bubble_chart Overview

Retroperitoneal hematoma is a common complication of abdominal and lumbar injuries, occurring in approximately 10-40% of cases, and can be caused by direct or indirect violence. The most frequent causes are pelvic and spinal fractures, accounting for about two-thirds of cases, followed by rupture of retroperitoneal organs (such as the kidneys, bladder, duodenum, and pancreas) and injuries to major blood vessels and soft tissues. Due to its frequent association with severe combined injuries and hemorrhagic shock, the mortality rate can reach 35-42%.

bubble_chart Clinical Manifestations

Retroperitoneal hematoma lacks characteristic clinical manifestations, and varies significantly depending on the degree of bleeding and the extent of the hematoma. Abdominal pain is the most common symptom, with some patients experiencing abdominal distension and fullness and back pain. Hemorrhagic shock occurs in one-third of cases. Large hematomas or those accompanied by infiltration into the peritoneal cavity may present with abdominal muscle rigidity and rebound tenderness, as well as weakened or absent borborygmi.

Abdominal major vascular (abdominal aorta and inferior vena cava) injuries causing retroperitoneal hematomas are over 90% due to penetrating trauma. Due to rapid and massive bleeding, most patients die at the scene, and even after emergency treatment upon arrival at the hospital, the mortality rate remains as high as 70%. Progressive abdominal distension and fullness and shock suggest this diagnosis, and immediate laparotomy to control bleeding should be performed while aggressively managing shock.

bubble_chart Diagnosis

Any abdominal, spinal, or pelvic trauma accompanied by abdominal pain, abdominal distension and fullness, back pain, hemorrhagic shock, abdominal muscle tension and rebound tenderness, or weakened or absent borborygmi should raise suspicion of retroperitoneal hematoma.

X-ray examinations may suggest the possibility of retroperitoneal hematoma based on signs such as spinal or pelvic fractures, disappearance of the psoas muscle shadow, or abnormal kidney shadows. B-ultrasound and CT scans often provide reliable diagnostic evidence. Retroperitoneal hematoma is also frequently accompanied by signs of peritoneal irritation (intestinal paralysis, tenderness and rebound tenderness, muscle tension, etc.), which complicates the determination of whether there is intra-abdominal organ injury. Simple retroperitoneal hematoma without major vascular or vital organ injury typically presents with delayed and mild peritoneal irritation signs, and most cases respond well to anti-shock treatment. Diagnostic peritoneal lavage can often differentiate it from intra-abdominal hemorrhage, but the puncture should not be too deep to avoid entering the retroperitoneal hematoma and mistakenly diagnosing it as intra-abdominal bleeding, leading to unnecessary laparotomy. If the diagnosis remains uncertain, close observation is absolutely necessary.

bubble_chart Treatment Measures

The treatment of retroperitoneal hematoma should follow the general principles of abdominal injury, but the management of various types and locations of hematomas should differ.

Penetrating abdominal injuries complicated by retroperitoneal hematoma require further exploration of the hematoma after addressing the intra-abdominal organ injuries, as such injuries often involve retroperitoneal organs and major blood vessels. Retroperitoneal hematomas in the upper abdomen are often indicative of injuries to the retroperitoneal duodenum or pancreas. A Kocher incision should be made, lifting the duodenum and pancreatic head to the left to explore the first and second segments of the duodenum. The Treitz ligament should be divided to further examine the third and fourth segments of the duodenum and the entire pancreas. For stable perirenal hematomas without shock or significant hematuria, non-surgical treatment may be considered. If necessary, intravenous pyelography can confirm the diagnosis. If the diagnosis remains uncertain or bleeding persists, renal arteriography is an accurate method for diagnosing renal artery and kidney injuries and can also be used for embolization to control bleeding. If non-surgical treatment fails, surgical exploration is warranted. First, the renal pedicle should be controlled before incising the renal fascia to carefully assess the extent of kidney injury and manage it accordingly. Retroperitoneal hematomas caused by lumbar fractures are best treated non-surgically. However, if the hematoma is massive and ruptures into the abdominal cavity, leading to shifting dullness and a positive abdominal puncture, distinguishing it from intra-abdominal organ injuries may be difficult, and it should be managed as an intra-abdominal organ injury. Retroperitoneal hematomas resulting from simple pelvic fractures usually stop bleeding on their own, and surgical exploration is often unnecessary. If, despite aggressive anti-shock treatment, circulation remains unstable and the hematoma continues to expand, ligation of one or both internal iliac arteries may be considered. If surgery reveals that the hematoma is confined to the pelvis and not expanding, it should not be incised to avoid severe and uncontrollable bleeding.

For retroperitoneal hematomas caused by major vascular injuries, thorough preparation, including blood transfusion, vascular occlusion, and repair or anastomosis, should be made before exploring the hematoma. For optimal exposure, the lateral peritoneum can be incised along the avascular plane of the left paracolic gutter, and the descending colon, spleen, stomach, pancreatic body and tail, and left kidney can be retracted to the right. A combined thoracoabdominal incision provides excellent exposure of the distal descending aorta and the aorta above the kidneys. After quickly assessing the vascular injury, blood flow proximal and distal to the rupture should be occluded for repair. Penetrating injuries often perforate both the anterior and posterior walls of the vessel. If the vessel cannot be rotated, the posterior wall can be repaired through the anterior wall rupture first, followed by repair of the anterior wall rupture. If the aortic wall defect cannot be repaired, vascular grafting is recommended. Simple lacerations of the inferior vena cava can be sutured and repaired. For larger defects, especially those above the level of the renal veins, vascular patches should be used for repair. If the inferior vena cava injury is extensive and the above methods are not applicable, vascular grafting or ligation of the inferior vena cava may be performed. For severe injuries below the level of the renal veins or those associated with complex injuries, ligation of the inferior vena cava is often advocated to achieve hemostasis and prevent pulmonary embolism. However, ligation should not be used for injuries above the level of the renal veins, as ligating the inferior vena cava at this level can often lead to fatal consequences.