1. Celiac Artery & Mesenteric Vessels Injuries Martha A. Quiodettis January 18, 2011

2. Introduction Abdominal Vascular Injuries (AVI) Most commonly due to penetrating trauma Highly lethal and challenging Varied presentation Hemorrhagic shock 2nd cause of trauma death 1st cause of preventable death Early resuscitation and control of bleeding is key

3. Mechanism Penetrating trauma 90-95% of injuries to abdominal vessels Accompany multiple intra-abdominal organ injuries 2-4 injuries Increase complexity of repair Blunt trauma Deceleration AP crushing Pelvic fractures

6. Ulvestad 1954 first report of SMA/SMV injury. Blunt trauma Kleitsch et al, 1957 SMA/SMV GSW repair Fleming,1961, SMA/SMV primary repair 1967, Shirkey et al first survivor SMA repair 0.01% to 0.1% of all vascular injuries.

7. Anatomy

8. SMA/SMV IMA/IMV superior and inferior pancreaticoduodenal Marginal artery Drummond Artery of Riolan

9. Fullen’s Zones

11. Operative approach Proximal control= aortic cross clamping or digital pressure at hiatus. Celiac artery or SMA zone I: Left medial visceral rotation Direct trough lesser sac Base of transverse mesocolon. Transection of avascular plane at neck of pancreas

13. SMA Damage control : ligate or shunt Zone I/II depends on collaterals. Definitive procedure: Lateral arteriorraphy (prolene 5 0 /6 0) Vein patch End to end anastomosis ( transected) Autogenous reverse saphenous vein PTFE Second look always!!!!!!

15. SMV damage control mode= Ligate Be ready for Definite repair: Venorraphy Graft saphenous vein Mesocaval shunt?

16. SMV (mesocaval shunt)

17. IMA/ IMV Approach directly Ligation Transect ligament of Treitz if necessary Retropancreatic portion: dissect inferior border of pancreas and retract cephalad.

18. Outcomes High mortality rates: Rapid volume loss Difficult exposure Complex vascular repair Late mortality/morbidity Isquemic bowel/ sepsis/ MOF Vascular repair failure Short gut sindrome

22. Mesenteric Vascular Injuries 1. when dealing with mesenteric vascular injuries a second look operation is advisable 2. blind clamping at the root of the mesentery is a recipe for disaster 3. beware of iatrogenic renal vein injury when exploring an inframesocolic hematoma

23. celiac artery a.injury to the celiac access is rare but deadly b. the celiac access is difficult to expose c. you may need to divide the stomach using a stapler to do get rapid exposure

24. Superior mesenteric artery a. Injuries to the proximal SMA above the pancreas are essentially aortic injuries, best exposed by Mattox maneuver b. Exposure through the lesser sac is another option c. Usually are associated with pancreatic and/or gastric injuries d. May be best to ligate and do retrograde reconstruction e. Control of the retropancreatic SMA is best achieved by dividing the pancreas f. May insert shunt in SMA as damage control maneuver g. Reconstruct the SMA away from the injured pancreas if possible h. Reconstruct SMA using 6 mm ringed PTFE from distal aorta of right common iliac artery

25. . Superior mesenteric vein a.you may need to divide the pancreas to repair injuries to the SMV b. repair the injured SMV if you can otherwise ligate it c. the consequences of portal or SMV ligation is massive fluid sequestration which translates into high post op fluid requirements and inability to close abdomen

26. Preoperative contrast- enhanced CT scan shows a vascular left adrenal tumor. The tumor extended toward the abdominal aorta and the origin of the CA and SMA Revascularization of the Celiac and Superior Mesenteric Arteries After Operative Injury. Using Both Splenic Artery and Saphenous Graft

27. Operative view after performing splenic artery (arrow) anastomosis to the infra-renal aorta (*). The cut end of the SMA (two arrows) is clamped by a Yasargil Buldog clamp

29. THANKS!!!