Presentation for a teaching session.

1. MANAGEMENT OF GREAT
ABDOMINAL VESSELS INJURIES
Raimundas Lunevicius MD PhD
King’s College Hospital London

2. Definition
§ The term Abdominal vascular injury refers to
injury to vessels located in zone I, zone 2,
zone 3, and zone 4

3. Clinical epidemiology
§ 14% from the whole body arterial injuries (1970)
§ Increasing in civil urban environment
§ Emory University Trauma: > 30 patients a year
§ 34% from all cardiovascular injuries
§ Main cause: penetrating mechanisms: 90-95%
ú Abdominal gunshot wounds: 20-25% vascular inj
ú Abdominal stab wounds: 10% vascular inj
ú Abdominal blunt trauma: 5% of cases
Goaley, Dente, Feliciano, 2006

4. Distribution of 226 acute
arterial injuries: 24 deaths
Civilian Vascular Injuries: A Critical Appraisal of Three Decades of Management. Drapanas et al. Ann Surg 1970
Frequency
1. Radial, ulnar: 20%
2. Brachial: > 17 %
3. Femoral: 17 %
4. Subclavian
5. Popliteal
6. Thoracic aorta: 5%
7. Carotid
8. Axillary
9. Abdominal aorta: 5%
10. Other abdominal: 3%
11. Iliac: 4%
12. Tibial
All abdominal vascular injuries: 14%

5. Patients with significant penetrating abdominal
injury tend to fall into 3 major categories:
§ Pulseless
ú Major vascular injury
Emergency laparotomy / Consider ED thoracotomy
§ Haemodynamically unstable
ú Vascular and/or solid organ injury AND/OR
Haemorrhage from other sites
Identify & control haemorrhage
§ Haemodynamically stable
ú Hollow viscus injury; Pancreas or renal
Identify & manage

6. Major abdominal vascular injuries are classified
as occurring in one of four zones described as follows
Goaley, Dente, Feliciano. PERSPECT VASC SURG ENDOVASC THER 2006 18: 102
Zone Location Major vessels
I Midline Retroperitoneum
Supramesocolic Region
Inframesocolic Region
suprarenal aorta,
celiac axis,
proximal superior mesenteric artery,
proximal renal artery,
superior mesenteric vein
infrarenal aorta,
infrahepatic inferior vena cava
II Upper Lateral Retroperitoneum renal artery and renal vein
III Pelvic Retroperitoneum common, external and internal iliac
arteries and veins
IV Porta Hepatis portal vein,
hepatic artery,
retrohepatic inferior vena cava

7. Magnitude of injury
§ Abdominal Vascular Organ Injury Scale grading
(described in 1992 by AAST):
ú AAST OIS:
II – V for injuries to great vessels of abdomen

8. Systematization of retroperitoneal hematoma according to
Feliciano et al., and Asensio et al
Management of penetrating abdominal vessel injuries. X. Chapellier, P. Sockeel and B. Baranger. J Visc Surg 147
(2), 2010: e1-e12
§ in violet (Zone IV); the portal and
retrohepatic area include the infra- and
retrohepatic inferior vena cava and the hepatic
pedicle;
§ in blue (Zone II) , the flanks include the
renal pedicles
§ in light yellow (Zone I), the
supramesocolic central column includes the
suprarenal aorta and its branches, including
the celiac axis and the superior mesenteric
artery
§ in yellow (Zone I), the inframesocolic
central column includes the aorta, from the
renal arteries to the iliac bifurcation, the
infrarenal inferior vena cava and the attributes
of the portal trunc
§ in white (Zone III), the pelvis includes
the common, internal and external iliac
arteries, as well as their veins of the same
name

9. Zone I injuries: supramesocolic

10. Zone I: Injuries in
Supramesocolic Region
Artery Procedure Survival
Aorta PROXIMAL CONTROL
• Suture: transverse
• Patch aortoplasty PTFE
• Interposition PTFE
21 – 50%
Celiac artery / axis Ligation +
cholecystectomy (?)
38%
100% (1), 33% (2), o% (3)
Common hepatic artery Ligation +
cholecystectomy (?)
Splenic artery Ligation + splenectomy
Left gastric artery Ligation

11. Proximal aorta control
§ Clamping
ú Transabdominal approach: >
ú Transthoracic approach: <

12. Compression of supraceliac aorta

14. Management of penetrating abdominal vessel injuries
X. Chapellier, P. Sockeel and B. Baranger.
Journal of Visceral Surgery
Volume 147, Issue 2, April 2010, Pages e1-e12
§ Laparotomy:
§ clamping the aorta at the
diaphragmatic hiatus,
§ the left liver retracted to the
right, the lesser omentum widely
opened, a nasogastric tube helps
to identify the esophagus which
can be retraced with the
stomach to the left;
§ radial phrenotomy facilitates
exposure and opening the
periaortic tissues and allows
clamping the aorta without
having to dissect the posterior
aspect.

15. Management of penetrating abdominal vessel injuries
X. Chapellier, P. Sockeel and B. Baranger.
Journal of Visceral Surgery
Volume 147, Issue 2, April 2010, Pages e1-e12
§ Emergency thoracotomy:
§ anterolateral incision in the
fifth left costal interspace.
Pushing the lung upwards,
dividing the triangular
ligament and opening the
pleura over the aorta, to
free the aorta on all its
aspects in order to clamp
the aorta quickly under the
left pulmonary pedicle.

16. Mattox manuever

17. Zone I: Injuries of superior
mesenteric artery
Superior
mesenteric artery
Definition Procedure
Fullen zone I Beneath the pancreas Exposure requires:
• Transsection of the
pancreas or
• Left-sided medial visceral
rotation (Mattox maneuver)
Aorta complete control
Intraluminal shunt,
stabilize – and definitive
Fullen zone II Between the pancreaticoduodenal
and the middle colic branches /
between pancreas and base of
transverse mesocolon
Intraluminal shunt,
stabilize -
saphenous vein or PTFE
bypass
Fullen zone III Beyond middle colic branch Must be repaired
Fullen zone IV Level of enteric branches Must be repaired

18. Fullen zone I of SMA:
Left-sided medial visceral rotation
(Mattox maneuver)

19. Fullen zone I/II of SMA:
definitive repair by PTFE bypass

20. Zone I: Injuries of superior
mesenteric vein
§ Digital control + Definitive repair
ú Behind the pancreas: pancreatic transsection
ú Continuous 5-0 polypropylene suture
§ Damage control setting SMV can be ligated
ú Vigorous postoperative fluid resuscitation
ú Consider ‘open abdomen’ approach (bowel
edema)
ú Survival rate up to 85%

21. Zone I: Injuries in Inframesocolic
Region: penetrating / blunt
Artery Procedure Survival
Aorta PROXIMAL and DISTAL CONTROL
EXPOSURE at the base of tran. Mesocolon
(Mattox maneuver)
• Suture: transverse (3-0)
• Patch aortoplasty PTFE
• Interposition PTFE
Inferior vena cava:
infrahepatic
Exposure:
right medial visceral rotation: Cattell-Braasch
Repair (! junction of the renal veins, confluence of
common iliac veins)
Definite: Repair
Damage control: Ligation:
1. Immediate bilateral below-knee 4-compartment
fasciotomies
2. Possible bilateral thigh fasciotomies within the first 48
hours
3. Aggresive fluid resuscitation
4. Bilateral lower extremity elastic compression wraps
5. Bilateral lower extremity elevation for 5 to 7 days.

22. Mattox maneuver to expose
inframesocolic aorta

23. Kocher + Cattell-Braasch maneuvers

24. Kocher + Cattell-Braasch
maneuvers performed

25. Management of penetrating abdominal vessel injuries
X. Chapellier, P. Sockeel and B. Baranger.
Journal of Visceral Surgery
Volume 147, Issue 2, April 2010, Pages e1-e12
§ Midline laparotomy and
intraoperative view on the left side
of the patient: gun shot wound of
the inferior vena cava.
§ Control by direct compression.
§ Abdominal pads have been placed in
all four quadrants, allowing for
summary exploration.
§ Peritoneal inundation with
intrahepatic retroperitoneal
hematoma were found.
§ Dissection of the right Told fascia,
bascule of viscera to the left, allows
to identify the inferior vena cava
wound (operator's finger).

26. Systematization of retroperitoneal hematoma according to
Feliciano et al., and Asensio et al
Management of penetrating abdominal vessel injuries. X. Chapellier, P. Sockeel and B. Baranger. J Visc Surg 147
(2), 2010: e1-e12
§ in violet (Zone IV); the portal and
retrohepatic area include the infra- and
retrohepatic inferior vena cava and the hepatic
pedicle;
§ IN BLUE (ZONE II) , the flanks include
the renal pedicles
§ in light yellow (Zone I), the
supramesocolic central column includes the
suprarenal aorta and its branches, including
the celiac axis and the superior mesenteric
artery
§ in yellow (Zone I), the inframesocolic
central column includes the aorta, from the
renal arteries to the iliac bifurcation, the
infrarenal inferior vena cava and the attributes
of the portal trunc
§ in white (Zone III), the pelvis includes
the common, internal and external iliac
arteries, as well as their veins of the same
name

27. Injuries in Zone II
Blunt Trauma Penetrating Trauma
Stable CT: conservatively
If celiotomy and stable
hematoma: do not open
retroperitoneum unless it
is ruptured, pulsatile, or
expanding
• CT: conservatively
• No CT: celiotomy with
exploration of zone II
(kidney and renal a +v) +
definitive procedure
Not-stable Surgery: definitine.
Consider nephrectomy, if
two kindeys
Surgery: definitive
Consider nephrectomy, if
two kindeys

28. Systematization of retroperitoneal hematoma according to
Feliciano et al., and Asensio et al
Management of penetrating abdominal vessel injuries. X. Chapellier, P. Sockeel and B. Baranger. J Visc Surg 147
(2), 2010: e1-e12
§ in violet (Zone IV); the portal and
retrohepatic area include the infra- and
retrohepatic inferior vena cava and the hepatic
pedicle;
§ in blue (Zone II) , the flanks include the
renal pedicles
§ in light yellow (Zone I), the
supramesocolic central column includes the
suprarenal aorta and its branches, including
the celiac axis and the superior mesenteric
artery
§ in yellow (Zone I), the inframesocolic
central column includes the aorta, from the
renal arteries to the iliac bifurcation, the
infrarenal inferior vena cava and the attributes
of the portal trunc
§ IN WHITE (ZONE III), the pelvis
includes the common, internal and external
iliac arteries, as well as their veins of the same
name

29. Injuries in Zone III
Vessels Blunt Trauma Penetrating
Trauma
Stable Arteries / veins Arteriography:
embolization
(with / without
fractures)
REPAIR:
CIA, EIA
CIV, EIV
Not-stable
Arteries / veins DAMAGE
CONTROL:
• Argyle shunt (Art)
• Ligation
REPAIR OF
ARTERIES (when
stabilized): several
options
DAMAGE
CONTROL:
• Argyle shunt
• Ligation
REPAIR OF
ARTERIES (when
stabilized): several
options

30. Systematization of retroperitoneal hematoma according to
Feliciano et al., and Asensio et al
Management of penetrating abdominal vessel injuries. X. Chapellier, P. Sockeel and B. Baranger. J Visc Surg 147
(2), 2010: e1-e12
§ IN VIOLET (ZONE IV); the portal and
retrohepatic area include the infra- and
retrohepatic inferior vena cava and the hepatic
pedicle;
§ in blue (Zone II) , the flanks include the
renal pedicles
§ in light yellow (Zone I), the
supramesocolic central column includes the
suprarenal aorta and its branches, including
the celiac axis and the superior mesenteric
artery
§ in yellow (Zone I), the inframesocolic
central column includes the aorta, from the
renal arteries to the iliac bifurcation, the
infrarenal inferior vena cava and the attributes
of the portal trunc
§ in white (Zone III), the pelvis includes
the common, internal and external iliac
arteries, as well as their veins of the same
name

31. Zone IV injuries: penetrating or blunt
§ Portal area:
ú Hematoma
ú Pringle maneuver
ú All components of portal triad
may be injured
CHD and CBD disect away from
vessels
ú Repair: PHA ligation? +
cholecystectomy
ú 4-0 polypropylene suture
§ Retrohepatic area:
ú Do not open hematoma unless
it is
Ruptured
Pulsatile
Rapidly expanding

32. Damage-control technique
§ Damage control is operative technique in which
control of bleeding and stabilization of vital signs
becomes the only priority in salvaging the patient.
§ This usually occur during laparotomy when there is
significant bleeding in the abdomen.
§ Attention is directed at using all available techniques
for controlling bleeding, including packing.
§ Definitive repair of bowel or visceral injuries is not
attempted and temporary wound closure is used.
§ Definitive procedure is performed after the patient is
stabilized.

33. Damage control vs definitive procedure

34. Damage control laparotomy
§ Injury of great abdominal vessels: ideal
candidates
ú Packing in most cases + spillage control
ú Plastic back is sewn to the skin edges
ú SCCU / SICU
ú Relaparotomy within 48 – 72 hours
§ When massive distension of midgut persist after
7 days in SICU and use of vacuum assisted
closure device
ú convert the patient to an open abdomen
ú cover with a double-thickess layer of absorbable mesh

35. References
1. Trauma Manual, by Moore, Matox, Feliciano, 2003
2. Goaley, Dente, Feliciano. PERSPECT VASC SURG ENDOVASC
THER 2006 18: 102
3. Civilian Vascular Injuries: A Critical Appraisal of Three Decades of
Management. Drapanas et al. Ann Surg 1970
4. Management of penetrating abdominal vessel injuries. X. Chapellier, P.
Sockeel and B. Baranger. J Visc Surg 147 (2), 2010: e1-e12
5. Clinical Manual, R Adams Cowley Schock Trauma Centre, University
of Maryland Medicine, 2005
6. Top knife, by Hirshberg, Mattox, 2005
7. ACS Surgery, Principles & Practice. 2007.
8. http://www.trauma.org (21 Nov 2010, date last access)