Overview of the diagnosis and initial management of traumatic retroperitoneal injury
- Samuel P Mandell, MD, MPH, FACS
Samuel P Mandell, MD, MPH, FACS
- Assistant Professor of Surgery, Department of Surgery
- Harborview Medical Center
- University of Washington
Traumatic injury to retroperitoneal structures often accompanies abdominal trauma. The retroperitoneum represents a potential anatomic space that is immediately posterior to the abdominal cavity. It contains organs that are entirely within the retroperitoneum, as well as some organs that traverse from and back into the abdominal cavity. Hemodynamically unstable patients with retroperitoneal hematoma represent an intraoperative diagnostic challenge. A high clinical suspicion is needed to recognize and appropriately manage retroperitoneal injuries.
An overview of the injury mechanisms, recognition, and management of traumatic injury to the retroperitoneum is provided. The initial evaluations of blunt and penetrating injury to the abdomen are reviewed separately.
Operative management and the decision for retroperitoneal exploration require a thorough knowledge of the mechanism of injury and of the organs contained within and adjacent to each other in the retroperitoneum (figure 1).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Feliciano DV. Management of traumatic retroperitoneal hematoma. Ann Surg 1990; 211:109.
- Goaley TJ, Dente CJ, Feliciano DV. Torso vascular trauma at an urban level I trauma center. Perspect Vasc Surg Endovasc Ther 2006; 18:102.
- El-Menyar A, Abdelrahman H, Al-Thani H, et al. Compartmental anatomical classification of traumatic abdominal injuries from the academic point of view and its potential clinical implication. J Trauma Manag Outcomes 2014; 8:14.
- Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for trauma. Injury 2014; 45:1378.
- American College of Surgeons Committee on Trauma. ATLS: Advanced Trauma Life Support for Doctors, 8th ed, American College of Surgeons, Chicago, IL 2008.
- Dormagen JB, Tötterman A, Røise O, et al. Efficacy of plain radiography and computer tomography in localizing the site of pelvic arterial bleeding in trauma patients. Acta Radiol 2010; 51:107.
- Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma 2006; 61:1453.
- Brown MA, Casola G, Sirlin CB, et al. Blunt abdominal trauma: screening us in 2,693 patients. Radiology 2001; 218:352.
- Shanmuganathan K, Mirvis SE, Sherbourne CD, et al. Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 1999; 212:423.
- Poplin GS, McMurry TL, Forman JL, et al. Nature and etiology of hollow-organ abdominal injuries in frontal crashes. Accid Anal Prev 2015; 78:51.
- Potoka DA, Gaines BA, Leppäniemi A, Peitzman AB. Management of blunt pancreatic trauma: what's new? Eur J Trauma Emerg Surg 2015; 41:239.
- http://www.aast.org/library/traumatools/injuryscoringscales.aspx (Accessed on December 19, 2016).
- Diamond IR, Hamilton PA, Garber AB, et al. Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma. J Trauma 2009; 66:1102.
- Mohseni S, Talving P, Kobayashi L, et al. The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures. Am Surg 2011; 77:1176.
- Hotaling JM, Sorensen MD, Smith TG 3rd, et al. Analysis of diagnostic angiography and angioembolization in the acute management of renal trauma using a national data set. J Urol 2011; 185:1316.
- Serafetinides E, Kitrey ND, Djakovic N, et al. Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol 2015; 67:930.
- Kuan JK, Wright JL, Nathens AB, et al. American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries. J Trauma 2006; 60:351.
- Rostas J, Simmons JD, Frotan MA, et al. Intraoperative management of renal gunshot injuries: is mandatory exploration of Gerota's fascia necessary? Am J Surg 2016; 211:783.
- Voelzke BB, McAninch JW. Renal gunshot wounds: clinical management and outcome. J Trauma 2009; 66:593.
- Osborn PM, Smith WR, Moore EE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009; 40:54.
- de Mestral C, Dueck AD, Gomez D, et al. Associated injuries, management, and outcomes of blunt abdominal aortic injury. J Vasc Surg 2012; 56:656.
- Harris DG, Drucker CB, Brenner ML, et al. Patterns and management of blunt abdominal aortic injury. Ann Vasc Surg 2013; 27:1074.
- Kautza B, Zuckerbraun B, Peitzman AB. "Management of blunt renal injury: what is new?". Eur J Trauma Emerg Surg 2015; 41:251.
- Simeone A, Demlow T, Karmy-Jones R. Endovascular repair of a traumatic renal artery injury. J Trauma 2011; 70:1300.
- Saour M, Charbit J, Millet I, et al. Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: a comparative study of 52 consecutive cases. Injury 2014; 45:894.
- Liao CH, Ouyang CH, Fu CY, et al. The current status and management of blunt adrenal gland trauma. Surgery 2015; 157:338.
- Stawicki SP, Hoey BA, Grossman MD, et al. Adrenal gland trauma is associated with high injury severity and mortality. Curr Surg 2003; 60:431.
- To'o KJ, Duddalwar VA. Imaging of traumatic adrenal injury. Emerg Radiol 2012; 19:499.
- Raup VT, Eswara JR, Vetter JM, Brandes SB. Epidemiology of Traumatic Adrenal Injuries Requiring Surgery. Urology 2016; 94:227.
- RETROPERITONEAL ZONES
- TRAUMA EVALUATION
- Injury mechanism
- Associated injuries
- CLINICAL EVALUATION
- Injury grading
- APPROACH TO MANAGEMENT
- When to explore retroperitoneal hematoma
- - Penetrating injury
- - Blunt injury
- Nonoperative management
- EXPLORATION OF RETROPERITONEAL HEMATOMA
- Damage control laparotomy
- Surgical approach by zone
- - Zone 1
- - Zone 2
- - Zone 3
- Left medial visceral rotation
- Right medial visceral rotation
- SPECIFIC INJURY MANAGEMENT
- Major vascular injury
- - Major venous injury
- - Major arterial injury
- Duodenum and pancreas
- Kidney/adrenal gland
- Collecting system
- Retroperitoneal colon
- SUMMARY AND RECOMMENDATIONS