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Chapter 28

Contents

CHAPTER XXVIII  

Retroperitoneal Hematoma (207 Casualties)

Hugh F. Swingle, M. D., and Dominic S. Condie, M. D.  

It is known that retroperitoneal hematoma, in the sense of an extravasation of blood, either circumscribed or diffuse, into the retroperitoneal tissues was frequently encountered in the 3,154 abdominal injuries observed by the 2d Auxiliary Surgical Group in 1944 and 1945. The exact frequency, however, is unknown because the data were recorded in only 207 cases, in 59 of which a hematoma was the only lesion present. 

There are several reasons why this number of cases of retroperitoneal hematoma cannot be accepted as correct:

1. It can be assumed that  missile which entered the retroperitoneal space almost inevitably produced a hematoma of some sort.

2. Blunt, nonpenetrating injuries frequently had the same effect.

3. The 207 recorded cases are far fewer than the 427 renal wounds in this series of abdominal injuries.  

4. A retroperitoneal hematoma was specifically mentioned in only 33 of the 75 grounds of the major abdominal blood vessels, though it is inconceivable that it was not present in every such injury. As a matter of fact, after only a brief experience, the surgeons of the 2d Auxiliary Surgical Group came to regard the presence of a hematoma as likely in any wound of the retroperitoneal space and usually did not record it unless it was the only lesion present or it was of significant severity. In other words, whatever the actual statistics may indicate, this was a lesion of considerable frequency in this series of abdominal wounds.  

CLINICAL CONSIDERATIONS  

It was usually impossible to make an accurate diagnosis of retroperitoneal hematoma by clinical means alone. It was equally impossible, prior to operation, to differentiate between it and intra-abdominal visceral injury. The signs and symptoms of both conditions were usually identical, and in this series both lesions frequently occurred in the same patient.  

There was no instance in this series of the so-called retroperitoneal syndrome observed by Jolly 1 in the Spanish Civil War and explained by the retroperitoneal infiltration of blood about the celiac plexus. This syndrome consists of a state of shock, with generalized pallor and sweating; a rapid, thready pulse, often becoming imperceptible; a complete absence of any symptoms or signs referable to the abdomen; and a semierection of the penis. 

1Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941.


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latter sign was not constantly present in Jolly's cases, but when it appeared it was of grave prognostic import and usually persisted until death. In this series of cases, on the contrary, the signs and symptoms of retroperitoneal hematoma were seldom distinguishable from those associated with perforation of a hollow viscus. Priapism was usually associated with injury to the spinal cord. In the occasional case in which it was present with retroperitoneal hematoma, the prognosis was not grave.  

TREATMENT  

Many of the retroperitoneal extravasations of blood observed in this series had little or no pathologic significance and required no special treatment. On the other hand, the feeling that most of them could be regarded as of no importance led, in the occasional case, to the overlooking of a serious injury and even to a fatality.  

From the standpoint of treatment, the 207 completely recorded retroperitoneal hematomas in this series can be divided into three groups:  

One hundred and eleven patients, of whom nineteen died, had no specific treatment related to the hematoma, presumably because it was thought to be too insignificant to warrant any.  

Sixty-three patients, of whom twenty-two died, for the most part were treated by drainage, with or without evacuation of the clot. Packing was occasionally employed, or, when it was possible, a, bleeding vessel was ligated.  

Thirty-three patients, of whom twenty-two died, had associated injuries of the great vessels of the abdomen. Treatment in these cases consisted of evacuation of the blood clot and control of the bleeding vessel by ligation, suture, or clamping.  

The most important implication of a retroperitoneal hematoma, aside from the fact that the clinical signs could not be distinguished from signs of visceral perforation, was that it might obscure injury to the vital retroperitoneal structures. That happened a number of times in this series. Lesions overlooked included a duodenal perforation, 2 ureteral injuries, 4 retroperitoneal injuries of the colon, and 6 injuries of the bladder. There were only 5 survivals in these 12 cases, 1 in the 4 injuries of the colon and 4 in the 6 injuries of the bladder. It is easy to understand how these errors occurred. While small hematomas required no treatment, large hematomas, and those in which there was evidence of continued bleeding, urgently required exploration and control of the bleeding vessels. Under these conditions, it was difficult to identify a coexisting lesion, such as a perforation of the colon on its retroperitoneal aspect.  

FACTORS OF MORTALITY  

There were 4 deaths (6.8 percent) among the 59 patients who had no injuries other than the retroperitoneal hematoma. The case fatality rate is of the same order as the rate (4.9 percent) in abdominal injuries without visceral wounds.


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The 19 fatalities in the 111 cases in which there was no specific treatment of the retroperitoneal hematoma were all attributable to concurrent visceral injuries. Similarly, the 22 deaths which occurred in the 33 hematomas associated with injuries of the great vessels were directly related to the vascular injuries. In both groups, the fatalities were not related to the retroperitoneal bleeding.  

Of the 22 deaths which occurred in the 63 retroperitoneal hematomas treated directly, 11 were attributable to the retroperitoneal lesion itself. Five patients died of shock and hemorrhage as a result of severe retroperitoneal bleeding, and three died of anuria following shock of the same origin. The three other patients died of retroperitoneal cellulitis, in one instance associated with pulmonary embolism.  

The low case fatality rate in the group of cases in which there was no lesion other than the retroperitoneal hematoma is apparently related to the relatively low incidence of shock. In 18 of the 59 cases, 1 of them a fatality, there was no record on this point. Twenty-five of the remaining 41 patients, 1 of whom died, were stated not to be in shock. Sixteen presented some degree of shock. There were no deaths in the 7 patients in mild shock, 1 death in the 6 in moderate shock, and 1 in the 3 in severe shock. In general, therefore, there was less shock, and less fatal shock, in this group than was usually encountered in a group of similar size with injury limited to a single viscus.  

As their experience with retroperitoneal hematoma increased, the surgeons of the 2d Auxiliary Surgical Group formulated a routine plan of management for this condition:  

1. After the evacuation of a large hematoma in the retroperitoneal space and control of the bleeding responsible for it, the surrounding structures were carefully explored. They were similarly explored in the presence of any hematoma, regardless of its size, if its anatomic location was such as to suggest possible injury to the ureter, the bladder, the duodenum, or the posterior aspect of the colon.  

2. Adequate extraperitoneal drainage was provided for retroperitoneal hematomas associated with injury to any portion of the urinary tract, the colon, or the pancreas. If a debrided missile wound of entry or exit was not suitable for this purpose, drainage was instituted through a surgical incision in the flank or through a posterior incision.  

3. Evacuation of the clot and ligation of the bleeding vessel or vessels were usually all that was necessary in large hematomas caused by vascular injuries. 

4. Any opening in the posterior peritoneum, whether made by the missile or created during the operative procedure, was carefully retroperitonealized, to eliminate communication between the peritoneal cavity and the retroperitoneal space.

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