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Abdominal Vascular Trauma Leslie M Kobayashi,1 Todd W Costantini,1 Michelle G Hamel,1 Julie E Dierksheide,1 Raul Coimbra2

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Abdominal Vascular Trauma Leslie M Kobayashi,1 Todd W Costantini,1 Michelle G Hamel,1 Julie E Dierksheide,1 Raul Coimbra2 Open Access Review Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2016-000015 on 20 July 2016. Downloaded from Abdominal vascular trauma Leslie M Kobayashi,1 Todd W Costantini,1 Michelle G Hamel,1 Julie E Dierksheide,1 Raul Coimbra2 1Division of Trauma, Surgical ABSTRACT the chin to the knees and suction available before Critical Care, Burns and Acute Abdominal vascular trauma, primarily due to penetrating opening a tense hemoperitoneum. The abdomen is Care Surgery, Department of Surgery, University of California mechanisms, is uncommon. However, when it does opened from the xyphoid to the pubis. Rapid San Diego, San Diego, occur, it can be quite lethal, with mortality ranging from packing of all four quadrants is then performed. An California, USA 20% to 60%. Increased early mortality has been assistant uses a large hand-held retractor to lift the 2 Department of Surgery, associated with shock, acidosis, hypothermia, anterior abdominal wall while the surgeon inserts Division of Trauma, Surgical coagulopathy, free intraperitoneal bleeding and the left hand into the abdomen to protect the Critical Care, and Burns, University of California, San advanced American Association for the Surgery of organs and uses the right hand to evacuate the clot Diego, California, USA Trauma Organ Injury Scale grade. These patients often and pack lap pads over the left hand. Packing of arrive at medical centers in extremis and require rapid the liver and spleen should be performed both Correspondence to surgical control of bleeding and aggressive resuscitation above and below the organs to create maximal tam- Dr Raul Coimbra; [email protected] including massive transfusion protocols. The most ponade. Once hemorrhage is controlled with important factor in survival is surgical control of packing, anesthesia should be allowed to resuscitate Received 22 May 2016 hemorrhage and restoration of appropriate perfusion to the patient, restoring circulating blood volume, at Revised 25 June 2016 the abdominal contents and lower extremities. These which point systematic exploration can be under- Accepted 30 June 2016 surgical approaches and the techniques of definitive taken to identify injuries. If packing of all four vascular repair can be quite challenging, particularly to quadrants fails to control blood loss, or if the the inexperienced surgeon. This review hopes to describe patient arrests, supraceliac control of the aorta may the most common abdominal vascular injuries, their be necessary. An assistant should retract the left presentation, outcomes, and surgical techniques to lobe of the liver to the patient’s right while the gas- control and repair such injuries. trohepatic ligament is opened vertically. The distal esophagus and stomach are then retracted. The aorta can then be manually compressed with a copyright. INTRODUCTION hand, sponge stick or aortic occluder. To clamp the Abdominal vascular trauma is rare, lethal, and pri- aorta at the hiatus, the right crus of the diaphragm marily associated with penetrating mechanisms. must be divided sharply and excess tissue cleared The most commonly injured abdominal vessels are from either side of the aorta with blunt dissection. the aorta, superior mesenteric artery (SMA), iliac Posterior dissection of the aorta should be avoided arteries, inferior vena cava (IVC), portal vein (PV), to prevent injury to posterior arterial branches. A and iliac veins. Mortality from abdominal vascular vascular clamp is then placed, completely occluding injuries in modern series remains high at 20–60%, the aorta. Another option for clamping the aorta is with early deaths due to exsanguination and late via a left anterolateral thoracotomy. This is per- deaths due to multisystem organ failure.1 formed by making an incision from the sternum to Presentation is dependent on whether the injury the posterior axillary line just above the fifth rib. http://tsaco.bmj.com/ has resulted in tamponade (retroperitoneal hema- The intercostal muscles are divided sharply with toma) or free rupture into the peritoneal cavity. If scissors just above the fifth rib taking caution to the hematoma has ruptured, patients will likely avoid injury to the intercostal neurovascular bundle present in volume unresponsive hemorrhagic running inferior to the rib. The rib spreader is then shock; however, if the injury remains contained in placed with the handle lateral so that it will not the retroperitoneum, the patient may remain stable impede extending the incision into a clamshell fl or be a transient responder to uid resuscitation. thoracotomy if necessary. The lung is then retracted on September 27, 2021 by guest. Protected When abdominal vascular injury is suspected, anteriorly after division of the inferior pulmonary immediate large bore intravenous access, immediate ligament. The pleura overlying the aorta is opened surgical exploration, and appropriate resuscitation with scissors. Blunt dissection is utilized to clear with 1:1:1 transfusion2 following surgical control the aorta anteriorly and posteriorly for ∼1–2 cm, of bleeding are essential for any possibility of which allows for placement of the vascular clamp rescue. Active rewarming of fluids and other efforts (a ‘side bite’ clamp preferentially) around the aorta. to maintain normothermia such as elevated operat- Care should be taken to avoid wide dissection of ing room temperature and Bair huggers are also the thoracic aorta as this can result in avulsion of important as hypothermia is likely given the intercostal arteries and significant bleeding as well volume of blood loss and body cavity exposure. as iatrogenic esophageal injury. Palpation of a previ- To cite: Kobayashi LM, ously placed nasogastric tube may aid in rapid iden- Costantini TW, Hamel MG, FREE INTRAPERITONEAL BLEEDING tification of the esophagus and avoidance of this et al. Trauma Surg Acute 34 Care Open Published Online Patients presenting with free intraperitoneal bleed- devastating complication. First: [please include Day ing are typically unstable and swift measures must Another option for aortic control is resuscitative Month Year] doi:10.1136/ be taken to prevent rapid exsanguination and endovascular balloon occlusion of the aorta tsaco-2016-000015 death. The patient should be widely prepped from (REBOA). The REBOA catheter is placed into the Kobayashi LM, et al. Trauma Surg Acute Care Open 2016;1:1–7. doi:10.1136/tsaco-2016-000015 1 Open Access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2016-000015 on 20 July 2016. Downloaded from aorta through the femoral artery via a direct cut down or percu- retroperitoneum to its root. The duodenum is Kocherized by taneously using the Seldinger technique. The balloon is posi- incising its lateral peritoneal attachments and is then mobilized tioned using fluoroscopy or X-ray, and aortic occlusion can be until the head of the pancreas is exposed to the uncinate positioned depending on the location of suspected bleeding. process and its posterior aspect visualized. The cecum and small There are three zones of inflation: zone 1 is from the left sub- bowel are swept out of the pelvis and toward the patient’s left clavian to the celiac, zone 2 is from the celiac to the renal arter- upper quadrant. A complete right medial visceral rotation ies, and zone 3 is from the renal arteries to the iliac bifurcation. exposes the IVC from the inferior border of the liver (supra- The larger 12 French (Fr) catheters typically used in the USA renal portion) to its bifurcation (figure 2).4 have required a femoral artery cut down for access; however, a 7 Fr catheter is now approved for use, allowing for percutan- ZONE 1 eous access, avoiding the need for a femoral artery cut down or Abdominal aorta suture repair of the arteriotomy, which may lead to increased Injury to the abdominal aorta is associated with high morbidity 5 use of this procedure. and mortality rates ranging from 50% to 78% in several – series.6 10 Injuries to the abdominal aorta are classified as dia- CONTAINED RETROPERITONEAL HEMATOMA phragmatic, suprarenal, and infrarenal, with diaphragmatic and suprarenal injuries carrying the highest mortality. The retroperitoneum is divided into three zones. Zone I spans the midline of the abdomen and can be divided into the supra- mesocolic and inframesocolic regions; it contains the aorta, Diaphragmatic aortic injuries IVC, celiac, and superior and inferior mesenteric arteries (SMA/ Injuries to the diaphragmatic aorta present more often with con- IMA). Zone 2 is located in the paracolic gutters bilaterally and tained hematoma than free rupture because of the dense con- contains the renal vessels and kidneys. Zone 3 begins at the nective tissue surrounding this portion of the aorta. Injuries to sacral promontory and contains the iliac arteries and veins. The the diaphragmatic aorta can be exposed via laparotomy and approach to contained retroperitoneal hematomas is dependent entry into the lesser sac, left anterolateral thoracotomy, or via on the mechanism of injury, location, and suspected vascular left medial visceral rotation with division of the left crus in the 11 injury. In general, suspected aortic and mesenteric arterial and two o’clock position. These approaches have been described left zone 2 injuries are approached via a left medial visceral previously in this chapter. rotation, while suspected IVC and right zone 2 injuries are approached via a right medial visceral rotation.4 During a left medial visceral rotation, the white line of Toldt is divided lateral to the entirety of the left colon and the left copyright. colon is rotated toward the patient’s right upper quadrant. The spleen is mobilized by dividing the lienosplenic ligament. The stomach, left colon, spleen, and tail of the pancreas are then rotated medially off the retroperitoneum by placing a hand anterior to the kidney (modified left medial visceral rotation). Left-sided medial visceral rotation can also be performed poster- ior to the kidney, based on the surgeon’s preference and loca- tion of injury. Rotation of the viscera will allow visualization of the aorta from its entry at the diaphragmatic hiatus to the bifur- 4 cation (figure 1).
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