1. R ETROPERITONEAL H EMATOMAS Patrick Dolan PGY-1 3/30/2015

2. O UTLINE Definition Incidence Etiology of hematomas Classification systems Diagnosis Management

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

4. I NCIDENCE 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

5. E TIOLOGY OF H EMATOMAS 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

6. C LASSIFICATION S YSTEMS

7. D IAGNOSIS : C LINICAL 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/journal s/lancet/article/PIIS0140- 6736%2813%2961943-1/fulltext

8. D IAGNOSIS : R ADIOLOGIC 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

9. D IAGNOSIS : R ADIOLOGY 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

10. M ANAGEMENT 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)

11. M ANAGEMENT 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

12. M ANAGEMENT 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

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

14. M ANAGEMENT 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

15. M ANAGEMENT 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.

16. M ANAGEMENT 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.

17. M ANAGEMENT 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

18. S UMMARY T ABLES

19. S OURCE Management of Traumatic Retroperitoneal hematoma. Feliciano. Annals of Surgery, Vol 211, Number 2. Feb1990