بسم الله الرحمن الرحيم و نَحن أقربُ إليه مِن حَبل الوريد

1. بسم الله الرحمن الرحيمو نَحن أقربُ إليه مِن حَبل الوريد

2. Spontaneous Retroperitoneal Hemorrhage by : FereshtehSalimi Department of General & Vascular Surgery Azar of 1392 e-mail: f_salimi@med.mui.ac.ir

3. Surgical Anatomy • The retroperitoneum is defined as the space between the posterior envelopment of the peritoneum and the posterior body wall . • It is bounded superiorly by the diaphragm , posteriorly by the spinal column and iliopsoas muscle and inferiorly by the levatorani muscles. • The anterior border is quite convoluted , extending into the spaces in between the mesenteries of the small and large intestines.

5. Retroperitoneal Structures • Kidneys • Ureters • Bladde r • Pancreas • Duodenum (D2 and D3) • Adrenal gland • Ascending colon • Descending colon • Rectum (upper two thirds) • Aorta • Inferior vena cava • Iliac vessel • Seminal vesicles • Vas deferens • Lymphatics (cysternachyli) • Vagina (upper most) • Ovaries • Nerves (lumbar sympathetics)

6. Retroperitoneal space Retroperitoneal space are classified on an anatomic basis: • zone 1 is the central area, bounded laterally by the kidneys and extending from the diaphragmatic hiatus to the bifurcation of the vena cava and the aorta • zone 2 comprises the lateral area of the retroperitoneum, from the kidneys laterally to the paracolic gutters • zone 3 is the pelvic portion

7. Retroperitoneal Regions

8. Retroperitoneal regions

9. Retroperitoneal Hematoma • The location of a retroperitoneal hematoma and mechanism of injury guide the decision to explore the hematoma. • The retroperitoneum is divided into three anatomic zones: • the midline retroperitoneum (zone 1) • the perinephric space (zone 2) • the pelvic retroperitoneum (zone 3)

10. Retroperitoneal Hematoma • Any hematoma in zone 1 mandates exploration for both penetrating and blunt injury because of the high likelihood and unforgiving nature of major vascular injury in this area. • The transverse mesocolon is the dividing line between the supramesocolic and inframesocolic compartments. • A central supramesocolic hematoma presents behind the lesser omentum, pushing the stomach forward • Inframesocolic hematoma develops behind the root of the small bowel mesentery, pushing it forward in a configuration similar to that of a ruptured abdominal aortic aneurysm

11. Retroperitoneal Regions • A hematoma in zone 2 is the result of injury to the renal vessels or parenchyma and mandates exploration for penetrating trauma to assess the damage and repair the injuries. • A nonexpanding stable hematoma resulting from a blunt trauma mechanism is better left unexplored because opening Gerota's fascia is very likely to result in further damage to the traumatized renal parenchyma and subsequent loss of the kidney. • In the severely injured patient with a stable hematoma from a penetrating injury, it is advisable not to explore the injured kidney because the patient may not have the physiologic reserves to tolerate an elaborate and time-consuming repair.

12. Retroperitoneal Regions • A pelvic retroperitoneal hematoma (zone 3) secondary to penetrating trauma mandates exploration because of the likelihood of iliac vessel injury. • zone 3 hematomas resulting from blunt trauma are usually associated with pelvic fractures and are not explored because the effective management of this type of bleeding is based not on operative control but on external fixation or angiographic embolization of the bleeding vessels. • The only exception is a rapidly expanding hematoma in which the surgeon suspects a major iliac vascular injury that requires operative repair.

13. Spontaneous Hemorrhage Precipitating factors: • Anticoagulation • Pre-existent benign adrenal cyst. • Factor ix and x deficiency • Von Willebrand disease • Anti-phospholipid syndrome • Patients on Clopidogril (plavix) • Rupture of tumour (kidney) • Rupture of aneurysm

14. Clinical presentation • Vague presentation , usually diagnosis is delayed if clinician is unaware of this condition, hypotension , mild tachycardia which improves with IVF. • Back pain , lower abdominal pain , groin discomfort and swelling. • Collapse , fall in Hb • Femoral neuropathy , causes groin pain , sever pain in affected groin and hip. Radiation to anterior thigh and lumbar region.

15. Cullen Sign

16. Diagnostic Images • Loss of psoas shadow • U/S: retroperitoneal hematoma , free fluid intraperitoneal in 16%. • C.T Spiral is sensitive in diagnosis • MRI: is very sensitive

17. C.T

18. C.T

19. C.T

23. Management • Conservative • Endovascular • Open surgery

24. Conservative • Admission to ICU • Monitoring • IVF Resuscitation • Blood Transfusion • Normalization of coagulation factors

25. Endovascular Treatment • Selective intra-arterial embolization by coil, gelatin or polyvinyl alcohol. • It is indicated : • if > 4 units of blood is needed in 24 hrs or 6 units in 48 hrs • After lumbar sympathectomy injury • After percutaneous nephrostomy • After renal biopsy

26. Open surgery • Hemodynamics instability , in spite of fluid resuscitation . • Abdominal compartment syndrome due to massive extension of hematoma. • In this condition , laparostomy is done with coverage of ant.abdomionalwall defect by Bogota bag

28. Retroperitoneal hematoma

29. Large RPH

30. Aortic Rupture

31. RPH w/Liver injury

32. Laparostomy

33. conclusion • Spontaneous retroperitoneal hemorrhage is a rare clinical entity which requires a high index of clinical suspicion. If treated inappropriately, retroperitoneal bleeding is associated with high morbidity and mortality. It should be suspected in elderly patients by anticoagulants or renal dialysis and those patients who have had an invasive procedure via the femoral artery or vein.

34. Correction of underlying coagulopathy and resuscitation with fluids and blood products is essential. Urgent high quality CT imaging is mandatory to document the type, site and extent of the hematoma.

35. Most patients with spontaneous or iatrogenic retroperitoneal hematoma can be monitored closely and treated conservatively without further intervention. Emergency angiography with a view to embolise or stent-graft the bleeding vessel(s) is indicated if the CT examination shows active extravasation of contrast.

36. Surgery can have its place in very selective cases, but removal of the hematoma may increase bleeding by removing the tamponade effect, and packing with large abdominal gauze may be the only surgical option, if no specific arterial bleed but general ooze can be identified per-operatively. Abdominal compartment syndrome may require decompression laparostomy.

37. Case Presentation • A 28 years old woman, in 33 week of her first pregnancy, who was admitted to our department for severe right flank pain, detected in right hypochondrium, associated with nausea, vomiting, and irritative bladder symptoms. • Personal and familial histories were unremarkable. • The patient was hemodynamically stable without hematuria, lumbar pain or other urological symptoms. • Physical examination revealed no specific findings, a good general condition, an axillary temperature of 38°C, blood pressure of 120/75 mmHg and a heart rate of 78 bpm. • Abdominal palpation revealed no masses. The only pathological laboratory test parameter was the hemoglobin 8,7 g/dl and hematocrit of 25,5%, that required the transfusion of two red cell concentrate units.

38. Abdominal ultrasound examination revealed a mass, with mixed echogenity, without acoustic shadowing well circumscribed, expanding at the upper pole of right kidney The mass confirmed with MRI, measuring approximately 7 × 7 × 5 cm in size with evidence of recent extensive retroperitoneal bleeding, with right perirenal and intrarenal hematoma

41. After a couple of hours she was developed an episode of fetal bradycardia, hypotension, and a hematocrit continued to decline, despite repeated blood transfusion, which combined with symptoms of intense lumbar pain and hematuria. • Considering the hemodynamic instability of the patient, emergency cesarean delivery, under general anaesthesia, was undertaken, because of foetal distress. • Exploration of the retroperitoneal space after foetal extraction, confirmed the presence of a large haematoma and the renal mass., which occupied the intrarenal space • Right nephrectomy was performed, and the haemorrhaging contents was evacuated.

44. The histological study of the resected mass revealed the presence of with admixture of mature adipose tissue, smooth muscle, and thick-walled blood vessels corrolated with Angiomyolipoma

45. Angiomyolipoma • Renal angiomyolipoma (AML) is a relatively infrequent clinical entity observed in 0.3% of the general population and accounting for 3% of all solid renal masses. • AMLs are benign mesothelial tumors, with three histologic characteristics: mature adipose tissue, blood vessels, and smooth muscle cells. • Most of AMLs are asymptomatic and found incidentally on imaging examinations. • To the best of our knowledge, during the past 10 years only three cases of massive retroperitoneal hemorrhage, resulting from rupture of a renal angiomyolipoma during pregnancy have occurred.

46. The majority of this kind of tumor, are often solitary, the mean age of presentation is 43 years, 4 times more common in men and, interestingly, involve the right kidney • Palpable abdominal mass, hematuria or flank pain are the main symptoms, and acute abdominal or even shock are the results of spontaneous rupture of the tumor

47. The management of AML is widely discussed in the literature. • Asymptomatic tumors smaller than 4 cm in size should be subjected to periodic ultrasound and CT controls every 6 months . • Symptomatic, bilateral lesions should be treated with selective arterial embolization or partial nephrectomy. • Radical nephrectomy is required when the patient is hemodynamic unstable, due to retroperitoneal hemorrhage • In our patient, the life threatening hemodynamic profile, in combination with fetal pulse abnormality, required emergency caesarian section and at the same time control of retroperitoneum bleeding, with radical right nephrectomy

48. In conclusion, it seems that these tumors show a greater growth index in pregnant women and the question that may be raised is when is the appropriate time for surgical interference. • The second trimester of pregnancy seems to be ideal since the risk of fetal organogenetic abnormalities decreases, even though the need of individualization of each case is necessary

49. Retroperitoneal hemorrhage presenting as a ruptured ectopic pregnancy. • Department of Surgery, University of Colorado Health Sciences Center, Denver. Abstract • A young woman presented with acute abdominal pain, anemia, and a positive pregnancy test. At surgery a large retroperitoneal hematoma secondary to a ruptured right kidney was found. Pathological examination revealed a hematogenic necrosis of a choriocarcinoma of the kidney. The patient tolerated subsequent chemotherapy with no evidence of recurrent disease after ten months of follow-up care. The diagnosis of choriocarcinoma must always be entertained when a patient presents with a positive pregnancy test and normal pelvic examination.

50. Spontaneous Retroperitoneal Hematoma: A Rare Devastating Clinical Entity of a Pleiada of Less Common Origins Department for Surgical treatment of End Stage Heart Failure and Mechanical Circulatory Support, Evangelisches and Johanniter Hospital Duisburg, Duisburg, Germany Journal of Surgical Technique and Case Report • Definition of Wunderlich syndrome, also known as spontaneous retroperitoneal hemorrhage (SRH), was first given in 1700 by Bonet and was more completely explained by Wunderlich. • Although SRH is commonly associated with Lenk's triad (acute flank pain,symptoms of internal bleeding, and upper and lower quadrant abdominal tenderness to palpation – costovertebral angle tenderness), • The most common signs and symptoms described are abdominal pain (67%), hematuria (40%), and shock (26.5%). • It is frequently found in conjunction with hypertension (33–50%) and atherosclerosis (80–87%).