Non-Operative Management of Stable, Non-Pulsatile, Retroperitoneal Hematomas in Blunt Abdominal Trauma

Abstract

Case Report

A 33 year-old male sustained blunt abdominal trauma requiring emergent exploration which revealed a grade IV liver injury with a right zone II retroperitoneal and supra-mesocolic hematoma, and a zone I central retroperitoneal hematoma, all of which were nonexpanding and nonpulsatile, and therefore were left undisturbed.

Discussion

Multiple techniques have been used for management of retroperitoneal hematomas such as manual tamponade with clamping and balloon occlusion catheters, tight sponge packing followed by temporary closure, percutaneous balloon catheter occlusion, and endovascular repair.

Conclusion

Stable, non-pulsatile, non-expanding, retroperitoneal hematomas can be observed, even in the face of other injuries.

Introduction

Abdominal vascular injuries from trauma are among the most lethal injuries.¹ The most frequently injured vein during trauma is the inferior vena cava (IVC), and laceration of it is associated with severe mortality rate.² Immediate control of hemorrhage is the key to successful management of IVC injuries. Generally, recommendations for stable, non-expanding retroperitoneal hematomas are non-operative management. Operative exploration is recommended when other injuries are associated, as well as zone 1 central retroperitoneal hematomas, paraduodenal, pericolonic, and portal retroperitoneal hematomas.³ We present a case of non-operative management of retroperitoneal hematoma, even when the patient required exploration in the operating room for other associated injuries, an indication that normally would indicate operative control.

Case Report

A 33-year-old male sustained blunt abdominal trauma in a motor vehicle collision, when his car collided with a parked bus. Upon presentation, he was diaphoretic, blood pressure was 115/57, and he complained of left sided chest pain and abdominal pain. He was noted to have a left hand degloving injury, multiple left hand extensor tendon lacerations, and a left open tibia fracture. Blood tests revealed a hemoglobin level of 12.8 g/dL. A CT scan of the chest, abdomen and pelvis revealed: (1) right 6–8 rib fractures, (2) right pulmonary contusion, (3) grade IV liver laceration, and (4) active venous bleeding possibly originating from the infrarenal IVC with associated hematoma measuring 4.2 × 12cm overlying the right psoas muscle (See Figures 1 and 2).

Figure 1.

CT scan showing the grade IV liver laceration.

Figure 2.

CT scan showing active venous bleeding originating from the infrarenal IVC with associated hematoma overlying the right psoas muscle.

The patient was taken emergently to the operating room for exploration as he became hemodynamically unstable after the CT scan was obtained. During operation, a grade IV liver laceration was encountered. The right and left upper quadrants were packed for hemostasis. Systematic exploration of the abdomen revealed a right zone II retroperitoneal hematoma, a right zone II supra-mesocolic hematoma, and a zone I central retroperitoneal hematoma, all of which were nonexpanding and nonpulsatile, and therefore were left undisturbed. The hepatic bleeding was managed with direct suture ligation, hemoclips and debridement. The retroperitoneal hematomas were once again inspected and noted to be stable. The abdomen was then closed. The orthopedic surgeon proceeded to perform internal stabilization of the left tibia, as well as repair of the extensor tendon lacerations over the dorsum of the left hand. The patient was then transferred to the intensive care unit for postoperative follow-up.

In the postoperative course, the hemoglobin dropped to 5.4g/dL on hospital day three, and a CT scan was obtained which revealed a stable pseudoaneurysm of the IVC. On hospital day six, the patient was transferred to the floor. A repeat CT scan on hospital day nine showed a high attenuated rounded 1.5 × 1.1cm lesion anterior to IVC. This was thought to be resolution of the pseudoaneurysm. The patient was discharged home on hospital day ten.

In follow-up, a CT scan was obtained one month from the time of injury and showed a marked interval decrease in the retroperitoneal hematoma, with complete resolution of the IVC pseudoaneurysm (See Figure 3). The patient was doing well and happy with his management.

Figure 3.

CT scan showing marked interval decrease in the retroperitoneal hematoma with resolved IVC pseudoaneurysm.

Discussion

Isolated blunt caval injury is rare because of its retroperitoneal position protected by adjacent musculoskeletal and visceral structures.^{4, 5} The IVC is the most frequently injured intra-abdominal vessel during blunt and penetrating trauma.⁵ Hospital mortality after blunt caval injury is estimated to be higher than 60%.⁶ More than one-third of patients with vena caval injury die before reaching the hospital, and of those that arrive to the hospital, 50% will die in the first 48 hours because of hemorrhage or its consequences.⁶

Traditional methods of vascular control include manual tamponade with sponge stick, gentle clamping, and balloon occlusion catheters.⁴ Iatrogenic clamp injury has been noted, and repair is difficult using manual tamponade with a sponge stick due to flattening of the IVC. Balloon occlusion catheters have been helpful when repair is difficult.^{7, 8}

The retrohepatic IVC is the most difficult part of the IVC to expose.¹ Several studies have shown that hepatic mobilization with attempted surgical repair is associated with high mortality rates. Therefore, for these injuries, tamponade with liver packing and damage control is recommended.⁴ Observation is recommended for a stable, nonpulsatile, retroperitoneal hematoma with a low suspicion for associated injuries. Surgical exploration and repair is recommended for an enlarging hematoma, active hemorrhage, hemodynamic instability, as well as paraduodenal, pericolonic, and portal retroperitoneal hematomas.^{3, 9, 10}

Fernando et al recently conducted a retrospective review of ten patients with blunt caval injuries ranging from intimal flap to extensive destruction. They noted seventy percent mortality with six out of seven deaths secondary to exsanguinations, and one out of seven deaths secondary to brain injury. Six patients responded to fluid bolus upon initial presentation, and proceeded to CT imaging. Active venous contrast extravasation was not seen in any patient; however, indirect signs were suggestive of blunt caval injury. One patient had an intimal flap and contained pericaval hematoma, and was managed nonoperatively. Their discussion commented that no extravasation of venous contrast was seen on CT scan possibly due to low caval pressure and the tamponade effect from adjacent structures. Survival was associated with hemodynamic stability, positive response to fluid resuscitation, younger age, lower speed of mechanism of trauma, and a small number of associated injuries. Their conclusions were that a CT scan is useful, but may underestimate the severity of injury, and that stable patients with intimal flaps and contained hematoma may be managed nonoperatively.⁶

Dalal et al reported two cases of IVC injury requiring exploration in the operating room. One case consisted of immediate surgical repair, with the patient subsequently dying on post-operative day seven. The other case consisted of emergency damage control surgery, with retrohepatic IVC hemorrhage controlled by tight sponge packing followed by temporary abdominal closure, and return to the operating room twenty-four hours later for definitive repair. This patient was discharged from the hospital. They concluded the most reliable method for immediate control of venous bleeding is tight sponge packing followed by temporary closure, and emergency damage control surgery reduces mortality.⁵

Bui and Mills recently reported a case of controlling a large retroperitoneal hematoma adjacent to the infrarenal IVC with extravasation by using a percutaneous balloon catheter occlusion. Using bilateral iliac venography, free extravasation from the right lateral wall of the IVC was noted. They inserted a 27mm Foley balloon and inflated it across a proximal IVC injury. Another Foley balloon was placed through a distal IVC injury and inflated caudally, while the previously placed occluding balloon catheter was advanced cranially. Primary repair of both injuries were then carried out. They concluded that percutaneously occluding the injury site allowed easier identification of injury, reduction in operative time, and reduction in blood loss.⁴

Castelli et al reported a case of endovascular exclusion of an infrarenal IVC injury by a covered stent. Their patient had a bleeding injury at the level of the ilio-caval bifurcation. They exposed the left common femoral vein and inserted a 20-French sheath stent under fluoroscopy. Final angiogram confirmed complete exclusion of the injury and absence of bleeding. Endovascular procedure time was nine minutes. The patient died two days later due to brain injury. They concluded that advantages of endovascular approach include relative ease, low procedure times, minimal additional tissue trauma, and no additional dissection of the IVC or adjacent structures.¹¹

We chose nonoperative management for several reasons. First, the patient had no evidence of being unstable once bleeding from the liver was stopped. Second, operating on the vena cava just above the confluence can be challenging. The aorta is in the way. One author recommends division of the right common iliac artery then subsequent repair after the vena cava has been reconstructed.¹²⁾ Also, the retroperitoneal region is a closed system and opening this imposes a “chimney effect,” such that when pressure on the bleeding injury is ended, the bleeding may become more serious. Third, percutaneous stenting was considered if the patient should begin to bleed. Since the patient was not bleeding we deemed this intervention unnecessary. Finally, this patient was going to be managed in a fully staffed critical care ICU with trauma surgeons available 24/7.

Injuries to vessels have undergone a significant shift over the last 15–20 years. Arterial injuries that mandated exploration 20 years ago can be successfully managed nonoperatively. Venous injuries because of their low pressure will frequently tamponade and therefore do not require operative intervention.

As we began this operation, we had every intention of opening the retroperitoneum and repairing the inferior vena cava. As the operation progressed, the hematoma was not expanding. The patient was stable. By the end of the case, we felt that we could safely manage this patient nonoperatively.

In summary, the location of the IVC injury plays a role in terms of management. Percutaneous balloon catheter occlusion has the benefits of easy identification of injury and a reduction in operative time. Endovascular repair has advantages of minimal additional tissue trauma and no additional dissection of the area of injury. Overall, we conclude that stable, non-pulsatile, non-expanding, retroperitoneal hematomas can be observed, even in the face of other injuries, as evidenced by the good outcome in our case.

Biography

Jenelle King, MD, MSMA member since 2009, is a third-year general surgery resident at the University of Missouri - Kansas City. Harry Wilkins, III, MD, MHCM, FACS, practices at St. Luke’s Hospital in Kansas City.

Contact: kingjen@umkc.edu