| Abstract: |
Summary & Conclusion:With the high number of civilian gun shot wounds and motor vehicle injuries, the incidence of retroperitoneal injury is quite high, and surgeons should be comfortable with exploration of the retroperitoneum. In fact, nearly three quarters of retroperitoneal hematomas were caused by motor vehicle accidents.Irreversibl shock secondary to massive retroperitoneal hematoma is one of our most frustrating problems. Fortunately this situation is uncommon. Such uncontrollable bleeding was most common in cases with associated posterior disruption of the pelvis.Therefore, in patients with traumatic injuries who have severe hemorrhagic shock or with falling hematocrit levels and in who massive blood loss from within the abdominal or thoracic cavities cannot be demonstrated, the retroperitoneal space must be strongly considered.Since there are no pathognomonic signs or symptoms of retroperitoneal hematoma, their presence should be suspected in patients who are found to have hematuria after abdominal trauma, particularly if fractures of the osseous pelvis are present. In such patients, excretory urograms and cystograms should be promptly obtained.The diagnostic tools available to the clinician making deci¬sions regarding the need for operative intervention include history, physical examination, laboratory investigation, radiology, diagnostic peritoneal lavage and direct emergency laparoromy. The choice and application of these tools and the significance placed on their results will depend upon a number of factors including:(1) The mechanism of injury.(2) Hemodynamic stability of the patient.(3) Availability and experince of surgical personnel.(4) Presence of other life-threatening injury.Retroperitoneal hematoma is commonly associated with significant intra-abdominal injury and almost always with positive results from peritoneal lavage. Therefore the most common situation for the trauma surgeon is being confronted with a retroperitoneal hematoma at the time of laparotomy. What is the treatment? This is a subject of great controversy. The subdivision of retroperitoneal hematoma into three zones provides a systematized approach to treatment. Surgical management will depend on the likely structures injured when hematomas arise in each of these zones.Another controversy question whether to or not to open the stable retroperitoneal hematoma of moderate size that is not enlarg¬ing. Some surgeons recommend that this always be done whereas oth¬ers believe that this approach is unnecessarily. In prac¬tice, most surgeons are selective; the bases for individual selectivity are difficult to define, but a few guidelines may be set out:1. Lateral paracolic hematomas may be observed if the urinary tract appears to be normal on IVP.2. Small hematomas in the base of the mesentery are left undis¬turbed but larger hematomas in the midline are opened for fear that these may communicate with a branch of the abdominal aorta or IVC. It is rare but not unknown for a patient with a transection of the aorta itself due to blunt trauma to reach the hospital alive. Ob¬viously, proximal and distal control always is obtained before any such hematoma is opened.3. Perirenal hematomas contained in Gerota’s fascia are not dis¬turbed unless:a) The IVP is grossly abnormal.b) There is reason to suspect injury to the renal artery or vein, orc) Signs of blood loss continue while the patient is under observation. Roughly (50%) of hematomas in Gerota’s fascia are opened. If the decision to open Gerota’s fascia is made, care must be taken to insure preliminary control of the renal vessels at the hilum.4- A retroperitoneal hematoma behind the second part of the duo¬denum is explored to exclude damage to the posterior duodenum, es¬pecially in patients who have been wearing seat belts. A retroperitoneal hematoma overlying the pancreas also should be opened to exclude a fracture of the pancreas. Rarely the anterior surface of the organ may be intact while the posterior surface is cracked. Failure to recognize and deal with a pancreatic injury may result in pancreatitis and later in the development of a pancreatic pseudocyst or ductal ste¬nosis.5. A retroperitoneal hematoma in the retrogastric area should be viewed with much suspicion, especially when it is not associated with any hematoma inferiorly. Such lesions possibly may have originated from ruptured thoracic aorta, which, whenever possible, should be excluded by aortography.6. Finally, what of the isolated retroperitoneal hematoma behind the liver? If stable, even though large, this retroperitoneal hematoma is best left undisturbed provided that it is not increasing in size or pulsating. The overlying liver has a tamponading effect by sheer weight. The IVC and its tributaries are a low-pressure system. The vessel responsible for the bleeding may be one or more of the small veins between the liver and the IVC, which will give no further trou¬ble unless the area is opened, the tamponading effect lost, and bleeding restarted iatrogenically. All instruments and cannulas needed should be at hand before the retroperitoneal hematoma is incised.
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