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Mesenteric Vessel Injuries and Surgical Management

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

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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.

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  2. Cattell-Braasch Maneuver:

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

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