Traumatic Retroperitoneal Hematoma

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Traumatic Retroperitoneal Hematoma Spreads Through the Interfascial Planes
J Trauma. 2005;59:595– 608.

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Traumatic Retroperitoneal Hematoma

  1. 1. Traumatic Retroperitoneal Hematoma Spreads Through the Interfascial Planes Volume 59(3), September 2005, pp 595-608
  2. 2. BACKGROUND • In the early 1980s, Sheldon introduced a treatment principle founded on a location-based classification of traumatic RH as 1. Central-medial (zone I) RH 2. Flank or perirenal (zone II) RH 3. Pelvic (zone III) RH • Feliciano established management strategies for various kinds of traumatic RH by sub-dividing the zones and by focusing on vascular injuries
  3. 3. 1. Central-medial (zone I) RH 2. Flank or perirenal (zone II) RH 3. Pelvic (zone III) RH
  4. 4. • Traditionally, the retroperitoneal space was believed to comprise only 3 compartments: 1. Anterior pararenal space (APS) 2. Perirenal space (PRS) 3. Posterior pararenal space (PPS) which are demarcated by 3 well- defined fascias: 1. Anterior renal fascia 2. Posterior renal fascia 3. Lateroconal fascia
  5. 5. Traditional tricompartmental theory New concept of interfascial planes anterior renal fascia posterior renal fascia lateroconal fascia retromesenteric plane retrorenal plane lateroconal plane 1. anterior pararenal space (APS) 2. perirenal space (PRS) 3. posterior pararenal space (PPS)
  6. 6. retrorenal plane retromesenteric plane combined interfascial plane Traditional tricompartmental theory New concept of interfascial planes
  7. 7. Spread of renal lesion by means of perinephric bridging septa and interfascial planes
  8. 8. Track of Perinephric Hematoma An 80-year-old man suffered renal injury from a motorcycle crash. Midlevel of a left renal CT scan shows extension of the perinephric hematoma along the perinephric bridging septa (dotted arrow), RMP (open arrow), and RRP (open arrowhead). Note that RH within the RMP traverses the midline, anterior to the aorta and inferior vena cava, and that RH extends into the LCP (closed arrowhead) by means of the fascial trifurcation (FT) (thin arrow). Perinephric bridging septa provide the conduit between the kidney and interfascial planes. This is considered Zone I + Zone II RH and Type II-a RH.
  9. 9. PATIENTS AND METHODS • Between January 1997 and December 2003, 594 trauma patients required abdominal or pelvic CT scans for evaluation of abdominal or pelvic injury within 24 hours after admission to Osaka Prefectural Senshu Critical Care Medical Center, a Level I trauma center in Japan. • RH was diagnosed when a high- attenuation (>30 hounsfield units) retroperitoneal lesion was identified on two or more consecutive CT images. According to this criterion, 169 (28.5%) of the 594 patients had traumatic RH.
  10. 10. Assessment of RH on CT Images 10 component parts of the retroperitoneal space were identified: • 3 compartments (APS, PRS, and PPS), • 4 interfascial planes comprise 1. Retromesenteric plane (RMP) 2. Retrorenal plane (RRP) 3. Lateroconal plane (LCP) 4. Combined interfascial plane (CIP), providing a route for the spread of disease from the abdominal retroperitoneum into the pelvis. • 3 other extraperitoneal spaces are 1. Retrohepatic space (rhe) 2. Prevesical space (PV) 3. Presacral space (PS)
  11. 11. Massive RH Resulting from Renal Injury A 53-year-old man suffered renal injury from an industrial accident. (A) Midlevel of the left renal CT scan reveals an enormous perinephric hematoma displacing the left kidney, spreading into the RRP (open arrowhead) and RMP (open arrow) by means of the bridging septa (dotted arrows). RH within the RMP spread across the midline. RH with a total volume of 2,248 mL can be clearly subdivided in to the PRS RMP, RRP, and LCP (closed arrowhead) components with intermediate adipose tissues. K, kidney.
  12. 12. CT scan at the level of the upper pole of the left kidney shows RH extension into the RRP (open arrowhead) by means of bridging septa (dotted arrow) behind the left kidney. Sp, spleen. (C) Below the promontory, RH extended into the retroperitoneum of the lesser pelvis and presacral space (PS) by means of the CIP (hatched arrowhead). Note that RH in the presacral space is clearly distinguished from hemoperitoneum (HP) in the Douglas pouch.
  13. 13. Delayed scans at the level of the lower pole of the left kidney and at a slightly lower level reveal thickened perinephric bridging septa (dotted arrow) and the expanded RMP (open arrow) and RRP (open arrowhead) stained with contrast medium. Note that RRP lies apposed to the psoas muscle. This is considered Zone I + Zone II + Zone III RH and Type II-b RH.
  14. 14. RESULTS • The study population included 169 patients with traumatic RH: • One or more injuries of retroperitoneal organs or major vessels were immediately identified in 70 patients (38.7%): renal injury (n = 52), adrenal injury (n = 12), pancreatic or duodenal injury (n = 7), liver injury in the bare area (n = 5), and vascular injury (n = 9). In 86 patients (50.9%), RH was attributed to pelvic fracture.
  15. 15. • There was a high incidence of intraperitoneal organ injury to the liver (n = 42), spleen (n = 20), or intestine (n = 12). Head or facial injury (n = 80), chest injury (n = 88), and fracture of the extremities (n = 101) were common associated injuries. • Shock was present in 112 (66.3%) patients at admission. Because of multiple injuries, the mean Injury Severity Score was 29.8 ± 14.5, much higher than the score (18.6 ± 15.6) of all trauma patients admitted to our institute during the same period.
  16. 16. • 51 patients (30.2%) were treated nonoperatively, most of whom underwent transfusion. • 61 patients (36.1%) were treated by emergent laparotomy, and 26 (15.4%) of these underwent retroperitoneal exploration. • 51 patients (30.2%) underwent TAE, C-clamp, or external fixation of the pelvic ring without laparotomy. • 6 patients died before aggressive treatment could be undertaken.
  17. 17. • There were 39 deaths among the 169 patients, yielding an overall mortality rate of 23.1%; the overall mortality rate of contemporary traumatic patients was only 10.9% in our institute. • In 27 study patients (16.0%), uncontrolled hemorrhage from multiple locations, including RH, was the major cause of death. • 4 died as a result of exsanguination apart from RH and 5 died as a result of severe head injury. The remaining 3 patients died as a result of complicated multiple organ dysfunction 40.0 ± 16.5 days after admission.
  18. 18. Distribution of total volume of RH and mortality rate by volume
  19. 19. • RH volume, need for surgical exploration, and patient mortality were significantly higher in the broadly defined Zone I RH patients (patients with RH in Zone I, in Zone I + Zone II , and Zone I + Zone II + Zone III than in any other group of patients, reconfirming the importance of the conventional Zone I RH classification. • However, of the 73 patients with broadly defined Zone I RH, 40 (54.8%) did not undergo laparotomy and 17 (23.3%) survived with only conservative treatment. • Major vascular injuries were identified in only 6 of the 73 patients.
  20. 20. Our interpretation of the relation between the PPS and the RRP it is neither the PPS nor the PRS but the RRP that lies immediately adjacent to the psoas muscle or QLM.
  21. 21. Extent of RRP identified with CT scanning. (A) A 41-year-old woman was shot in the abdomen. CT scan shows that the RRP (open arrowhead) seems to terminate at the lateral edge of the QLM and divides the PPS from the PRS. Note gases in the PRS caused by the gunshot injury. This is considered Zone II RH and Type II-a RH. Open arrow, RMP; closed arrowhead, LCP; thin arrow, fascial trifurcation. (B) A 35-year-old man suffered renal injury from a motor vehicle crash. CT scan shows that the RRP seems to terminate at the lateral face of the psoas muscle. This is considered Zone I + Zone II RH and Type II-a RH.
  22. 22. Percentage distribution of RH and partial volume of RH by component. • The largest volume (61 ± 96 mL) and percentage distribution (66.1%) occurred in the CIP. • RH in interfascial planes accounted for 78.1% of the total RH volume.
  23. 23. Extension of RH from pancreatic injury. A 45-year- old man was kicked in the abdomen. (A) CT scan obtained at level of the pancreatic uncinate process shows a large hematoma with extravasation from the pancreaticoduodenal artery (hatched arrow) pressing on the inferior vena cava. Du, duodenum; P, pancreas. (B) CT scan obtained below the kidney shows RH spreading along either side of the RMP (open arrow). This is considered Zone I + Zone II RH and Type I-a RH.
  24. 24. Extension of RH from pelvic fracture. A 63-year-old man was hit by a dump truck. (A) CT scan at level of the anterior superior iliac spine shows pelvic fracture and RH in the PV and CIP (hatched arrowhead).
  25. 25. (B and C) RH ascended within the CIP (hatched arrowhead) near the left kidney. This is considered Zone II + Zone III RH and Type III-b RH.
  26. 26. • In patients with great vessel injuries, because the artery or inferior vena cava is located in the RRP or CIP, bleeding in the planes spread uninhibitedly upward and downward within interfascial planes.
  27. 27. Extension of RH from aortic injury. A 68-year-old man was involved in a motor vehicle collision. (A) CT scan at level of the fourth lumbar vertebra shows aortic injury with an enormous RH and massive extravasation of contrast medium (short arrows). RH within the CIP (hatched arrowhead) extends into the LCP (closed arrowhead) and contralateral CIP. (B) CT scan at the level of the right renal hilus shows ascending extension of RH into the RRP (open arrowhead), RMP (open arrow), and PRS by means of bridging septa in retrograde fashion. (C) CT scan at the level of the acetabulum shows RH extension into the presacral space. HP, hemoperitoneum. Note that this 1,508-mL RH is confined to interfascial planes and the PRS. The abdominal aorta was repaired, but the patient died as a result of multiple hemorrahages complicated with coagulopathy. This is considered Zone I + Zone II + Zone III RH and Type IV-b RH.
  28. 28. Extension of RH from lumbar artery injury. A 62-year-old man fell from a height of 8 m. (A) Midlevel right renal CT scan shows massive RH in the RMP (open arrow), LCP (closed arrowhead), and RRP (open arrowhead) surrounding the right kidney. There is neither perirenal hematoma nor thickened perirenal bridging septa. (B) CT scan at the level of the third lumbar vertebra shows continuity of the massive RH (1,356 mL). Note extravasations from both sides of the lumbar arteries (short arrows) that were misidentified as fractures in the transverse process of the lumbar vertebra. Emergent laparotomy with retroperitoneal exploration revealed that bleeding was derived from a psoas injury. Despite bilateral TAE for the third and fourth lumbar arteries, he died as a result of uncontrollable hemorrhage from multiple areas complicated with coagulopathy. Note hematoma escaping from the lateral edge of the QLM. (checkmark sign, curved dotted arrows). This is considered Zone I + Zone II + Zone III RH and Type IV-b RH with checkmark sign. (C) Schematic diagrams of the checkmark sign. Hematoma intrudes into another potential space among the PPS, QLM, and transversalis fascia, forming the checkmark sign (curved dotted arrow).
  29. 29. Extension of RH from inferior vena cava injury. A 14-year-old boy was involved in a motorcycle crash. CT scan at the midlevel of the left kidney shows an enormous RH (1,484 mL) with massive extravasation from the inferior vena cava (short arrows) and right renal laceration. Extravasion from the inferior vena cava intruded directly into the RMP (open arrow) and RRP (open arrowhead) and spreading into the LCP (closed arrowhead), whereas RH in the PRS seemed to derive from the renal laceration. The checkmark sign is also visible (curved dotted arrow). He died as a result of massive hemorrhage complicated with coagulopathy during retroperitoneal exploration. This is also considered Zone I + Zone II + Zone III RH and Type IV-b RH with the checkmark sign.
  30. 30. New Classification of RH • Each RH was first classified by the component where bleeding originated: – Type I derived from the APS or RMP – Type II from the PRS, LCP, Rhe, or PPS above the pelvis – Type III from the pelvis – Type IV from the RRP or CIP • Each type was subdivided according to the degree of extension into subtype – “a” if the RH never exceeded the promontory or – “b” if the RH spread beyond the promontory.
  31. 31. • Ten of 13 patients with Type I RH underwent surgical repair of an injured organ or vessels. • Renal or adrenal injury consisted mostly of Type II RH, which occurred in 43 of 51 patients. Most of these 43 patients were treated conservatively. It is noteworthy that 4 of these patients underwent TAE into the adrenal artery or capsular artery and 7 underwent nephrectomy, which in retrospect was considered unnecessary in 3 patients, and was ineffective in 3 other patients with renal vein injury.
  32. 32. • No patient with Type III RH underwent laparotomy with retroperitoneal exploration for hemostasis, but TAE, C-clamp, or external fixation was often applied. • Unfortunately, we could not save many patients with Type IV RH. This type of RH, which resulted not only from great vessel injuries but also from psoas injury, had an unexpectedly high mortality rate (62.1%) despite aggressive therapy, including retroperitoneal exploration in 8 patients and TAE in 12. In particular, the checkmark sign, indicated an extremely poor prognosis. Patients with Type IV-b had the highest mortality rate; 13 of the 15 patients with the checkmark sign and and only 2 of the 12 without the checkmark sign died as a result of uncontrollable hemorrhage. Of the 12 patients with other types of RH who died as a result of uncontrollable hemorrhage, 6 manifested a clear checkmark sign.
  33. 33. DISCUSSION • RH was identified in interfascial planes in most cases in this study (88.8%) and the partial volume of RH in interfascial planes accounted for 78.1% of the total volume. It is no exaggeration to say that interfascial planes are the base and center of RH. • We suspected that the tri- compartmental theory was inappropriate for classification of traumatic RH because it was impossible to assign the major part of the RH located within interfascial planes, as shown in this study, to any of the three compartments.
  34. 34. This Classification Also Indicated The Appropriate Treatment Policy 1. Type I RH requires emergent retroperitoneal exploration, which also affords a good prognosis. 2. Type II RH is treatable with conservative therapy unless renal vein injury is complicated. 3. Type III RH requires TAE, C-clamp, or external fixation but no laparotomy for RH hemostasis. 4. Treatment of Type IV RH is still challenging and requires further investigation.
  35. 35. • Traditional RH management strategies have recommended that all Zone I hematomas discovered at laparotomy should be explored because of the high possibility of major vascular or visceral injury. • In this study, RH involving the Zone I area required retroperitoneal exploration more frequently (30.1%) and had a higher rate (27.4%) of mortality caused by uncontrollable hemorrhage in comparison with RH that did not invade Zone I, reaffirming the value of conventional strategies.
  36. 36. • Exploration of all Zone I RH is not always necessary, and indication for exploration is assessed by determining the bleeding source and extension by means of interfascial planes, as we did. • Type I RH, derived from the APS or the RMP, should always be explored because of the high possibility of major vascular or visceral injury.
  37. 37. • We detected 113 RHs intruding into the broadly defined Zone II area. The original bleeding derived from renal or adrenal injury in only 43 (38.1%) of 113 cases and from flank injury in 3 cases (1.8%) because RH in the PRS; LCP; PPS; or the lateral part of the RMP, PPR, or CIP was considered Zone II RH. Hemorrhage from the PRS, LCP, Rhe, or suprapelvic PPS should be considered Type II RH.
  38. 38. • Among the 43 cases of RH derived from the PRS, only 4 required effective retroperitoneal exploration for hemostasis. 3 patients died because of renal vein injury, with extravasation clearly apparent on CT scans. This low mortality rate supports use of the conservative treatment advocated in conventional strategies.
  39. 39. • Type III RH corresponds to conventional broadly defined Zone III RH, usually requiring no retroperitoneal exploration. • The fact that the source of pelvic bleeding has been identified as predominantly a bone or vein in the PPS serves as the basis for a recent strategy for initial management of unstable pelvic fracture, prioritizing pelvic bony stability with a C-clamp or external fixation over TAE.
  40. 40. • Type III-b RH ascended beyond the promontory by means of the CIP and sometimes spread all the way up to the diaphragm. In such patients, the bleeding source could be located in the CIP in the pelvis; thus, angiography and TAE should be performed along with pelvic stabilization with a C-clamp or external fixation because external fixation cannot generate enough pressure to stop arterial bleeding. Gauze packing is often performed in the PS or PV, a part of interfascial planes, suggesting that pelvic packing can serve to tampon interfascial planes.
  41. 41. • Because of the high mortality rate, we have distinguished Type IV RH, bleeding from the RRP or CIP, from broadly defined Zone I RH. The RRP and CIP contain great vessels and lie just above the psoas muscles. • Vessel injuries or psoas disruption could induce direct bleeding into interfascial planes without interference from the compartments, which are expected to have a tamponade effect in other types of RH, and the hemorrhage could spread rapidly throughout the expansile interfascial planes, leading to a high likelihood of mortality.
  42. 42. • If extravasations from great vessels are detected in contrast-enhanced CT scanning, the patient must undergo emergent laparotomy and retroperitoneal exploration. • Angiography and TAE have recently been shown to be safe and effective modalities for evaluating and controlling lumbar artery hemorrhage. • In our study, many patients with psoas injury died as a result of exsanguination after apparent coagulopathy despite aggressive application of TAE.
  43. 43. • The checkmark sign was frequently detected among nonsurvivors. • The checkmark sign must be considered a predictor of uncontrollable massive RH.
  44. 44. CONCLUSION • The major portion of RH exists within the interfascial planes, not in the three compartments, and that RH extends by means of interfascial planes and bridging. • We formulated an RH management strategy by classifying RH into four types according to the original location and the extension. • Type IV-b RH with the checkmark sign have the worst prognosis.
  45. 45. DISCUSSION Dr. Felix D. Battistella: Do your findings, which are based on CT scan appearance of retroperitoneal hematoma, alter current treatment recommendations for retroperitoneal hematomas discovered during laparotomy? Dr. Kazuo Ishikawa Our findings do not change the treatment strategies of Dr. Sheldon and Dr. Feliciano. In fact, we treat patients with retroperitoneal hematoma according to their principles. We must determine the real bleeding source, by means of the concept of interfascial planes, to exactly apply their strategies.

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