TRAUMATIC RETROPERITONEAL HAEMATOMA

R.A.S HEMAT, MB;BCh, FRCSI, DUL.

The sources of haemorrhage and natural history of the retroperitoneal haematoma differ considerably depending on the aetiology. The retroperitoneal space lies posterior to the sac of the peritoneal cavity and contains completely or envelops anteriorly a number of visceral and vascular structures in the gastrointestinal, genitourinary, vascular, musculoskeletal, and nervous systems.

Injury to GU structures such as the kidneys, adrenal glands, ureters, and the bladder may be obvious on preoperative radiological screening. A pelvic retroperitoneal haematoma is caused by the loss of blood from sites of fractures, disruption of deep pelvic arteries, which are often distal branches of deep pelvic arteries, which are often distal branches from the internal iliac vessels.

The most common cause of midline retroperitoneal haematomas from blunt trauma could be deceleration with avulsion of small branches from the aorta, inferior vena cava, superior mesenteric artery, or portal vein beneath the pancreas.

Grey-Turner’s sign is usually not present during the first day after injury; it is not helpful in the early diagnosis of the retroperitoneal haematoma.

Haematuria with more than 30 RBCs/hpf suggests that CT may be indicated. Should a pelvic fracture be present in a patient with haematuria, a retrograde cystogram/retrograde urethrogram is indicated.

Haemorrhage can be tamponaded by the retroperitoneum with posterior stab wounds to any organs. Supramesocolic haematoma may be due to avulsion of the left renal vein or of small peripancreatic branches of the portal vein. Midline inframesocolic retroperitoneal haematoma may be due to avulsion of posterior lumbar branches of the infrarenal abdominal aorta or IVC accounts for most haematoma in this location. Extraperitoneal rupture of the bladder may be managed nonoperatively, intraperitoneal rupture mandates laparotomy.

Damage control, abbreviated laparotomy was described in the early 1990s. The goal of the damage control approach is to preserve the living patient. The triad hypothermia, acidosis, and coagulopathy in the patient with multiple injuries is often lethal. A common complication of abbreviated or damage control laparotomy with planned reoperation for severely injured patients is abdominal compartment syndrome (ACS). ACS can result from abdominal trauma accompanied by visceral swelling, haematoma, or the use of abdominal packs. Direct compression of the kidneys can elevate renal vascular resistance. Respiratory dysfunction results from increased abdominal pressure with resultant decreases in thoracic volume and lung compliance.

Managing stab wounds to the back represents a challenge. The back is an area that is difficult to evaluate clinically because of the thick musculature and the vertebral column that protects it. The risk of a stab wound to the back penetrating the peritoneal cavity, thoracic cavity, or the diaphragm is significant, and these injuries need to be identified and managed appropriately.

The rate missed injuries in patients with multisystem trauma is at least 10%. During the excitement of a resuscitation, the immediately life-threatening injuries are addressed first, and other injuries, whether clinically significant or not, may be overlooked.

Note: The information in this article has been excerpted from the following books: urotext-ebook simplifying urology, Principles of modern urology, by Dr. R.A.S HEMAT. Permission is granted to copy and redistribute this document electronically as long as it is unmodified. This article may not be sold in any medium, including electronic, CD-ROM, or database, or published in print, without the explicit, written permission of Dr. R. A. S. Hemat.

March, 2003

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Dr. R.A.S HEMAT declares no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria.