CHAPTERXXVIII
Retroperitoneal Hematoma (207 Casualties)
HughF. Swingle, M. D., and Dominic S. Condie, M. D.
Itis known that retroperitoneal hematoma, in the sense of an extravasation ofblood, either circumscribed or diffuse, into the retroperitoneal tissues wasfrequently encountered in the 3,154 abdominal injuries observed by the 2dAuxiliary Surgical Group in 1944 and 1945. The exact frequency, however, isunknown because the data were recorded in only 207 cases, in 59 of which ahematoma was the only lesion present.
There are several reasons why this number of cases of retroperitonealhematoma cannot be accepted as correct:
1. It can be assumed that missile which entered the retroperitonealspace 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 thisseries of abdominal injuries.
4.A retroperitoneal hematoma was specifically mentioned in only 33 of the 75grounds of the major abdominal blood vessels, though it is inconceivable that itwas not present in every such injury. As a matter of fact, after only a brief experience, the surgeons of the2d Auxiliary Surgical Group came to regard the presence of a hematoma as likelyin any wound of the retroperitoneal space and usually did not record it unlessit was the only lesion present or it was of significant severity. In otherwords, whatever the actual statistics may indicate, this was a lesion ofconsiderable frequency in this series of abdominal wounds.
CLINICALCONSIDERATIONS
It was usually impossible to make an accurate diagnosis ofretroperitoneal hematoma by clinical means alone. It was equally impossible,prior to operation, to differentiate between it and intra-abdominal visceralinjury. The signs and symptoms of both conditions were usually identical, and inthis series both lesions frequently occurred in the same patient.
There was no instancein this series of the so-called retroperitoneal syndrome observed by Jolly 1in the Spanish Civil War and explained by the retroperitoneal infiltrationof blood about the celiac plexus. This syndrome consists of a state of shock,with generalized pallor and sweating; a rapid, thready pulse, often becomingimperceptible; a complete absence of any symptoms or signs referable to theabdomen; and a semierection of the penis.
1Jolly, Douglas W.: FieldSurgery in Total War. NewYork: 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 retroperitonealextravasations of blood observed in this series had little or no pathologicsignificance and required no special treatment. On the other hand, the feelingthat most of them could be regarded as of no importance led, in the occasionalcase, to the overlooking of a serious injury and even to a fatality.
From the standpoint of treatment, the 207completely recorded retroperitoneal hematomas in this series can bedivided into three groups:
Onehundred and eleven patients, of whom nineteen died, had no specific treatmentrelated to the hematoma, presumably because it was thought to be tooinsignificant to warrant any.
Sixty-threepatients, 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-threepatients, of whom twenty-two died, had associated injuries of the great vesselsof the abdomen. Treatment in these cases consisted of evacuation of the bloodclot and control of the bleeding vessel by ligation, suture, or clamping.
The most importantimplication of a retroperitoneal hematoma, aside from the fact that the clinicalsigns could not be distinguished from signs of visceral perforation, was that itmight obscure injury to the vital retroperitoneal structures. Thathappened a number of times in this series.Lesions overlooked included a duodenal perforation, 2ureteral injuries, 4retroperitoneal injuries of the colon, and 6injuries of the bladder. There were only 5 survivals in these 12cases, 1 in the 4 injuries of the colon and 4 in the 6 injuries of thebladder. It is easy to understand how these errors occurred. While small hematomas required no treatment, large hematomas, and thosein which there was evidence of continued bleeding, urgently required explorationand control of the bleeding vessels. Underthese conditions, it was difficult to identify a coexisting lesion, such as aperforation of the colon on its retroperitoneal aspect.
FACTORSOF MORTALITY
There were 4 deaths (6.8percent) among the 59 patients who had no injuries other than theretroperitoneal hematoma. The case fatality rate is of the same order as therate (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 the22 deaths which occurred in the 63 retroperitoneal hematomas treated directly,11 were attributable to the retroperitoneal lesion itself. Five patients died ofshock and hemorrhage as a result of severe retroperitoneal bleeding, and threedied of anuria following shock of the same origin. The three other patients diedof retroperitoneal cellulitis, in one instance associated with pulmonaryembolism.
The lowcase fatality rate in the group of cases in which there was no lesion other thanthe retroperitoneal hematoma is apparently related to the relatively lowincidence of shock. In18 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 bein shock. Sixteen presented some degree of shock. There were no deaths in the 7patients 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, andless fatal shock, in this group than was usually encountered in a group ofsimilar size with injury limited to a single viscus.
As their experience with retroperitoneal hematomaincreased, the surgeons of the 2d Auxiliary Surgical Group formulated a routineplan of management for this condition:
1. Afterthe evacuation of a large hematoma in the retroperitoneal space and control ofthe bleeding responsible for it, the surrounding structures were carefullyexplored. Theywere similarly explored in the presence of any hematoma, regardless of itssize, if its anatomic location was such as to suggest possible injury to theureter, the bladder, the duodenum, or the posterior aspect of the colon.
2. Adequate extraperitonealdrainage was provided for retroperitoneal hematomas associated with injury toany portion of the urinary tract, the colon, or the pancreas. If a debrided missile wound of entry or exit was not suitable for thispurpose, drainage was instituted through a surgical incision in the flank orthrough a posterior incision.
3. Evacuation of the clot andligation of the bleeding vessel or vessels were usually all that was necessaryin large hematomas caused by vascular injuries.
4. Any opening in the posteriorperitoneum, whether made by the missile or created during the operativeprocedure, was carefully retroperitonealized, to eliminate communication betweenthe peritoneal cavity and the retroperitoneal space.
