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Overview of the diagnosis and initial management of traumatic retroperitoneal injury

Overview of the diagnosis and initial management of traumatic retroperitoneal injury
Literature review current through: Jan 2024.
This topic last updated: Jun 23, 2023.

INTRODUCTION — 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.

(See "Initial evaluation and management of blunt abdominal trauma in adults".)

(See "Initial evaluation and management of abdominal stab wounds in adults".)

RETROPERITONEAL ZONES — 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).

The retroperitoneum is divided into three anatomic regions, which are also used to describe the location of retroperitoneal hematomas.

Zone 1 is the central retroperitoneum, which extends from the diaphragm superiorly to the bifurcation of the aorta inferiorly. Zone 1 contains the aorta, the inferior vena cava, the origins of the renal and major visceral vessels, a portion of the duodenum, and the pancreas.

Zone 2, which is not contiguous, includes both of the lateral perinephric areas of the upper retroperitoneum from the renal vessels medially to the lateral reflection of posterior parietal peritoneum of the abdomen (ie, to the "white line of Toldt"), and extending from the diaphragm superiorly to the level of the aortic bifurcation inferiorly. Zone 2 contains the adrenal glands, the kidneys, the renal vessels, the ureters, and the ascending and descending colon.

Zone 3 is inferior to the aortic bifurcation and includes the right and left internal and external iliac arteries and veins, the distal ureter, the distal sigmoid colon, and the rectum [1,2].

EPIDEMIOLOGY — Although retroperitoneal injury is common in patients who have abdominal trauma, estimates of its incidence range widely. Most data come from case series, predominantly based on diagnosis of retroperitoneal injury at the time of laparotomy. For blunt trauma, estimates range from 44 to 80 percent, and, for penetrating injury, from 20 to 33 percent [1]. In a review of nearly 7000 trauma admissions, 15 percent had abdominal injury, with 15 percent of those involving the retroperitoneum [3].

In another review of 488 patients who had trauma laparotomy, 30 percent had an associated retroperitoneal hematoma [4]. Among these, there were 58 zone 1 (35 percent), 69 zone 2 (42 percent), and 38 zone 3 (23 percent) hematomas. The most commonly injured organs were the colon, kidney, duodenum, pancreas, urinary bladder, and rectum, in that order.

TRAUMA EVALUATION — The initial resuscitation, diagnostic evaluation, and management of the patient with blunt or penetrating injury, including suspected retroperitoneal injury, are based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma [5]. The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal injury are discussed separately.

(See "Initial evaluation and management of blunt abdominal trauma in adults".)

(See "Initial evaluation and management of abdominal stab wounds in adults".)

The patient history should include detail about the mechanism of injury. The AMPLE (allergies, medications, previous medical/surgical history, last meal, events) history covers the important elements. For retroperitoneal injury, a history of anticoagulant use is particularly important. In the setting of acute trauma, many patients cannot relate their symptoms or medical history due to altered mental status (eg, neurologic injury, intoxication) or because they are intubated and sedated. Every attempt should be made to identify preexisting medical conditions by contacting the patient's primary care physician or family members. The presence of significant medical comorbidities and medical conditions requiring antiplatelet or anticoagulation should be determined.

Initial radiologic studies obtained during the initial evaluation of the trauma patient typically include plain chest and pelvis radiographs and a focused assessment with sonography for trauma (FAST). Of these, the pelvis radiograph is most likely to raise the possibility of retroperitoneal injury with the identification of pelvic fracture, which may be associated with zone 3 bleeding [6]. Although FAST is a useful, validated test for detecting hemoperitoneum in the setting of blunt trauma, FAST does not evaluate the retroperitoneum and may be less reliable in patients with pelvic fracture [7]. Approximately one-third of patients with retroperitoneal injuries, including injuries of the duodenum and pancreas, will have normal FAST examinations [8,9]. Nevertheless, a negative FAST in a hypotensive patient with negative chest findings should increase suspicion for retroperitoneal bleeding. Retroperitoneal injury may also be suspected based on the mechanism of injury as well as associated injuries identified during the course of the trauma evaluation.

Injury mechanism — Retroperitoneal injury can be due to blunt or penetrating trauma.

Blunt trauma, such as falls or motor vehicle crashes, can injure the retroperitoneum through one or a combination of several mechanisms, including direct transfer of energy causing organ compression, shear stress from deceleration, or organ puncture from an adjacent rib fracture [10]. The kidneys are large, solid retroperitoneal organs and are more likely to undergo injuries with a direct transfer of force, such as a blow to the back or flank. All retroperitoneal organs are susceptible to shear injury as they are tethered posteriorly. The duodenum, pancreas, and great vessels lie over the spine and are also at risk for crush injury with the spine serving as an "anvil."

Blunt injury is less likely to injure contiguous tissue planes, thus allowing containment of hematomas. By contrast, penetrating injuries, such as gunshot wounds or stab injuries, violate tissue planes and can lead to hemorrhage from the retroperitoneum freely into the chest or abdomen.

The nature of the penetrating injuries depends upon the trajectory of the missile or implement used and the amount of force that is transmitted. Stab wounds are generally confined to the area contacted by the object. The size and shape of a stab injury will correspond to the implement, although there can be increased damage from twisting of the object. Projectile injuries, on the other hand, show wide variation in the amount of tissue damage. Primary injury results from the projectile passing through the tissue, but secondary injury also occurs due to the cavitation wave of gas and fluid of surrounding tissue or from fragmentation of adjacent bone. Both the kinetic energy imparted by the missile, which increases exponentially with its velocity, and the characteristics of the missile (size, shape, and rotation) influence the amount of tissue damage that is produced.

Associated injuries — Injuries to abdominal organs or bony structures adjacent each retroperitoneal zone should raise suspicion for potential retroperitoneal injury. Examples for zone 1 include: injury to the liver, spleen, stomach or spine; for zone 2: injury to the spleen, intestines, mesentery, or lower ribs; and for zone 3: injury to the bladder, vagina, pelvis, and spine.

CLINICAL EVALUATION — History and physical examination are nonspecific and are not reliable for detecting retroperitoneal injury. While there is no particular exam for the retroperitoneum, the examiner should be aware that retroperitoneal injury is often accompanied by injury to other organs. (See 'Associated injuries' above.)

A true "seatbelt" sign with bruising over the abdomen above the iliac crests may indicate a crush mechanism to the retroperitoneum. Although large ecchymosis may be suggestive (eg, flank ecchymosis [Grey-Turner sign], periumbilical ecchymosis [Cullen's sign], proximal thigh ecchymosis [Fox's sign], scrotal ecchymosis [Bryant's sign]), these physical exam signs have poor sensitivity and specificity and are not reliable indicators for retroperitoneal bleeding.

Examination of the pelvis may indicate instability and if accompanied by hypotension, should raise suspicion for zone 3 hemorrhage. This exam should be performed only once, preferably by a senior examiner.

Laboratory evaluation should be guided by clinical suspicion for injury and patient physiology. For severe trauma, this usually includes complete blood count, serum electrolytes, liver function tests, amylase or lipase, and coagulation studies. While amylase and lipase are commonly obtained, they are neither sensitive nor specific for pancreatic injury [11]. (See "Management of duodenal trauma in adults", section on 'Diagnosis' and "Management of pancreatic trauma in adults", section on 'Diagnosis'.)

Urinalysis investigating the presence of microscopic hematuria should be obtained to screen for urinary tract injury. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Urinalysis'.)

For patients with hemodynamic abnormalities or suspected hemorrhage, a sample for blood type and crossmatch should be sent immediately. Triggering a massive transfusion protocol may be indicated based upon the anticipated need for transfusion (eg, severe pelvic fracture). (See "Etiology and diagnosis of coagulopathy in trauma patients" and "Massive blood transfusion".)

DIAGNOSIS — Injury to the retroperitoneum may be diagnosed based upon findings on cross-sectional imaging studies in hemodynamically stable patients or in the operating room by direct identification of retroperitoneal hematoma during abdominal exploration of hemodynamically unstable patients. (See 'Exploration of retroperitoneal hematoma' below.)

Imaging — For patients who are hemodynamically stable with a high-risk mechanism, cross-sectional imaging should be obtained. Due to its ready availability and speed of image acquisition, the imaging study of choice to evaluate the retroperitoneum is computed tomography (CT) scan with intravenous contrast.

CT with delayed venous phases may be helpful to evaluate the collecting system if there is suspicion for renal trauma. Cystography (CT or radiograph imaging) should be considered in those with a pelvic fracture and/or hematuria.

Injury grading — Injuries to the organs are classified according to the American Association for the Surgery of Trauma (AAST) Injury Scoring Scale. Injury grading of specific organs is provided in the linked topic reviews and on the AAST website [12].

Vascular injury – Aortoiliac vascular injury is graded as type I through type IV, depending on the severity of the disruption of vascular wall integrity. (See "Clinical features and diagnosis of blunt thoracic aortic injury", section on 'Aortic injury grading'.)

Duodenum/pancreas – Duodenal and pancreatic injuries are graded I through V, depending on the severity of hematoma or laceration to the organ. (See "Management of duodenal trauma in adults", section on 'Duodenal injury grading' and "Management of pancreatic trauma in adults", section on 'Pancreas Injury grading'.)

Stomach, small intestine, colon, and rectum – (See "Traumatic gastrointestinal injury in the adult patient", section on 'Injury grading'.)

Kidney, ureter, adrenal gland – (table 1 and figure 2 and table 2 and table 3). (See "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management" and "Management of blunt and penetrating renal trauma".)

APPROACH TO MANAGEMENT — The initial approach to management of the trauma patient depends on the clinical status of the patient with management of retroperitoneal injury occurring simultaneously with management of injuries sustained to the abdomen or chest.

For hemodynamically unstable patients, resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for obtaining control of noncompressible hemorrhage, particularly in the abdomen or pelvis. The potential indications for using REBOA, particularly in the context of abdominal or pelvic trauma with shock, is reviewed in detail separately. REBOA is a temporizing maneuver and needs to be followed urgently by surgical or angiographic control of hemorrhage. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Endovascular methods for aortic control in trauma".)

When to explore retroperitoneal hematoma — Management of retroperitoneal injuries can range from observation to mandatory retroperitoneal exploration, depending on the mechanism, affected zone of injury, and organ injury severity.

Whether to explore a retroperitoneal hematoma identified at the time of exploratory laparotomy is summarized below. This general approach can also be used to guide management when a retroperitoneal hematoma is identified on cross sectional imaging. Although some specific injuries identified on cross sectional imaging may mandate exploration (eg, colon perforation), for some injury mechanisms/zones, nonoperative management with angioembolization may control active bleeding/expanding hematoma without the need for surgery. (See 'Nonoperative management' below.)

Penetrating injury

Zone 1 – Explore; likely a major vascular injury. Zone 1 contains the visceral segment, which in emergency settings is generally not amenable to less invasive vascular options such as endovascular repair with fenestrated grafts. (See 'Zone 1' below and 'Major vascular injury' below.)

Zone 2 – Selectively explore the kidney for active hemorrhage or an expanding hematoma. Mobilize the colon to rule out retroperitoneal colon injury, and explore the ureters if in proximity to the wound. (See 'Zone 2' below and 'Kidney/adrenal gland' below and 'Retroperitoneal colon' below and 'Collecting system' below.)

Zone 3 – Explore; likely a major vascular injury. (See 'Zone 3' below and 'Major vascular injury' below.)

Blunt injury

Zone 1 – Explore; likely a major vascular injury. Zone 1 contains the visceral segment, which in emergency settings is generally not amenable to less invasive vascular options such as endovascular repair with fenestrated grafts. (See 'Zone 1' below and 'Major vascular injury' below.)

Zone 2 – Explore for an expanding hematoma or one that has failed alternative methods of hemorrhage control (angioembolization). Do not explore a contained, nonexpanding hematoma. (See 'Zone 2' below and 'Kidney/adrenal gland' below and 'Collecting system' below.)

Zone 3 – Do not explore; use an alternative method for hemorrhage control including intraoperative preperitoneal packing or angioembolization (intraoperative with hybrid operating room capability, or postoperatively). (See "Severe pelvic fracture in the adult trauma patient".)

Nonoperative management — Retroperitoneal injuries in hemodynamically stable patients who do not have other indications for surgical exploration (see 'When to explore retroperitoneal hematoma' above), often do not require operative exploration.

Nonoperative management may be appropriate for the following injuries:

Minimal vascular injury (ie, intimal disruption without dissection)

Grade I through IV renal injuries

All adrenal injuries

Minor duodenal and pancreatic injuries

Management includes pain control, serial abdominal examination, serial laboratory studies (tailored to the specific injuries identified), and follow-up imaging, as indicated. (See "Overview of inpatient management of the adult trauma patient".)

If active extravasation or pseudoaneurysm is identified on computed tomography (CT; pelvic, renal, other vessels), angioembolization can often be used to control bleeding, rather than surgery [6,13,14]. This is particularly true with blunt renal trauma, where embolization has been shown to decrease the rate of nephrectomy [15]. (See 'Kidney/adrenal gland' below and "Blunt genitourinary trauma: Initial evaluation and management".)

Angioembolization can also be used to treat selected patients with pelvic fracture with retroperitoneal hemorrhage who may initially be hemodynamically unstable and who have no other indications for immediate surgical exploration (abdominal or thoracic). However, some trauma surgeons advocate pelvic packing over attempts at angioembolization in hemodynamically unstable patients with pelvic fracture and bleeding. Local resources should be considered when choosing angiography or pelvic packing. (See "Severe pelvic fracture in the adult trauma patient".)

For patients who have been managed nonoperatively, failure of observation (eg, expanding hematoma) can occur. Operative exploration should be considered in cases of persistent hemodynamic instability, bleeding that is not responsive to minimally invasive control measures (ie, angiography), or development of abdominal compartment syndrome due to a large retroperitoneal hematoma. (See "Abdominal compartment syndrome in adults".)

Surgery may also be needed for delayed organ system repair (eg, ureteral injury).

EXPLORATION OF RETROPERITONEAL HEMATOMA — Retroperitoneal injury is often identified at the time of laparotomy for trauma patients in shock, requiring the surgeon to identify and address injuries as they are discovered. Exploration for retroperitoneal injury may also be needed to address a specific injury identified on imaging, or for failure of nonoperative management. (See 'Approach to management' above.)

Damage control laparotomy — During laparotomy in the hemodynamically unstable patient, the surgeon needs to gain access, control hemorrhage and contamination, and use damage control principles to address injuries in a stepwise fashion. The peritoneal cavity should be explored prior to venturing into the retroperitoneum. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury", section on 'Damage control laparotomy'.)

Hematoma in the retroperitoneum is a common sight, particularly in blunt mechanisms. With blunt trauma mechanisms, injury within the retroperitoneum often remains contained within the closed space without free hemorrhage into the abdominal cavity. With penetrating trauma, the path of the projectile or implement is often suggested, and the surgeon should proceed immediately to the area of injury.

A decision to explore the retroperitoneum should be based upon the overall condition of the patient; the injury mechanism, such as the likely path of the injuring object in penetrating trauma; the presence and size of hematoma; and the likely severity of the injury. Overly aggressive exploration of the retroperitoneum can turn a controlled situation into one of unmanageable hemorrhage. (See 'When to explore retroperitoneal hematoma' above.)

Once bleeding and contamination within the abdominal cavity under control, the bowel can be wrapped and retracted to allow a clearer view for the systematic evaluation the retroperitoneum. The intraperitoneal organs make it impossible to see the retroperitoneum all at once. Exposing one area will necessitate obscuring another from view.

Accessing the retroperitoneum involves the systematic retraction of the abdominal contents and frequently their mobilization from the left or right. The choice of direction depends on anatomic need for access. As an example, for a penetrating injury to the right colon, the colon must be evaluated circumferentially. This requires mobilization of the colon along the "white line of Toldt" with an approach from the right. It is important to realize that other retroperitoneal structures located in the vicinity, such as the ureter, may also need to be examined.

Surgical approach by zone

Zone 1 — In general, all zone 1 hematomas are explored because these are likely due to major vascular injury. Exploration may convert a slowly expanding hematoma to rapidly uncontrolled exsanguination. Prepare for hematoma exploration by communicating with all members of the operative team prior to intervention and ensure that appropriate blood products are immediately available. (See 'Major vascular injury' below.)

The region above the transverse mesocolon in zone 1 is one of the most inaccessible locations of the retroperitoneum. The aorta in this area is obscured by the stomach, pancreas, and a dense nerve plexus. The optimal approach is with a left-sided visceral rotation to gain control of the supraceliac aorta. (See 'Left medial visceral rotation' below.)

Whether to temporarily clamp the supraceliac aorta or proceed directly to left medial visceral rotation depends on the clinical status of the patient. If there is direct hemorrhage into the abdominal cavity, a rapidly expanding hematoma, or the patient has already lost vital signs, clamping the supraceliac aorta can quickly control bleeding and help anesthesia with the resuscitation. Temporary control of the aorta can be gained by applying pressure to the anterior aorta at the diaphragmatic hiatus.

One approach to quickly clamping the supraceliac aorta is through the lesser sac by opening the gastrohepatic ligament and, beginning at the superior aspect of the pancreas, bluntly dissecting the stomach and esophagus from the aorta. This exposure is limited and can injure branches to the esophagus or potentially the celiac axis, given that a portion of this dissection is performed without a direct line of sight. Proper positioning of the clamp requires avoiding clamping redundant tissue within the clamp. The area will also almost assuredly be obscured by bleeding. It is for these reasons a left medial visceral rotation is preferred for definitive identification and repair of injuries in this zone.

For inframesocolic hematomas, the aorta or inferior vena cava may be involved. The infrarenal aorta can be exposed by sweeping the small bowel to the right and mobilizing the fourth portion of the duodenum and the ligament of Treitz (as with abdominal aortic aneurysm repair). For the widest exposure including the inferior vena cava, the best approach is a left medial visceral rotation. (See 'Left medial visceral rotation' below and 'Major arterial injury' below.)

The inferior vena cava can also be fully exposed using a right-sided medial visceral rotation. Initial hemorrhage control from vena cava injury can be achieved using manual, direct pressure. The injury can then be isolated between sponge sticks. This should allow a direct view of the injury. If possible, direct control of the vein wall should be obtained. (See 'Right medial visceral rotation' below and 'Major venous injury' below.)

Zone 2 — A contained, nonexpanding hematoma in zone 2 due to blunt injury does not warrant exploration [16,17]. Hematomas around the kidney from penetrating injury in zone 2 should be explored selectively in cases of active hemorrhage or expanding hematoma. Hematomas suggesting a potential for colonic or ureteral injury require exploration of these structures [18,19].

For hemodynamically stable patients with minimal oozing from a hole in the retroperitoneum from a penetrating injury, temporary packing with surgical sponges may be a better option rather than exploration, provided the colon and ureters are not at risk.

If exploration is necessary in the hemodynamically stable patient, controlling the renal artery and vein near the midline is advised prior to unroofing the hematoma. In a hemodynamically unstable patient, rapid lateral mobilization of the kidney to approach the vessels is preferred.

Zone 3 — Hematomas from penetrating injury in zone 3 should be explored and may indicate a major vascular injury. Hematomas from blunt trauma should not be explored, regardless of the presence or absence of pelvic fracture, unless there is rapid expansion suggestive of a major vascular injury.

Venous plexus injuries associated with pelvic fracture do not represent major venous injuries and are not explored; however, depending upon the circumstance, pelvic packing or angioembolization may be used to control hemorrhage. For a hemodynamically unstable patient with significant venous hemorrhage from deep in the pelvis during abdominal exploration, intraoperative preperitoneal packing should be attempted for hemorrhage control [20]. (See "Severe pelvic fracture in the adult trauma patient", section on 'Preperitoneal pelvic packing'.)

A right-sided medial visceral rotation provides better exposure to zone 3 compared with a left-sided approach. (See 'Right medial visceral rotation' below.)

For arterial injuries in zone 3, control of arterial inflow can be obtained by clamping the infrarenal aorta above the bifurcation. A clamp should also be placed distal to the injury where the vessel can be easily identified and mobilized. The arterial injury can then be isolated between the clamps by "walking" them sequentially closer to the injury. For venous injury, pressure with sponge sticks on both sides of the injury can temporarily control bleeding until the location of the injury is identified. Ligation of the inferior vena cava ligation should be avoided for zone 3 injuries, as this may increase venous bleeding in the pelvis. (See 'Major vascular injury' below.)

Left medial visceral rotation — Optimal access to zone 1 uses a left-sided medial visceral rotation (ie, Mattox maneuver), which exposes the aorta from the diaphragmatic hiatus to the bifurcation as well as most of its branches, including the celiac, superior mesenteric artery, left renal artery, and left iliac artery. Much of the dissection may have already been done by the hematoma itself, allowing much of the maneuver to be accomplished with blunt finger dissection.

To perform left medial visceral rotation:

Retract the left colon medially and incise the white line of Toldt to the splenic flexure (caudal to cephalad). Once the peritoneal reflection is incised, the peritoneal contents can be swept downward.

Continue the dissection up to the lateral attachments of the spleen. This will allow rotation of the spleen, pancreas, left kidney, and left colon toward the midline directly off the musculature of the posterior abdominal wall. It is also possible to leave the kidney in place, mobilizing it only if needed.

Mobilize the esophagus off the supraceliac aorta anteriorly to isolate the aorta for clamping. The left crus of the diaphragm can be divided, if necessary, for further exposure.

Right medial visceral rotation — To gain access to the right retroperitoneum, a right-sided medial visceral rotation (ie, Cattel-Braasch maneuver)can be used, which provides exposure to most of the retroperitoneum below the mesocolon. Along with a Kocher maneuver, a right medial visceral rotation exposes the inferior vena cava to its retrohepatic termination, the third and fourth portions of the duodenum, the head of the pancreas, the superior mesenteric vessels, and the bilateral renal vessels.

To perform right medial visceral rotation:

Start with a Kocher maneuver (figure 3), and mobilize the duodenum medially. Continue caudally incising the white line of Toldt to mobilize the right colon to the cecum. Alternatively, the hepatic flexure of the colon can be mobilized first, followed by the Kocher maneuver to mobilize the duodenum.

Divide the attachments between the small bowel mesentery and the retroperitoneum toward the ligament of Treitz, gathering and retracting the colon and small bowel cephalad and to the left.

Caution: With this exposure, the sole attachment of the right colon is the colonic mesentery, and care should be taken handling the colon. Excessive retraction can easily tear the right colic vein from the superior mesenteric vein resulting in significant hemorrhage. Twisting the mobilized mesentery can also result in bowel ischemia.

SPECIFIC INJURY MANAGEMENT

Major vascular injury

Major venous injury — Injuries to the inferior vena cava (IVC; zone 1), superior or inferior mesenteric veins (zone 1), or the common internal or external iliac veins (zone 3) represent major venous injuries that can be life-threatening. Venous plexus injuries associated with pelvic fracture do not represent major venous injuries and are not explored.

In general, veins are repaired where able, provided that doing so will not jeopardize the patient’s overall care. For small penetrating injuries, direct suture repair can be performed. For larger lacerations, full or partial application of vascular clamps across the tear will help align the edges to allow closure of the defect. It is important to mobilize and assess the vessel circumferentially prior to repair. If the injury is complex or multiple lacerations exist and the wound edges cannot be defined, or the injured area is not accessible, the vein can be ligated and possibly reconstructed at a later date. Ligating the inferior vena cava should be reserved as a last-resort technique. In critically ill patients, the infrarenal IVC can be ligated without subsequent reconstruction. However, inferior vena cava ligation should be avoided for zone 3 injuries, as this may increase venous bleeding in the pelvis.

Injuries to the superior mesenteric vein can be particularly challenging to control and isolate as the vessel passes behind the pancreas to join the splenic vein forming the portal vein. The pancreas may need to be elevated off the portal vein confluence and divided. When using a stapling device, caution should be used to avoid further injury to these veins. Once exposed, control of the edges of the venous injury and direct repair should be possible. In the face of exsanguinating hemorrhage, ligation remains the damage control option. Ligation of the portal vein or superior mesenteric vein, however, will sometimes result in venous hypertension of the bowel, and result in bowel ischemia. Thus ligation of these vessels should be reserved for dire circumstances and may require later reconstruction.

Limited iliac vein injuries should be repaired, if technically feasible. In the hemodynamically unstable patient, ligation may be necessary. Iliac vein injuries from penetrating trauma can be accessed and controlled between sponge sticks. Care should be taken to identify the ureter and avoid iatrogenic injury to pelvic veins while attempting exploration. Injuries to the right common iliac vein where it lies beneath the right common iliac artery can be challenging to manage. Injuries in this area or to the inferior vena cava bifurcation can be accessed by dividing the overlying right iliac artery in cases of life-threatening hemorrhage. However, the artery must be repaired immediately or shunted to prevent acute lower limb ischemia.

Major arterial injury — Abdominal aortic injury can range from minimal aortic injury (ie, intimal disruption without dissection) to severe aortic injury in the form of dissection, pseudoaneurysm formation, branch avulsion, rupture, or overt transection. The most commonly associated injuries include lumbar spine fractures, pelvic fractures, splenic injury, small bowel, colon, pancreas and kidney injuries [21]. As with blunt thoracic aortic injury, with minimal abdominal aortic injuries (ie, intimal disruption without dissection), conservative management has been tried [21,22]. Observed patients should undergo repeat imaging during the index admission to evaluate for progression. In one study, five of nine patients with minimal blunt abdominal aortic injury required aortic-related repairs [22]. Arterial injuries identified within the retroperitoneum during abdominal exploration should be repaired after obtaining proximal and distal control of the vessel. For iliac artery injuries in the unstable patient or if a surgeon experienced in arterial repair is not immediately available, temporary placement of a vascular shunt is an option until definitive repair can be performed. (See "Abdominal vascular injury".)

Duodenum and pancreas — Duodenal and pancreatic injuries are uncommon, but injury should be suspected in those with a mechanism that crushes the anterior abdomen into the spine (such as with seatbelt injury, a blow to the abdomen, or fall onto bicycle handlebars) or with a penetrating injury to the upper abdomen. Examination of the duodenum and pancreas should be performed in any patient with suspected injuries undergoing laparotomy for trauma. Evaluation of these retroperitoneal organs should take place following control of hemorrhage and intraperitoneal contamination. (See "Management of duodenal trauma in adults" and "Management of pancreatic trauma in adults".)

Kidney/adrenal gland — In the hemodynamically unstable patient, renal injury may be identified at the time of laparotomy. Renal injuries, particularly blunt injuries, should only be explored in the setting of ongoing, potentially life-threatening hemorrhage with a pulsatile, expanding zone 2 hematoma. In this setting, nephrectomy may be necessary to control bleeding and is required in approximately 60 percent of patients with this type of injury [23]. (See "Overview of traumatic upper genitourinary tract injuries in adults" and "Management of blunt and penetrating renal trauma".)

In the hemodynamically stable patient, renal injuries can be identified reliably on abdominal computed tomography (CT) scan. The majority of renal injuries and blunt injuries, in particular, can be managed nonoperatively. The goals of nonoperative intervention are renal salvage and the avoidance of complications. If hemorrhage is from the renal parenchyma, surgical interventions for organ salvage may be appropriate for those experienced with repair or with aid from those with urologic expertise. Grade V injury, which is an avulsion of the renal hilum, remains an indication for operative intervention based on CT. For patients with focal renal artery dissection, renal artery stenting may restore flow and salvage the kidney [24]. For hemodynamically stable patients who have persistent bleeding, angioembolization of parenchymal lesions increases the likelihood of success of nonoperative management, though for high-grade injuries it increases the risk of postembolization acute kidney injury (AKI) [25].

Adrenal injury is rare, occurring in less than 1 percent of trauma patients. The majority are minor hematomas from blunt mechanisms. Other serious injuries are commonly present. It is often a silent injury that is easily missed and can rarely lead to persistent bleeding, abscess, or adrenal crisis. Diagnosis has improved with high-resolution abdominal CT. In one review, right-side injury predominated [26]. Isolated adrenal injury does not require operative intervention [27-29]. For persistent bleeding, angioembolization has been used with reasonable success [26]. In one case series, adrenalectomy was required in 1 to 2.5 percent. None of these was an isolated injury, and most were due to penetrating trauma.

Collecting system — When injury to the collecting system is suspected in the patient with pelvic trauma, a retrograde urethrogram should be performed. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)

If no extravasation is seen, a Foley catheter can be inserted and a cystogram can be performed with an upper tract study, as indicated. In the hemodynamically stable patient, this is usually an abdominopelvic CT scan with intravenous contrast and delayed phases to evaluate the collecting system (image 1). (See "Overview of traumatic lower genitourinary tract injury" and "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram' and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management".)

Blunt ureteral injury is rare, but when it occurs, it can be difficult to identify. The presence of flank pain, bruising and tenderness, posterior rib or spine fractures, and gross hematuria should raise suspicion. For penetrating trauma, a trajectory in proximity of the ureters may require additional evaluation. The surgical management of traumatic ureteral injuries follows similar general principles as for iatrogenic injury, typically being cared for by urologic surgeons. (See "Surgical repair of an iatrogenic ureteral injury".)

Retroperitoneal colon — Blunt injuries to the colon are uncommon, but injury can occur at the transition points where the colon becomes fixed retroperitoneally. The trajectory of a penetrating object usually suggests the possibility of colonic injury. Genitourinary injuries are associated with blunt trauma to the distal colon and upper rectum. The management of colonic injuries is reviewed separately. (See "Traumatic gastrointestinal injury in the adult patient".)

MORTALITY — Mortality rates for retroperitoneal injury depend upon the patient's clinical condition, the zone of injury, injury severity score, and associated injuries. In a review of 488 patients with abdominal trauma, the overall mortality rate among 151 patients identified with retroperitoneal hematoma was 18 percent [4]. Mortality rates for patients with zone 1, 2, 3, and 4 injuries (where zone 4 includes more than one zone) were 14, 4, 29, and 35 percent, respectively. Mortality was highest for blunt trauma and lowest for stab wounds. The main causes of death were multiorgan failure (15), hypovolemic shock (6), and sepsis (4). One-half of the patients who presented with shock (12 of 24) died compared with 12 percent (14 of 121) without shock. Vascular injury contributed to 19 percent of the mortality. Other factors significantly associated with death (in addition to shock) included delay of surgery >6 hours, injury severity scale ≥9, and zone 1-only injury.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Genitourinary tract trauma in adults".)

SUMMARY AND RECOMMENDATIONS

The retroperitoneum represents a potential anatomic space that is immediately posterior to the abdominal cavity. Retroperitoneal injury is often seen in conjunction with other injuries in both blunt and penetrating trauma. (See 'Introduction' above and 'Epidemiology' above and 'Associated injuries' above.)

The retroperitoneum is divided into three anatomic regions that are also used to describe the location of retroperitoneal hematomas and help guide management (figure 1). (See 'Retroperitoneal zones' above.)

Retroperitoneal injury can be due to blunt or penetrating trauma. (See 'Injury mechanism' above.)

Blunt trauma causes retroperitoneal injury through direct energy causing organ compression, shear stress from deceleration, or organ puncture from an adjacent rib fracture.

Penetrating injuries directly violate tissue planes. The nature of the resulting injuries depends upon the trajectory of the missile or implement and the amount of force that is transmitted. If the peritoneum is violated, exsanguinating hemorrhage freely into the abdomen can occur.

For the hemodynamically unstable patient, a Focused Assessment with Sonography in Trauma (FAST) is obtained but does not evaluate the retroperitoneum and may be less reliable in patients with bleeding from pelvic fracture (zone 3). However, a negative FAST in a hypotensive patient with negative chest findings should increase suspicion for retroperitoneal bleeding. In these cases, retroperitoneal injury is diagnosed in the operating room by direct identification of retroperitoneal hematoma during abdominal exploration. (See 'Diagnosis' above.)

For hemodynamically stable patients, a diagnosis of retroperitoneal injury is based upon findings on cross-sectional imaging, typically computed tomography (CT). If there is suspicion for renal or ureteral injury, CT should include a delayed venous phase. (See 'Diagnosis' above.)

Injuries to the organs are classified according to the American Association for the Surgery of Trauma Injury Scoring Scale, which helps guide management. Management of retroperitoneal injury occurs simultaneously with injuries sustained to the abdomen or chest. (See 'Injury grading' above.)

Management of retroperitoneal injuries can range from observation to mandatory retroperitoneal exploration, depending on the mechanism, affected zone of injury, and organ injury severity. Whether to explore a retroperitoneal hematoma identified at the time of exploratory laparotomy is summarized below.

For penetrating injury:

Zone 1 – Explore; likely a major vascular injury.

Zone 2 – Selectively explore the kidney for active hemorrhage or an expanding hematoma. Mobilize the colon to rule out retroperitoneal colon injury, and explore the ureters if in proximity to the wound.

Zone 3 – Explore; likely a major vascular injury.

For blunt injury:

Zone 1 – Explore; likely a major vascular injury.

Zone 2 – Explore for an expanding hematoma or one that has failed alternative methods of hemorrhage control (angioembolization). Do not explore a contained, nonexpanding hematoma.

Zone 3 – Do not explore; use an alternative method for hemorrhage control including intraoperative preperitoneal packing or angioembolization (intraoperative with hybrid operating room capability, or postoperatively).

Hemodynamically stable patients who do not have indications for surgical exploration can often be managed nonoperatively. Management includes pain control, serial abdominal examination, serial laboratory studies, and follow-up imaging, as indicated. If active extravasation is identified on CT scan, angioembolization will often control bleeding. However, among patients being managed conservatively, it is possible for a very large retroperitoneal hematoma to result in abdominal compartment syndrome, which may require abdominal decompression. Surgery may also be indicated for those with persistent bleeding in spite of nonoperative measures for control. (See 'Nonoperative management' above and 'Specific injury management' above.)

Surgical access to the retroperitoneum involves the systematic retraction of the abdominal contents and mobilization from the left or right. The choice of direction depends on anatomic need for access. Surgical access above the mesocolon is best achieved with a left medial visceral rotation. Access below the mesocolon and to the inferior vena cava can be achieved with a right medial visceral rotation. (See 'Surgical approach by zone' above and 'Left medial visceral rotation' above and 'Right medial visceral rotation' above.)

Mortality rates for retroperitoneal injury depend upon the patient's clinical condition, the zone of injury, injury severity score, and associated injuries. Mortality is greater for blunt compared with stab injury. The main cause of death is multiorgan failure. The presence of major vascular injury significantly increases mortality rates. (See 'Mortality' above.)

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Topic 15588 Version 15.0

References

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