Download RTC CELIAC AND MESENTERIC VASCULAR INJURY

Celiac Artery &
Mesenteric Vessels
Injuries
Martha A. Quiodettis
January 18, 2011
Introduction
•Abdominal Vascular Injuries (AVI)
• Most commonly due to penetrating
trauma
• Highly lethal and challenging
• Varied presentation
• Hemorrhagic shock
• 2nd cause of trauma death
•1st cause of preventable death
• Early resuscitation and control of
bleeding is key
Mechanism
• Penetrating trauma
•90-95% of injuries to abdominal vessels
• Accompany multiple intra-abdominal organ
injuries
•2-4 injuries
•Increase complexity of repair
•Blunt trauma
•Deceleration
•AP crushing
•Pelvic fractures

Ulvestad 1954 first report of SMA/SMV
injury. Blunt trauma

Kleitsch et al, 1957 SMA/SMV GSW repair

Fleming,1961, SMA/SMV primary repair

1967, Shirkey et al first survivor SMA
repair

0.01% to 0.1% of all vascular injuries.
Anatomy
superior and inferior
pancreaticoduodenal
Marginal artery
Drummond
Artery of Riolan
SMA/SMV
IMA/IMV
Fullen’s Zones
 Proximal
control= aortic cross
clamping or digital pressure at
hiatus.
 Celiac artery or SMA zone I:
 Left medial visceral rotation
 Direct trough lesser sac
 Base of transverse mesocolon.
 Transection of avascular plane at
neck of pancreas
Operative approach
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Damage control : ligate or shunt Zone I/II
depends on collaterals.
Definitive procedure:
Lateral arteriorraphy (prolene 5 0 /6 0)
Vein patch
End to end anastomosis ( transected)
Autogenous reverse saphenous vein
PTFE
Second look always!!!!!!
SMA
damage control mode= Ligate
 Be ready for

Definite repair:
 Venorraphy
 Graft saphenous vein
 Mesocaval shunt?

SMV
SMV (mesocaval shunt)
Approach directly
Ligation
 Transect ligament of Treitz if necessary
 Retropancreatic portion: dissect inferior
border of pancreas and retract cephalad.

IMA/ IMV
High mortality rates:
 Rapid volume loss
 Difficult exposure
 Complex vascular repair
 Late mortality/morbidity
 Isquemic bowel/ sepsis/ MOF
 Vascular repair failure
 Short gut sindrome
Outcomes
Mesenteric Vascular Injuries
1. when dealing with mesenteric vascular
injuries a second look operation is
advisable
2. blind clamping at the root of the
mesentery is a recipe for disaster
3. beware of iatrogenic renal vein injury
when exploring an inframesocolic
hematoma
celiac artery
a. injury to the celiac access is rare but
deadly
b. the celiac access is difficult to
expose
c. you may need to divide the stomach
using a stapler to do get rapid
exposure
Superior mesenteric artery
a. Injuries to the proximal SMA above the pancreas
are essentially aortic injuries, best exposed by Mattox
maneuver
b. Exposure through the lesser sac is another option
c. Usually are associated with pancreatic and/or
gastric injuries
d. May be best to ligate and do retrograde
reconstruction
e. Control of the retropancreatic SMA is best achieved
by dividing the pancreas
f. May insert shunt in SMA as damage control
maneuver
g. Reconstruct the SMA away from the injured
pancreas if possible
h. Reconstruct SMA using 6 mm ringed PTFE from
distal aorta of right common iliac artery
. Superior mesenteric vein
a. you may need to divide the pancreas
to repair injuries to the SMV
b. repair the injured SMV if you can
otherwise ligate it
c. the consequences of portal or SMV
ligation is massive fluid sequestration
which translates into high post op fluid
requirements and inability to close
abdomen
Revascularization of the Celiac
and Superior Mesenteric
Arteries After Operative Injury.
Using Both Splenic Artery and
Saphenous Graft
Preoperative contrastenhanced CT scan shows a
vascular left adrenal tumor.
The tumor extended
toward the abdominal aorta
and the origin of the CA and
SMA
Operative view after performing splenic artery
(arrow) anastomosis to the infra-renal aorta (*). The cut
end of the SMA (two arrows) is clamped by a Yasargil Buldog
clamp
THANKS!!!