Injuries to the Great Vessels of the Abdomen

In patients who have injuries to the great vessels of the abdomen, the findings on physical examination generally depend on whether a contained hematoma or active hemorrhage is present.1 In the case of contained hematomas around the vascular injury in the retroperitoneum, the base of the mesentery, or the hepatoduodenal ligament, the patient often has only modest hypotension in transit or on arrival at the emergency center; the hypotension can be temporarily reversed by the infusion of fluids and may not recur until the hematoma is opened at the time of laparotomy.This is usually the situation when an abdominal venous injury is present. In the case of active intraperitoneal hemorrhage, the patient typically has significant hypotension and may have a distended abdomen on arrival. Another physical finding that is occasionally noted in association with an injury to the common or external iliac artery is intermittent or complete loss of a pulse in the ipsilateral femoral artery; this finding in a patient with a transpelvic gunshot wound is pathognomonic of an injury to the iliac artery. Injuries to the great vessels of the abdomen are caused by penetrating wounds in 90% to 95% of cases; accordingly, they are often accompanied by injuries to multiple intra-abdominal organs, including those in the gastrointestinal tract.2-5The general principles governing the sequencing of repairs of injuries to the great vessels and the GI tract are outlined elsewhere [see 7;6 Operative Exposure of Abdominal Injuries and Closure of the Abdomen]. A hematoma [see Figures 1 and 2] or hemorrhage associated with an injury to a great vessel of the abdomen occurs in one of the three zones of the retroperitoneum or in the portal-retrohepatic area of the right upper quadrant [see 7:6 Operative Exposure of Abdominal Injuries and Closure of the Abdomen].The magnitude of injury is usually described according to the Abdominal Vascular Organ Injury Scale, devised in 1992 by the American Association for the Surgery of Trauma [see Table 1].6