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Chapter 8: Trauma

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A 33-year-old male is transported to your facility following a single stab wound to the anterior abdomen at the umbilicus. Initial vital signs are blood pressure 93/67 mmHg, heart rate 125 bpm, and respiratory rate 28 breaths/min. Intraoperatively, a large midline retroperitoneal hematoma is explored, and transection of the superior mesenteric artery (SMA) is identified posterior to the pancreas. Appropriate operative management of the mesenteric artery includes

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(A) Ligation only if proximal arterial injury

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(B) Ligation only if distal arterial injury

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(C) Proximal arterial ligation with bypass graft originating at the infrarenal aorta

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(D) End-to-end anastomosis with polytetrafluoroethylene (PTFE) graft

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(E) End-to-end anastomosis with saphenous vein graft

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(C) Operative management of the SMA is determined by the anatomic location of SMA injury, as described by Fullen et al (Table 8-1). The injury in the presented case is a Fullen zone I injury (posterior to the pancreas). Proper exposure and subsequent vascular control can be achieved by two methods, either by division of the pancreas or by medially rotating the left-sided abdominal viscera (Mattox maneuver; see Fig. 8-13). Repair should proceed with end-side anastomosis with saphenous vein graft or prosthetic graft, at the level of the infrarenal aorta. Such distal origin of the graft is preferred to avoid suture line in close proximity to pancreas or other upper abdominal injuries. Although the SMA has collateral blood supply, in the setting of trauma, there is often concomitant vasoconstriction that limits adequate collateral blood flow for bowel viability, and thus, ligation alone is not a plausible approach (choices A and B).

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Table 8-1 Fullen Zones of Superior Mesenteric Artery (SMA) Injury
Fullen Zone Description Exposure Treatment
I Posterior to pancreas Medial visceral rotation Infrarenal bypass (saphenous vein or polytetrafluoroethylene [PTFE])
II Between the pancreaticoduodenal artery and the middle colic artery branches Transection of pancreas Infrarenal bypass (saphenous vein or PTFE)
III Distal to middle colic artery - Repair (may include microsurgery); if repair not possible, then colon resection
IV Enteric branches - Repair (may include microsurgery); if repair not possible, then colon resection

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FIGURE 8-13. Mattox maneuver. From Skandalakis JE, Colborn GL, Weidman TA, et al. Skandalakis’ Surgical Anatomy. New York, NY: McGraw-Hill; 2004.

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BIBLIOGRAPHY

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Demetriades D, Inaba K. Vascular trauma: abdominal. In: Rutherford RB (ed.), Vascular Surgery, 7th ed. Philadelphia, PA: W.B. Saunders; 2010.

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Dente CJ, Feliciano DV. Abdominal vascular injury. In: Mattox KL, Moore EE, Feliciano DV (eds.), Trauma, 7th ed. New York, NY: ...

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