Skip to content

ABDOMINAL VASCULAR INJURY

Abdominal Vascular Injury: Detailed Overview

Abdominal vascular injuries, often resulting from penetrating trauma, are treated through a generous midline laparotomy to allow proper exposure and repair. These injuries can involve major vessels such as the aorta, inferior vena cava (IVC), and iliac arteries and veins, and each presents unique challenges for repair.

Abdominal Aorta Injury

  • Exposure & Control:
    • Penetrating injuries to the abdominal aorta are best accessed via a left medial visceral rotation, which exposes the aorta from the diaphragmatic hiatus to the iliac bifurcation.
    • Initial control of the injury is achieved with direct digital pressure, followed by the placement of vascular clamps proximal and distal to the site of the injury.
  • Repair Techniques:
    • Stab wounds: Often repaired primarily without significant complexity.
    • Gunshot wounds: Typically require patch repair or an interposition graft due to the severity of damage.
    • In rare cases, blunt abdominal aortic injuries may occur without significant hemorrhage, which can be managed using endovascular techniques for a more minimally invasive approach.

Inferior Vena Cava (IVC) Injury

  • Exposure & Control:
    • The IVC is exposed using a right medial visceral rotation, which allows visualization from the iliac vein confluence to the inferior border of the liver.
    • Injuries are best controlled initially with direct digital pressure. Proximal and distal control can be further achieved using sponge sticks or vessel loops.
    • Lumbar tributaries and renal veins may also need to be controlled for better visualization and repair.
  • Repair Techniques:
    • Injuries to the anterior or lateral surfaces of the IVC are often managed with primary repair, as long as the lumen is not narrowed by more than 50%.
    • Through-and-through injuries may require repair of both the anterior and posterior sides. The posterior IVC can be repaired through the anterior opening, or by mobilizing the IVC after ligating and dividing lumbar veins.
    • Complex injuries: May necessitate patch repair, interposition graft, shunting with delayed repair, or ligation depending on the patient’s hemodynamic stability.
    • In unstable patients with ongoing hemorrhage, ligation or shunting may be necessary to prevent exsanguination. For stable patients with injuries above the renal veins, more complex reconstructions can be attempted.

Iliac Arteries Injury

  • Exposure & Control:
    • The right common, external, and internal iliac arteries are exposed by mobilizing the cecum.
    • Left iliac arteries are exposed by mobilizing the sigmoid colon. Care must be taken to avoid damaging the ureter, which crosses the iliac vessels.
    • Initial control of these injuries is typically achieved with digital pressure, followed by proximal and distal control using vascular clamps or vessel loops.
  • Repair Techniques:
    • Injuries to the common and external iliac arteries may require primary repair or, more commonly, a synthetic interposition graft.
    • Ligation of the common and external iliac arteries is contraindicated, even in unstable patients. In such cases, shunting is performed, followed by delayed repair.
    • Internal iliac arteries, however, can be routinely ligated if needed.

Iliac Veins Injury

  • Exposure & Control:
    • The iliac veins are exposed similarly to the iliac arteries, although exposure is complicated by the confluence of the iliac veins with the IVC, which lies posterior to the right common iliac artery.
    • Mobilizing the right iliac artery allows access to the confluence, although division of the iliac artery is generally not recommended for exposure.
    • Digital pressure is used for initial control, followed by proximal and distal control using vessel loops.
  • Repair Techniques:
    • Simple injuries to the iliac veins can be managed with primary venorrhaphy.
    • Complex or destructive injuries should not be subjected to extensive repair attempts and are best managed by ligation to prevent further complications.

Conclusion

Abdominal vascular injuries, particularly to major vessels like the aorta, IVC, and iliac arteries and veins, are highly challenging and require rapid intervention to prevent fatal hemorrhage. The approach to exposure and repair depends on the specific vessel involved, the severity of the injury, and the patient’s hemodynamic status.

  • Aorta: Best exposed with left medial visceral rotation, with repair options ranging from primary repair for stab wounds to grafts for gunshot wounds.
  • IVC: Requires a right medial visceral rotation, with primary repair for anterior injuries and patch repair or ligation for more complex cases.
  • Iliac arteries: Should never be ligated unless absolutely necessary, with shunting preferred in unstable patients.
  • Iliac veins: Primary venorrhaphy is preferred for simple injuries, with ligation for more complex cases.

The success of treatment depends on rapid control of hemorrhage, proper exposure, and the use of appropriate repair techniques based on the patient's condition.

MESENTERIC VASCULAR INJURY

Introduction

  • Injuries to the mesenteric vessels are among the most challenging trauma injuries to expose and repair due to their deep retroperitoneal location.
  • Celiac trunk and superior mesenteric artery (SMA) injuries, in particular, require distinct approaches based on their anatomy and injury zones.

Celiac Trunk Injuries

  • Approach in Elective Setting:
    • Typically approached through the lesser sac.
    • However, in trauma, this approach can be complicated by large hematomas obscuring anatomical landmarks.
  • Approach in Trauma:
    • The best exposure is achieved through a left medial visceral rotation (mobilizing the spleen and tail of pancreas).
    • Repair vs. Ligation:
      • In most cases, ligation of the celiac trunk is preferred as repair is difficult.
      • Ligation is well tolerated in the majority of patients due to collateral circulation.

SMA Injuries

  • Proximity to Celiac Trunk:
    • SMA and celiac trunk arise 1-2 cm apart from the aorta but require different exposure and management approaches.
  • Fullen Classification of SMA Zones:
    • Zone I: Beneath the pancreas (proximal SMA).
    • Zone II: Between the inferior pancreaticoduodenal artery and middle colic artery.
    • Zone III: Beyond the middle colic artery.
    • Zone IV: Enteric branches of the SMA.
  • Management Based on Location:
    • Contained Central Hematoma at Root of Mesentery:
      • Best managed by a left medial visceral rotation for exposure and control.
      • Allows access to clamp the aorta proximal and distal to the SMA or the SMA itself.
    • Zone I and Zone II Injuries:
      • Exposed through the lesser sac by dividing the gastrocolic ligament.
      • Pancreas retracted inferiorly (for SMA origin) or superiorly (for proximal SMA).
      • In cases of severe injury, the pancreas may need to be divided to fully expose the SMA.
    • Zone III and Zone IV Injuries:
      • Approach involves reflecting the transverse colon and mesentery superiorly, with or without taking down the ligament of Treitz.
  • Repair Options:
    • All zones of SMA injuries, except for distal Zone IV injuries, should be repaired.
    • Options include:
      • Primary repair.
      • End-to-end anastomosis.
      • Interposition graft using a reversed saphenous vein.
    • For patients in extremis, the SMA can be shunted with plans for delayed repair.

Superior Mesenteric Vein (SMV) Injuries

  • Exposure: Similar approach to SMA exposure.
  • Management:
    • Repair or reconstruction is preferred.
    • Shunting with delayed repair is an option in unstable patients.
    • Ligation of the SMV may be necessary for patients at risk of exsanguination.

Inferior Mesenteric Artery and Vein Injuries

  • Inferior Mesenteric Artery (IMA):
    • Can be safely ligated if there is adequate collateral circulation from:
      • Middle colic branch of the SMA.
      • Inferior and middle hemorrhoidal branches of the internal iliac arteries.
  • Inferior Mesenteric Vein (IMV):
    • May also be safely ligated if required during surgery.

Surgical Maneuvers for Exposure

  1. Left Medial Visceral Rotation (Mattox Maneuver):
    • Provides exposure to the proximal trunk of the SMA by mobilizing the spleen and pancreas.
  2. Cattell-Braasch Maneuver:
    • Provides extensive retroperitoneal exposure to the root of the mesentery and the SMA.

Key Takeaways

  • Early diagnosis and prompt surgical intervention are critical for improving outcomes in mesenteric vessel injuries.
  • Ligation of major vessels, such as the celiac trunk and IMA, can be performed safely due to adequate collateral circulation.
  • Zone-specific approaches are essential for effective management of SMA injuries, with repair being the preferred approach unless the patient is in extremis.

SMA Trauma - Fullen Zones

image.png

Mortality Rates by Fullen Zones:

  1. Zone I:
    • Location: The trunk proximal to the inferior pancreaticoduodenal artery.
    • Mortality Rate: 76-100%.
  2. Zone II:
    • Location: Between the inferior pancreaticoduodenal artery and the middle colic artery.
    • Mortality Rate: 44%.
  3. Zone III:
    • Location: The segment distal to the middle colic artery.
    • Mortality Rate: 25%.
  4. Zone IV:
    • Location: Gives off the segmental branches.
    • Mortality Rate: 25%.

Surgical Maneuvers for SMA Exposure:

  1. Mattox Maneuver:

    • Left-sided medial visceral rotation.
    • Provides exposure to the proximal trunk of the superior mesenteric artery.

    image.png

  2. Cattell-Braasch Maneuver:

    • Provides extensive retroperitoneal exposure.
    • Access to the root of the mesentery and the superior mesenteric artery.

    image.png

Portal Vein Injuries: Surgical Approach and Management

Anatomy and Initial Control

  • Portal vein is the most posterior structure in the portal triad, located close to the inferior vena cava (IVC).
  • It runs closely with the common bile duct and hepatic artery.
  • Initial control is achieved through direct manual pressure over the portal vein to prevent hemorrhage.

Exposure and Surgical Maneuvers

  1. Right Medial Visceral Rotation:
    • Includes a Kocher maneuver (mobilization of the duodenum and head of the pancreas).
    • This maneuver provides exposure to the lateral and inferior portal vein.
  2. Mobilization of the Common Bile Duct & Hepatic Artery:
    • To fully expose the anterior surface of the portal vein, the common bile duct and hepatic artery must be carefully mobilized.
  3. Division of the Neck of the Pancreas:
    • In certain cases, to expose the entirety of the portal vein, the neck of the pancreas may need to be divided (similar to approaches used for SMA and SMV exposure).

Management of Portal Vein Injuries

  1. Repair or Reconstruction:
    • The preferred method for most cases is direct repair or reconstruction of the portal vein to restore vascular integrity.
  2. Shunting with Delayed Repair:
    • If the patient is unstable, a temporary shunt can be placed with plans for delayed repair once the patient is stabilized.
  3. Ligation:
    • Ligation of the portal vein is only considered for patients in extremis who are at

risk of exsanguination. Ligation is a last resort, as it can lead to severe hemodynamic consequences, but may be necessary to save the patient's life in critical situations.

Summary

  • Portal vein injuries are complex and require swift manual control and exposure using a right medial visceral rotation combined with a Kocher maneuver.
  • The exposure is similar to the approach used for SMA and SMV injuries, sometimes requiring division of the neck of the pancreas for full access.
  • Repair or reconstruction is the preferred treatment for most portal vein injuries, with shunting reserved for unstable patients. Ligation is considered only in dire circumstances when the patient is at risk of fatal blood loss.