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J. E. Schoen and H. A. Phelan
later. If a site of frank perforation or bleeding is found, one
should just place a quick gure-of-eight stitch at the serosal
edges to control the spill of succus/stool or quickly clamp
and tie a discrete “pumper” to get rapid hemostasis. Cut the
tails of your stitch long to make the site easier to nd in a
little while. Do this to the bowel in its entirety.
At the completion of these maneuvers, one should sit
back for a moment and take stock of the situation. You have
completely inspected the abdomen, temporized the spill of
bowel contents, and gotten an idea of the magnitude of injuries with which you are contending. Is your patient dying?
Do you expect them to rapidly start getting sicker or better?
What are the number and complexity of their associated
injuries, both known and suspected? Are you dealing with an
isolated hollow viscus injury? How much peritoneal soilage
and blood loss has occurred? The answers to these questions
will dictate how you manage that uted segment of small
bowel and blown-out sigmoid that you just nished whipstitching. This is a good time to take a moment, catch your
breath, and come up with a plan before you just start xing
things. One should start by resisting the urge to overthink
things and just ask, “How sick is the patient?”
cult for all involved. Begin by placing the root of the mesentery between the index and middle ngers of the nondominant
hand (Fig.53.1). Then place your index nger and thumb on
opposite sides of the injury (Fig.53.2). By tenting the injury
across the middle nger in this fashion, one can quickly get a
signicant degree of proximal and distal control of most injuries in this area. Once the eld is dry, open up the sheets of the
mesentery to precisely dene the bleeding vessels and address
them. Blindly clamping, suturing, or using an energy device
can lead to catastrophic vascular injury to the SMA or SMV
in this high-priced real estate.
If the injury is to the bowel itself, at this point in the operation, you should be looking at several rapidly closed holes
with long silk tags or areas of hematoma adjacent to the
53.3 The Second Pass Through
theAbdomen: TheStable Patient
Few operations for trauma are as enjoyable as the isolated
hollow viscus injury in the hemodynamically stable patient
after penetrating trauma, as they are straightforward in
nature and yield immensely satisfying results. The pace of
the case is relaxed, and glances up at the telemetry monitors
are reassuring. There are some traps that one should still be
aware of, however, which can turn a nice case into a delayed
horror show.
When dealing with mesentery bleeding that is adjacent to
the bowel but not involving the viscus itself, a simple whip
stitch will frequently be all that is needed. Once hemostasis is
secured, however, you will need to watch the adjacent bowel
for ischemia. Typically, if this is going to be a problem, it will
declare itself within several minutes, and the relationship of
the injury to the vascular arcade closest to the bowel will dictate the likelihood of devascularization. In my experience,
devascularization is unusual for the peripheral mesenteric
defects that result after penetrating injury, as they are typically smaller than the larger, ragged mesenteric injuries that
are commonly seen after blunt trauma. Injuries close to the
root of the mesentery are much more problematic. These frequently present with an expanding hematoma within the
sheets of the mesentery, and efforts to address them are
fraught with the potential for iatrogenic injury to the superior
mesenteric artery (SMA) or vein (SMV). Usually the injured
vessel has retracted back into the mesentery making life dif-
Fig. 53.1 To control injuries at the base of the mesentery, begin by
placing the root of the mesentery between the index and middle ngers
of the nondominant hand
Fig. 53.2 Next, place the thumb and index nger on opposite sides of
the injury. By squeezing the area of injury in this fashion, effective
hemostasis is quickly achieved. The sheets of mesentery can then be
incised and the points of bleeding accurately identied and addressed
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colon or at the bowel/mesentery junction without frank spill.
The rst step is to avoid the temptation to start contending
with the holes that you know you have and instead fully
dene all of the injuries with which you are dealing. This
may save you from wasting time on primary repairs that will
later wind up in a resected piece of bowel after other injuries
are discovered. While this is frequently straightforward, a
few particulars are worth mentioning. First, any pericolonic
hematoma needs to be completely inspected. This means
rolling the colon and dissecting all other tissues away until
only the colonic serosa remains. If a subserosal hematoma is
found, unroof it. Similarly, any hematoma at the junction of
the bowel wall and mesentery should be considered to be an
injury until proven otherwise by direct visual inspection of
the serosa of the involved area. Don’t let the fear of an iatrogenic injury stop you from completely inspecting the area of
concern. Occasionally, for injuries close to the root of the
mesentery, it will be necessary to actually take the ligament
down. The important thing to remember is to never look at a
hematoma immediately adjacent to a viscus and leave it
thinking that it’s probably okay. In the words of the esteemed
surgeon Benton DuPont, “That works about as well as ball
bearing book ends.” Similarly, an odd number of holes in the
bowel should trigger fears for a missed injury. While tangential wounds can occur, this should be a diagnosis of exclusion—keep looking until you are sure there isn’t another
hole. Keep in mind the mobility of the small bowel, that
people get shot in all manner of bodily positions, and that
bullets do not travel in straight lines. In short, when looking
for bowel injuries, paranoia is a healthy attitude.
Once an injury to the bowel wall is located, determining if
the injury is repairable or requires resection is the rst step.
Earlier, we systematically evaluated the bowel in order to
nd all of the injuries, and this is where that pays dividends.
Few things are more annoying than repairing an enterotomy
only to nd another one near it that requires the whole area
to be resected. With an isolated injury less than 50% the
bowel circumference, debriding the edges to healthy tissue
and a transverse, primary repair should be the default rst
choice. Personally, I prefer a single-layer interrupted repair
with braided absorbable suture, with all sutures placed and
laid out and then subsequently tied. If I have a relatively
short segment of small bowel that has been uted (i.e. ayed
open), I will resect it in order to minimize the number of
suture lines. When making the decision about whether or not
to resect an intervening piece of small bowel between two
injured segments in order to save an anastomosis, I will
check to see if I am leaving the patient with at least 250cm
of small bowel if a resection is performed as short bowel
syndrome should not be a concern with that length. In adults,
particularly those lacking a functional colon, lifelong TPN
dependence is likely to occur in those who have 100cm or
less. While the presence of a functional ileocecal valve is
thought to increase this length to an unknown degree, trauma
patients are clearly at higher risk for subsequent bowel resections at their initial admission as well as over their lifetime
(trauma recidivism rates are signicant, proving the old saying, “Trauma is a chronic disease with acute exacerbations”).
Given that, it is smart to leave them with plenty of bowel to
spare. When dealing with two enterotomies that are within a
centimeter or so of each other, the bridging wall of bowel
separating them can become devascularized and slowly
necrose over the course of a few days. Avoid the temptation
to perform two primary repairs in this setting, as it is prudent
to debride this segment and convert them into one larger
enterotomy which can then be closed easily or to simply
resect that segment.
If a resection is required, the decision to perform an anastomosis versus diversion has vexed generations of surgeons.
It is often said that during the twentieth century, military surgeons faced court martial if diversion wasn’t used in the
treatment of a penetrating colon injury, though little evidence
actually exists of a “colostomy or court martial” policy.
Regardless, in that era diversion was the prevailing sentiment. With time it came to be realized that civilian injuries
are not necessarily comparable to military injuries and that
ostomy reversal carried its own morbidity, and the pendulum
began to swing toward a lower threshold for anastomosis at
the time of rst operation. Several factors are predictive of a
leak in these situations, namely intraoperative hypotension
or pressor requirement, blood transfusions, or known recent
treatment with medications that affect wound healing (e.g.,
immunomodulators and steroids). If any of the aforementioned are present, consideration for primary anastomosis
should be tabled. When these factors are absent, I will always
perform a primary anastomosis regardless of injury location
or feculent spillage, including in left colon injuries. The one
exception to this general rule is the elderly patient with minimal physiologic reserve. In that setting, I will still perform
enteroenterostomy and enterocolostomy, but not a colocolostomy. When considering the higher risks and the fact that an
anastomotic leak in this specic population is often a death
sentence, I will generally opt to perform resection and diversion in those patients. One should realize, though, that it frequently means these will become permanent ostomies.
Typically the stable patient has relatively normal caliber
bowel, and if this is the case, either hand-sewing or stapling
the anastomosis should be ne.
53.4 The Second Pass Through
theAbdomen: Damage Control
First, let’s talk about damage control surgery. You’re reading
this, so you are probably already familiar with the “less is
more” consideration in damage controlling trauma. It is also
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important to not overuse damage control surgery, as that has
become a problem since its advent with increased costs and
worse outcomes in institutions overutilizing it. Nonetheless,
it has an important role when used appropriately. Let’s consider such a situation:
You have just nished a fast right nephrectomy and packing the liver; a quick glance up shows you multiple units of
blood products hanging on the IV pole and on the oor around
anesthesia’s side of the drapes. Despite your best efforts,
anesthesia tells you that the patient’s core temperature is 33.9
°C. You need to be getting out of this patient’s abdomen ASAP.
Having temporized the patient’s enterotomies on the rst pass
with whip stitches, what do you do now?
For the patient who is in extremis, the answer is simple:
nothing. Leaving the injuries alone with gure-of-eight closures is not something about which you should be cavalier,
because this suboptimal technical closure is prone to breaking down (particularly in the setting of bowel edema and
splanchnic vasoconstriction from shock and pressors). In the
patient who is actively dying, however, the risk posed by this
strategy may be balanced out by the benet of saving a few
minutes in a setting where time is critical. If one elects to
leave the whipstitches in place, it is important that you take
the patient back at or around 24hours post injury as longer
delays begin to make the risks of breakdown with renewed
spill of stool prohibitive. While I realize that the plural of
anecdote is not data, I can say that I have resorted to this
strategy a handful of times and have yet to have a whipstitch
closure break down in this time frame.
If a damage control approach is being utilized but the
patient is not in extremis, a different approach is used for hollow viscus injuries temporized on the rst pass through the
abdomen. If it is a matter of dealing with three or fewer
small, discrete perforations, I will take the time necessary to
perform single-layer closures. These denitive repairs are
quick, and a time-consuming second layer is unnecessary. If
multiple injuries are in close proximity, or a destructive
injury is present, one should resect the involved piece of
bowel between linear cutting stapler res and using an
energy device on the mesentery for expediency, leaving the
patient in discontinuity. Alternatively, if necessary one can
re a linear cutting stapler adjacent to both sides of an injury
without coming across the mesentery with an energy device,
effectively leaving the bowel in place but with the injury
excluded from the enteric stream and preventing spill. With a
functioning nasogastric tube, patients tolerate being left in
discontinuity surprisingly well and can be left in this fashion
for 48hours or longer if circumstances require it. Caution
should be used when leaving multiple areas of discontinuity,
as you are effectively leaving closed loop obstruction in the
intervening areas—this is allowable for short periods, but
protracted periods between takebacks should not occur.
Proximal diversion in this early setting is unnecessary and in
fact can be problematic as the abdominal wall frequently
becomes quite edematous in damage control patients. This
can put an ostomy that initially looked good under signicant tension and predispose it to ischemia.
53.5 The Planned Reoperation After
Successful Resuscitation
The rst thing worth mentioning is that this operation does not
necessarily need to take place in the operating room. When
your patient is on very high levels of positive end expiratory
pressure and has a high pressor requirement, a “road trip” to
the operating room can be a perilous undertaking. For the
patient in whom ongoing bleeding is not a concern, a bedside
reexploration may be appropriate (Fig.53.3). The only thing
that should be different from the usual performance of the
operation is its geographic location and the lack of an anesthesiologist, depending on your institution. Laparotomy trays and
electrocautery should be brought in, the abdomen should be
prepped and draped in the usual fashion, and a scrub nurse and
circulator should be present. Bowel resections and ostomies
can be performed in a relatively straightforward manner.
Typically, patients this ill are not candidates for a bowel anastomosis, but one can be performed if necessary—the closed
loop scenario described above has forced me to begrudgingly
perform an anastomosis on pressors on several occasions, with
which I have thus far gotten away. If removing packing at the
bedside in the ICU, I would advise requesting the full OR
team including anesthesia and having blood products at the
ready. In ICU explorations, the lighting is typically suboptimal, access to the head of the bed is usually difcult, and even
a strong ICU nurse is not an adequate substitute for an anesthesiologist if trouble is encountered. Having said that, I have
become more and more comfortable with doing larger caliber
procedures at the bedside as my career has progressed and can
recommend the technique without hesitation when dealing
with the very, very sick patient.
At the time of reoperation, the rst thing that one should
do is to sit back and take a look at exactly what you are dealing with in terms of resected bowel and small perforations
that have been either whipstitched or denitively addressed.
Then one should develop a plan based on the general principle of balancing the number of suture lines versus the length
of bowel remaining. As previously mentioned, there is a signicant chance that this will not be the patient’s last resection over their lifetime: Anastomotic leaks, stulae, bowel
obstructions, and trauma recidivism all conspire to make this
patient population high risk for future operations on their GI
tract. In general, I try to avoid leaving a patient with more
than three anastomoses total.
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Fig. 53.3 Bedside reexploration. In the severely ill patient in whom intrahospital transport is problematic, reexploration at the bedside in the
intensive care unit is a legitimate option. Bowel can be resected, ostomies matured, and fascial closure can be safely performed
Injuries that were whipstitched at the time of a damage
control procedure should have the suture cut out, the edges
of the wound trimmed to get back to healthy, bleeding
bowel wall, and a primary repair performed. This should be
done in either the small bowel or the colon. If you are dealing with a segment of bowel that has been left in discontinuity, the situation gets more complicated as you have to
take other factors into account when making the decision as
to whether to perform a high-risk anastomosis or commit
the patient to an ostomy and all of its sequelae. In my practice, I follow the management strategy promulgated by the
Eastern Association for the Surgery of Trauma (EAST) for
colon injuries, most recently updated in 2019. The evidence-based guidelines which they put forth essentially
suggest that for a destructive colonic injury, diversion
should be performed if the patient had sustained pre- or
intraoperative hypotension or ongoing shock or has signicant underlying disease, associated injuries, or peritonitis.
While useful as a general philosophy, one can see that there
is still considerable room for interpretation and individual
judgment. What about the 19-year-old patient who initially
got fourunits of blood at the time of rst operation and now
looks good with no pressor requirement and a plan for extubation after the OR? What about sixunits? Or eight? What
constitutes signicant preexisting disease? These gray
areas have been the cause of signicant dyspepsia for me
throughout my career. While categorical statements can’t
be made about these situations, it’s important to remember
that, generally speaking, patients who are sick enough to
require damage control procedures are ones in whom diversion should be the default plan (this is particularly true with
colocolonic anastomoses). To contemplate an anastomosis
of any kind in the setting of a pressor requirement is to be
mentioned only to be condemned as the patient’s natural
splanchnic vasoconstriction from a hypotensive state is
magnied by the pressor effect. Together, these serve to
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J. E. Schoen and H. A. Phelan
doom any reconstruction. In the very proximal small bowel
where the nutritional and physiologic consequences of a
high output ostomy are serious enough that the risk/benet
ratio begins to tilt in favor of reestablishing gastrointestinal
continuity, I will lower my threshold for anastomosis (albeit
at the expense of some sleepless nights). If the patient is off
pressors and is completely resuscitated, I will consider a
proximal small bowel anastomosis in a young patient
regardless of transfusion requirement. For more distal small
bowel resections, I will perform an anastomosis in a patient
who received as many as eight to tenunits of blood if the
patient resuscitated easily, is relatively young, and has a
promising clinical trajectory. If any of these caveats are
violated, or if a higher blood volume was administered, I
will perform an ileostomy. The morbidly obese patient with
superimposed abdominal wall edema can make exteriorization of an ischemia-free ostomy difcult. When faced with
a patient who mandates diversion but in whom an ostomy
was not technically possible, a former colleague would
place a large-caliber Malecot catheter into the afferent limb
of bowel and exteriorize the catheter. This would theoretically convert it into a controlled stula, and while I would
not personally endorse this technique without rst failing
an ostomy, he reported good results.
Concluding Take-Home Points
• On the rst pass through the abdomen, just whip stitch
enterotomies and colotomies.
• Beware of an odd number of holes in the bowel.
• Avoid blind whipstitching at the root of the mesentery.
• Paranoia is a healthy attitude when looking for bowel
injuries.
• Leaving patients in discontinuity during a damage control
procedure is safe and well-tolerated for up to 48hours.
• Planned reexplorations in which bleeding is not a concern
can be safely done at the ICU bedside.
• Injuries less than 50% of the circumference of the bowel
wall need only a primary repair.
• Colocolostomy should be your rst choice after resection
in young patients with no shock.
• For the patient who has had a damage control procedure,
diversion should be the default choice.
Summary
Along with control of hemorrhage, control of spill from the
alimentary tract is the overriding goal for the rst phase of an
operation after penetrating abdominal injury. This is most
easily accomplished with a rapid gure-of-eight suture. In
the large majority of stable patients without shock, primary
repair should be performed for nondestructive injuries, and
resection with anastomosis (including colocolonic) should
be performed for destructive ones. In the setting of damage
control, the whip stitches may be left in place, or resection
without anastomosis should be performed at the time of the
rst operation. Planned reexploration may be done at the
ICU bedside for profoundly ill patients. After damage control surgery, diversion should be considered when factors
predictive of anastomotic failure are present (shock, transfusions, pressors, and steroids).
Acknowledgment The current chapter is a revision of the original
chapter written by Kareem R.Abdel Fattah and Herbert A.Phelan in the
previous edition of the book.
Suggested Reading
Cullinane DC, Jawa RS, Como JJ, Moore AE, Morris DS, Cheriyan
J, Guillamondegui OD, Goldberg SR, Petrey L, Schaefer GP,
Khwaja KA, Rowell SE, Barbosa RR, Bass GA, Kasotakis G,
Robinson BRH.Management of penetrating intraperitoneal colon
injuries: a meta-analysis and practice management guideline from
the Eastern Association for the Surgery of Trauma. J Trauma
Acute Care Surg. 2019;86(3):505–15. https://doi.org/10.1097/
TA.0000000000002146.
Demetriades D, Murray JA, Chan LS, etal. Penetrating colon injuries
requiring resection: diversion or primary anastomosis? An AAST
prospective multicenter study. J Trauma. 2001;50:765–75.
Demetriades D, Murray JA, Chan LS, etal. Handsewn versus stapled
anastomosis in penetrating colon injuries requiring resection: a multicenter study. J Trauma. 2002;52:117–21.
Diaz JJ Jr, Mauer A, May AK, etal. Bedside laparotomy for trauma: are
there risks? Surg Infect. 2004;5:15–20.
Diaz JJ Jr, Mejia V, Subhawong AP, et al. Protocol for bedside lapa-
rotomy in trauma and emergency general surgery: a low return to
the operating room. Am Surg. 2005;71:986–91.
Higa G, Friese R, O’Keeffe T, Wynne J, Bowlby P, Ziemba M, Lati
R, Kulvatunyou N, Rhee P.Damage control laparotomy: a vital tool
once overused. J Trauma. 2010;69(1):53–9. https://doi.org/10.1097/
TA.0b013e3181e293b4.
Injury oftheKidney, Ureter,
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andBladder
BrianI.Shaw andSureshAgarwal
54
Including both blunt and penetrating trauma, renal injuries
occur in up to 1.2% of all trauma patients, and 15–25% of
patients with pelvic fracture incur urologic injury. The
American Association for the Surgery of Trauma (AAST)
Injury Criteria are used to characterize severity of renal and
urologic injury (Tables 54.1, 54.2, 54.3, and 54.4). Repair of
injury to the kidney, ureter, urethra, or bladder whenever
possible is essential to preserve long-term function.
When a urologic injury is suspected in the context of penetrating trauma to the ank, abdomen, or low chest, imaging
of the upper urinary system is crucial for diagnosis. CT scan
with IV contrast and delayed lms at 10min is the imaging
Table 54.1 Kidney injury scale
a
Grade
I Contusion Microscopic or gross hematuria, urologic
II Hematoma Nonexpanding perirenal hematoma conrmed
III Laceration <1.0cm parenchymal depth of renal cortex
IV Vascular Main renal artery or vein injury with
V Laceration Completely shattered kidney 866.03 5
a
Advance one grade for bilateral injuries up to grade III
Type of injury Description of injury ICD-9 AIS-90
studies normal
Hematoma Subcapsular, nonexpanding without
parenchymal laceration
to renal retroperitoneum
Laceration <1.0cm parenchymal depth of renal cortex
without urinary extravasation
without collecting system rupture or urinary
extravasation
Laceration Parenchymal laceration extending through
renal cortex, medulla, and collecting system
contained hemorrhage
Vascular Avulsion of renal hilum which devascularizes
kidney
modality of choice for hemodynamically stable patients. CT
imaging should permit accurate injury staging based on the
AAST criteria, which are highly predictive for operative
management. Medial hematoma, with or without extravasation, on early lms suggests renal vascular injury while that
on delayed lms is usually indicative of renal pelvic injury or
proximal ureteral injury. Any part of the renal parenchyma
that fails to show contrast on early-phase images suggests
arterial injury.
CT cystogram should be included in initial imaging when
bladder injury is suspected as a result of trauma to the lower
abdomen or pelvis. Indications include gross hematuria in
866.01 2
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4
B. I. Shaw · S. Agarwal (*)
Division of Trauma, Acute and Critical Care Surgery, Department
of Surgery, Duke University, Durham, NC, USA
e-mail: suresh.agarwal@duke.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_54
447
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Table 54.2 Ureter injury scale
a
Grade
I Hematoma Contusion or hematoma without
II Laceration <50% transection 867.2/867.3 2
III Laceration
IV Laceration Complete transection with <2cm
V Laceration Avulsion with >2cm of
Moore etal.
a
Advance one grade for bilateral up to grade III
Table 54.3 Bladder injury scale
a
Grade
I Hematoma Contusion, intramural hematoma 867.0/867.1 2
II Laceration Extraperitoneal bladder wall laceration
III Laceration
IV Laceration Intraperitoneal bladder wall laceration
V Laceration Intraperitoneal or extraperitoneal bladder
a
Advance one grade for multiple lesions up to grade III
Type of injury Description of injury ICD-9 AIS-90
867.2/867.3 2
devascularization
≥50% transection
devascularization
devascularization
Injury type Description of injury ICD-9 AIS-90
Laceration Partial thickness 3
<2cm
Extraperitoneal (≥2cm) or
intraperitoneal (<2cm) bladder wall
laceration
≥2cm
wall laceration extending into the bladder
neck or ureteral orice (trigone)
867.2/867.3 3
867.2/867.3 3
867.2/867.3 3
867.0/867.1 4
867.0/867.1 4
867.0/867.1 4
867.0/867.1 4
B. I. Shaw and S. Agarwal
Table 54.4 Urethra injury scale
a
Grade
I Contusion Blood at urethral meatus; retrography
II Stretch injury Elongation of urethra without
III Partial disruption Extravasation of urethrography contrast
IV Complete disruption Extravasation of urethrography contrast
V Complete disruption
a
Advance one grade for bilateral injuries up to grade III
the setting of blunt trauma, blunt trauma with any degree of
hematuria and a pelvic ring fracture, and penetrating trauma
to the pelvis with hematuria. The sensitivity and specicity
of CT cystogram for bladder rupture are 95% and 100%, but
should CT cystogram not show evidence of bladder injury
despite clinical suspicion, retrograde cystography with full
bladder distension should be performed and post-drainage
images obtained. Retrograde cystography should be performed only in the absence of urethral injury. Retrograde
urethrogram to evaluate for urethral injury should be performed when urethral injury is suspected—in the setting of
Injury type Description of injury ICD-9 AIS-90
normal
extravasation on urethrography
at injury site with visualization in the
bladder
at injury site without visualization in the
bladder; <2cm of urethra separation
Complete transaction with ≥2cm
urethral separation or extension into the
prostate or vagina
gross hematuria, a high riding prostate, swelling or ecchymosis of the perineum, or a high riding prostate—and should
be delayed until after CT imaging of the pelvis to evaluate
for vascular injuries as retrograde contrast can interfere with
these modalities.
When CT imaging is bypassed in the hemodynamically
unstable patient who proceeds immediately to surgery, an
on-table one-shot intravenous pyelogram (IVP) should be
performed by giving a 2mg/kg IV contrast bolus followed
by at plate X-ray 10min later. The main purpose of the IVP
is to demonstrate two functioning kidneys and an intact
867.0/867.1 2
867.0/867.1 2
867.0/867.1 2
867.0/867.1 3
867.0/867.1 4
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drainage system. The presence of an injured solitary kidney
should prompt aggressive measures to spare nephrectomy
that would commit the patient to a lifetime of dialysis or
future transplantation.
Angiography with selective embolization is a more
recently developed modality that now has robust evidence
for use in the majority of blunt renal injury and some
cases of penetrating renal injury. Indications for embolization include active hemorrhage, pseudoaneurysm, and
vascular stulas. Higher AAST grade renal injuries are
associated with increased failure rates with attempts at
embolization, particularly when comparing penetrating to
blunt trauma. Additionally, failed embolization often ends
in nephrectomy.
54.1 Indications forOperative
Management
Due to improvements in computed tomography imaging and
resuscitation methods, operative intervention for renal injuries has been signicantly reduced. AAST stage I–III renal
injuries are usually hemodynamically stable and are managed nonoperatively. With the broadening criteria for nonoperative management of renal injury, even in penetrating
trauma including some gunshots, the only absolute indications for operative management are hemodynamic instability, expanding or pulsatile perirenal hematoma, incomplete
renal injury staging, renal pelvic injury, or non-visualization
of the injured kidney on IVP.Isolated stage IV renal injuries
may be managed nonoperatively when hemodynamically
stable but must be continually reassessed and re-imaged by
CT scan at 48h or sooner if there is clinical decompensation.
Superselective embolization may be attempted for certain
patients with stage IV and V renal injuries who fail conservative management due to persistent bleeding. With these
guidelines in mind, however, renal injuries suffered from
penetrating trauma are frequently associated with other injuries that require operative management. Indeed, recent data
from a prospective study shows that up to 80% of blunt
and >40% of penetrating renal injuries classied as “high
grade” (grade III or greater) are managed non-operatively.
Analysis of the National Trauma Databank has shown
nephrectomy to be an independent risk factor for mortality
even when accounting for other concomitant predictors of
mortality among patients with grade IV and V renal injury.
Almost all ureteral injuries require immediate operative
repair. In the event a ureteral injury is initially unrecognized
and consequently not repaired immediately, reconstruction
should be deferred for 3–6months to allow inammation to
resolve. All bladder neck and intraperitoneal bladder injuries
mandate repair, while most extraperitoneal bladder injuries
can be observed unless the patient undergoes laparotomy for
other injuries.
54.2 Operative Technique
Once committed to operative management, a standard transabdominal midline incision is best for assessing renal injury
because both kidneys can be inspected through this approach
and midline incision allows access to the remainder of the
abdominal cavity. Abdominal packing, in typical trauma laparotomy fashion, will help control bleeding. Attention should
rst be turned to the destabilizing injury, urologic or otherwise.
54.3 Vascular Control
When the time comes to assess the bleeding kidney, vascular
exposure is the rst priority. Lift the transverse colon to the
chest with a moist laparotomy pad and move the small bowel
to the right in order to expose the retroperitoneum. Carefully
incise the retroperitoneum over the aorta at the inferior mesenteric artery and extend superiorly to the ligament of Treitz
(Fig. 54.1). The left renal vein can be identied where it
crosses the aorta anteriorly, noting that the vein rarely crosses
posteriorly and when it does it may be duplicated. Sometimes
a large retroperitoneal hematoma distorts the anatomy. In
this case, make the incision just medial to the inferior mesenteric vein and proceed to identify the left renal vein. Wrap a
Fig. 54.1 Carefully incise the retroperitoneum over the aorta at the
inferior mesenteric artery and extend superiorly to the ligament of
Treitz (dotted line)
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Fig. 54.2 Apply vessel loops to the renal arteries and veins but only
occlude the vessels if severe bleeding must be controlled
vessel loop around the vein without occluding it, unless
bleeding from this vessel is heavy. The remaining renal vessels should be identied in order: left renal artery, right renal
vein, and right renal artery. The left and right renal arteries
are posterior and superior to the left renal vein on either side
of the aorta. Apply vessel loops to the renal arteries and
veins, but only occlude the vessels if severe bleeding must be
controlled (Fig.54.2).
Renal occlusion time must be minimized to preserve function. Generally, arterial occlusion alone is enough to control
hemorrhage. If occlusion is necessary for more than 60min
and patient stability permits, ice slush or cold renal perfusion
solution may be used to cool the kidney to minimize warm
ischemia time, thus prolonging ischemic tolerance.
Anatomic variation of the renal vasculature is not uncommon with a high frequency of multiple renal arteries and
veins making vascular control potentially difcult. Most
notable is the prevalence of renal arteries originating below
the IMA, multiple right renal veins, and less frequently retroaortic or circumaortic left renal vein. When bleeding is not
controlled with occlusion of standard renal vessels, anatomic
variants must be considered. When more urgent hemostasis
is required or if the source of bleeding is unclear, proximal
control may be gained by transiently occluding the aorta at
the gastroesophageal junction or in the chest.
B. I. Shaw and S. Agarwal
case of a solitary kidney or bilateral injuries and if the injury
is less than 6h old.
Arterial and venous injuries should be repaired with running or interrupted vascular sutures such a 5-0 or 6-0 Prolene.
Segmental veins can be ligated given the extensive collateral
venous drainage in the kidney. On the other hand, ligation of
segmental renal arteries is problematic because they are endorgan vessels. If their sacrice is necessary, distal parenchyma
will become ischemic and may infarct, and subsequent evaluation and debridement of infarcted parenchyma must follow.
Complete renal artery disruption requires debridement
and excision of damaged vessel tissue followed by end-toend, tension-free anastomosis. Use saphenous vein or internal iliac artery graft to augment repair of arterial defects
greater than 2cm that may result in severe narrowing without interposition graft. Avoid synthetic graft material due to
the contaminated nature of the trauma laparotomy and the
increased risk of infection with synthetic material.
Renal autotransplantation may be considered if the renal
artery pedicle is severely injured but the kidney itself is salvageable, especially if the patient has multiple injuries and
damage control is the priority. The removed kidney may be
reimplanted up to 48h later if it is appropriately preserved.
Complete renal vein disruption may result in nephrectomy
unless it is the left main renal vein at its origin with the vena cava,
in which case the vein may be ligated because the left kidney has
collateral drainage via the gonadal and adrenal veins.
54.5 Renal Exposure
Attention may be turned to renal exposure once renal vascular identication and control have been established. These
techniques may also be applied to renal vascular exposure,
especially in case of a large retroperitoneal hematoma.
Incise the retroperitoneum lateral to the colon at the white
line of Toldt and reect medially. On the left side, division of
the splenorenal ligament followed by medial reection of the
spleen and colon will completely expose the left kidney and
associated vasculature. When exploring the right side, incise
the hepatic exure in addition to the retroperitoneum lateral to
the colon. Once the duodenum and pancreatic head are mobilized medially, the right renal artery and vein can be identied
along with the origin of the left renal vein. Gerota’s fascia may
be incised along its lateral aspect for complete renal exposure.
Preserve as much of the renal capsule as possible as it will
likely be used for closure of the reconstruction.
54.4 Vascular Repair
Vascular injuries to renal vessels are rare in the context of
trauma and their repair is successful less than half of the
time. Renal artery salvage should only be attempted in the
54.6 Partial Nephrectomy
Partial nephrectomy is required when either pole of the kidney is severely damaged. Generously debride nonviable
renal tissue down to actively bleeding parenchyma noting
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54 Injury oftheKidney, Ureter, andBladder
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that only 30% of a single normal kidney is needed to avoid
dialysis. Suture ligate individual bleeding vessels with 4-0
chromic sutures. Do not use nonabsorbable suture material
in the parenchyma or collecting system. Parenchymal hemostasis may be achieved with direct pressure. Alternatively, a
Keith needle with absorbable suture can be passed through
the full thickness of the parenchyma, from capsule to capsule
and back, with supporting pledgets to help achieve hemostasis. This should not be attempted if the collecting system is
involved. Diffuse oozing can be managed with direct compression while electrocauterizing the denuded surface.
Close the collecting system with a watertight running 4-0
chromic suture. Integrity of the closure may be tested by
injecting methylene blue dye into the renal pelvis while compressing the ureter and inspecting for extravasation.
Thrombin-soaked gelfoam may be placed between cut
parenchymal edges to improve hemostasis. Gently pull the
capsule directly over the defect and secure. If sufcient capsule is unavailable, an omental pedicle ap may be used to
cover the defect (Fig.54.3).
54.7 Renorrhaphy
Renorrhaphy is necessary for middle kidney damage. As
for partial nephrectomy, debride nonviable tissue to bleeding parenchyma. Ligate vessels and close the collecting
system with 4-0 chromic suture as above. Approximate
parenchymal edges and secure with interrupted 3-0
absorbable sutures anchored to the capsule for support,
tied over an absorbable gelatin bolster. As for partial
nephrectomy, an omental pedicle ap can be used to close
the defect if capsule quantity is inadequate. Similarly,
absorbable mesh can help stabilize the extensively
repaired kidney. The kidney, once repaired, should be
placed back within Gerota’s fascia but the fascia should
not be re-approximated.
Following partial nephrectomy or renorrhaphy, a retroperitoneal drain should be placed without suction, to decrease
likelihood of a urine leak, and left in place for 2–3days or
longer if output is high or creatinine from the drainage is
elevated.
a
Fig. 54.3 The injured kidney is debrided sparsely (a). Gently pull the capsule directly over the defect and secure (b) after closure of the collecting
system (c). If sufcient capsule is not available, an omental pedicle ap may be used to cover the defect
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