Retroperitoneum exposure

• General
  • Injuries are often missed, underestimated or have high rate of mortality
• Zones
  • I - Central
    • Between both psoas muscles and contains the abdominal aorta, inferior vena cava, pancreas, and midline duodenal structures
  • II - Lateral x 2
    • Lateral to the psoas muscles on bilateral sides and contains the kidneys, ureters, and portions of the colon
  • III - Pelvic
• Management
  • Zone 1 - Upper midline central retroperitoneal haematoma
    • All should be explored
    • Potential sites of injury
      • Aorta/IVC
      • Kidneys, Ureters, Renal vessels
      • Duodenum/Pancreas
      • Colon
  • Zone 2 - Lateral retroperitoneal haematomas
    • Only explore if expanding, thought to have injury to Colon or Ureter
    • Usually related to renal bleed which should tamponade
  • Zone 3 - Pelvic
    • Non - expanding - don’t explore
    • Ongoing bleeding
      • External fixation of pelvis
      • Angioembolization
      • If angio is unavailable and enlarging pelvic haematoma/ongoing bleeding
        • Extra-peritoneal pelvic packing
    • General
      • Unstable and peritonitis - Laparotomy
      • Observe if stable, not too sore and imaging is reassuring
      • Serial abdominal examinations

Retroperitoneal Haematoma

• Zones
  • I - central (further subdivision based on apex of haematoma)
    • Supracolic
      • Juxtarenal or suprarenal aorta, SMA, coeliac
    • Infracolic
      • Aortic bifurcation/IMA
      • Transperitoneal or left medial visceral rotation approach
    • Left or right
      • If apex is right of midline and primarily venous bleeding
        • Right medial visceral rotation
        • Access to Infrarenal IVC, aorta and portal vein
      • If apex is left of midline and primarily arterial bleeding
        • Left medial visceral rotation
        • Access aorta, coeliac, SMA, splenic A/V, left renal A/V
        • Mobilise kidney to access posterior wall of aorta
  • II - Lateral x 2
    • Leave alone if not expanding
    • Renal injuries - non operative and selective embolization approach
    • If penetrating injury or expanding - explore
      • Need to rule out occult post colonic and ureteric injury
      • To prevent abscess/urinoma formation
  • III - Pelvic
    • If stable and CT proven blush - Angioembolise
    • If found at surgery and non-expanding - Leave alone
    • If found at surgery and expanding - Manage
      • Extraperitoneal pelvic packing
        • Pelvic binder is on
        • Grasp peritoneal edge of inferior 25% of laparotomy wound
        • Develop Retzius space (pre-peritoneal plane) all the way round to posterior rectum on both sides
        • Evacuate clot
        • Packs x 2-3 on each side
        • If fails then culprit Internal Iliac Artery ligation
        • If works then to IR for assessment/embolization
        • Pelvic fixation/binder