A lecture about the management approaches for abdominal vascular injuries. Injury to the major arteries and veins in the abdomen are technical challenge to the surgeon and are often fatal. All vessels are susceptible to injury with penetrating trauma. Vascular injuries in blunt trauma are far less common and usually involve the renal arteries and veins, though all other vessels, including the aorta, can be injured. Blunt trauma results from deceleration, AP compression or pelvic fractures.

1. ABDOMINAL VASCULAR
INJURIES
PROFESSOR
ABDULSALAM Y TAHA
School of Medicine
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. INTRODUCTION
• Injury to the major arteries and veins in the
abdomen are technical challenge to the surgeon
and are often fatal.
• All vessels are susceptible to injury with
penetrating trauma.
• Vascular injuries in blunt trauma are far less
common and usually involve the renal arteries
and veins, though all other vessels, including the
aorta, can be injured.
• Blunt trauma results from: deceleration, AP
compression or pelvic fractures.

3. History
• DeBakey and Simeone (1946, Ann Surg)
2,471 arterial injuries during WWII
49 AVI (2%)
• Rich et al. (1970, J Trauma)
1,000 arterial injuries during Vietnam War
29 AVI (2.9%)
• Clouse, et al. (2007, J Am Coll Surg)
301 vascular injuries during Operation Iraqi
Liberation (Freedom)
18 AVI (6%)

4. Diagnosis
• Critical patient:
exploratory
laparotomy.
• Stable patient:
plain film: GSW
trajectory and pelvic
fractures.
CT/Angiography:
useful in late
penetrating trauma.

5. Retroperitoneal bleeding caused by
blunt abdominal trauma

6. • Several vessels are notoriously difficult to
expose. These include the retrohepatic
IVC; suprarenal aorta; the celiac axis; the
proximal SMA; the junction of the SMV,
splenic, and portal veins; and the
bifurcation of the vena cava.
• Maneuvers have been described to aid in
the exposure of all of these vessels.

7. VASCULAR SUPPLY

8. ZONES OF INJURY
1. Zone II:
2. Lateral RP
Zone III: Pelvis
Zone I
Zone I:
RP midline
From hiatus to
Sacrum.

9. LEFT MEDIAL VISCERAL
ROTATION
• This maneuver is used to expose the suprarenal
aorta, celiac axis, proximal SMA and left renal
arteries.
• This is accomplished by incising the left lateral
peritoneal reflection beginning at the distal
descending colon and extending the incision
past the splenic flexure, around the posterior
aspect of the spleen, behind the gastric fundus,
and ending at the oesophagus.

10. LEFT MEDIAL VISCERAL ROTATION

12. LEFT MEDIAL VISCERAL ROTATION
• This incision permits the left colon, spleen,
pancreas, and stomach to be rotated
toward the midline.
• Division of the left crus of the diaphragm
will permit access to the aorta above the
celiac axis.
• The maneuver is much more difficult and
time consuming than it first appears.

13. RIGHT MEDIAL VISCERAL ROTATION
• Mobilization of the right colon and a
Kocher maneuver will expose the entire
vena cava except the retrohepatic portion.
• It is technically simple.
• The kidney can be left in situ or mobilized
with the remaining viscera with both right
and left medial rotations.

14. RIGHT MEDIAL VISCERAL ROTATION

16. • The junction of the SMV, splenic, and portal
veins can be exposed in elective surgery by
dissecting the vessels from the pancreas as
required when performing a distal spleno-renal
shunt.
• However, in the presence of massive bleeding
from a venous injury, this may be impossible.
• Therefore, in trauma surgery, the neck of the
pancreas is divided without hesitation. This
provides excellent exposure of this difficult area.

19. IVC BIFURCATION
• The bifurcation of the IVC is obscured by
the right common iliac artery.
• This vessel should be divided to expose
extensive vena caval injuries of this area.
• The artery MUST be repaired after the
venous injury is treated or AMPUTATION
occurs in as many as 50% of patients.

20. EXPOSURE OF IVC BIFURCATION

21. PELVIC VASCULAR ISOLATION

22. PELVIC VASCULAR ISOLATION
• As the dissection continues, the
clamps are moved progressively
closer to the vascular injuries until
definitive control of hemorrahage is
achieved.

23. Emergent Abdominal Exploration
• All abdominal explorations in adults are
performed using a long midline incision.
• For children under the age of 6, a transverse
incision may be advantageous.
• The incision should be made with a scalpel
rather than with a cautery because it is faster.
• Liquid and clotted blood is rapidly evacuated
with multiple laparotomy pads and suction.
• Additional pads are then placed in each
quadrant to localize haemorrhage.
• The aorta is palpated to assess blood pressure.

24. Emergent Abdominal Exploration
• If exsanguinating haemorrhage is
encountered upon opening the abdomen,
it is usually caused by injury to the liver,
aorta, IVC, or iliac vessels.
• If the liver is the source, the hepatic
pedicle should be immediately clamped
( a Pringle maneuver) and the liver
compressed posteriorly by packing.

25. PRINGLE MANEUVER

26. Emergent Abdominal Exploration
• If exsanguinating haemorrhage originates near
the midline in the retroperitoneum, direct manual
pressure is applied with a laparotomy pad and
the aorta is exposed at the diaphragmatic hiatus
and clamped.
• The same approach is used in the pelvis except
that infrarenal aorta can be clamped, which is
both easier and safer because splachnic and
renal ischaemia can be avoided.

27. Emergent Abdominal exploration
• Injuries of the iliac vessels pose a unique
problem for emergency vascular control.
• Because they are so many large vessels in
proximity, multiple vascular injuries are common.
• Furthermore, venous injuries are not controlled
with aortic clamping.
• A helpful maneuver in these circumstances is
pelvic vascular isolation.
• For stable patients with large midline
haematomas, clamping the aorta proximal to
the haematoma is also a wise precaution.

28. Emergent Abdominal Exploration
• All abdominal organs are systematically
examined by visualization, palpation, or both.
Missed injuries are a serious problem with often
fatal results.
• In penetrating trauma missed injuries can occur
if wound tracks are not completely explored or
due to failure to explore retroperitoneal
structures such as the ascending and
descending colons, the second and third
portions of the duedenum, and ureters.

29. Emergent Abdominal Exploration
• Furthermore, injuries of the aorta or IVC may be
temporarily tamponated by overlying structures.
• If the retroperitoneum is opened and the injury
overlooked, delayed massive haemorrhage may
occur following abdominal closure.
• Blunt abdominal injuries are usually obvious, but
injuries of the pancreas, duodenum, bladder,
and even aorta can be overlooked.

30. Endovascular options?
• There are limited case series and reports.
• Contraindicated in
1. hemodynamically unstable patients.
2. in the presence of other injuries requiring
exploration.
3. Lower limb ischemia
• Blunt injuries causing intimal disruption are
more amenable to endovascular therapy.
N/B., Intimal disruption is the most common
cause of renal artery injury.

33. SUMMARY
• Up to 25% of patients with abdominal trauma may have
major vascular injury.
• Shock out of proportion to the extent of external injury
suggests abdominal vascular injury.
• Isolated abdominal injury in patients with shock suggests
major vascular injury that requires emergency laparotomy
for control.
• After the abdomen is entered, immediate control of the
supraceliac aorta should be considered before continuing
the operation.
• Retroperitoneal hematomas should not be explored right
away unless they are actively bleeding.
• Stopping the procedure after the initial exploration for
damage control to allow time for resuscitation in the
intensive care unit is often a reasonable initial treatment.
• If the patient’s condition allows and if endovascular
methods are available, consider placing an aortic balloon
from the left brachial artery for temporary occlusion