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A R T I C L E I N F O A B S T R A C T
Article history: Aim: To review our local experience with presentation and management of retroperitoneal haematomas
Accepted 25 January 2014 (RPH) discovered at laparotomy and factors affecting outcome.
Methods: Patients with retroperitoneal haematomas (RPHs) were identified from a prospective
Keywords: database. Data collected included demographics, clinical presentation, zones and organs involved,
Retroperitoneal management and outcome.
Haematomas Results: Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of
Blunt trauma
whom were male (M:F = 15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was
Penetrating trauma
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.
0020–1383/$ – see front matter ß 2014 Elsevier Ltd. All rights reserved.
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
G Model
JINJ-5631; No. of Pages 6
2 N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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
G Model
JINJ-5631; No. of Pages 6
N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx 3
Table 1 Table 3
Number of organs injured in each zone and their management in 145 patients. Mortality with respect to different parameters.
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
G Model
JINJ-5631; No. of Pages 6
4 N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Morbidity and mortality rates associated with traumatic RPH all central haematomas blindly an attempt should be made to
remain high despite improvements in pre-hospital care, transport, determine the bleeding source and the possible extension by
and intensive care [4]. The complication rate of 36% was slightly means of inter-fascial planes [4]. For example bleeding that oozes
higher than the reported 28% but the mortality rate of 18% from Zone II into Zone I may not necessarily need to be managed as
compared favourably to the reported 18–60% [1,2,12,13,21–23]. Zone I haematoma [4].
This mortality rises to 90% in patients who are in extremis on arrival The working algorithm shown in Fig. 2 is our suggested protocol
in hospital [22]. The main mechanism of death in patients with for the management of RPH and is similar to previous suggestions
RPH is either exsanguination from uncontrollable haemorrhage or but it incorporates the modifications suggested by Feliciano et al.
MODS as an inevitable consequence of devastating injury and the [1] and Ishikawa et al. [4]. All central haematomas regardless of
resultant instability [13]. aetiology must be explored after proximal and distal vascular
The ISS was a significant predictor of mortality suggesting that control because of the possibility of major vascular injury. The
the severity of injury is a reliable predictor of MODS and death. selective approach is advisable for Zones II and III haematomas due
However, some authors have failed to show an association to blunt injuries. Lateral haematoma due to blunt trauma is
between ISS and mortality [23]. Shock, as previously reported in generally not explored and exploration is advised after renovas-
a local study [8], was associated with mortality in this series cular control only if the haematoma is pulsatile or expanding or in
signifying the role played by haemodynamic instability in the the presence of severe medullary injury, urinary extravasation,
mechanism of death. Other features of physiological instability polar avulsion or blunt rupture. The para-duodenal and peri-
which have been shown to influence mortality are massive colonic haematomas require special attention, especially following
transfusion, metabolic acidosis, hypothermia and coagulopathy penetrating trauma, because they may house hollow visceral
[8,21]. The number of injured organs has also been shown to be injuries [1,2,4]. We advocate that these so-called medio-lateral
directly related to mortality [8,21]. haematomas should be explored for this reason. However, as
Hollow visceral injury did not influence mortality suggesting opposed to opening the whole haematoma, there is a place for
that the involvement or sparing of hollow viscera had no influence. opening the haematoma along the tract of the missile to exclude
Blunt trauma was associated with a higher mortality rate injury to hollow visceral structures. In patients with pelvic
compared to penetrating trauma but this association did not haematoma the status of the femoral pulses should always be
reach statistical significance in this study although Mnguni et al. assessed before a decision is made on how to address the
showed a positive relationship between injury mechanism and haematoma.
mortality in abdominal trauma [8]. The lack of significant The management of active retroperitoneal haemorrhage
difference in mortality between zones attests to the fact that the depends on the source of the haemorrhage. The surgical
cause of mortality is the organ injury rather than the anatomical interventions to achieve haemostasis include surgical exploration
location of the haematoma. Bleeding in more than one retroperito- of the vessels, use of fixation devices, and damage control surgery
neal compartment results from trauma to a larger surface area [7]. Pelvic haemorrhage from sites of fractures is not usually
and multiple organs; hence the high mortality associated with amenable to direct surgical control but may be slowed or stopped
more than one zone seen in this and other series [2]. by fracture stabilisation [1]. Haemorrhage from venous plexuses or
The higher mortality for early presenters was surprising in this smaller veins will be tamponaded by the intact retroperitoneum
study. Intuitively one would expect that a longer delay before [1]. Active venous bleeding can be stopped by extra-peritoneal
surgery would be associated with a higher mortality. This packing and active arterial bleeding needs direct control or trans-
aberration can be explained by the concept of ‘‘self-triage’’ arterial embolisation [4,7,22].
whereby delays in reaching definitive care would select those Where haemodynamic stability cannot be achieved at laparot-
with lesser severity of injury who are more likely to survive. omy by addressing the cause of pelvic haemorrhage damage
Unfortunately, even within an urban environment, delays in control can be achieved by packing to control venous bleeding
reaching definitive surgical care are common in our practice with [4,7,12,16,22,26–29]. In patients with associated pelvic fracture
inter-hospital transfer times frequently exceeding 8 h [24]. additional pelvic stabilisation will assist in diminishing haemor-
The management of RPH depends on the haematoma location rhage, provide easier nursing and allow early mobilisation [17,28–
and its behaviour as described by Kudsk and Sheldon [3]. 30]. If bleeding persists after packing the site of bleeding is most
Traditional RPH management strategies have recommended likely arterial in origin [12]. Trans-arterial embolisation should be
mandatory exploration of all Zone I haematomas discovered at reserved for those patients who remain haemodynamically
laparotomy because of the high possibility of major vascular or unstable and acidotic and require further transfusions after
visceral injury and selective exploration of Zones II and III packing [4,7,16,22,28,29,31]. Ligation of one or both hypogastric
haematomas depending on the cause and its behaviour, the main arteries has been suggested in patients who are too unstable to
indication for exploration being a pulsating or expanding wait for angiographic embolisation [12,32]. Pelvic fixation devices,
haematoma and possible visceral and vascular injury which are thought to facilitate venous haemostasis are comple-
[1,2,12,13,23]. Exploration permits direct control of bleeding mentary to arterial embolisation [7].
and management of hollow visceral injuries [25]. Surgical There are some limitations in this study. Firstly, whereas our
exploration of the injured organs, however, necessitates retroperi- approach is similar to that depicted in Fig. 1, we concede that the
toneal access with the attendant risk of uncontrollable haemor- data on blunt trauma in this study are based on only 12 patients
rhage [5,7]. The limitation of this approach has been the and this figure is too small to give a generalisation with regard to
assumption that blunt and penetrating trauma behave similarly. the management of RPH following blunt trauma. Secondly the data
This classic tri-compartment model has been recently modified, were collected up to and including 2004 and are thus dated. We
however, to reflect the understanding that the fascia separating the believe, however, that the principles enunciated in the paper are
spaces is laminar, variably fused, and potentially expandable as a valid and are valuable to the trauma surgeon.
result of embryologic partial fusion of the dorsal mesenteries [4]. In conclusion, penetrating trauma accounts for the majority of
Inter-fascial communication exists between the retroperitoneal injuries in our setting. Haemodynamic instability, injury mecha-
spaces and retroperitoneal haemorrhage or rapidly expanding fluid nism and high ISS are associated with a high mortality rate.
collections have been shown to spread via these inter-fascial Paradoxically, a delay in surgery had an inverse relationship to
connections [4,6]. Ishikawa et al. cautions that rather than explore 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
G Model
JINJ-5631; No. of Pages 6
N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx 5
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
G Model
JINJ-5631; No. of Pages 6
6 N. Manzini, T.E. Madiba / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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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