
spleen

50. MANAGEMENT
Non operative
Operative

51. NONOPERATIVE Indications-
grade 1 ,2 and 3 patients without hemodynamic instability
no assctd intra-abdominal injuries requiring surgery
no co-morbidities to preclude close observation
50-70% injury in stable patients can be managed
Spleen preserved specially in children

52. Nonoperative…. Prevents POST SPLENECTOMY SEPSIS
Adequate mobilization from its attachments
Ongoing bleeding-digital compression
Capsular tears –topical hemostatic agents
Minor lacerations-sutured using absorbable sutures teflon pledgets,omental patches

53. CONTRAINDICATIONS Patient has protracted hypotension
Assctd intraabdominal injury requiring surgery
Continued splenic hrrge
Replacement of more than 50%of blood volume

54. OPERATIVE PROCEDURES
Splenic tear-ligation of segmental vessels at hilum
Deep tear-partial splenectomy
Mesh wrap to tamponade bleeding in numerous parenchymal lacerations

55. SPLENECTOMY INDICATIONS -Hemodynamically unstable patient
-Multiple abdominal injuries
-Injury at hilum of spleen
-Shattered spleen
-Failure of splenorrhaphy

56. Thank you