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Abstract
With the high number of civilian gun shot wounds and motor vehicle injuries, the incidence of retroperitoneal injury is quite high, and surgeons should be comfortable with exploration of the retroperitoneum. In fact, nearly three quarters of retroperitoneal hematomas were caused by motor vehicle accidents. Irreversibl shock secondary to massive retroperitoneal hematoma is one of our most frustrating problems. Fortunately this situation is uncommon. Such uncontrollable bleeding was most common in cases with associated posterior disruption of the pelvis. Therefore, in patients with traumatic injuries who have severe hemorrhagic shock or with falling hematocrit levels and in who massive blood loss from within the abdominal or thoracic cavities cannot be demonstrated, the retroperitoneal space must be strongly considered. Since there are no pathognomonic signs or symptoms of retroperitoneal hematoma, their presence should be suspected in patients who are found to have hematuria after abdominal trauma, particularly if fractures of the osseous pelvis are present. In such patients, excretory urograms and cystograms should be promptly obtained. The diagnostic tools available to the clinician making deci¬sions regarding the need for operative intervention include history, physical examination, laboratory investigation, radiology, diagnostic peritoneal lavage and direct emergency laparoromy. The choice and application of these tools and the significance placed on their results will depend upon a number of factors including:
(1) The mechanism of injury.
(2) Hemodynamic stability of the patient.
(3) Availability and experince of surgical personnel.
(4) Presence of other life-threatening injury. Retroperitoneal hematoma is commonly associated with significant intra-abdominal injury and almost always with positive results from peritoneal lavage. Therefore the most common situation for the trauma surgeon is being confronted with a retroperitoneal hematoma at the time of laparotomy. What is the treatment? This is a subject of great controversy. The subdivision of retroperitoneal hematoma into three zones provides a systematized approach to treatment. Surgical management will depend on the likely structures injured when hematomas arise in each of these zones. Another controversy question whether to or not to open the stable retroperitoneal hematoma of moderate size that is not enlarg¬ing. Some surgeons recommend that this always be done whereas oth¬ers believe that this approach is unnecessarily.