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C
FIGURE 11.4. Duodenal retroperitoneal rupture. (A) The plain abdominal radiograph after blunt
trauma shows streaks of retroperitoneal air around the right kidney (arrows), indicating duodenal
rupture. (B) Water-soluble contrast material given orally shows the site of rupture in the transverse
duodenum (arrows). (C) This CT scan demonstrates the extent of the retroperitoneal air from the
duodenal rupture. The air dissects around the kidney, inferior vena cava, and aorta (arrows). (Courtesy
of Vincent McCormick, MD, and Henry I. Goldberg, MD.)
B
M anagement of Specific I ntraabdominal Organ I njuries.................................................................... 339
A
FIGURE 11.5. Cattel maneuver. The best exposure of the retroperitoneal duodenum is obtained using
the Cattel maneuver. (A) The peritoneal reflection lateral to the ascending colon is incised sharply.
(B) The right colon and its mesentery and that of the small intestine are reflected medially. The
retroperitoneal duodenum is then exposed throughout its length.
FIGURE 11.6. Pyloric exclusion procedure. The retroperitoneum should be adequately drained with a
soft closed-drainage system.
B
The most important complications of this type of
rupture are: duodenal leak, retroperitoneal abscess,
delayed gastric emptying, and pancreatitis. The ancillary
Major Duodenal Disruption Involving
Ampulla or Distal Common Bile Duct
(Grade IV Injury)
procedures described above anticipate all of these complications. The morbidity and mortality rates of this injury
are significant and increase with delay in treatment and
presence of other associated injuries.
Grade IV injury of the duodenum is fortunately rare
and usually the result of a bullet wound. In this injury,
major disruption of the duodenum occurs involving the
340 ............................................................................................................................ Abdominal T rauma
M anagement of Specific I ntraabdominal Organ I njuries.................................................................... 341
ampulla or distal common bile duct (CBD). The diagnosis is usually made on abdominal exploration. When the
injury is amenable to repair, surgical treatment consists of
repair of the duodenal tear followed by pyloric exclusion.
Otherwise, pancreaticoduodenectomy is required.
Massive Disruption of Duodenopancreatic
Complex; Devascularized Duodenum
(Grade V Injury)
This type of injury is serious and associated with a high
mortality rate. The only treatment option is pancreaticoduodenectomy.
PANCREATIC INJURY
The pancreas may be injured in blunt or penetrating
trauma. In either case, associated injury of the duodenum
may be present. A simple classification of pancreatic injury
is given in Table 11.3 and serves to guide treatment.
Penetrating pancreatic trauma is often associated with
vascular injury.
Diagnosis
Penetrating pancreatic injury is diagnosed and evaluated
in the operating room. Pancreatic injury due to blunt
trauma, on the other hand, can be difficult to diagnose.
The mechanism of injury is usually a blow to the upper
abdomen, often caused from being slammed against the
steering wheel in car accidents. The patient may complain
of upper abdominal pain radiating to the region of L-1.
Ecchymosis may be present in the epigastrium. Signs of
peritoneal irritation may or may not be present. Serum
amylase is elevated in approximately 70% of cases; hence,
normal levels of serum amylase do not exclude the presence of pancreatic injury. When the possibility of pancreatic injury is seriously entertained, or when the serum
amylase level is elevated, a CT scan should be obtained.
The CT scan may show swelling of the pancreas, mass
effect, or rarely, fracture of the pancreas at its neck (Figure
11.7). Pancreatic duct injury may sometimes be detected.
Management
All patients with penetrating trauma require prompt
abdominal exploration. The indication for surgery in
blunt trauma is not clear. A patient who is hemodynamically stable and without peritoneal signs, but who has
evidence of pancreatic injury because of CT findings or
elevated serum amylase, may be observed with repeated
abdominal examinations. Such a patient usually has a
Class I injury. Patients with severe disruption of the pancreas, however, require operative treatment.
A midline incision is performed and careful exploration of the abdomen undertaken. Thorough examination of the pancreas requires complete mobilization of the
head by the Kocher maneuver. An associated duodenal
injury will be evident if present. The lesser sac is entered
through the gastrocolic omentum, and the anterior surface
of the pancreas is carefully examined. Complete examination of the body and tail of the pancreas requires reflecting the spleen and the pancreas medially after division of
the lateral attachments of the spleen. Further management
depends on extent of the injury.
Class I Injury
Simple contusions (Class I injury) of the pancreas should
be treated nonoperatively. If an operation must be performed for other indications, however, it is judicious to
establish closed-suction drainage of the lesser sac.
Class II Injury
Class II injury involves laceration of the body or tail of the
pancreas. One such injury is fracture of the pancreas at its
neck as a result of blunt trauma (Figure 11.7). In these
injuries, the surgeon encounters a hematoma of the body
or tail of the pancreas. The key question at that point—
whether there is disruption of the pancreatic duct—is
TABLE 11.3. Classification and Surgical Management of Pancreatic Injury
Class Type of injury Treatment
I Simple contusions Observation ± lesser sac drainage
II Lacerations of the No ductal injury: Drainage of lesser sac
parenchyma in the
body or tail
III Severe disruption of
䊏
Involving head: Drainage ± gastrostomy and jejunostomy
the head or body
䊏
If severe: Pancreaticoduodenectomy
䊏
If involving body: Distal pancreatectomy
IV Associated with
䊏
Simple duodenal injury: Primary repair and drainage
duodenal injury
䊏
Complex duodenal injury: Primary repair and pylorus exclusion
䊏
Severe disruption: Pancreaticoduodenectomy
FIGURE 11.7. Pancreatic fracture. This CT scan shows a fracture (arrow) of the neck of the pancreas
due to blunt abdominal trauma. The pancreas (P) is surrounded by fluid but otherwise appears
normal. (Courtesy of Vincent McCormick, MD.)
often difficult to answer. Operative pancreatogram can be
obtained but requires opening the duodenum. This procedure is used rarely and only if ductal injury is seriously
suspected. If available, on-table endoscopic retrograde
cholangiopancreatography (ERCP) should be done.
Otherwise, the hematoma should be opened to facilitate
operative evaluation for ductal injury. If no ductal injury
is present, only drainage of the lesser sac is necessary. If
ductal disruption is present, however, distal pancreatectomy should be performed.
Class III Injury
Class III injury involves severe disruption of the head or
body of the pancreas. When the body of the pancreas is
involved, the injury is treated with distal pancreatectomy.
When the head is disrupted, however, the options are
simple drainage or pancreaticoduodenectomy. The latter
procedure is associated with a high mortality rate, and
the surgeon may opt instead for drainage. If drainage is
elected, a pancreatic fistula and protracted postoperative
course should be anticipated. Hence, gastrostomy and
feeding jejunostomy are advisable. Opening the gastrointestinal tract, however, increases the risk of infection;
therefore, some surgeons prefer only total parenteral
nutrition (TPN) and nasogastric drainage.
Class IV Injury
In Class IV trauma, both the pancreas and the duodenum
are injured. Typically, the injury is to the pancreatic head.
Surgical treatment depends on the severity of injury.
Simple duodenal injuries are primarily repaired, and the
pancreatic injury is managed by drainage. If this is possible, the addition of tube gastrostomy and feeding
jejunostomy is wise. More complicated injury of the
duodenum requires the pylorus exclusion procedure.
Massive injuries of the duodenum and pancreas require
pancreaticoduodenectomy.
HEPATIC INJURY
The liver, the largest solid organ in the abdomen, is frequently injured in both blunt and penetrating trauma.
Blunt trauma is more common, accounting for 85% of
all cases of liver injury. In the urban setting, however, the
incidence of penetrating trauma may be higher. The most
common cause of blunt hepatic trauma is motor vehicle
accident. The force required to injure the liver causes associated injuries of other organs in approximately 65% of
cases of penetrating trauma and approximately 10% of
blunt trauma. The single most important recent change in
management of blunt trauma to the liver is the application of nonoperative treatment. Perhaps the single most
important recent development that has made nonoperative management possible is accurate imaging of the liver
and abdomen by CT, ultrasound, and MRI. The incidence
of missed injury when nonoperative treatment is applied
to blunt liver trauma is now less than 1%; most of these
associated injuries are enteric.
Table 11.4 gives the organ injury scale of the American
Association for the Surgery of Trauma. With each increase
in injury grade, there is an associated increase in the sever-
342 ............................................................................................................................ Abdominal T rauma
M anagement of Specific I ntraabdominal Organ I njuries.................................................................... 343
ity of the injury. Most liver injuries are Grades I through
III and most can be treated nonoperatively.
Diagnosis
Physical examination alone is not reliable because it can
miss 50% of hepatic injuries. Diagnostic peritoneal lavage
(DPL) was once the mainstay of diagnosis and remains
so wherever modern imaging techniques are unavailable.
DPL, however, does not enable a physician to assess the
severity of liver injury itself and, when a positive tap is
the basis for laparotomy, 3% to 25% of patients undergo
unnecessary exploration. Indeed, more than 50% of
patients with liver injuries are not bleeding when laparotomy is performed on the basis of positive DPL.
Ultrasound scanning, often done by the surgeon, is an
expeditious way to determine whether or not liver injury
is present. Major limitations of the technique are that its
accuracy is operator-dependent and, unless the injury is
appreciated during the examination, the test lacks specificity when free fluid within the abdomen is the only sign.
Hence, CT scan and, increasingly, MRI are necessary to
assess liver trauma, even after DPL has indicated the presence of injury. CT scan may show a fracture of the liver
or large parenchymal injury (Figure 11.8). CT scan or
MRI, however, can be done safely only if the patient is
hemodynamically stable. A patient with positive DPL who
is hemodynamically unstable requires prompt surgical
exploration of the abdomen. CT scan facilitates accurate
assessment of the severity of liver injury, but even then, the
decision to operate depends not on the CT findings, but
on the patient’s hemodynamic stability.
Blunt Liver Trauma
ATLS guidelines are used for resuscitation. The response
to resuscitation is a key determinant of whether operative
treatment is necessary.
Nonoperative Treatment of Hepatic Trauma
Patients can almost always be treated nonoperatively.
Many are adequately resuscitated with crystalloids. Patients who require blood transfusions and never become
stable during resuscitation require surgery. Another group
of patients comprises those who are resuscitated to hemodynamic stability but require continuous administration
of large amounts of fluids and blood transfusions to maintain blood pressure. Surgical decision-making is most difficult in this group. The issue is whether to undertake early
surgical exploration or better evaluate vascular trauma by
performing angiography, which may also enable transcatheter embolization to control bleeding (Figure 11.9).
The latter choice depends on available physical resources
and technical expertise. Table 11.5 outlines the criteria for
nonoperative management of patients with blunt liver
injuries. When these criteria are used, nonoperative management is usually successful, but failure necessitates
immediate operation.
C
OMPLICATIONS OF NONOPERATIVE TREATMENT
1. Hemobilia. This condition results from the formation of an intrahepatic vascular fistula and is seen in 0.2%
to 0.3% of blunt liver injuries. Symptoms include: (a)
upper gastrointestinal bleeding, manifested usually as
melena and infrequently as hematemesis; (b) jaundice;
and (c) right upper quadrant colicky pain. CT scan shows
intrahepatic artery pseudoaneurysm and hepatic angiography confirms this. Nearly all patients can be successfully
treated with angiographic embolization.
2. Delayed hemorrhage. This occurs in fewer than 3%
of patients with blunt trauma treated nonoperatively.
Hepatic angiography can identify the site of bleeding.
Control of bleeding is usually accomplished with transcatheter embolization.
3. Liver abscess and biloma. These occur with an
incidence of less than 0.5%. Liver abscess and a persistent
biloma are successfully treated with percutaneous catheter
drainage. When abscess is present, broad-spectrum antibiotic treatment is also required.
4. Extrahepatic bile duct injury. This infrequent complication is probably a result of increased survival of
patients with serious liver injury. Jaundice and subhepatic
fluid accumulation seen on ultrasonographic examination
suggest the diagnosis. Definite confirmation is obtained by
ERCP. The injury may be amenable to treatment by endoscopic stenting but in most cases requires operative intervention and, ultimately, hepaticojejunostomy.
TABLE 11.4. Liver Injury Scale: American Association for the
Surgery of Trauma
Grade Injury
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm depth
II Hematoma Subcapsular, 10%–50% surface area
Intraparenchymal, <10 cm diameter
Laceration 1–3cm depth, <10 cm in length
III Hematoma Subcapsular, >50% surface area or expanding
Intraparenchymal, >10 cm or expanding
Laceration >3cm depth
IV Laceration Parenchymal disruption of 25%–75% hepatic
lobe or 1–3 segments within single lobe
V Laceration Parenchymal disruption of >75% hepatic lobe
or >3 segments within single lobe
Vascular Juxtahepatic venous injuries, i.e., retrohepatic
vena cava/central major hepatic veins
VI Vascular Hepatic avulsion
Source: Reprinted with permission from Moore EE, et al. Organ injury
scaling: spleen and liver. J Trauma 1995;38:323–324.
A
B
FIGURE 11.8. Major hepatic trauma. (A) This CT scan of the liver demonstrates a well-defined fracture
of the left lobe due to a steering wheel injury (arrows). (B) CT scan in another patient following a
motor vehicle accident demonstrates a large intrahepatic parenchymal injury (arrows) in the right lobe
of the liver. (Courtesy of Henry I. Goldberg, MD, and Vincent McCormick, MD.)
344 ............................................................................................................................ Abdominal T rauma
A
B
FIGURE 11.9. Selective hepatic angiogram in trauma. (A)
Arteriogram performed after a CT scan demonstrates hepatic
laceration with extravasation of contrast material. The arterial
supply of the bleeding site (arrow) is a branch of the hepatic
artery. (B) A catheter is placed selectively (small arrows) into
the hepatic artery branch feeding the bleeding site (large
arrow). (C) The bleeding site (arrow) is embolized by instilling
coils through the selectively placed catheter to control
bleeding. (Courtesy of Henry I. Goldberg, MD.)
C
M anagement of Specific I ntraabdominal Organ I njuries.................................................................... 345
TABLE 11.5. Indications for Nonoperative Management in
Blunt Liver Injuries
1. Hemodynamic stability on admission or after initial
resuscitation
2. CT-scan evidence of liver injury and little free intraperitoneal
blood
3. Absence of CT evidence of enteric or retroperitoneal injury
4. Liver-related blood transfusion of 4 U or less
5. CT-documented improvement or stabilization of liver injury,
when indicated
Source: Reprinted with permission from Carrillo EH, Wohltmann C,
Richardson JD, et al. Evolution in the treatment of complex blunt liver
injuries. Curr Probl Surg 2001;38:1–60.
Abbreviation: CT, computerized tomography.
5. Posttraumatic liver cyst. This rare complication
causes right upper quadrant pain, mild jaundice, increased
abdominal girth, and anorexia. Diagnosis is established
by ultrasound or CT scan. Treatment with percutaneous
drainage may be attempted, but the scant available experience with this complication suggests that operative
drainage with decortication is often required.
Operative Treatment of Hepatic Trauma
All patients with penetrating injuries and those who fail
nonoperative management of blunt liver trauma require
operative treatment. A midline incision is used and can
be extended into median sternotomy or a right anterior
thoracotomy incision if necessary. Subcapsular
hematomas due to blunt injury (Figure 11.10) require surgical treatment if they undergo progressive expansion as
detected by CT scan or if ongoing bleeding is documented
by angiography.
The required procedure depends on type and extent
of injury, but the principles of surgical treatment are
always the same. They include: (1) control of bleeding, (2)
removal of devitalized tissue, and (3) establishment of
adequate drainage. Any associated diaphragmatic injury
must be located and repaired.
Specific Approaches to Hepatic Injuries
Specific approaches to specific types of hepatic injuries are
as follows:
1. Subcapsular hematoma. The hematoma is opened
and evacuated. Control of bleeding is accomplished by
exploration of the underlying liver fracture and ligation of
bleeders. If control cannot be accomplished by ligation of
bleeders within the liver parenchyma, the Pringle maneuver should be attempted. The Pringle maneuver is accomplished by compressing the portal triad manually or using
noncrushing vascular clamps. If the Pringle maneuver
controls bleeding, it may be necessary to ligate the hepatic
artery as close to the liver as possible.
2. Major parenchymal disruption. Parenchymal disruption requires removal of all dead tissue and control
of bleeding. When the injury is unilobar and extensive,
the treatment of choice is formal lobectomy. When the
parenchymal disruption is central or massive, if bleeding
cannot be controlled and coagulopathy develops, the
injury should be packed and the abdomen closed. Subse-
FIGURE 11.10. Subcapsular liver hematoma. The CT scan in a patient hit by a tractor shows a large
subcapsular hematoma (H) deforming the liver (L). (Courtesy of Henry I. Goldberg, MD.)
346 ............................................................................................................................ Abdominal T rauma
M anagement of Specific I ntraabdominal Organ I njuries.................................................................... 347
quent operation to remove the packing is undertaken in
24 to 72h, by which time bleeding may have stopped. If
not, suture control or hepatic resection is performed (see
Figure 6.20). Adequate sump drainage must also be
instituted.
3. Retrohepatic caval injury. This Grade IV injury is
associated with a high rate of mortality. Survival depends
on promptness of operation and speed with which bleeding is controlled. The diagnosis is usually made intraoperatively when the Pringle maneuver fails to control
bleeding. The midline abdominal incision is extended into
a median sternotomy. Control of the infrahepatic inferior
vena cava above the renal veins and the suprahepatic vena
cava is obtained. A large shunt is then inserted through a
pursestring suture in the right atrium, advanced into the
inferior vena cava to below the renal arteries, and secured
in place by occlusion at the previously dissected infra- and
suprahepatic sites. Although repair of retrohepatic caval
injury may be attempted with total venous occlusion,
intracaval shunt is preferred due to the significant incidence of severe hypotension associated with the former
approach.
Complications of Operative Treatment of
Liver Injury
COMPLICATIONS DUE TO MASSIVE BLO OD TRANSFUSION
In severe liver injury, where bleeding is excessive and
massive blood transfusion is needed, hypothermia and
coagulopathy commonly occur. Prevention of these complications requires warming of all fluids and blood administered intravenously. To prevent dilutional coagulopathy,
coagulation studies including platelet count should be
measured after 8 to 10U of blood are transfused; based on
these measurements, fresh-frozen plasma and/or platelets
should be given as necessary.
C
OMPLICATIONS DUE TO HEPATIC RESECTION When a
significant portion of liver is resected, complications may
develop including hypoglycemia, coagulopathy, hyperbilirubinemia, and hypoalbuminemia. Hypoglycemia is
caused by a loss of glycogenolysis and can be prevented by
continuous administration of 10% glucose in water. Coagulopathy is treated with administration of fresh-frozen
plasma or specific coagulation factors. Hyperbilirubinemia
is transitory and requires no specific therapy. Hypoalbuminemia may require albumin administration, but patients
with mild symptoms can be treated with TPN. These four
complications are transient and improve with rapid liver
regeneration.
C
OMPLICATIONS DUE TO BILE DUCT INJURY Intrahep-
atic injuries can lead to hemobilia or biloma (see discussion above under “Management of Blunt Liver Trauma”).
Extrahepatic bile duct injury can lead to biliary fistula or
stricture. Some of these injuries may be amenable to endoscopic stenting with ERCP but many require hepaticoje-
junostomy at a later date. Fortunately, these complications
are uncommon.
S
EPTIC COMPLICATIONS Intraabdominal or intrahep-
atic abscess can occur and cause fever and leukocytosis.
Diagnosis is confirmed with ultrasound or CT scan. The
abscess may be successfully treated with percutaneous
catheter drainage and broad-spectrum antibiotics.
INJURY OF THE SMALL INTESTINE
Although uncommon in blunt abdominal trauma, injury
of the small intestine is the most commonly encountered
injury after penetrating abdominal trauma. Injuries can
vary from simple bruising to small perforation, massive
disruption, and devascularization.
Diagnosis
All patients with penetrating trauma are promptly
explored, looking for small intestinal injury by carefully
examining the small bowel from the ligament of Treitz to
the ileocecal valve. Diagnosis of small bowel injury in
blunt trauma is readily made in the conscious patient who
develops symptoms of peritoneal irritation. It is considerably more difficult in the unconscious patient, in whom
intestinal injury is best diagnosed with DPL. DPL is positive if gross blood is present in free aspiration or if, after
peritoneal irrigation with 1 L of saline, there are ≥100,000
RBC/mL; ≥500 WBC/mL; ≥175 U amylase/dL; bacteria on
Gram stain; bile; or food particles. The presence of
amylase, bacteria, bile, and food particles is particularly
suggestive of small bowel injury. Plain films of the
abdomen may show an ileus but rarely, if ever, free air in
the peritoneal cavity.
Treatment
An operation should be performed promptly. A midline
incision is used and complete exploration undertaken.
Two types of injury are seen in blunt abdominal trauma:
mesenteric tear and intestinal perforation. Tears of the
mesentery may be small and bleeding readily controlled
without compromising the blood supply of the small
bowel. At times, however, rents in the mesentery are large,
and blood supply of a segment of the small intestine is
compromised. In this case, bowel resection and primary
anastomosis are necessary.
Perforation of the jejunum or ileum usually occurs in
association with other injuries. In Chance’s fracture,
caused by a seat belt injury in motor vehicle accidents, a
proximal jejunal or distal ileal perforation, usually single,
is found in association with vertebral fracture. This injury
can usually be repaired in two layers transversely without
compromising bowel lumen.
As mentioned earlier, penetrating injuries are more
common. Wounds from sharp objects may be single or
multiple and may involve other organs in the abdomen.
348 ............................................................................................................................ Abdominal T rauma
They are amenable to debridement of the edges and
closure in two layers. It is critical to examine the whole
length of the small intestine and colon before beginning
repair. Bullet wounds of the abdomen cause more severe
and more complex injuries.
Whether trauma is blunt or penetrating, the surgical
decision to be made is whether to close individual perforations or to resect a segment of small intestine. Resection
is indicated when: (1) half the circumference of the bowel
is missing after debridement; (2) several holes are present
within a short segment of intestine (e.g., 2–3 feet); and (3)
perforation of the terminal ileum is associated with injury
of the right colon, in which case right hemicolectomy may
be the appropriate treatment.
COLONIC INJURY
Ninety-five percent of colon injuries are due to penetrating trauma, caused most often by bullet wounds. The diagnosis and evaluation, therefore, is relatively simple. Colon
perforation nearly always results in signs and symptoms of
peritonitis. Should plain abdominal films be obtained, free
air is usually seen in the peritoneal cavity (Figure 11.11).
The key to minimizing morbidity and mortality is early
surgical treatment.
Treatment
All patients with suspected colon injury should be given
broad-spectrum antibiotics intravenously. Selective use of
tetanus toxoid is indicated, depending on the vaccination
history. Controversy has raged for years over whether or
not to perform primary closure of perforation and, if
resection is required, whether or not to perform primary
anastomosis. The surgeon should use common sense.
Simple perforations of the colon not associated with much
contamination can be treated with debridements and
primary closure, especially when treated early. When treatment is delayed or when there is significant fecal peritonitis, exteriorization of the perforated colon or diversion of
the fecal stream may ultimately be safer.
When resection is necessary, primary anastomosis can
be performed safely in low-risk patients; these include
those with early injury, absence of preoperative hypotension, fewer than three organs injured, and less than 1 L of
blood in the peritoneal cavity.Some surgeons advocate ontable colon irrigation to achieve mechanical preparation;
others have used intracolonic bypass tube (Coloshield)
to protect the anastomosis. Several contraindications to
primary anastomosis must be cited when:
1. Colon injury is associated with multiple organ trauma.
2. The patient is in shock.
3. The colon is fecally loaded or significant fecal contamination of the peritoneal cavity is present.
4. Treatment is delayed more than 6h and peritonitis has
developed.
RECTAL INJURY
Most rectal injuries are due to bullet wounds. The rectum
can also be perforated by displaced pelvic fracture as a
result of a motor vehicle accident or sexual misadventure.
Diagnosis
When rectal perforation is above the peritoneal reflection,
signs and symptoms are similar to those of colonic perforation. Rectal perforation below the peritoneal reflection
may be difficult to diagnose unless suspected. Most rectal
injuries are diagnosed preoperatively. Blood on digital
examination is seen in approximately 80% of cases. Proctosigmoid examination establishes the diagnosis in fewer
than 75% of cases. If the diagnosis is still in question, a
low-pressure x-ray examination with water-soluble contrast medium should be performed.
Treatment
Perforation of the intraperitoneal rectum is treated with
debridement and closure in two layers, then protection by
sigmoid loop colostomy. If the injury is severe, however,
Hartman’s procedure is more appropriate.
Rectal injury below the peritoneal reflection is more
difficult to treat. The main principles are:
1. Closure of perforation whenever possible.
2. Construction of diverting sigmoid loop colostomy.
3. Closed sump drainage of the pelvis.
4. Presacral drainage via the perineum posterior to the
anus.
5. Irrigation of distal rectal stump.
Retroperitoneal Hematoma
Retroperitoneal hematoma is diagnosed with imaging
techniques or at the time of laparotomy. For decisionmaking purposes, retroperitoneal hematoma is classified
by three zones (Figure 11.12).
S
URGICAL MANAGEMENT
1. Zone 1 retroperitoneal hematoma must always be
explored. This is best done by reflecting the ascending
colon and small intestine to the left after incising the peritoneal reflection laterally (Cattell maneuver). The most
common injuries associated with this type of hematoma
are: (a) retroperitoneal duodenal rupture, (b) injury to the
head of the pancreas, and (c) vascular injury.
2. Zone 2 retroperitoneal hematomas need not be
explored provided: (a) they are not expanding, (b) colon
injury is not suspected, and (c) CT or angiographic studies
have shown a functioning kidney on that side. Expanding
hematomas must be explored and may be due to avulsion
of the renal pedicle. Hence, before opening the hematoma,
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