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Abdominal vascular injuries are among the most lethal injuries encountered by trauma surgeons as the vast majority of these patients arrive at trauma centers in profound hemorrhagic shock. Patients sustaining abdominal vascular injuries best exemplify the lethal vicious cycle of shock, with secondary hypothermia, acidosis and a coagulopathy.
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The major sites of hemorrhage in patients sustaining blunt or penetrating abdominal trauma are the viscera, the mesentery, and the major abdominal vessels. The term “abdominal vascular injury” generally refers to injury to major intraperitoneal or retroperitoneal vessels and is generally classified into four zones described as follows and in Table 34-1:
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Zone 1: midline retroperitoneum
Supramesocolic region
Inframesocolic region
Zone 2: upper lateral retroperitoneum
Zone 3: pelvic retroperitoneum
Porta hepatis/retrohepatic inferior vena cava
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As most of the vessels in these areas are in the retroperitoneum, they are difficult to quickly access via a midline laparotomy incision. Therefore, a systematic operative approach is required to adequately diagnose and manage these potentially devastating injuries. A general discussion of epidemiology and methods of diagnosis, with subsequent descriptions of the operative management of abdominal vascular injuries within each region of the abdomen follows.
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In reviews of vascular injuries sustained in military conflicts, abdominal vascular injuries have been extraordinarily rare. For example, DeBakey and Simeone’s classic article on 2471 arterial injuries during World War II included only 49 that occurred in the abdomen, an incidence of 2%.1 Reporting on 304 arterial injuries from the Korean conflict, Hughes noted that only 7, or 2.3%, occurred in the iliac arteries.2 In the review by Rich et al of 1000 arterial injuries in the Vietnam War, only 29, or 2.9%, involved abdominal vessels.3 Finally, a recent review of abdominal injuries during the Iraqi conflict documented only four injuries to major vessels in 145 patients undergoing laparotomy (2.8%).4
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The data from civilian trauma centers are quite different. In 1979, 15% of patients with ...