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P. Talving et al.
56.2.3 Complications
Ligation of the portal vein is compatible with survival; however, this requires a patent hepatic artery for adequate hepatic
oxygenation. Portal vein ligation results in transient hypotension from the splanchnic pooling of intravascular volume.
Fluid requirements must be vigorously addressed. Use a
temporary abdominal closure, and do not close the abdominal fascia after portal vein ligation as massive bowel edema
is expected within 24–72 h post-ligation. By default, you
should plan on a “second look” to evaluate for bowel ischemia and to reassess the fascia for closure.
56.3 SMV Injuries
SMV injuries are associated with injury to their arterial counterparts in 34% of cases. Patients sustaining SMV injury also
sustain three to four associated visceral injuries per vascular
injury. The mortality associated with SMV injuries ranges
from 29% to 57% over the last decades.
56.3.1 Exposure
SMV (Fig.56.10). As discussed above, if this is not sufcient,
stapled transection of the pancreas is an acceptable option.
56.3.2 Repair Versus Ligation
If lateral repair is feasible, this is the best option. If the
patient is physiologically unstable, you may at this point
insert a vascular shunt. When anchoring the shunt, care must
be taken to place your ties as close as possible to the wound
to spare the vessel length for subsequent reconstruction at
secondary intervention (Fig.56.11). If the patient is in extremis, ligation is required and is compatible with survival.
The main trunk of the SMV passes anteriorly to the third segment of the duodenum and in front of the uncinate process of
the pancreas. The SMV joins the splenic vein to form the portal vein behind the neck of the pancreas. Intraoperatively, the
injury presents either as a hematoma at the base of the transverse mesocolon or as a supramesocolic hematoma in the
lesser sac at the neck of the pancreas. Dividing the avascular
ligament of Treitz between the base of the transverse mesocolon and the fourth portion of the duodenum accesses the proximal SMV.Start dividing the ligament of Treitz horizontally
from left to right with Metzenbaum scissors. The rst vessel
encountered is the superior mesenteric artery (SMA). The
SMV is located just right to the SMA.Reect the transverse
mesocolon cranially and the small bowel caudally which will
expose the SMV at the root of the mesentery. You will note
the middle colic vein conuencing with the SMV at the base
of the transverse mesocolon. Control the bleeding with compression or pinch the root of the mesentery. As soon as an
injury is identied, while exposing the injury, start thinking
about your plan for repair, shunting, or ligation depending on
the extent of the injury and the patient’s overall condition.
Further exposure of the SMV becomes more difcult as the
vessel courses behind the neck of the pancreas and is frequently embedded in the pancreatic tissue. You may try to
access it from the lesser sac. Open the retroperitoneum just
below the neck of the pancreas, and isolate the proximal and
distal ends of the vessel. With careful traction of the pancreatic neck cranially, you will achieve more distal access to the
SMV
Fig. 56.10 Access to the superior mesenteric vein
Fig. 56.11 Temporary shunted superior mesenteric vein (shown with
blue arrow). (Courtesy of P.Talving)
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56.3.3 Complications
Complications of the SMV ligation are similar to the ligation
of the portal vein.
56.4 Renovascular Injuries
Renovascular injuries occur in 5–7% of penetrating abdominal trauma. However, the renal vein is the third most common venous injury in the abdominal cavity, and an isolated
injury carries a mortality rate of approximately 10%. Renal
salvage is expected in approximately 50% of isolated renal
vein injuries. Mortality is linked to the associated vascular
and visceral injuries. At laparotomy, you will nd a hematoma overlapping the transition of Zones I and II.A peripheral non-expanding Zone II hematoma does not mandate
renal exploration.
56.4.1 Exposure
For renal trauma, recent studies have noted a decreased
nephrectomy rate by obtaining proximal vascular control
prior to renal mobilization. For proximal vascular control,
retract the transverse colon cranially, and identify the inferior mesenteric vein (IMV) coursing left of the aorta to conuence with the splenic vein under the body of the pancreas
in the retroperitoneal Zone I.Next, open the retroperitoneum
between the aorta and IMV with Metzenbaum scissors longitudinally, identify the left renal vein coursing over the aorta,
vessel loop it, and pull cranially. The left renal artery is
behind the vein that is likewise vessel-looped. On the right
side, the renal vein is also anterior and the artery courses
behind the IVC.Again, control the right renal vessels one by
one with vessel loops and/or vascular clamps as necessary.
This is only an option for hemodynamically stable patients
and may be tedious. The simplest approach on both sides is
to proceed laterally with a medial visceral rotation. Open
Gerota’s fascia, and mobilize the kidney gently by inserting
your ngers below the kidney and bringing the kidney up
into the wound. The exposed kidney is grasped in the palm of
the surgeon controlling the hilum with the thumb and index
nger. This provides excellent exposure to vascular injuries
on both sides, controls hemorrhage, and allows injury grading of the renal unit.
56.4.2 Repair Versus Ligation
Your options on the right side are lateral repair and ligation.
Avoid complex repairs, especially if the patient requires
damage control. Ligation equals nephrectomy on the right
side. On the left, ligation of the renal vein close to the IVC
and distal to the gonadal vein is compatible with renal salvage as the venous outow will be rerouted through the
gonadal, adrenal, and lumbar veins.
56.4.3 Complications
Even if the injury is repairable, preoperative and intraoperative hypotension along with renal inow occlusion results in
ischemic damage. Despite the anecdotal successes with ischemia times in excess of 3–5h, function starts to decline after
even 1h of warm ischemia time. These patients are therefore
at high risk of acute renal failure postoperatively.
56.5 Iliac Vein Injuries
Mortality is in excess of 35% for isolated iliac vein injuries.
Penetrating injuries to the lower abdomen, pelvis, or buttocks in the presence of hypotension are suspicious for iliac
vascular injury. The incidence of penetrating iliac vessel
injury in the civilian setting ranges from 10 to 22%, and in
70% of those instances, a combined arteriovenous injury is
identied. The most frequent segment injured is the common
iliac vessel. At laparotomy, the intra-abdominal nding of
iliac vessel injury is a hematoma in Zone III.These hematomas must be explored in conjunction with penetrating
trauma.
56.5.1 Exposure
Iliac vein injuries are often more challenging than arterial
injuries due to the difcult surgical exposure and the risk of
air embolism. The distal right common iliac vein is particularly cumbersome to expose. Similarly, the conuence of the
iliac veins behind the right common iliac artery is a real challenge. Local hemostatic control is obtained initially by direct
compression. The left iliac vein is exposed by mobilizing the
lateral peritoneal attachments of the sigmoid colon and rotating the bowel medially. On the right, the cecum should be
mobilized and displaced cranially exposing both the proximal IVC and right iliac vessels. Apply vessel loops on the
common, external, and internal iliac arteries to expose the
vein behind. Difculty in exposure has led many authors to
advocate transection of the overlying artery, while experienced trauma surgeons would argue strongly against it.
Ligation and division of the internal iliac artery, however,
may further facilitate the mobilization of the artery to allow
access to the venous injury behind. For distal injuries, the
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midline incision can be continued obliquely through the
inguinal ligament on the appropriate side. Exposure is crucial for these injuries and will facilitate distal control.
56.5.2 Repair Versus Ligation
You should consider repair whenever it is simply feasible
with lateral repair. If repair is difcult or if the patient is
unstable, simply ligate! This is well tolerated by most
patients. Be cautious to avoid injury to the ureter, which rides
over the iliac artery at the bifurcation.
56.5.3 Complications
The mortality associated with isolated iliac vein injuries is 10%.
However, the injury very infrequently occurs in isolation. Repair
of the iliac vein with subsequent stenosis is associated with a
risk of venous thrombosis and pulmonary embolism. In cases
where repair would result in stenosis, we advocate ligation.
Signicant edema and postphlebitic syndrome will be decreased
by wrapping the extremity in the OR and elevation postoperatively in ICU.You may consider anticoagulation if the vessel
was repaired, with signicant stenosis.
Important Points
• Vascular injuries must be ruled out in hypotensive pene-
trating abdominal trauma.
• Spare no time for investigations if the patient is hypoten-
sive: Run to the OR!
• Hemostatic resuscitation should be started promptly and
continued through the OR and into the ICU.
• Have a complete vascular tray in your OR before you
start.
• Your mind should be attuned to the need for damage con-
trol even prior to laparotomy.
• Divide the skin and fascia fully prior to decompressing
the hemoperitoneum.
• Right medial visceral rotation exposes most of the abdom-
inal veins.
• Attempt lateral repair or shunt the suprarenal IVC, portal
vein, and SMV if feasible.
• In a life-threatening scenario, there is no role for complex
repair; just ligate.
• Abdominal compartment syndrome will follow ligation
of the SMV or portal vein.
• Wrap the legs on patients with ligated IVC or iliac veins.
• Consider the risk of venous thromboembolism after
venous repair.
Suggested Reading
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Asensio JA, Petrone P, Roldán G, Kuncir E, Rowe VL, Chan L, etal.
Analysis of 185 iliac vessel injuries: risk factors and predictors of
outcome. Arch Surg. 2003;138:1187–93.
Balogh ZJ, Butcher NE. Compartment syndromes from head to toe.
Crit Care Med. 2010;38:S445–51.
Bowley DM, Barker P, Boffard KD. Intraoperative blood salvage in
penetrating abdominal trauma: a randomised, controlled trial. World
J Surg. 2006;30:1074–80.
Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado
RP, et al. A clinical series of resuscitative endovascular balloon
occlusion of the aorta for hemorrhage control and resuscitation. J
Trauma Acute Care Surg. 2013;75:506–11.
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B, et al. Hemodynamically “stable” patients with peritonitis after
penetrating abdominal trauma: identifying those who are bleeding.
Arch Surg. 2005;140:767–72.
Buckman RF Jr, Pathak AS, Badellino MM, Bradley KM.Portal vein
injuries. In: Rich NM, Mattox KL, Hirshberg A, editors. Rich’s vascular trauma. 2nd ed. Philadelphia: Elsevier Saunders; 2004.
Bulger EM, Jurkovich GJ, Nathens AB, Copass MK, Hanson S, Cooper
C, etal. Hypertonic resuscitation of hypovolemic shock after blunt
trauma: a randomized controlled trial. Arch Surg. 2008;143:139–48.
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vs a 1:1:2 ratio and mortality in patients with severe trauma. JAMA.
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PM.Effects of lactated Ringer’s solutions on human leukocytes. J
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injuries. Eur J Vasc Endovasc Surg. 2005;30:499–503.
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57
Vascular injuries are the most common cause of death after
penetrating abdominal trauma. Any penetrating injury to the
abdomen should be considered a potential vascular injury
until proven otherwise. This is critical for understanding that
this is a true emergency and requires running the patient to
the operating room (OR) before they exsanguinate. Only a
novice would saunter over. In this chapter, we will address
how to quickly access and manage injuries to the major arteries in the abdomen. We will begin with key features that
include staying calm, rapid exposure, obtaining temporary
control until further decisions can be made, and various
approaches to treatment.
Abdominal arteries can range from small, inconsequential
branches to major trunks that, when injured, can commonly
determine whether life or death results after penetrating
trauma. Vascular injuries are found in 10–20% of patients
undergoing laparotomy for penetrating injury. Mortality
rates of up to 70% have been documented for major abdominal arterial injury; the treatment of which, despite many
advances in medical technology, has not changed since
DeBakey’s initial description in 1946. The general approach
to penetrating abdominal trauma can be found in Chap. 39.
For these patients, quick indicators that a vascular injury
may be present are hypotension, peritonitis, mental status
changes, diminished lower pulses, and a distended abdomen.
It is important to recognize that hypotension can be your
friend! Relative hypotension will decrease the amount of
hemorrhage and theoretically not dislodge any clot that may
have formed. It is okay to maintain relative hypotension until
you reach the operating room.
In patients meeting criteria for a laparotomy after penetrating trauma, there is always the chance that there may be a
vascular injury and an experienced trauma surgeon will
understand that the patient’s best shot at survival is to control
the bleeding STAT! This has been documented in several
L. Lam (*) · K. Inaba
Division of Trauma and Surgical Critical Care, Department of
Surgery, LAC + USC Medical Center, Los Angeles, CA, USA
e-mail: lydia.lam@med.usc.edu; kinaba@surgery.usc.edu
studies looking at factors affecting mortality in major
abdominal vascular trauma. The underlying message is the
same: Rapid identication and control of bleeding will allow
for adequate resuscitation and improved survival. It is a race
for time if vascular injury is suspected. Never walk to the
OR; always run!
While running to the OR, the rst vessel that comes to
mind is the aorta. However, there are a few others that can
challenge your skills, requiring rapid identication and control. These arteries include the superior mesenteric artery
(SMA), splenic artery, iliac arteries, and renal arteries. These
are the vessels that are at the root of the dreaded “expanding
hematoma” in the retroperitoneum. When injured, these vessels appear chaotic and messy when seen for the rst time,
very different from the clean drawings of textbooks or the
careful cadaver dissections during medical school. Get as
much experience as you can while training, and if you are
not experienced, get help as soon as you realize what the
injury is. Ensure that blood and plasma are ordered and a
rapid infuser is prepared while the patient is intubated,
prepped, and draped. If your institution has a massive transfusion protocol, activate it at this time. Prepare the area from
the sternal notch to the knees. This will be important in the
event that you have to cross clamp above the diaphragm for
hypotension or require the saphenous vein to bypass. In addition, have vascular instruments opened or, in the room, you
may need them on a seconds notice; you are now ready.
57.1 Stay Calm
It is imperative that when you see the expanding hematoma,
pulsatile bleeding, or bright red blood welling up in your
eld, you stay calm. As the captain of the ship, if you panic,
everyone else will panic. Panic prevents clear decisionmaking, stalls rapid treatment, and decreases the efciency
of the entire surgical team. Keep your senses in check and let
anesthesia know that you have arterial bleeding. Make sure
that they have enough help and that blood products are on the
© 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_57
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L. Lam and K. Inaba
way. Additionally, anticipate and secure all of the tools you
may need including vascular sutures, vascular clamps, vessel
loops, shunts, and retractors that may not normally be available but needed during emergency to gain immediate control
of a vessel.
57.2 Get Temporary Control
While anesthesia is preparing for war and the surgical scrub
is loading up your “emergent” Prolene 2-0 to 5-0 noncutting
sutures, it is critical for you to obtain temporary control.
Remember your hands; these are some of the best tools
you have! They are accurate, allow highly variable pressure
application, are quick and easy to apply, and (usually) are
atraumatic to the vessel wall. A nger with direct pressure on
the injured vessel is the best way to obtain control, while you
regroup and allow the others in the operating room to catch
up to the torrential bleeding.
Recognizing when your patient is in trouble is key to a
good outcome. Major vascular injury is in fact one of the
most common triggers for initiating damage control. The
concept of damage control is covered in a separate chapter.
For arterial injuries, the damage control options include ligation and shunting (Table57.1).
Alternatively, a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter may be a viable option
for temporary control. Whether vascular injury is suspected
before or during OR, a REBOA catheter can be placed. After
ruling out thoracic vascular injury, the REBOA catheter can
be placed in Zone I for control until the vascular injury is
identied. The benets of REBOA would be to free up hands
during the case and allow for better exposure. The balloon on
the catheter can be slowly deated to help locate the source
of bleeding and still maintain control of the bleeding. Specic
use of REBOA can be found in its dedicated chapter.
The shunt is an important tool to keep in your back pocket.
It is a rapid, inexpensive, technically simple tool that allows
you to follow the underlying principle in vascular trauma
which is to restore blood ow and reperfuse ischemic tissue
or organs. If the patient begins that downward spiral of the
lethal triad and the vessel that is bleeding can be ligated,
ligate. If not, get a shunt into the vessel, restore ow, and
proceed to the ICU.A shunt can be anything from a feeding
tube for smaller vessels to a chest tube for a large vessel such
as the aorta. Typically, we use commercially available and
purpose-designed vascular shunts at our institution; however, any hollow tube is acceptable, ensuring it is slightly
smaller than the vessel lumen so as to not damage the endothelium. A silk tie is secured to the center of the shunt to
mark the middle and prevent shunt migration. After placing
the middle silk tie, slip the proximal and distal ends of the
shunt into the respective ends of the injured vessel. Keep in
mind that the segment of the vessel that is tied down to hold
in the shunt will be damaged and will have to be removed
during denitive repair. Therefore, do not trim or debride the
injured vessel prior to shunt insertion to maximally preserve
native vessel length. In addition, secure the shunt as close as
possible to the end of the injured vessel so as to preserve
length. In general, the ow drives shunt patency and anticoagulation is not used, as patients requiring damage control
shunting often have diffuse nonsurgical bleeding which may
be exacerbated by this. You have now restored ow and can
bring the patient safely to the ICU for further resuscitation.
Table 57.1 Options of repair, graft, and ligation in selected vessels
Graft or vein (native,
Artery Primary repair
Aorta Prolene 3-0 or 4-0 Dacron 14–20mm No Prefer left medial visceral rotation exposure
Splenic N/A N/A Ye s Splenectomy
Common hepatic Prolene 5-0 or 6-0 Saphenous vein graft Ye s Need intact portal vein
Celiac axis Prolene 5-0 or 6-0 N/A Ye s Ligate
SMA Prolene 5-0 or 6-0 Vein preferred No Ligate in lifesaving scenario only
IMA Prolene 6-0 N/A Ye s Ligate
Common iliac Prolene 4-0 or 5-0
External iliac Prolene 4-0 or 5-0
Internal iliac Prolene 4-0 or 5-0 N/A Ye s Ligate
Renal Prolene 5-0 or 6-0 Vein or PTFE No Nephrectomy if ligation required
Mesentery
(unnamed)
No N/A Ye s Ligate with impunity
regenerative, or cryopreserved) Ligate? Recommendations
Cholecystectomy
Shunt whenever possible for damage control
PTFE ≥6mm
Vein or PTFE ≥6mm
No Shunt or immediate bypass
Watch for need of leg fasciotomy
No Shunt or immediate bypass
Ensure contralateral kidney function prior to
ligation
Explore all hematomas for arteries in spasm
that need ligation
Renal
Te
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477
After the patient is adequately resuscitated, acidosis corrected, and hypothermia eradicated, you are now ready to
return for denitive repair of this vessel which can be a simple primary repair or more involved with an interposition
graft comprising the saphenous vein or a synthetic graft.
57.3.1.1 Aorta
The suprarenal aorta can be accessed by a left medial visceral rotation also known as the Mattox maneuver. This can
expose the entire length of the aorta and its branches to
include the celiac axis, superior mesenteric artery, and inferior mesenteric artery. After making your midline incision
from the xiphoid to the pubis, take down the falciform liga-
57.3 Retroperitoneal Hematomas: Plan
ofAction
ment posteriorly making sure to stop short of the hepatic
veins. Non-xed retractors such as the Balfour or Titan are
simple instruments for retracting the abdominal wall quickly.
When discussing abdominal bleeding and the trauma exploratory laparotomy, it is common to refer to the areas of hematoma that will help you plan your exploration. The
retroperitoneum is divided into four areas: Zones I–III and
Zone IV, the retrohepatic area (Fig. 57.1). The retrohepatic
area is composed of the hepatic veins and retrohepatic IVC
and thus will not be discussed in this chapter.
For larger patients or for areas such as the iliac vessels, a
large xed retractor may be required. Reect the omentum
and transverse colon superiorly, eviscerate the small bowel
to the right, and nd the sigmoid colon. Lift the sigmoid
colon up into the eld, and start your dissection on the white
line of Toldt (a.k.a. the peritoneal reection). Once the peri-
toneum is taken down, your hand can easily dissect through
the loose areolar tissue in the retroperitoneal space, espe-
cially if blood has dissected through the soft tissue planes.
57.3.1 Zone I
Continue this dissection superiorly keeping on top of the
psoas muscle to include the descending colon, splenic exZone I refers to a central retroperitoneal hematoma. A hematoma in the supramesocolic location suggests that the suprarenal aorta and celiac or superior mesenteric artery (SMA)
may have been injured, while an inframesocolic location
would suggest injury to the distal SMA or infrarenal aorta.
ure, stomach, spleen, and pancreatic tail. This will allow you
to bluntly lift up these structures and mobilize them into the
midline. At this point, the aorta and its branches can be
visualized.
If bleeding is not adequately controlled with direct pressure and cross clamping of the aorta is your next move, the
supraceliac aorta should be accessed. Keep in mind that
Zone I
Zone IIZone II
inow control will cause ischemia to all structures distal;
thus, the time the cross clamp remains on the aorta needs to
Splenic
be kept as short as possible. The longer the clamp remains in
place, the more difcult removal becomes and the more profound the reperfusion effect. For intra-abdominal supraceliac
Hepatic
SMA
control, direct compression manually is best, especially if
there is sufcient blood pressure to allow for easy palpation
of the aorta as it exits the chest. If dissection is required or if
you are going to attempt clamp placement, cutting the left
crus of the diaphragm (at 2 o’clock to avoid bleeding) will
sticular
facilitate exposure. Using your ngers, bluntly dissect away
the dense neural and brous tissue over the aorta, and create
IMA
a space on either side. You may attempt to place a large vascular clamp across the aorta. If successful, secure the clamp
so that it cannot fall off or be knocked off inadvertently.
Left
common
iliac
Zone III
Practically, however, it is usually very difcult to keep the
clamp in place because it slips off easily. What we recommend for better control of the aorta is direct compression of
the aorta against the vertebral bodies. This can be achieved
by a compression device, a sponge stick, or your assistant’s
hand (Fig. 57.2). If time and anatomy permits, REBOA
placement can be considered in lieu of aortic cross clamp.
Fig. 57.1 Anatomical vascular regions
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Fig. 57.2 Supraceliac aortic
control
Right crus
incised
Gastro-
hepatic lig.
divided
Injury
L. Lam and K. Inaba
Adrenal
gland
Celiac
trunk
Hepatogastric
ligament divided
Centers that use REBOA more frequently will advocate to
place an arterial sheath early in the patient’s presentation for
easy access and catheter placement. Keep in mind, in some
rare instances with high supramesocolic injuries, a left thoracotomy may be the safest and quickest way to achieve proximal aortic control.
Any repair of the aorta will need to be done with a nonabsorbable monolament suture, usually a 4-0. If possible,
try a lateral aortorrhaphy or polytetrauoroethylene (PTFE)
patching. Unfortunately, if it is a gunshot wound, quite a bit
of damage may result requiring resection of that portion.
Direct primary repair is difcult due to limited mobility.
Therefore, after obtaining exposure and proximal and distal
control, insert a short interposition graft of 14–20 mm
Dacron and perform an end-to-end anastomosis. When size
matching, remember that the acutely injured aorta is likely
vasoconstricted; so, if trying to decide between two sizes,
choose the larger size. Although the vast majority of penetrating aortic injuries will be accompanied by other injuries, commonly hollow viscus, enteric spillage is not a strict
contraindication to prosthetic graft placement, and all gross
spillage should be washed out. In addition, after you have
achieved blood ow back to the lower part of the body,
omental covering over the anastomotic site is strongly
encouraged; this will protect your graft and help prevent
aorto-enteric stula formation. Find an avascular line in the
omentum and take down a portion to adequately cover up
the repair.
57.3.1.2 Celiac Axis
The celiac artery is a rare injury but can become deadly fast.
Because it is tucked behind the stomach, there is usually an
associated stomach or liver injury. In one review, over a
10-year period of celiac artery injuries at a single institution,
the majority (92%) were, not surprisingly, due to penetrating
injury with a mortality rate of 38%. The majority of these
patients underwent ligation of the artery.
When a hematoma is found in the lesser sac, it can take a
while to perform a Mattox maneuver to attain proximal control. In this case, supraceliac aortic control may be helpful. If
there is massive bleeding, although in general blind clamping or suturing is not encouraged, directed ligation can be
useful since it is acceptable to ligate the celiac trunk.
If this does not stop the bleeding, medially rotate the
spleen and pancreas to expose the root of the celiac artery
while leaving the kidney down. This should allow access to
the celiac takeoff. Although direct dissection through the
lesser sac is possible, it is often difcult while holding direct
pressure on the injury. Once the injury is exposed, then either
ligation or reconstruction can begin. Again, keeping in mind
the patient’s physiological state, ligation in almost all cases
is the easiest and safest way to proceed. However, if the
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patient is rock solid and the burden of associated injury is
low, reconstruction may be attempted using autologous graft.
Transection of the stomach has also been described to
access the vessel. This is not routinely performed, nor is it
recommended. If it is done in the face of a concomitant gastric injury, ligation will be your only option.
57.3.1.3 Superior Mesenteric Artery
An expanding hematoma in the region of the base of the
mesentery or the lesser sac is concerning for an SMA injury
and must be explored. The mortality associated with injury
to the SMA can approach 70%. The SMA has been described
using the Fullen classication:
• Zone I—beneath the pancreas
• Zone II—between the pancreaticoduodenal and middle
colic branches of the SMA
• Zone III—beyond the middle colic branch
• Zone IV—enteric branches
As expected, the more proximal the injury, the higher the
mortality rate because more of the bowel will be affected.
This injury is usually associated with multiple other injuries,
and the patient is often in profound hypovolemic shock on
presentation to the hospital.
After direct compression, the most important thing is adequate exposure. A key maneuver for the temporary control of
the SMA is to rapidly perform a Kocher maneuver and place
your hand behind the head of the pancreas to the root of the
mesentery and grasp the vessels between your thumb and
ngers. Your assistant can be doing this while you continue
the dissection for better exposure and control. Start with the
Mattox maneuver which will give you good access to the
aorta, which can then be clamped superior and inferior to the
SMA takeoff. Once proximal control is achieved, Fullen
Zones I and II can be exposed anteriorly by using a retractor
to reect the inferior edge of the pancreas upward; however,
this can be awkward (Fig.57.3). If this still proves inadequate, stapled transection of the pancreas neck to give full
exposure of the artery is indicated. Bluntly dissect anterior to
the common bile duct (CBD) with your nger, much like a
Whipple, and lift up the pancreatic neck for stapling.
Alternatively, use either a knife or cautery to transect the
pancreas over your nger to allow you to access the SMA.
Fullen Zone III and IV hematomas are below the pancreas
and are exposed by reecting the transverse mesocolon
cephalad and taking down the ligament of Treitz. Behind this
lies the SMA and it can be dissected out for direct visualization of the injury. A Cattell-Braasch maneuver (see gure in
Chap. 48) for this part of the SMA is also possible as it will
allow good exposure to the posterior vessel.
Ligation of the SMA, despite the theoretical collateral
ow that may allow gut viability with the proximal ligation,
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SMA
Fig. 57.3 Superior mesenteric artery exposure
should be avoided. Patients sustaining SMA injuries have
compromised distribution of blood ow through all organ
beds, and there is no guarantee of gut viability even if intraoperative ischemia is not seen. The best damage control
maneuver is shunting. If stable, denitive repair to any part
of the SMA can include primary repair (preferable if possible without narrowing), patch angioplasty, or reconstruction.
Ideally, autologous grafts would be preferred for reconstruction, but a ringed synthetic graft would be acceptable. If
damage control shunting is performed, delayed reconstruction can be done from the right common iliac artery or the
infrarenal aorta to the SMA using autologous graft. Do this
as a staged operation to maximize your chance of success.
Position the reconstruction as far away from any pancreatic
leak as possible to avoid any anastomotic breakdown or
arterio- enteric stula formation. Always remember the
omentum; place some omentum around your anastomosis to
protect it. Even in the best hands, postoperative bowel ischemia is a risk and must be carefully watched for. Most of
these patients will have an open abdomen post reconstruction, facilitating a second-look operation.
57.3.2 Zone II
The major arteries in this zone include the renal arteries and
adrenal arteries, with the renal arteries being of signicant
concern. Virtually all penetrating renal injuries are diagnosed
intraoperatively and usually close to the time of injury. This
is important as the kidneys do not tolerate ischemia well.
Most surgeons avoid revascularization after 6 h as renal
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function is affected after even 90min of ischemia. The results
of revascularization are poor, and postoperative hypertension
is a problem that may require nephrectomy. Therefore, it is
not commonly done but depends on the extent of injury burden, patient status, and contralateral kidney. If the injured
kidney is the only kidney, we are much more aggressive
about attempting revascularization with the caveat that you
do not want to end up with a well-perfused kidney in a dead
patient.
There are two approaches to the renal arteries—laterally
and medially. In general, all Zone II hematomas after penetrating trauma are explored. Small lateral hematomas away
from the hilum that are not expanding may be left alone by
some surgeons.
Fig. 57.4 (a) Right renal
artery exposure. (b) Left renal
artery exposure
a
The medial method approaches the renal vessels directly.
The advantage of this approach is that you can obtain proximal control of the renal vessels and the kidney in the face of
bleeding. The disadvantage is that this can be a difcult dissection. The advantage to the lateral approach is that the
majority of the dissection has been done by the expanding
hematoma and is therefore very fast. Start by performing a
left lateral medial visceral rotation as discussed in the exposure of the aorta for the left kidney and a right medial visceral rotation for the right kidney (Fig. 57.4a, b). As the
dissection moves cephalad, keep your hand on top of the
psoas muscle as the kidney is lifted up bluntly. Once that
kidney is in your hand, vascular control can be obtained by
pinching the hilum in your ngers to allow you time to care-
Rt
Kindney
Pancreas
b
57 Major Abdominal Arteries
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fully place a clamp across the vessels. Another advantage to
this approach is that, at this point, you have the injured kidney mobilized and up into the eld of the operation. Again,
rarely will there be an isolated renal artery injury. With the
kidney mobilized and bleeding controlled, the extent of the
damage can be rapidly assessed.
Once the lesion has been identied, you have some
choices to make. A simple injury can be repaired with interrupted sutures, while a larger laceration may need a saphenous vein patch so as not to narrow the vessel. Complex
repairs include resection and primary end-to-end anastomosis or using an autologous graft. Again, prior to attempting a
complex repair, the patient condition must be taken into consideration along with the ischemia time and predicted chance
of success. In most cases, as the arterial injury will be associated with a concurrent venous injury, the damage control
procedure would be a nephrectomy rather than shunting.
57.3.3 Zone III
In penetrating trauma, a pelvic hematoma has a high incidence of iliac vessel injury and should always be explored. In
1 report of 185 iliac vessel injuries, the vast majority were
seen after penetrating trauma, and the mortality rate was seen
to be high at 43% and 62% if combined with an iliac vein
injury.
These patients may present with evidence of intraabdominal bleeding or may present with a unilateral pulse
discrepancy in the lower extremity on the injured side. To
expose a right-sided Zone III hematoma, start at the cecum
and dissect along the peritoneal reection. Mobilize the
entire cecum and reect it toward the head. At this point,
you are looking into the retroperitoneal area and should be
able to see the psoas muscle. Place your nger on the psoas
muscle, and move medially and toward the feet to nd the
pulse that will be the iliac artery. With a major hematoma,
the anatomy may become distorted, and you may need to go
toward the head to identify the aorto-bifurcation and then
each common iliac trunk. Remember that the ureter comes
across anteriorly at the bifurcation of the common iliac, so
look out for it and do not transect it. Similarly, if the hematoma is on the left side, take down the peritoneal reection
along the sigmoid colon, reect it medially, and identify the
psoas muscle. Again, palpate along the muscle until you feel
a pulse and that will be the iliac artery. Bluntly dissect,
using your ngers, the loose areolar tissue around the vessel
using the Cattell-Braasch maneuver. Remember to stay
anterior to the artery and you will not encounter any
branches. At this point, you should have a pretty good idea
of where the bleeding is coming from, and your goal is to
obtain local control with direct compression using your nger. Carefully dissect an area proximally and distally to
place a vessel loop around the iliac artery. This will help
with proximal and distal control. Remember, if the injury is
distal, exposure is critical, and the incision should be continued across the inguinal ligament and into the groin. Next,
identify the internal iliac arteries which are easy to recognize because they take a direction straight down toward the
back of the patient. If the injury is localized to the internal
iliac artery, you can ligate it. Although the proximal segment is easy to manage, distal segment gunshot injuries
within a tight hole that is bleeding can be difcult to control.
In the unstable patient requiring damage control, packing or
balloon occlusion may be used.
Contrary to the internal iliac arteries, ligation of the external iliac arteries is associated with a signicant amputation
rate. If the injury is located at the external iliac artery, then a
decision will have to be made about your next step: Repair
primarily, shunt, or proceed with graft. When the injury
requires a resection with an interposition graft, autologous
graft is preferred if suitably size matched. However, a synthetic graft of at least 6mm is quite acceptable as this is a
large-caliber, high-ow vessel. Often the size match is better
and insertion of PTFE is much quicker with good results. As
discussed earlier, concomitant hollow viscus injury is not a
contraindication to synthetic graft placement.
For the external iliac artery, if the patient meets criteria
for damage control, be prepared to shunt. We have had excellent success with this technique for temporizing with a
delayed repair once the patient is stabilized. We do not advocate prophylactic fasciotomies but have a high index of suspicion postoperatively for intervening.
57.4 Afterthoughts
Almost all patients with an abdominal vascular injury will
have sustained a major physiologic stress, and many will
have associated injuries. Once the patient has made it through
the operation, it is important to continuously reassess their
physiological status as it normalizes. Adequate resuscitation
and careful monitoring of their hemoglobin will be important over the next 24–72h. If there are no contraindications,
consider starting a platelet inhibitor for up to 3months for
specic injuries where there is high concern for thrombosis.
Consider rhabdomyolysis from reperfusion injury or compartment syndrome as well, depending on the length of ischemia the patient has sustained. Routine creatine kinase (CK)
levels and extremity exams should be done.
Important Points
• Never walk to the OR—always run!
• Hypotension can be your friend.
• Stay calm. Be in control.
• Temporary control can start with your hands.
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