Important aspects of managing retroperitoneal injuries:
1) identify if the injury is arterial or venous?
- arterial: hematoma extends into mesentery, pulsatile
ACCESS:
Supraceliac aortic injury - becuase of dense neural plexus network at celiac plexus unable to really get much above renal arteries with a Mattox maneuver
- therefore a thoracotomy to get supradiaphragmatic control of aorta necessary
"Mattox" maneuver - start incision 1 cm lateral to the white line of toldt: keeps you from damaging ?retroperitoneal structures
- leave kidneys in place generally
Superior Mesenteric Vessel injuries:
Fullen's zones: (1-4) - describes areas of injury to SMA
Zone 1: proximal to infero-pancreaticoduodenal branch
Zone 2: between IPD and middle colic branches
Zones 1-2 are proximal and sit behind the pancreas
- access in trauma situation can be gained by simply cutting pancreas with scissors
Zone 3: between middle and ileocolic branches
Zone 4: distal to ileocolic
Moore advocates repairing ALL SMA injuries with possible exception of most distal SMA where you just accept some dead SB and resect it.
- this is a long process and a temporary shunt can be used
Inferior Vena Cava:
- control: use sponge sticks proximally and distally, a vascular clamp is likely to lacerate the IVC even further
- a posterior IVC injury can be difficult to access, enlarging your anterior injury to gain access to the posterior wall is probably your easiest option.
- try to close transversely as a longitudinal repair is likely to cause hourglass deformity
Pearls: - if you can't find your injury after exploring the hematoma, perform an immediate CTA as the injury is probably temporarily sealed but if it lets loose in ICU it will be catastrophic
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