Download - Retroperitoneal Collections
Retroperitoneal Collections;Retroperitoneal Collections; Causes , Diagnosis and Causes , Diagnosis and
ManagementManagement
Dr Maha Khalid AL MadiDr Maha Khalid AL MadiUrology ResidentUrology Resident
KFHU – Khobar – Saudi ArabiaKFHU – Khobar – Saudi Arabia20102010
Objective…
Retroperitoneal anatomy Interfascial planes Interfascial plane extensions Retroperitoneal collections & extension Retroperitoneal Hematoma
- Causes- Approach to RPH- Diagnostic imaging- Management
Retroperitoneal Anatomy
Retroperitoneal Anatomy
The retroperitoneum is conventionally divided into three distinct compartments:
Retroperitoneal Anatomy
1 . Posterior pararenal space,
Fat
connective tissue nerves
Retroperitoneal Anatomy
2 . Anterior pararenal space
Colon
Pancreas
Duodenum
Retroperitoneal Anatomy
3. Perirenal space
Kidneys
Adrenal glands
Upper portion of ureters
Interfascial Planes
Interfascial Planes
• Tricompartmental anatomy does not completely explain the spread of fluid collections.
• Collections tend to escape site of origin into expandable interfascial planes.
Interfascial Planes
• These interfascial planes are represented by
- Retromesenteric
- Retrorenal
- Lateroconal interfascial plane,
- Combined interfascial planes
Interfascial Planes
The Retromesenteric plane
Expansile plane located between the APR and PRS
Interfascial Planes
The Retrorenal plane
Between the PRS and PPS
Interfascial Planes
The lateral conal interfascial plane
Between layers of the LCF. It communicates with the RMP and RRP at the fascial trifurcation.
Interfascial Planes
The combined interfascial plane
formed by the inferior blending of the RMP and RRP . It continues into the pelvis.
Interfascial Planes
The fascial trifurcation
The point at which the RMP, RRP, and LCF planes communicate mutually
Interfascial Plane Extensions
Interfascial Planes
Medial Extension
• RMPs and RRS are continuous across the midline.
Interfascial Planes
Right superior extension
• The superior PRS is in continuity with the bare area of the liver
Interfascial Planes
Left superior extension
• The RMP ,RRP and PRS on the left extend to the left hemidiaphragm
Retroperitoneal collections & their
extensions
Types of Collections
- hemorrhagic
- bilious
- uriniferous
- enteric
- infectious
- inflammatory
- malignant
Extension of fluid collections
• Fascial planes/adhesions confine retroperitoneal fluid collections to their compartment of origin
• Large or rapidly developing fluid collections may decompress along retroperitoneal fascial planes
Extension of fluid collections
Fluid originating from the APS
Pancreatitis Pancreatic injury Appendicitis abscess of the colonic wall
Extension of fluid collections
Fluid originating from the PRS
Ruptured AAA
Renal injury Hge/urinoma
Extension of fluid collections
Fluid originating from the PPS
bleeding after spinal trauma/surgery
Extension of fluid collections
Pelvic Extension
By the infrarenal retroperitoneal space
RetroperitonealHematomas
Causes
factor IX ,X deficiency, von Willebrand APL syndrome anticoagulation*
*0.6-6.6% of patients undergoing therapeutic anticoagulation.Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: nt J Clin Pract. 2008;
Injury ( to bony structures, major vessels, intestinal or retroperitoneal viscera)
Iatrogenic
Great Vessel Injuries
Rupture of AAA
• Most bleed posteriorly confined by the psoas space or extend into the retrorenal interfascial plane behind the left kidney.
Great Vessel Injuries
IVC Injury
• Often found to bleed directly into the right retrorenal space.
Perirenal Hematomas
• Renal trauma (incidence 5%)*• Helical CT is the imaging modality of choice in
stable patients
* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: nt J Clin Pract. 2008;
Perirenal Hematomas
• Hematoma from the PRS spreads by bridging septa to the interfascial planes
• From there can spread upward near the esophagus or downward to the pelvis
Pelvic fracture w/ Hematoma
2 Routes of spread are possible
- from the PPS into the combined interfascial plane,
- from the prevesical space to the combined interfascial plane.
Pelvic fracture w/ Hematoma
• Can then ascend within the combined interfascial plane into the
RRS
RMP
Approach to RPH
Approach to RPH
• The location and mechanism of injury guide the decision to explore
• the midline retroperitoneum (zone 1)
• the perinephric space (zone 2)
• the pelvic retroperitoneum (zone 3)
Approach to RPH
ZONE 1
ZONE 2
ZONE 3
Approach to RPH
zone IMandates exploration for both penetrating and blunt injury because of the high likelihood of major vascular injury in this area.
zone I (central) retroperitoneal hematoma with active extravasation from ruptured AAA
Approach to RPH
zone IIinjury to the renal vessels or parenchyma and mandates exploration for penetrating trauma
A nonexpanding stable hematoma resulting from a blunt trauma mechanism is better left unexplored
Large zone II (lateral) retroperitoneal hematomaFrom renal injury
Approach to RPH
zone III
• Penetrating trauma mandates exploration
• Blunt trauma are usually with pelvic fractures management is based external fixation or angiographic embolization
Approach to RPH
Clinical Presentation
• Is varied ,may be vague, and diagnosis is often missed
• Patients initially exhibit subtle clinical signs of hypotension and mild tachycardia that transiently improves with administration of fluids.
Approach to RPH
Clinical Presentation
• Patients may present with back, lower abdominal or groin discomfort and swelling,
May progress to haemodynamic instability.
Approach to RPH
Diagnostic Imaging
• Plain abdominal /pelvic XRAY may demonstrate ;
loss of the psoas shadow unstable pelvic ring fracture
Approach to RPH
Diagnostic Imaging
• Ultrasound is often limited
• Free fluid often passes into the abdominal or pelvic cavity, and can be detected as free abdominal fluid on US
Approach to RPH
Diagnostic Imaging
• CT (type, site and extent of fluid collections(
• CT Angio shows the site of the bleed and contrast outside the vessels
Approach to RPH
Diagnostic Imaging
• In haemodynamically unstable, digital subtraction angiography with selective embolisation or placement of a stent graft is indicated.
Approach to RPH
Management
• Controversial.
• all patients should initially be managed in an intensive care unit with careful monitoring, fluid resuscitation, blood transfusion and normalization of coagulation profile
Approach to RPH
Management
• If the patient is haemodynamically stable with no evidence of on-going bleeding, conservative management is recommended *
* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Iatrogenic Retroperitoneal Bleed by .C. Chan,1 J.P. Morales,1 J.F. Reidy,2 and P.R. Taylor 1
Int J Clin Pract. 2008;
Approach to RPH
Management• In spontaneous RPH the mainstay of
management remains conservative,
withdrawal of anticoagulation
correction of coagulopathy
volume resuscitation
* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Iatrogenic Retroperitoneal Bleed by .C. Chan,1 J.P. Morales,1 J.F. Reidy,2 and P.R. Taylor 1
Int J Clin Pract. 2008;
Approach to RPH
Endovascular Treatment
• Selective intra-arterial embolization OR stent-grafts.
• Indication: HD instability despite ≥ 4 units of blood IN 24 h, or ≥ 6 units in 48 h
Approach to RPH
Open Surgery
• Indications
- the patient remains unstable
- interventional radiology is not successful or unavailable.
- patient develops abdominal compartment syndrome
Approach to RPH
• RPH (Zone 1) after penetrating trauma implies injury to the great vessels and always requires urgent surgical exploration.
Approach to RPH
• RPH in other zones should be evaluated by CT and/or angiography; ongoing hemorrhage may respond to therapeutic embolization
Thank Thank YouYou
References…•Comprehensive reviews of the interfascial plane of the retroperitoneum: normal anatomy and pathologic entitiesSu Lim Lee & Young Mi Ku & Sung Eun Rha28 April 2009 Soc Emergency Radiol 2009
Cameron: Current Surgical Therapy, 9th ed. By JOHN L. CAMERON, MD, FACS, FRCS
Sabiston Textbook of Surgery, 18th ed by Beaughamp,Evers, Mattox
Management of Retroperitoneal Haemorrhage, Y.C. Chan; J.P. Morales; J.F. Reidy; P.R. Taylor, Int J Clin Pract. 2008http://www.medscape.com/viewarticle/582645
•Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings1 October 2008 RadioGraphicsKevin P. Daly, MD, Christopher P. Ho, MD,