1. The management of retroperitoneal haematoma discovered at laparotomy for trauma (1)

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JINJ-5631; No. of Pages 6
Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
The management of retroperitoneal haematoma discovered at
laparotomy for trauma§
N. Manzini, T.E. Madiba *
Department of Surgery, University of KwaZulu-Natal, King Edward VIII Hospital, Durban, South Africa
A R T I C L E I N F O
A B S T R A C T
Article history:
Accepted 25 January 2014
Aim: To review our local experience with presentation and management of retroperitoneal haematomas
(RPH) discovered at laparotomy and factors affecting outcome.
Methods: Patients with retroperitoneal haematomas (RPHs) were identified from a prospective
database. Data collected included demographics, clinical presentation, zones and organs involved,
management and outcome.
Results: Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of
whom were male (M:F = 15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was
7 h. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty-four patients
(17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median
injury severity score (ISS) was 9. Fifty-two patients (36%) developed complications and 26 (18%) patients
died. Sixty-four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were
explored; Zones II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%,
29% and 35%, respectively. Mortality was highest for blunt trauma and lowest for stabs (p = 0.146).
Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p < 0.0001).
Eighteen of 64 patients with <6-h delay before surgery died (28%) compared to 8 of 81 (10%) with >6-h
delay (p < 0.017). Mortality increased with increasing ISS. Median hospital stay was 8 days.
Conclusion: RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay
before surgery and ISS showed a significant association with mortality.
ß 2014 Elsevier Ltd. All rights reserved.
Keywords:
Retroperitoneal
Haematomas
Blunt trauma
Penetrating trauma
Introduction
The retroperitoneal area is a wide space lying posterior to 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 [1]. It is bounded posteriorly by the transversalis fascia
and extends from the diaphragm to the pelvic inlet. A
retroperitoneal haematoma (RPH) results from injury to gastrointestinal, genito-urinary, vascular and muscular structures
within this space [1,2].
Kudsk and Sheldon [3] first introduced a location-based
classification of traumatic RPH as central–medial (Zone I), flank
or peri-renal (Zone II), and pelvic (Zone III). This principle was
§
Presented at Congress of the Surgical Research Society of Southern Africa,
Stellenbosch, 12–13 July 2012.
* Corresponding author at: Department of Surgery, University of KwaZulu-Natal,
Private Bag 7, Congella 4013, South Africa. Tel.: +27 31 260 4219;
fax: +27 31 260 4389.
E-mail address: [email protected] (T.E. Madiba).
immediately accepted and became a standard treatment policy for
RPH [4]. A Zone I haematoma is bounded superiorly by the central
diaphragm, by the medial borders of the psoas muscles at its sides
and the pelvis inferiorly. Injuries of the great vessels of the
abdomen, pancreas and duodenum are the commonest aetiologies
[5]. A Zone II haematoma lies lateral to the psoas muscles, above
the iliac wings and under the diaphragm and may result from
injuries to the ascending or descending colon, duodenum, kidney,
genito-urinary vascular structures, ureters and muscular vessels
[5,6]. A Zone III haematoma is located in the pelvis limited with the
dome of the bladder at the front, sacral promontory at the rear and
iliac wings at both sides [5]. The majority of pelvic haematomas
arise from injury to the pre-sacral or pre-vesical veins; other less
common causes include arterial bleeds and haemorrhage from a
variety of pelvic fracture sites [1,7]. Bleeding of venous origin may
stop spontaneously when local venous pressure and the pressure
of the retroperitoneal space equalise [7]. Fig. 1 shows a CT scan of a
patient with a Zone II retroperitoneal haematoma with medial
extension in to Zone I area.
Despite adequate data regarding the management of RPH in
developed countries, data emanating from developing countries
are scarce. We hypothesised that this condition occurs with equal
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http://dx.doi.org/10.1016/j.injury.2014.01.026
Please cite this article in press as: Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for
trauma. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.01.026
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N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
employed in stable patients following blunt trauma. Haemodynamic instability or shock is defined as systolic blood pressure
below 90 mmHg despite administration of 2000 ml crystalloids or
2 units packed red blood cells [7]. All haemodynamically unstable
patients are resuscitated; if they respond to resuscitation they are
assessed regarding the need for emergency laparotomy. Patients
with equivocal signs are managed by regular clinical evaluation
and CT scan where indicated. Patients who do not respond to
resuscitation undergo emergency laparotomy. This study therefore
includes patients with refractory shock or haemodynamic
instability, and stable patients with signs of intra-peritoneal
haemorrhage or injury who require immediate laparotomy. The
severity of injuries was measured using the injury severity score
(ISS) [9]. The severity of organ injury was graded according to
American Association for the Surgery of Trauma [10].
The management of RPH at laparotomy depended on the site
and behaviour of the haematoma, and the haemodynamic status of
the patient. All Zone I injuries were explored by ‘opening’ the
haematoma after vascular control was achieved and the various
organs were managed on their merit. Zones II and III haematomas
were selectively explored, the indications for exploration being a
pulsating or expanding haematoma, overt bleeding and evidence
of hollow visceral injury. If the patient was unstable and there was
no other identifiable cause of bleeding, the haematoma was
explored regardless of the site. The management of all injured
organs followed standard management protocols for the various
organ injuries.
Data were collected on a proforma datasheet and were
subsequently transferred into a Microsoft Excel1 spreadsheet.
Fractions were rounded off to one decimal place. Percentages were
rounded off to the nearest whole numbers. Statistical analysis was
carried out using the Statistical Package for the Social Sciences
version 21 (SPSS-SA, Cape Town, South Africa). The chi-squared
test with Yates’ continuity correction was used for shock, hollow
visceral injury and delay. The chi-squared test was used for type of
trauma, ISS category and zone.
Fig. 1. CT scans showing retroperitoneal haematoma. (A) An axial CT scan with the
haematoma designated by solid arrows. The hollow arrow shows traumatic injury
to the right kidney. (B) is a sagittal CT scan of the same patient.
frequency regardless of income level and that management
principles are the same. The purpose of the study therefore was
to document local experience with traumatic retroperitoneal
haematomas discovered at laparotomy and to establish factors
that may affect outcome.
Patients and methods
Ethics approval was attained from the University of KwaZuluNatal’s Biomedical Ethics Research Committee (E057/98). A
database of patients with abdominal trauma [8] was established
in 1998 in a single surgical ward at King Edward VIII Hospital, a
tertiary hospital with three surgical wards, situated in Durban, on
the south coast of the KwaZulu-Natal Province of South Africa. The
database spanned a period of seven years (1998–2004) and
excluded all paediatric patients (age < 12 years) as they are
managed separately by the paediatric surgeons. From a dedicated
proforma data were subsequently transferred onto an Excel
database and included demographics, clinical presentation, findings at surgery, management and outcome. Patients who were
found to have retroperitoneal haematoma at laparotomy were
extracted and analysed for the purpose of this study.
The management of abdominal trauma in our institution
adheres to the following protocol. All patients with trauma are
resuscitated according to Advanced Trauma Life Support principles. Computed Tomography (CT) scan is the first investigation
Results
There were 488 patients with abdominal trauma of whom 145
(30%) had RPH, with 136 males giving a male: female ratio of 15:1.
The mean age was 28.8 (SD 10.6) years. One hundred and thirty
three injuries were due to penetrating trauma (firearms 109, stabs
24) and 12 were due to blunt trauma. Twenty-four patients (17%)
presented with haemorrhagic shock. The median delay before
surgery was 7 h with an interquartile range (IQR) of 5.5 (the 25th
centile was 4.5 and the 75th centile was 10).
There were 58 Zone I, 69 Zone II, 38 Zone III haematomas.
Twenty of these patients had involvement of more than one zone
(Zone IV). The median ISS was 9 with an interquartile range of 7
(25th centile was 9 and the 75th centile was 16). The individual
organ injuries and their management are shown in Table 1. The
most commonly injured organs were the colon, kidney, duodenum,
pancreas, urinary bladder, and rectum in that order. Twenty-one
(64%) of 33 injured kidneys were salvaged with only 12 (36%)
undergoing nephrectomy. Eleven nephrectomies (41%) followed
firearms injuries. Twenty-two (96%) of 23 pancreatic injuries were
managed by simple drainage. Sixty-one of 64 injuries in Zone I
(95%) required some form of surgical intervention such as repair,
drainage or ligation. Sixty of 75 injuries in Zone II (80%) required
surgical intervention and all Zone III injuries (100%) required
intervention.
Fifty-two (36%) patients developed complications (Table 2).
There were eleven patients with fistulae [pancreatic (4), enterocutaneous (3), colo-cutaneous (1), gastro-cutaneous (1), rectovesical (1) and colo-vesico-cutaneous (1)]. Six patients developed
Please cite this article in press as: Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for
trauma. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.01.026
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Table 1
Number of organs injured in each zone and their management in 145 patients.
Organ injury
Surgical
intervention
Conservative
management
Zone I
Duodenum (n = 27)a
Pancreas (n = 23)b
Inferior vena cava (n = 8)c
Aorta (n = 4)d
Superior mesenteric vessel (n = 1)e
Gonadal vessel (n = 1)f
24
23
8
4
1
1
(88%)
(100%)
(100%)
(100%)
(100%)
(100%)
3 (12%)
0
0
0
0
0
Zone II
Kidney (n = 33)g
Colon (n = 36)h
Ureters (n = 6)i
18 (55%)
36 (100%)
6 (100%)
15 (45%)
0
0
Zone III
Bladder (n = 19)j
Rectum (n = 18)k
19 (100%)
18 (100%)
a
b
c
d
e
f
g
h
i
j
k
0
0
Table 3
Mortality with respect to different parameters.
Parameter
n (died)
Mortality (%)
p
Shock (n = 24)
No shock (n = 121)
HVI (n = 109)
No HVI (n = 36)
Delay < 6 h (n = 64)
Delay > 6 h (n = 81)
Stabs (n = 24)
Firearms (n = 109)
Blunt (n = 12)
ISS < 9 (n = 86)
ISS = 10–20 (n = 40)
ISS > 20 (n = 19)
Zone I only (n = 41)
Zone II only (n = 50)
Zone III only (n = 34)
Zone IV (n = 20)
12
14
21
4
18
8
1
22
3
10
7
9
8
3
8
7
50
12
19
11
28
10
4
20
25
12
18
47
20
6
24
35
<0.0001
0.324
0.017
0.146
0.001
0.021
HVI, hollow visceral injury; ISS, injury severity score.
Primary repair (19), pyloric exclusion (5).
Drainage (22), duct ligation (1).
Repaired (7), ligated (1).
All repaired.
Repaired.
Ligated.
Nephrectomy (12), renorrhaphy (6).
All primary repair.
All primary repair.
Primary repair (12), suprapubic catheter (7).
Primary repair (8), colostomy (10).
trauma and lowest for stabs (p = 0.146). Eighteen (28%) patients
with delay of <6 h before surgery died compared to seven (10%)
with a delay >6 h (p = 0.017). Factors influencing mortality are
shown on Table 3. The median hospital stay was 8 days with an IQR
of 11 (25th centile 5; 75th centile 16).
Discussion
peritonitis; turbid sero-sanguinous fluid was discovered at
laparotomy in four patients and purulent peritonitis in two (one
with multiple solid organ injuries and the other with gastric injury
in addition to other solid organ injuries). Sixty-four (44%) patients
were managed in the ICU with a median ICU stay of 3 days and IQR
of 5.3 (25th centile = 1.8; 75th centile 7).
Twenty-six patients died, giving a mortality rate of 18%. Causes
of death were MODS (15), hypovolaemic shock (6), sepsis (4) and
one died from overwhelming tuberculous infection. Eight of
41 patients with Zone I only haematomas died (20%); three of these
had associated major vascular injury. Three of 50 patients with
Zone II only haematomas died (6%) none of whom had associated
major vascular injury. Eight of 34 patients with Zone III only
haematomas died (24%) none of whom had major vascular injury.
Seven of 20 patients with haematoma involving more than one
zone (Zone IV) died (35%) of whom two had major vascular injury.
In summary vascular injury contributed 19% to the mortality;
among central haematomas vascular injury contributed 38%.
Three of 12 (25%) patients with blunt trauma died compared to
23 of 133 (17%) with penetrating trauma. Twelve of 24 patients
with shock on presentation (50%) died compared to 14 of 121 (12%)
without shock (p < 0.0001). Mortality was highest for blunt
Table 2
Complications in 145 patients with RPH.
Complication
n
%
Chest infection
MODS
Wound sepsis
Fistulae
Peritonitis
Intestinal obstruction
Shock
Bleeding
Sepsis
Intra-abdominal abscess
Deep venous thrombosis
Anastomosis dehiscence
20
15
14
11
6
6
6
5
4
1
1
1
14
10
10
8
4
4
4
3
3
1
1
1
MODS, multiple organ dysfunction syndrome.
3
RPH accounted for 30% of patients with abdominal trauma in
this series, with males predominating, whereas the incidence of
RPH based on aetiology is quoted at 44–80% for blunt trauma and
6–33% for penetrating trauma [1,2,5,11–13]. Firearms were
responsible for 81% of penetrating trauma which is higher than
the reported 64% [14]. These differences are not surprising
inasmuch as clinical presentation is determined by the organ
involved, the severity of the injury and the causative mechanism
[13]. The variation in the prevalence further attests to the differing
trends in penetrating and blunt trauma in various centres, which is
dependent upon the environment of the receiving institution [14].
This fact was highlighted by Muckart et al. who demonstrated a
change in trauma patterns over two consecutive decades in the
KwaZulu-Natal Province of South Africa [15].
Patients with RPH can be categorised into (i) patients with
refractory shock or haemodynamic instability, (ii) stable patients
with signs of intra-peritoneal haemorrhage and (iii) asymptomatic
patients [2]. Patients in this series included only the first and
second categories and immediate laparotomy was therefore
mandatory and preoperative investigations were not an option.
In patients with haemodynamic instability timely resuscitation is a
vital component of initial management [16,17]. Where haemodynamic stability and metabolic correction cannot be established
laparotomy remains part of resuscitation. CT of the abdomen and
pelvis is the mainstay of diagnosis for abdominal injury in the
haemodynamically stable patient [6,7,14,18].
As in other series [2] the most commonly injured organ was the
colon. The management of specific injuries was according to
standard management principles. In total 64% of injured kidneys
were salvaged. The majority of pancreatic injuries were managed
conservatively by simple drainage (96%), which supports the local
trend of conservative surgical management of pancreatic injuries
[19,20]. Ninety-five per cent of injuries in Zone I required some sort
of surgical intervention such as repair, drainage or ligation. This
strongly supports the need for exploration of Zone I injuries. The
proportion of haematomas harbouring injuries requiring similar
intervention was 80% and 100% for Zones II and III respectively.
These figures again send a very clear argument for exploration of
RPHs following penetrating trauma.
Please cite this article in press as: Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for
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Morbidity and mortality rates associated with traumatic RPH
remain high despite improvements in pre-hospital care, transport,
and intensive care [4]. The complication rate of 36% was slightly
higher than the reported 28% but the mortality rate of 18%
compared favourably to the reported 18–60% [1,2,12,13,21–23].
This mortality rises to 90% in patients who are in extremis on arrival
in hospital [22]. The main mechanism of death in patients with
RPH is either exsanguination from uncontrollable haemorrhage or
MODS as an inevitable consequence of devastating injury and the
resultant instability [13].
The ISS was a significant predictor of mortality suggesting that
the severity of injury is a reliable predictor of MODS and death.
However, some authors have failed to show an association
between ISS and mortality [23]. Shock, as previously reported in
a local study [8], was associated with mortality in this series
signifying the role played by haemodynamic instability in the
mechanism of death. Other features of physiological instability
which have been shown to influence mortality are massive
transfusion, metabolic acidosis, hypothermia and coagulopathy
[8,21]. The number of injured organs has also been shown to be
directly related to mortality [8,21].
Hollow visceral injury did not influence mortality suggesting
that the involvement or sparing of hollow viscera had no influence.
Blunt trauma was associated with a higher mortality rate
compared to penetrating trauma but this association did not
reach statistical significance in this study although Mnguni et al.
showed a positive relationship between injury mechanism and
mortality in abdominal trauma [8]. The lack of significant
difference in mortality between zones attests to the fact that the
cause of mortality is the organ injury rather than the anatomical
location of the haematoma. Bleeding in more than one retroperitoneal compartment results from trauma to a larger surface area
and multiple organs; hence the high mortality associated with
more than one zone seen in this and other series [2].
The higher mortality for early presenters was surprising in this
study. Intuitively one would expect that a longer delay before
surgery would be associated with a higher mortality. This
aberration can be explained by the concept of ‘‘self-triage’’
whereby delays in reaching definitive care would select those
with lesser severity of injury who are more likely to survive.
Unfortunately, even within an urban environment, delays in
reaching definitive surgical care are common in our practice with
inter-hospital transfer times frequently exceeding 8 h [24].
The management of RPH depends on the haematoma location
and its behaviour as described by Kudsk and Sheldon [3].
Traditional RPH management strategies have recommended
mandatory exploration of all Zone I haematomas discovered at
laparotomy because of the high possibility of major vascular or
visceral injury and selective exploration of Zones II and III
haematomas depending on the cause and its behaviour, the main
indication for exploration being a pulsating or expanding
haematoma and possible visceral and vascular injury
[1,2,12,13,23]. Exploration permits direct control of bleeding
and management of hollow visceral injuries [25]. Surgical
exploration of the injured organs, however, necessitates retroperitoneal access with the attendant risk of uncontrollable haemorrhage [5,7]. The limitation of this approach has been the
assumption that blunt and penetrating trauma behave similarly.
This classic tri-compartment model has been recently modified,
however, to reflect the understanding that the fascia separating the
spaces is laminar, variably fused, and potentially expandable as a
result of embryologic partial fusion of the dorsal mesenteries [4].
Inter-fascial communication exists between the retroperitoneal
spaces and retroperitoneal haemorrhage or rapidly expanding fluid
collections have been shown to spread via these inter-fascial
connections [4,6]. Ishikawa et al. cautions that rather than explore
all central haematomas blindly an attempt should be made to
determine the bleeding source and the possible extension by
means of inter-fascial planes [4]. For example bleeding that oozes
from Zone II into Zone I may not necessarily need to be managed as
Zone I haematoma [4].
The working algorithm shown in Fig. 2 is our suggested protocol
for the management of RPH and is similar to previous suggestions
but it incorporates the modifications suggested by Feliciano et al.
[1] and Ishikawa et al. [4]. All central haematomas regardless of
aetiology must be explored after proximal and distal vascular
control because of the possibility of major vascular injury. The
selective approach is advisable for Zones II and III haematomas due
to blunt injuries. Lateral haematoma due to blunt trauma is
generally not explored and exploration is advised after renovascular control only if the haematoma is pulsatile or expanding or in
the presence of severe medullary injury, urinary extravasation,
polar avulsion or blunt rupture. The para-duodenal and pericolonic haematomas require special attention, especially following
penetrating trauma, because they may house hollow visceral
injuries [1,2,4]. We advocate that these so-called medio-lateral
haematomas should be explored for this reason. However, as
opposed to opening the whole haematoma, there is a place for
opening the haematoma along the tract of the missile to exclude
injury to hollow visceral structures. In patients with pelvic
haematoma the status of the femoral pulses should always be
assessed before a decision is made on how to address the
haematoma.
The management of active retroperitoneal haemorrhage
depends on the source of the haemorrhage. The surgical
interventions to achieve haemostasis include surgical exploration
of the vessels, use of fixation devices, and damage control surgery
[7]. Pelvic haemorrhage from sites of fractures is not usually
amenable to direct surgical control but may be slowed or stopped
by fracture stabilisation [1]. Haemorrhage from venous plexuses or
smaller veins will be tamponaded by the intact retroperitoneum
[1]. Active venous bleeding can be stopped by extra-peritoneal
packing and active arterial bleeding needs direct control or transarterial embolisation [4,7,22].
Where haemodynamic stability cannot be achieved at laparotomy by addressing the cause of pelvic haemorrhage damage
control can be achieved by packing to control venous bleeding
[4,7,12,16,22,26–29]. In patients with associated pelvic fracture
additional pelvic stabilisation will assist in diminishing haemorrhage, provide easier nursing and allow early mobilisation [17,28–
30]. If bleeding persists after packing the site of bleeding is most
likely arterial in origin [12]. Trans-arterial embolisation should be
reserved for those patients who remain haemodynamically
unstable and acidotic and require further transfusions after
packing [4,7,16,22,28,29,31]. Ligation of one or both hypogastric
arteries has been suggested in patients who are too unstable to
wait for angiographic embolisation [12,32]. Pelvic fixation devices,
which are thought to facilitate venous haemostasis are complementary to arterial embolisation [7].
There are some limitations in this study. Firstly, whereas our
approach is similar to that depicted in Fig. 1, we concede that the
data on blunt trauma in this study are based on only 12 patients
and this figure is too small to give a generalisation with regard to
the management of RPH following blunt trauma. Secondly the data
were collected up to and including 2004 and are thus dated. We
believe, however, that the principles enunciated in the paper are
valid and are valuable to the trauma surgeon.
In conclusion, penetrating trauma accounts for the majority of
injuries in our setting. Haemodynamic instability, injury mechanism and high ISS are associated with a high mortality rate.
Paradoxically, a delay in surgery had an inverse relationship to
mortality.
Please cite this article in press as: Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for
trauma. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.01.026
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Fig. 2. Suggested algorithm for the management of retroperitoneal haematoma (* in penetrating trauma just following the tract is adequate to exclude injury. In blunt trauma
exploration can be achieved by mobilisation of the colon and/or duodenum by means of right or left visceral rotation and Kocher’s manoeuvre).
Please cite this article in press as: Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for
trauma. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.01.026
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N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
6
Conflict of interest
Both authors do not have any conflict of interest.
Acknowledgement
The authors would like to thank Professor DJJ Muckart, Head of
the Trauma Unit, Inkosi Albert Luthuli Central Hospital, for
providing us with the picture of a CT scan taken from a patient
with a retroperitoneal haematoma.
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Please cite this article in press as: Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for
trauma. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.01.026