Overview of The Diagnosis and Initial Management of Traumatic Retroperitoneal Injury - UpToDate

17/6/23, 20:22 Overview of the diagnosis and initial management of traumatic retroperitoneal injury - UpToDate
Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Overview of the diagnosis and initial management of

traumatic retroperitoneal injury
AUTHOR: Samuel P Mandell, MD, MPH, FACS
SECTION EDITOR: Eileen M Bulger, MD, FACS
DEPUTY EDITOR: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2023.

This topic last updated: Oct 14, 2021.
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).
https://www-uptodate-com.pbidi.unam.mx:2443/contents/overview-of-the-diagnosis-and-initial-management-of-traumatic-retroperitoneal-injury/pr… 1/28
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 "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
https://www-uptodate-com.pbidi.unam.mx:2443/contents/overview-of-the-diagnosis-and-initial-management-of-traumatic-retroperitoneal-injury/… 10/28
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 the majority 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
https://www-uptodate-com.pbidi.unam.mx:2443/contents/overview-of-the-diagnosis-and-initial-management-of-traumatic-retroperitoneal-injury/p… 11/28
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.
For blunt 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.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Feliciano DV. Management of traumatic retroperitoneal hematoma. Ann Surg 1990;

211:109.
2. Goaley TJ, Dente CJ, Feliciano DV. Torso vascular trauma at an urban level I trauma
center. Perspect Vasc Surg Endovasc Ther 2006; 18:102.
3. 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.
4. Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at

laparotomy for trauma. Injury 2014; 45:1378.
5. American College of Surgeons Committee on Trauma. ATLS: Advanced Trauma Life Supp
ort for Doctors, 8th ed, American College of Surgeons, Chicago, IL 2008.
6. 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.
7. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J
Trauma 2006; 61:1453.
8. Brown MA, Casola G, Sirlin CB, et al. Blunt abdominal trauma: screening us in 2,693
patients. Radiology 2001; 218:352.
9. 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.
10. 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.
11. Potoka DA, Gaines BA, Leppäniemi A, Peitzman AB. Management of blunt pancreatic
trauma: what's new? Eur J Trauma Emerg Surg 2015; 41:239.
12. http://www.aast.org/library/traumatools/injuryscoringscales.aspx (Accessed on Decembe
r 19, 2016).
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. 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.
19. Voelzke BB, McAninch JW. Renal gunshot wounds: clinical management and outcome. J
Trauma 2009; 66:593.
20. 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.
21. 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.
22. Harris DG, Drucker CB, Brenner ML, et al. Patterns and management of blunt abdominal
aortic injury. Ann Vasc Surg 2013; 27:1074.
23. Kautza B, Zuckerbraun B, Peitzman AB. "Management of blunt renal injury: what is
new?". Eur J Trauma Emerg Surg 2015; 41:251.
24. Simeone A, Demlow T, Karmy-Jones R. Endovascular repair of a traumatic renal artery

injury. J Trauma 2011; 70:1300.
25. 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.
26. Liao CH, Ouyang CH, Fu CY, et al. The current status and management of blunt adrenal
gland trauma. Surgery 2015; 157:338.
27. Stawicki SP, Hoey BA, Grossman MD, et al. Adrenal gland trauma is associated with high
injury severity and mortality. Curr Surg 2003; 60:431.
28. To'o KJ, Duddalwar VA. Imaging of traumatic adrenal injury. Emerg Radiol 2012; 19:499.
29. Raup VT, Eswara JR, Vetter JM, Brandes SB. Epidemiology of Traumatic Adrenal Injuries
Requiring Surgery. Urology 2016; 94:227.
Topic 15588 Version 14.0
GRAPHICS
Zones of the retroperitoneum
The figure illustrates the zones of the retroperitoneum and their contents.
Graphic 110393 Version 1.0
AAST kidney trauma grading
AAST Severity imaging

Operative goals Pathologic criteria
grade criteria (CT findings)
I Subcapsular hematoma Nonexpanding Subcapsular hematoma

and/or parenchymal subcapsular hematoma or parenchymal
contusion without Parenchymal contusion contusion without
laceration without laceration parenchymal laceration
II Perirenal hematoma Nonexpanding perirenal Perirenal hematoma

confined to Gerota hematoma confined to confined to Gerota
fascia Gerota fascia fascia
Renal parenchymal Renal parenchymal Renal parenchymal
laceration ≤1 cm depth laceration ≤1 cm depth laceration ≤1 cm depth
without urinary without urinary without urinary
extravasation extravasation extravasation
III Renal parenchymal Renal parenchymal Renal parenchymal

laceration >1 cm depth laceration >1 cm depth laceration >1 cm depth
without collecting without collecting without collecting
system rupture or system rupture or system rupture or
urinary extravasation urinary extravasation urinary extravasation
Any injury in the
presence of a kidney
vascular injury or active
bleeding contained
within Gerota fascia
IV Parenchymal laceration Parenchymal laceration Parenchymal laceration

extending into urinary extending into urinary extending into urinary
collecting system with collecting system with collecting system
urinary extravasation urinary extravasation Renal pelvis laceration
Renal pelvis laceration Renal pelvis laceration and/or complete
and/or complete and/or complete ureteropelvic disruption
ureteropelvic disruption ureteropelvic disruption Segmental renal vein or
Segmental renal vein or Segmental renal vein or artery injury
artery injury artery injury Segmental or complete
Active bleeding beyond Segmental or complete kidney infarction(s) due
Gerota fascia into the kidney infarction(s) due to vessel thrombosis
retroperitoneum or to vessel thrombosis without active bleeding
peritoneum without active bleeding
Segmental or complete
kidney infarction(s) due
to vessel thrombosis
without active bleeding
V Main renal artery or vein Main renal artery or vein Main renal artery or vein
laceration or avulsion of laceration or avulsion of laceration or avulsion of
hilum hilum hilum

Devascularized kidney Devascularized kidney Devascularized kidney
with active bleeding with active bleeding Shattered kidney with
Shattered kidney with Shattered kidney with loss of identifiable
loss of identifiable loss of identifiable parenchymal renal
parenchymal renal parenchymal renal anatomy
anatomy anatomy
Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal

collection of vascular contrast that decreases in attenuation with delayed imaging. Active bleeding
from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or
attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.
Grade based on highest grade assessment made on imaging, at operation or on pathologic

specimen.
More than one grade of kidney injury may be present and should be classified by the higher grade
of injury.
Advance one grade for bilateral injuries up to Grade III.
AAST: American Association for the Surgery of Trauma; AIS: Abbreviated Injury Scale; CT:
computed tomography.
From: Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J
Trauma Acute Care Surg 2018; 85:1119. DOI: 10.1097/TA.0000000000002058. Copyright © 2018 American Association for
the Surgery of Trauma. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this
material is prohibited.
Kidney injury grades according to the AAST
AAST: American Association for the Surgery of Trauma.
Redrawn and reproduced with permission from: Moore, EE, Shackford, SR, Pachter, HL, et al. Organ
injury scaling: spleen, liver, and kidney. J Trauma 1989; 29:1664. Copyright © 1989 Lippincott
Williams & Wilkins.
Ureter injury scale
Injury
Grade* Description of injury
type
I Hematoma Contusion or hematoma without devascularization
II Laceration <50% transection
III Laceration ≥50% transection
IV Laceration Complete transection with <2 cm devascularization
V Laceration Avulsion with >2 cm of devascularization
* Advance one grade for bilateral up to grade III.
From: Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling. III: Chest wall, abdominal vascular, ureter, bladder,
and urethra. J Trauma 1992; 33:337. Copyright © 1992 American Association for the Surgery of Trauma. Reproduced with
permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
AAST adrenal organ injury scale
Grade* Description of injury
I Contusion
II Laceration involving only cortex (<2 cm)
III Laceration extending into medulla (≥2 cm)
IV >50% parenchymal destruction
V Total parenchymal destruction (including massive intraparenchymal hemorrhage)
Avulsion from blood supply
AAST: American Association for the Surgery of Trauma.
* Advance one grade for bilateral lesions up to grade V.
Reproduced with permission from: Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling VII: cervical vascular,
peripheral vascular, adrenal, penis, testis, and scrotum. J Trauma 1996; 41:523. Copyright © 1996 Lippincott Williams &
Wilkins. Available at: https://www.aast.org/resources-detail/injury-scoring-scale#adrenal (Accessed on December 10,
2019).
Kocher maneuver
Dissection of the lateral peritoneal attachments of the duodenum (A) exposes

the first, second, and third portion of the duodenum and the head and neck of
the pancreas (B).
Delayed CT image showing collecting system injury
This delayed CT image shows contrast extravasating from an injury

to the left collecting system (arrow). Delayed CT images are often
necessary to reveal injuries to the renal pelvis and ureters.
CT: computed tomography.
Courtesy of Michael S Runyon, MD, FAAEM.

Overview of The Diagnosis and Initial Management of Traumatic Retroperitoneal Injury - UpToDate

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Overview of The Diagnosis and Initial Management of Traumatic Retroperitoneal Injury - UpToDate

Uploaded by

Copyright:

Available Formats

17/6/23, 20:22 Overview of the diagnosis and initial management of traumatic retroperitoneal injury - UpToDate

Official reprint from UpToDate®

Overview of the diagnosis and initial management of

Literature review current through: May 2023.

Traumatic injury to retroperitoneal structures often accompanies abdominal trauma. The

An overview of the injury mechanisms, recognition, and management of traumatic injury to

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

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

Although retroperitoneal injury is common in patients who have abdominal trauma,

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

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

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

Associated injuries — Injuries to abdominal organs or bony structures adjacent each

Urinalysis investigating the presence of microscopic hematuria should be obtained to screen

Injury to the retroperitoneum may be diagnosed based upon findings on cross-sectional

● Duodenum/pancreas – Duodenal and pancreatic injuries are graded I through V,

For hemodynamically unstable patients, resuscitative endovascular balloon occlusion of the

When to explore retroperitoneal hematoma — Management of retroperitoneal injuries

Whether to explore a retroperitoneal hematoma identified at the time of exploratory

● Zone 2 – Selectively explore the kidney for active hemorrhage or an expanding

Nonoperative management — Retroperitoneal injuries in hemodynamically stable patients

Nonoperative management may be appropriate for the following injuries:

● Minimal vascular injury (ie, intimal disruption without dissection)

If active extravasation or pseudoaneurysm is identified on computed tomography (CT; pelvic,

some trauma surgeons advocate pelvic packing over attempts at angioembolization in

EXPLORATION OF RETROPERITONEAL HEMATOMA

Damage control laparotomy — During laparotomy in the hemodynamically unstable

Hematoma in the retroperitoneum is a common sight, particularly in blunt mechanisms. With

retroperitoneum. The intraperitoneal organs make it impossible to see the retroperitoneum

Surgical approach by zone

To perform left medial visceral rotation:

To perform right medial visceral rotation:

cephalad and to the left.

SPECIFIC INJURY MANAGEMENT

Major vascular injury

Kidney/adrenal gland — In the hemodynamically unstable patient, renal injury may be

If no extravasation is seen, a Foley catheter can be inserted and a cystogram can be

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● The retroperitoneum represents a potential anatomic space that is immediately

● Retroperitoneal injury can be due to blunt or penetrating trauma. (See 'Injury

● For the hemodynamically unstable patient, a Focused Assessment with Sonography in

● For hemodynamically stable patients, a diagnosis of retroperitoneal injury is based

● Management of retroperitoneal injuries can range from observation to mandatory

For penetrating injury:

• Zone 1 – Explore; likely a major vascular injury.

• Zone 2 – Selectively explore the kidney for active hemorrhage or an expanding

• Zone 3 – Explore; likely a major vascular injury.

For blunt injury:

• Zone 1 – Explore; likely a major vascular injury.

• Zone 3 – Do not explore; use an alternative method for hemorrhage control

● Surgical access to the retroperitoneum involves the systematic retraction of the

Use of UpToDate is subject to the Terms of Use.

1. Feliciano DV. Management of traumatic retroperitoneal hematoma. Ann Surg 1990;

4. Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at

injuries: is mandatory exploration of Gerota's fascia necessary? Am J Surg 2016; 211:783.

24. Simeone A, Demlow T, Karmy-Jones R. Endovascular repair of a traumatic renal artery

Zones of the retroperitoneum

Graphic 110393 Version 1.0

AAST kidney trauma grading

AAST Severity imaging

I Subcapsular hematoma Nonexpanding Subcapsular hematoma