Major Abdominal Vascular Trauma

Abstract

Management of major vascular bleeding in the abdomen poses significantly different challenges in the resource-limited combat environment. Deployed settings for surgical care vary widely, and the surgeon must be prepared to tackle major abdominal bleeding with few resources and no imaging. The goal of this chapter is to provide some guidance and advice for dealing with an abdominal catastrophe in the absence of a robust medical support system.

Civilian Translation of Military Experience and Lessons Learned

• David V. Feliciano 

Key Similarities

• Penetrating trauma predominates as the mechanism for major abdominal vascular injury in both civilian and military settings.

• The primary initial modality of treatment of major abdominal vascular injuries is operative in almost all settings and circumstances.

• Damage control techniques and “second-look” operations are liberally utilized in both civilian and military settings.

Key Differences

• Access to resources such as computed tomography and endovascular techniques may not be available in the combat environment; this usually does not affect the initial primary surgical approach, but may impact secondary diagnostic and therapeutic maneuvers.

• The rare stable patient with a contained major abdominal vascular injury may have more options for treatment in civilian settings.

• There may be more options for treatment of major hemorrhage associated with pelvic fractures in civilian environments, including rapid external fixation and angioembolization.

• Drs. Singh and King reviewed the anatomy, vascular exposures, and options for repair, shunting, and/or ligation of injured abdominal vessels in a condensed, but comprehensive, way. This brief commentary will reemphasize their critical points and suggest some alternate approaches.

Prep and Drape

Having a prep and drape from the chin to the bilateral toenails allows access to intrathoracic structures and to the greater saphenous vein in either the groin or at the ankle. Also, pulses can be assessed immediately after repair of the common or external iliac artery.

Cross-Clamping of the Supraceliac Abdominal Aorta When a Hematoma Is Present in the Supramesocolic Area

By placing a finger or Kelly clamp inside the muscle fibers of the aortic hiatus of the diaphragm at the 2 o’clock position, the fibers can be divided with the electrocautery. Further exposure of the distal descending thoracic aorta (without overlying celiac ganglia or lymphatics in the way) can be obtained by continuing to divide the posterior part of the left hemidiaphragm at the same position.

Graft from Infrarenal Aorta to Superior Mesenteric Artery (SMA)

Patients with combined pancreatic-proximal SMA injuries will benefit from insertion of a temporary intraluminal shunt at a first “damage control” operation. At the reoperation in a stable patient, the infrarenal aorta and the proximal SMA on the underside of the mesentery are exposed and controlled in proximity to one another. A Doppler flowmeter is helpful in finding the posterior aspect of the SMA as flow through the proximal shunt is diminished as compared to normal arterial inflow. Bypass grafting is accomplished from the right anterolateral aorta to the underside of the SMA using an 8–10 cm reversed autogenous saphenous vein graft excised from an uninjured thigh. The proximal shunt is removed, and both ends of the SMA are closed with 4-0 polypropylene suture and covered with a viable omental pedicle.

Ligation of the Infrarenal Abdominal Aorta

I have never done this, but understand the possible need in the patient with hypothermia and a severe intraoperative coagulopathy. If the insertion of an interposition graft is chosen instead, a polytetrafluoroethylene graft is avoided (bleeding from needle holes). A woven or albumin-coated Dacron graft should be used in this situation.

Posterior Hole in Inferior Vena Cava (IVC)

Performing a repair of a posterior perforation of the IVC through an extended anterior bullet or shrapnel venotomy results in an hourglass narrowing. With proximal and distal vascular control using DeBakey aortic clamps, the IVC is rolled toward the aorta. Lumbar veins near the perforation on the right side of the spine are clipped to decrease backflow into the area of injury. A meticulous repair with 4-0 or 5-0 polypropylene suture is then performed with the other advantage that no suture knots are in the lumen of the IVC .

Ligation of the Infrarenal Inferior Vena Cava (IVC) , Common Iliac Vein (CIV) , or External Iliac Vein (EIV)

Ligation of these major veins decreases arterial inflow at the capillary level which affects the arteriovenous gradients in the myofascial compartments of the lower extremities. Significant postoperative elevation of the injured extremity or both extremities further adversely affects this arteriovenous gradient. These two factors contribute to an increased risk of a below knee or thigh compartment syndrome. Therefore, it is worthwhile to measure the compartment pressures in the anterior and deep posterior myofascial compartments below the knee before completing the first trauma laparotomy (or after ligation of the femoral or popliteal vein in a lower extremity). A compartment pressure in the 30–35 mm range is likely to worsen with postoperative elevation of the extremity as noted above. Depending on the level of the patient’s “physiologic exhaustion,” unilateral or bilateral below knee 2-incision 4-compartment fasciotomies should be performed (20 min with attending surgeon and fellow or senior resident) at the first operation. If this is not performed, serial measurements of below knee and thigh anterior compartment pressures should be performed in the intensive care unit.

Ligation of the Suprarenal Inferior Vena Cava (SIVC)

Shunting after a complex injury of the SIVC is awkward because of the size of the vessel and proximity of the orifices of the renal veins. Therefore, ligation is occasionally performed. While some patients and their kidneys survive this maneuver, every effort should be made to return the patient to the operating room in 4–6 h. A large externally supported polytetrafluoroethylene (PTFE) interposition graft is then inserted using 4-0 or 5-0 PTFE sutures .

Complex Repair of the Common (CIA) or External Iliac Artery (EIA) in the Presence of Enteric or Colonic Contamination

With an end-to-end repair or insertion of an interposition graft into the CIA or EIA in the presence of enteric or fecal contamination, there is an increased risk of an anastomotic blowout (end-to-end or plastic graft) or dissolution of the graft (saphenous vein) in the postoperative period. Proximal and distal ligation around the arterial injury and insertion of an extra-anatomic crossover femoro-femoral PTFE graft immediately or within 4–6 h is an option, but few trauma vascular surgeons choose this. If the complex arterial repair is performed in situ, the greater omentum should be mobilized off the transverse colon. The vascularized pedicle of the omentum is then wrapped around the entire area of repair of the vessel like a gauze wrap around an extremity.

Bleeding from Presacral Veins

The defect in a bleeding sacral vein can often be visualized if two suction devices are available. The time-honored insertion of a tack using an orthopedic hammer into or on either side of the defect is one option, but can rarely be performed in the deep posterior part of the narrow male pelvis. Another option is to cut off a 2 cm piece of greater omentum and suture this devascularized tissue using 3-0 or 4-0 polypropylene sutures into the periosteum of the sacrum on either side of the venous injury.