Retroperitoneal bleed

Presentation

• Seen in around 30% of patients who have a trauma laparotomy
• Can be due to blunt or penetrating trauma
  • Blunt trauma - contained haematomas
  • Penetrating - free haemorrhage
• FAST scan not useful
  • Negative FAST in setting of hypotension/no chest findings should raise suspicion for retroperitoneal bleed

Zone-based classification

• Zone 1
  • Centrally, and down as far as aortic bifurcation
  • Supramesocolic - suprarenal aorta, coeliac axis, proximal SMA, proximal renal artery
  • Inframesocolic - infra-renal IVC or aorta
• Zone 2 - laterally
  • Renal artery/vein/kidney
• Zone 3 - inferiorly from bifurcation downwards
  • Can be associated with pelvic fractures
  • Suggest iliac vessel injury

Management

• If unstable - REBOA (resuscitative endovascular balloon occlusion of the aorta) is an option to temporise
• Penetrating - usually explore, because it's likely a true vascular injury needing repair
  • Zone 1 - explore, high risk for vascular injury
  • Zone 2 - explore kidneys for active haemorrhage or expanding haematoma. Mobilise colon to rule out retroperitoneal colon injury, explore ureters if in proximity to wound
  • Zone 3 - explore, major vascular injury likely
• Blunt - try not to explore unless it's a great vessel injury
  • Zone 1 - explore
  • Zone 2 - explore expanding haematomas or ones that have failed alternative methods (angioembolisation). If contained and stable, no need to explore.
  • Zone 3 - do not explore
• Non-op management - consider angioembolisation for these injuries
  • minimal vascular injury
  • Grade I through IV renal injuries
  • All adrenal injuries
  • Minor duodenal and pancreatic injuries

Exploring a central haematoma

• Supramesocolic
  • Likely aortic injury
  • Should get proximal and distal control before entering
    • Proximal - either supra-coeliac aorta, or left medial visceral rotation then clamp above hiatus - see 'trauma laparotomy' for Mattox manoeuvre
    • Distal - at aortic bifurcation
  • Then fix the injury
• Inframesocolic
  • Aortic
    • Same as above
  • IVC
    • Cattell-Brasch
    • Swab on a stick to directly control the bleeding
    • Babcock's on each side of vein, pull up, apply Satinsky clamp across the injury
    • Suture it closed

Exploring a zone two haematoma

• To isolate and resect the kidney, perform a medial visceral rotation on that side, clamp the vessels, check if it needs to be resected or can be repaired, and proceed