Major Abdominal Vascular Injuries
Combat Military Centers: 2-5% of vasc. cases
Civilian Trauma Centers: 25% of vasc. cases
Incidence with penetrating trauma = 10-25%
Retroperitoneum
Zone 1 - Midline: Great vessels
Zone 2 - Lateral: Kidneys, Ureters, Adrenals
Zone 3 - Pelvis
Blunt Retroperitoneal Injuries
Zone 1 - Explore
Zone 2 - Explore if expanding
Zone 3 - Never explore
Penetrating Retroperitoneal Injuries
Zone 1 - Explore
Zone 2 - Selective exploration
Zone 3 - Explore if expanding
Retroperitoneal Zone 1
Supramesocolic - Supraceliac aorta, celiac vessels, RH IVC
Inframesocolic - Infraceliac aorta, IVC, Proximal Renals, Proximal Iliacs
Supramesocolic <-- The Surgical Soul --> Inframesocolic
Surgical soul:
• Superficial layer - PD Vessels, pancreas
• Middle layer - SMA, SMV, Portal Vein
• Deep layer - IVC, Renal vessels
Supramesocolic Zone 1
• Typical Presentation - hematoma behind lesser omentum or stomach
• Involved structures - SC Aorta, celiacs
Control Options
• L Thoracotomy
• Transient SupraCeliac Control
• Definitive SC Control
• Gross Hemostatic Stitch
Transient SuperCeliac Aortic Control
1. Pull stomach down & to left
2. Bluntly open HG Lig. (like c Nissen)
3. Feel Aortic Pulse (deep & to right of esophagus)
4. Compress c Large Sponge Stick or Rich
5. Have assistant hold & go after bleeder
Gross Hemostatic Stitch
• Problem c Celiac Bleeding – inability to control back bleeding behind/above lesser curve of stomach from celiac branches
• Stay Left of Portal Triad
• Alternative – Transect Stomach to reach vessels
“Definitive” SC Aortic Control
• Mobilize L Triangular Lig.
• Retract Liver to Right
• Open HG Ligament
• Retract Esophagus to Left (Deaver or Penrose)
• Open retroperitoneum
• Incise R crus
• Dissect around Aorta (in Thorax)
• X-clamp
• Hold in place c vessel loops
• Expose & Fix
Formal repair:
• Exposure: L Medial Visceral Rotation, Mattox maneuver
- Original Description – Debakey for Thoracic Aortic Aneurysm repair
- Extended to Trauma by DeMeester, et al.
- Refined / Validated by Mattox - provided best exposure and associated with best survival with 26 SR aortic injuries
1. Mobilize L Colon
2. Mobilize spleen & distal pancreas
- Affords control of Left Renal Pedicle & SMA
- Extension to Mattox Maneuver to gain Suprarenal Aorta
3. Bluntly Mobilize L Kidney medially c Gerota’s fascia (feel posterior wall muscles)
4. Ligate/Transect L Lumbar Vein
5. Medialize to Aortic Hiatus
6. Cut L Crus
7. Bluntly dissect around aorta up into chest
Traumatic Abdominal Aortic Repair
• Suture
• Patch
• Graft
• Extra-anatomic
• Overall mortality: 50-80%
• Supra-renal mortality: 70-90%
• Infra-renal mortality: 30-45%
Supramesocolic Zone 1
Typical Presentation: Hematoma behind lesser omentum or stomach
Involved structures: SC aorta, celiac
Control: L AL Thoracotomy
Exposure: L Medial Visceral Rotation
Retroperitoneal Zone 1
Supramesocolic
- Supraceliac Aorta
- Celiac Vessels
- RH IVC
Inframesocolic
- Infraceliac aorta
- IVC
- Proximal Renals
- Proximal Iliacs
Zone 1 Inframesocolic Hematoma
Modified Cattell-Braasch Maneuver to Expose RPT & Duodenum (R Medial Visceral Rotation)
• R Colon Mobilization
• Incision to Mesenteric Root
• Kocher Maneuver
• IVC Exposure
Penetrating IVC Injuries
• Most 2/2 GSW
• High rate of other injuries - 10% other major vascular injury (aorta, portal vein)
• Majority require exploration & repair - Exceptions: RH IVC, Oblique, Non-expanding and other injuries excluded
Blunt IVC Injuries
• Less common
• Result of severe decelerations
• Occur at traction points: Atrio-caval junction, retrohepatic, bifurcation
• Never open RH hematoma unless liver is “excluded”
• ? Role for observing non-expanding infrahepatic hematomas
• 10-40% of unroofed IAC lacs exanguinate in the OR <--> risk of missed injuries, risk of delayed bleed
Preparation
• Introducer line (NO FEMORAL LINES!!!)
• Massive Transfusion Protocol
• Hot room
• Cell-Saver
• Instruments ready - ?angio/balloon
• Adequate help
• Control the Bleeding
• Spongesticks above & Below
• Alternative up High = Large Deaver to retract liver & compress IVC
• Once you can see…
• Look for silver intima – sew & keep sewing
• Compress Lumbars as needed
• Alternative if you’re lucky…
• Side Biter Application
• Followed c oversew
• Through & Through
• IVC Ligation - Outcomes of ligation and repair of infrarenal IVC injuries are comparable
• When you have to shoot, shoot. Don’t Talk. - Eli Wallach (Tuco) in The Good the Bad and the Ugly, 1966
The Iliacs
Expose/Control above – Cattel Maneuver
Expose /Control below - Femorals
More rapid: Transient SC Control & plunge in
Avoid stupid things:
-- Iatrogenic injuries (intentional or unintentional)
-- diving into Psoas (lumbar bleeding can ruin your day!)
Retroperitoneal Zone 1
Supramesocolic <-- Surgical Soul --> Inframesocolic
The Surgical Soul
Superficial Layer -- PD vessels, Pancreas
Middle Layer -- SMA, SMV, Portal Vein
Deep Layer -- IVC, Renal vessels
Superficial “Soul”
Pancreas & PD Vessels
Control: Kocher & Compression or “Ligation” c Penrose
Middle “Soul”
SMA, SMV, Portal Vein
Control:
- Kocher c compression
- +/-Compression of Mesenteric Root
- +/- Pringle Maneuver
Exposure Options:
- Cattel Maneuver
- Mattox Maneuver
- Pancreatic Transection
SMA Injuries
Fullen’s Classification
I - Proximal to inferior PDA, high ischemic risk, associated with pancreatic injuries
II - Between inferior PDA and middle colic, moderate ischemic risk
III - Trunk distal to middle colic, minimal ischemia risk
IV - Segmental branches, amenable to segmental resection
Other Visceral Vessels
• SMV, Celiac, Hepatics – Simple Repair or Ligate (cholecystectomy with celiac or hepatic ligation
• Portal Vein – repair if possible, ligate otherwise unless very stable
If both hepatic artery and portal vein injured - 1 must be repaired
Prepare for high volume ascites and increase need for IVF after ligating SM or portal V
Portal Vein Injuries
• "Double Pringle"
Deep “Soul”
• IVC, Renals
• Control:
- Kocher
- Pack/Compress Deeply
• Exposure: Cattel Maneuver
Exception: Pandora’s Box - keep the lid closed
Approach to RH IVC Injuries
Pack liver and hold pressure --persistent bleeding--> pringle manuver--Persistent bleeding -->total hepatic isolation
If improvement with any intervention, consider adjuvent angioembolization
Proper Packing
• Relies on Clot – most effective when done early
• Is a Sandwich Not a Wrap
Pringle Manuever
• Create window to Left of Portal Triad to clamp
• Can leave clamped for up to 45 min
• Primarily effective for Arterial Bleeding
Total Hepatic Isolation
1. Pringle Maneuver
2. Infrahepatic IVC Clamping
3. Suprahepatic IVC Clamping
Pringle Maneuver + IVC Clamping
Intrapericardial IVC Clamping
+/- Thoracic Aortic Cross Clamping
Zone 1 Retroperitoneal Trauma Summary
Supramesocolic
- Initial control: Thoracotomy or SC Aorta
- Exposure Mattox Manuver
Retrohepatic
- Initial control: Pack, pringle, total hepatic isolation
- Exposure: Whatever it takes
Inframesocolic
- Initial control: Clamp or pressure above/below
- Exposure: Cattel Maneuver