RETROPERITONEAL HEMATOMA - ZONES - APPROACH k.s. sanju

HISTORY…… Retroperitoneal zones were described by Monson

RETROPERITONEAL ZONES

ZONE 1 (MIDLINE RETROPERITONEUM) Extends from diaphragmatic hiatus to sacral promontory Contents- Aorta vena cava duodenum pancreas

ZONE 2 (PERINEPHRIC SPACE) Both abdominal flanks Contents -kidney ureters colon

ZONE 3 (PELVIC RETROPERITONEUM) Confined to pelvis Contents-rectum bladder ureter iliac vessel

Causes of injury BLUNT TRAUMA PENETRATING TRAUMA crush injury blast seatbelt injury PENETRATING TRAUMA stab gunshot wounds

Clinical features Abdominal tenderness flank mass discoloration of flanks(grey turner’s sign)with or with out features of shock

APPROACH HEMATOMAS DUE TO PENETERATING INJURY ARE EXPLORED ALL RETROPERITONEAL HEMATOMAS DUE TO PENETERATING INJURY ARE EXPLORED

APPROACH IN ZONE 1 (central hematoma) ALL CENTRAL HEMATOMAS MUST BE EXPLORED WHY??? Due to major abdominal vascular injury

ZONE 2 (lateral hematomas) Associated with injuries to genitourinary tract KIDNEY is the MOST COMMONLY INJURED organ Colon injuries

MANAGEMENT Treatment is individualised conservative exploratory

exploration??? Penetrating injury Hematoma is adjacent to colon,concealing an occult colonic injury Expanding hematoma Major renal injury

Conservative??? Hematoma not expanding IVU or CT SCAN normal Critically injured patient with a stable renal hematoma from penetrating injury

Zone 3 (pelvic retroperitoneal hematoma) PELVIC FRACTURE IS MOST OFTEN PRESENT AND IS THE MAJOR CAUSE OF RETROPERITONEAL HEMATOMA Treatment exploratory conservative

exploration??? Penetrating trauma to exclude iliac vessel injury Rapidly expanding hematoma

Conservative??? Pelvic fracture effective management is -external fixation -angiographic embolisation

Investigations Blood –group,hemoglobin,hematocrit Urine-hematuria Serum amylase Plain Xray abdomen - pelvic # - obliterated psoas shadow

Investigations…….contd Plain xray abdomen contd… -gas bubbles in right upper quadrant -Abdominal mass displacing bowel loops -Site of missile in penetrating injury CT SCAN is the PREFERRED INVESTIGATION Arteriography IVU DPL USG-FAST

RENAL INJURY Most common causes Blunt trauma Penetrating trauma Motor vehicle accidents deceleration injuries Fall from heights Assaults Penetrating trauma Gun shot Stab wounds

INDICATOR.. HEMATURIA –best indicator Microscopic-5 red blood cells per high power field Macroscopic-visible blood

GRADING GRADE 1- Contusion,subcapsular hematoma without parenchymal laceration

Grading…. GRADE 2- Non expanding perirenal hematoma,cortical laceration<1cm

Grading…. GRADE 3- Parenchymal laceration more than 1cm deep, no urinary extravasation

Grading… GRADE 4- Parenchymal Laceration extending into the collecting system or thrombosis of a segment of renal artery

Grading… GRADE 5- thrombosis of a renal artery, avulsion of the renal vessels OR a shattered kidney

Indications for imaging Penetrating injuries with any degree of hematuria All blunt trauma patients with gross hematuria Microscopic hematuria and shock(SBP <90 mm hg) suspicion of renal injury on basis of history or examination To visualise the un injured kidney

IMAGING STUDIES Preferred imaging study for renal trauma is CONTRAST-ENHANCED CT Spiral CT Excretory urography USG Arteriography

MANAGEMENT 1 Non operative 2 Operative

NON OPERATIVE- indications HEMODYNAMICALY STABLE patient with injury well staged by CT Scan 98% of renal injuries can be managed High grade injuries that are WELL STAGED Penetrating trauma if carefully staged with CT

OPERATIVE- indications…. ABSOLUTE Evidence of persisting renal bleeding Expanding perirenal hematoma pulsatile perirenal hematoma RELATIVE Urinary extravasation Non viable tissue Delayed diagnosis of arterial injury Segmental arterial injury incomplete staging

RENAL EXPLORATION….. TRANSABDOMINAL APPROACH Renal vessels are isolated before exploration- may bleeds once gerota’s fascia is opened Injured kidney is completely dissected from the surrounding hematoma

RENAL RECONSTRUCTION…. Complete renal exposure Debridement of non viable tissue Hemostasis by individual suture ligation of bleeding vessels Water tight closure of collecting system Coverage or approximation of parenchymal defect

Renovascular injuries Occlusion of involved vessel with vascular clamps Injured renal vessels repaired with 5 -0 non absorbable vascular suture Renal artery thrombosis need immediate renal exploration

NEPHRECTOMY ?? Extensive parenchymal vascular or combined injury Hemodynamic instability Shattered kidney

COLONIC INJURIES… Majority due to penetrating or perforating trauma Relatively refractory to blunt injury(5%) Peritoneal irritation ,tenderness

Investigations.. CT scan(triple contrast-iv,oral ,rectal)-free extraluminal air,retroperitoneal free fluids,bowel wall hematoma,intramural air DIGITAL EXAMINATION-blood XRAY-free air in peritoneal cavity Proctoscopy,sigmoidoscopy Lab studies not helpful DPL not useful in extraperitoneal injury

MANAGEMENT Prophylactic antibiotics IV ALWAYS OPERATIVE -Primary repair -Resection and colostomy

Criteria –primary repair <6 hours interval from injury <2 assctd intraperitoneal inuries Absence of hemorrhagic shock Otherwise stable patient

Criteria-resection and colostomy Pre-operative hypotension Intraperitoneal hemorrhage exceeding 1 litre >2 assctd injuries(hepatic ,splenic,pancreatic) Significant fecal spillage >6 hours since injury

SPLEEN COMMONEST ORGAN INJURED in blunt abdominal trauma Penetrating injuries uncommon due to its small size History helpful in diagnosis

Clinical features Left upper quadrant pain Pain in left shoulder(kehr’s sign) Fixed dullness in left upp quad(Ballance’s sign) Palpable mass Signs of blood loss

INVESTIGATIONS HEMATOCRIT shows a fall LEUCOCYTOSIS >15000/cu mm PLAIN XRAY fracture of lower ribs, elevation of the left hemidiaphragm medial displacement of gastric bubble loss of splenic outline…

Investigations contd…. CT SCAN IS THE MAIN STAY OF DIAGNOSIS -show blood around spleen -show active bleeding sites

GRADING… GRADE 1 subcapsular hematoma <10% surface area, capsular tear <1cm parenchymal depth

Grading…. GRADE 2 subcapsular haem 10-50% surface area. intraparenchymal haem <5cm in diam,laceration extending 1-3cm into parenchyma

Grading… GRADE 3 subcapsular hematoma >50% surface area intraparenchymal hematoma >=5cm or expanding laceration >3cm into paenchyma

Grading… GRADE 4 ruptured intraparenchymal hematoma with active bleeding laceration involving hilar vessel

Grading.. GRADE 5 completely shattered,devascularised spleen

MANAGEMENT Non operative Operative

NONOPERATIVE Indications- grade 1 ,2 and 3 patients without hemodynamic instability no assctd intra-abdominal injuries requiring surgery no co-morbidities to preclude close observation 50-70% injury in stable patients can be managed Spleen preserved specially in children

Nonoperative…. Prevents POST SPLENECTOMY SEPSIS Adequate mobilization from its attachments Ongoing bleeding-digital compression Capsular tears –topical hemostatic agents Minor lacerations-sutured using absorbable sutures teflon pledgets,omental patches

CONTRAINDICATIONS Patient has protracted hypotension Assctd intraabdominal injury requiring surgery Continued splenic hrrge Replacement of more than 50%of blood volume

OPERATIVE PROCEDURES Splenic tear-ligation of segmental vessels at hilum Deep tear-partial splenectomy Mesh wrap to tamponade bleeding in numerous parenchymal lacerations

SPLENECTOMY INDICATIONS -Hemodynamically unstable patient -Multiple abdominal injuries -Injury at hilum of spleen -Shattered spleen -Failure of splenorrhaphy

Thank you