Retroperitoneal and Soft Tissue

Injury
 Kidney Injuries
• 1-5% of all trauma injuries
• Fall from heights, MVA, bicycle crash, direct
blows
• Children have relatively larger kidneys
• 10% of all penetrating injuries
 Initial evaluation
• Hematuria – degree is not an indicator for extent
of disease
• Blunt trauma
– Deceleration injury from fall or MVA
– Trauma to flank, abdomen, or lower chest
• Penetrating trauma
– Wounds identified with radiopaque markers
– High velocity cause blast effect and delayed tissue
necrosis
– Stab wounds anterior to axillary line usually have
simultaneous abdominal injury
 Imaging (stable patients)
• Indications
– Blunt trauma and gross hematuria
– Blunt trauma, microscopic hematuria (>5RBC/hpf),
shock (<90)
– Major acceleration or deceleration injury
– Any hematuria after penetrating injury
– Pediatric trauma with any degree of significant
hematuria
– Associated injuries and physical signs (flank
ecchymosis, tenderness, lumber spine or lower rib
fx)
 CT
• Imaging study of choice
• Arteriographic phase of CT identifies hilum
injuries
– Blush (extravascular contrast extravasation)
implies arterial injury
– Hematoma medial to injury without blush
identifies renal vein injury
– Renal artery occlusion shows lack of parenchymal
enhancement, cortical rim sign (8 hours after
injury)
 Ultrasound
• Focused assessment by sonography for
trauma (FAST)
• Blood and urine often contained in Gerota’s
fascia
• Limited by obesity, subQ air, previous
abdominal surgeries
 IV urography
• Replaced by CT
• Nonenhancing kidney with kidney identified
on contralateral side
• May identify perirenal hematoma
 Arteriography
• Replaced by CT angiography
• Can be used with coil embolization to treat
arterial extravasation and AV fistulas
• Stent placement
 Unstable patient
• Does not need further imaging prior to
laparotomy
 Indications for renal exploration
• Absolute
– Persistent and life threatening renal bleeding
– Pulsatile, expanding, or uncontained
retroperitoneal hematoma
• Relative indications
– Devitalized parenchyma (>50%)
– Urinary extravasation (resolves 75% of the time)
– Arterial thrombosis (torn intima)
– Penetrating renal injury (III and IV)
– Incomplete staging
 Retroperitoneal exploration
• Zone I – mandatory exploration
– Medial visceral rotation of left or right colon
– Mattox maneuver – over aorta
– Catell maneuver – over IVC
• Zone II – selectively explored in penetrating
injury, observed in blunt injury
Exsanguinating retroperitoneal injuries
• Two conditions
– Full thickness injury of blood vessel
– Failed spontaneous containment or tamponade
• Vascular control vs. mobilizing kidney from
Gerota fascia laterally
• Dissect kidney laterally to mobilize medially
and anteriorly
 Stable retroperitoneal injuries
• Zone I
– Displace small bowel along root of mesentery
– Find IMV and ligament of Treitz and dissect
between the two to find infrarenal aorta
– Palpate left renal vein crossing aorta
 Nonoperative conservative
management
• Strict bed rest until hematuria clears
• Transfusions as needed, may require
intervention
• Reimage kidney 3-5 days after initial injury for
grade III-IV
 Complications after renal trauma
• Early – prolonged urinary extravasation
– >4cm prone to abscess
– Shock, infarction, abscess formation, within 2
weeks of injury
• Late
– Delayed bleeding, arterial pseudoaneurysm,
abscess, urinary fistula, hydronephrosis
• Hypertension – transient
• Hydronephrosis – perinephric fibrosis that
involves the UPJ
 Ureteral and renal pelvis injuries
• Penetrating injuries to ureter are rare, 2.5% of
GSW
– 5% are from blunt
• Iatrogenic
– .5-1% of pelvic operations
– Most common in transabdominal hysterectomy
– Uterine vessels, cardinal and uterosacral ligaments
 Diagnosis of ureteral injury
• Preoperative diagnosis
– Hematuria absent in up to 43% of penetrating and
67% of blunt ureteral injuries
• Intraoperative diagnosis
– Most accurate method
– Viability assessed by incision and monitoring for
bleeding edge
– IV indigo carmine
• Missed ureteral injury
– Prolonged ileus, persistent flank/abdominal pain,
palpable abdominal mass, urinary obstruction,
abscess, sepsis
 Imaging
• IV urography
– Replaced by CT
• CT
– Perirenal extravasation of contrast shows renal
ureteropelvic injury
– Hematomas
• Retrograde pyelography – nope
• Percutaneous nephrostomy
– Can place stents while evaluating for injury
 Management of ureteral injuries
• Explored and reconstructed through midline
incision
• Lack of bleeding implies ischemia, requires
debridement
• Contusion – stent and drain
• Severe contusion – sugmentally resected,
debrided, and reanstomosed over stent
• Crush injury – excision and reconstruction
 Surgical principles of repair
• Careful ureteral mobilization and preservation of
adventitia
• Debridement of nonviable tissue to a bleeding
edge
• Mucosa to mucosa spatulated tension free and
watertight anastomoses
• Ureteral stenting or urinary diversion
• Isolation of repair form associated injuries with
vascularized tissue
• Placement of retroperitoneal drain
Ureteral injuries below iliac vessels
• Ureteroneocystostomy
– Reimplantation of refluxing ureter into fixed area of
bladder (floor/trigone)
– Tunneled nonrefluxing reimplant is unnecessary and
increases chance for stenosis
– Stents placed for 4-6 weeks
• Psoas hitch
– Suture apex of bladder to psoas minor tendon
• Transureterostomy (TUU)
– Diverting urine over ureteral stent to abdominal wall
– Associated rectual, major pelvic vascular, or extensive
bladder injuries
 Midurethral and upper ureteral
injuries
• Ureteroureteostomy
– Spatulated, watertight tension free anastomoses
over double-J stent
 Ureteropelvic junction injuries
• Avulsions after blunt trauma
• Primary surgical repair, ureteral stenting,
retroperitoneal drain
 Large ureteral loss
• Ileal interposition
• Boari flap
• Renal displacement
• Urinary ileal conduit
• Autotransplantation
 Unstable patient
• Temporary cutaenous ureterostomy over
single-J ureteral stent or pediatric feeding
tube
• Can be ligated proximal to injury follow by
percutaneous nephrostomy tube
 Complications and delayed diagnosis
• Occurs to up to 60% or patients
• Sepsis, abscess formation, hydronephrosis,
loss of renal function
• Explore and repair undiagnosed injuries within
two weeks of trauma unless hostile abdomen
• Suture to be removed from iatrogenic ligation
• Delayed reconstruction for at least three
months
 Snakebites
• 6 of 8000 total snake bites in US die a year
• Rattlesnakes, copperheads, cottonmouths are
99%
• Venom contains peptides that damage
vascular endothelium, increasing permeability
 Clinical manifestations
• Local
– 20% bites lack venom
– Swelling, bullae
• Systemic
– Weakness, nausea, vomiting, perioral paresthesia,
metallic taste, muscle twitching
– Edema
– Acute renal failure
 Management
• Field treatment
– Evacuation to definitive care
– Wound cleaned and immobilized
• Hospital management
– History and physical
– Mark bitten extremity
– Labs (coags, fibrin)
– Antivenom (serum sickness)
• Dose based on amount of venom injected
• Wound care and blood products
– Cleaned, splinted, elevated
– Blood products for bleeding not reversed with
antivenom
• Fasciotomy
– Usually subQ deposition of venom, sometimes
into muscle compartments
– >30-40 mmHg
 Mammalian bites
• Dogs responsible for 80-90%
– Cats, then humans
• 4.7 million bites a year, 1% of ED visists
• Pit bulls and rottweilers are most fatal
• Usually on extremities of adults, head, face,
and neck of children
 Treatment
• Evaluation
– Both blunt and penetrating trauma
• Wound care
– Cleansing to prevent zoonotic disease
– Primary closure for incisions seen within 24 hours
– Delayed primary closure after 3-5 days if seen
after 24 hours
• Fight bites
• Micro
– 3-18% of dog wounds get infected, 50% of cat
– Pasturella are most common (50% of dog, 75% of
cat)
– Rabies, cat scratch, cow pox, tulermia,
leptospirosis, brucellosis
– Hep B/C, tuberculosis, syphilis, HIV
• Antibiotics – augmentin, unasyn
• Rabies
– Dogs most common, (raccoons for wild)
 Black widow spiders
• Every state but Alaska
• Neurotoxic venom releases neurotransmitters,
stimulates sympathetics and parasympathetics
• Abdominal cramps, dyspnea, HTN,
diaphoresis, nausea, vomiting
• Local wound care
• Calcium gluconate
• Antivenom for pregnant women, children <16,
>60
 Brown recluse spider
• Sphingomyelinase D, dermonecrosis and
hemolysis
• Pain, itching, swelling, erythema
• Eschar forms over necrotic area
• Headache, nausea, comiting, fever, malaise,
arthralgias, maculopapular rash
• Dapsone
• Debrdiement as necessary
 Scorpions
• Bark scorpion
• Neurotoxic
• Mild, local irritation, with slight swelling
• Cranial nerve and neuromuscular
hyperactivity
• Cold compresses
 Ticks
• Rocky Mountain spotted fevers, relapsing
fever, Lyme disease
• Removal with instrument
• Lyme disease
– Oral doxycycline, amoxicillin
 Bees, wasps, yellow jackets, ants
• Vasoactive compounds with histamine and
serotonin
• Toxic reaction with nausea, vomiting,
diarrhea, edema, cardiovascular collpase,
hemolysis
• Anaphylaxis
• Remove stingers