Step 0

Profound hypotension, defined as a systolic blood pressure <70 mm Hg, identifies the patient who benefits from therapeutic aortic occlusion ²⁹. If the management group has implemented the use of the REBOA, it can be inserted by a parallel team while the main surgeon prepares and performs the laparotomy and control of the bleeding. However, delaying the bleeding control procedure due to insertion of the intravascular device may be associated with an increased likelihood of death ³⁰.

Performing a thoracotomy before a laparotomy ³¹, for clamping the descending aorta was not associated with better outcomes and, on the contrary, causes additional trauma and creates an additional source of bleeding, so its routine use is not recommended ^12,16.

Abdominal aortic occlusion in the diaphragmatic hiatus immediately after entering to the abdomen is preferable.

Step 1

When preparing for the management of severely traumatized patients, the hospital must have an available operating room that allows temperature regulation, has the elements for hemodynamic monitoring, the prevention and management of hypothermia, rapid infusion of warm fluids and blood components, as well as the surgical instrumentation required to access the different cavities, the management of vascular structures and the insertion of intravascular devices. In addition, prompt access to laboratory tests is essential to assess metabolic status and coagulation. Ideally, a cell salver device should be available.

In all cases, the patient is placed in the supine position and is prepared from the edge of the jaws and from side to side of the table. The abdomen is accessed through a xipho-pubic midline laparotomy. The cavity is quickly evacuated with the help of aspiration and laparotomy pads. The recovered blood can be transferred to the cell saver device. The presence of hollow viscera injury does not contraindicate the use of recovered blood for autotransfusion ^32,33.

Loose pad placement in all four quadrants allows rapid identification of the bleeding source.

Step 2: Transitory control of bleeding

The priority in a trauma laparotomy is bleeding control. It should be considered that a vascular injury is not the only cause of exsanguinating abdominal bleeding, nor is it the most common. In a series of 60 patients with abdominal trauma from firearms and systolic pressure <70 mm Hg, major vascular injuries were the third leading cause of bleeding (20%), after liver (47%), and renal injuries (21%) ³⁴.

Intraperitoneal hemorrhage is controlled by applying pressure, clamping, or packing. Retroperitoneal bleeding is temporarily controlled by applying pressure, which should be as selective as possible to allow exposure and management of the lesion (Figure 2). In addition to providing transient hemodynamic support, Aortic occlusion contributes to the reduction of distal bleeding to the site of occlusion (Figure 3).

Figure 2 Penetrating trauma to the right iliac artery. A) Transient bleeding control with local pressure. B) Definitive vascular control with atraumatic clamps 

Figure 3 Clamping of the supraceliac aorta. A) Entering the lesser sac. The left hepatic lobe has been pushed back, the gastrohepatic ligament (Ghl) has been divided with a blunt maneuver with the index finger. The body of the pancreas (Pa) and the fibers of the diaphragmatic hiatus (DC) are observed. Li Liver. St stomach B) Guided by the pulsations of the aorta, the surgeon longitudinally dissects the fibers of the diaphragm at the hiatus (D). He surrounds the vessel on each side and clamps it between his index and middle fingers. Occasionally, some diaphragm fibers must be separated with an electrosurgical device. It is not recommended to completely surround the aorta during this maneuver. Ao Supraceliac Aorta. C) Aortic clamp placement. The surgeon keeps his fingers embracing the aorta. He advances the aortic clamp until he feels the resistance of the prevertebral fascia. D) Without removing the fingers, the clamp is closed, and the complete occlusion of the vessel is verified. HD. Hiatus day. 

Step 3: Exposure of the injured vessel

After temporary bleeding control is achieved, the surgeon proceeds to identify the compromised vascular structure. This determines the specific approach to the definitive management. The location of the hematoma or site of active bleeding and involvement of other organs suggests the possible damaged structure ³⁵. In penetrating trauma, the topographic location of the wound provides an additional hint.

The graph illustrates the location of the hematomas (Figure 4) and Table 3 lists the potentially injured structures in each location and their approaches.

Figure 4 Location of retroperitoneal hematomas. 1. Central Medial 1A. Central supra-mesocolic.1 B. Central infra-mesocolic. 2. Flank. 2A. Peri-renal flank. 2B. Flank, pericolic. 3. Pelvic. 4. Portal. 5. Retro-hepatic 

In relation to the classification popularized since the 1980s, some distinctions are added that are clear in the management of retroperitoneal vascular injuries in the context of penetrating trauma ³⁵. Central hematomas are divided into supra and infra mesocolic due to the difficulties in exposure and the high lethality of the lesions of the suprarenal abdominal aorta and its visceral branches. Flank hematomas are differentiated into perirenal and pericolic, as stable perirenal hematomas should not be explored. Hematomas of the portal area and the retro-hepatic area are added, due to their particularities in terms of prognosis and surgical exposure. Table 3 relates the location of the hematomas, the vessels most frequently associated with each location, and the maneuvers suggested according to the suspected injury.

Asensio et al. ¹¹, reported the presence of retroperitoneal hematomas in 91% of patients with abdominal vascular trauma managed at their institution. The location was central in 50% of the cases (supramesocolic 20%, infra mesocolic 30%), the flanks in 18% and pelvic in 32%. Additionally, 13% of patients had multiple zones of involvement.

The surgeon must select an approach that allows proximal and distal control to the injury, without compromising bleeding control, to perform the surgical repair after the proximal and distal occlusion (Figure 2) attempting to repair a vascular injury without achieving control results in unnecessary blood loss, which is unacceptable in a critically hypovolemic patient.

Step 4: Management of vascular injury

The prompt decision to perform damage control in patients who is indicated is of crucial importance. Prolonging surgery unnecessarily, attempting the definitive management of the lesions in an individual with depletion of its physiological reserve, is associated with a higher probability of death ³⁶.

Frequent communication with the anesthesiologist will allow the surgeon to identify and follow the alterations that reveal the profound metabolic, hemodynamic, or coagulation alteration that forces the conversion towards a damage control procedure if the decision has not been taken previously.

The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with the postponement of definitive management. Their management includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces regarding vascular injuries. In general terms, grade I to III injuries should be ligated, while IV and V injuries should be considered for repair (Table 4).

The specific management of the most important vascular lesions is discussed below.

Aorta: Wounds to the suprarenal abdominal aorta and its visceral branches are usually presented by intra-abdominal exsanguination, with an operative finding of a central supramesocolic hematoma. Given this finding, proximal control should be carried out by performing a left medial visceral rotation (Mattox maneuver) ^37,38 (Figure 5). Approaching the injury directly through the hematoma through the lesser sac or the transverse mesocolon is not very productive and is associated with prohibitive mortality. In some cases, when the hematoma is extremely voluminous or the patient is In Extremis, a left thoracotomy may be performed to clamp the aorta. Occasionally, proximal control may be performed with a REBOA deployed in zone I, which greatly facilitates exposure and reduces surgical trauma. In any case, it must be taken into consideration that occlusion of the supra-celiac aorta for more than 30 minutes causes severe ischemia and reperfusion, which is unlikely to survive. In these cases, the surgeon must consider partial or intermittent occlusion strategies and implement the most selective control in lesions of the visceral branches of the aorta. Exposure of the aorta to this level is completed by severing the fibers of the cross of the diaphragm and dissecting and ligating the lymphatic and nerve plexuses, which are very firm and surround it completely. Distal control is performed by dissection and clamping of the iliac vessels. After identifying the anatomical location of the wound, a more selective control and clamping is carried out. The repair to be made will depend on the clinical condition of the patient and the anatomical damage ³⁸. Aortic injury caused by sharps weapons or low-velocity projectiles can be directly repaired by suturing. Other wounds will need to be repaired with a synthetic patch or graft (Figure 6A).

Figure 5 Mattox maneuver. A) Identification of the peritoneal reflection line of the descending colon, where the avascular plane that allows access to the retroperitoneum will be dissected. B) Identification of the peritoneal reflection line of the splenic flexure of the colon, spleen and stomach, to perform the medial rotation of these organs. C) By sharp and blunt dissection, the descending colon, the splenic flexure of the colon (Co), the spleen, and the stomach are mobilized medially. As it is advanced posteriorly in the retroperitoneum (R), the pancreas and kidney are mobilized. D) The lesion was located between the celiac trunk (CT) and the superior mesenteric artery. In addition to medial rotation of the viscera, the exposure required sectioning the fibers of the diaphragm and completely dissecting the firm plexus surrounding the aorta and the origin of its branches. Ao Aorta, St stomach, Spl spleen. E) Lesion located in the aorta (Ao) above the left renal artery (Re). SM superior mesenteric artery, K Kidney, Ur ureter. F) Exposure of the supraceliac and visceral aorta (Ao). A lesion of the celiac trunk (CT) has been managed with ligation. The remnants of the plexus surrounding the aorta can be seen. MS superior mesenteric artery, Re left renal artery. 

Figure 6 Injury to the suprarenal aorta and its branches. A) Injury between the inferior mesenteric artery and the renal artery. Note the medial rotation of the viscera on the left side. The injured segment has been replaced by a dacron graft. B) Celiac trunk injury. Note the medial rotation of the viscera on the left side. The injured vessel was handled with ligature (yellow arrow).  

The coeliac trunk and its branches can be ligated with a low risk of ischemic complications (Figure 6B). In extreme situations, the superior mesenteric artery or vein can be ligated since the probability of survival depends more on the hemodynamic status of the patient than on the ligation or repair of the vessel (Table 5). Under extreme conditions, if circumstances permit, vascular continuity can be maintained with a transient bypass in the aorta or superior mesenteric artery ³⁹.

Infrarenal aortic wounds present as a midline hematoma. Depending on the specific location of the lesion and the size of the hematoma, proximal control may be performed with a more limited mobilization of the viscera on the left side (Figure 7), through the midline or utilizing a Catell-Braasch maneuver. Repair of the injury follows the principles mentioned ^40,41.

Figure 7 Exposure and control of an infrarenal aortic injury with medial mobilization of the left colon. 

Inferior Vena Cava (IVC): Wounds to the infra-hepatic, juxta-renal, and infra-renal segments of the vena cava present as a central or right lateral hematoma or hemorrhage ^42-44.

Proximal control of the vessel is performed with medial mobilization of the viscera on the right side (Catell-Braash maneuver) (Figure 8), while maintaining digital compression on the injury site, thereby achieving temporary hemorrhage control. The extent of exposure is determined by the location of the wound and the size of the hematoma. Proximal and distal controls can be accomplished with forceps, swabs or even with the assistant's own fingers. Juxtarenal injuries will often require dissection and occlusion of the renal veins. Lateral clamping with Satinsky forceps will allow repair of the lesion in selected cases.

Figure 8 Catell Braasch maneuver. A) Hematoma in zones 2 and 3 on the right side. The arrows indicate the peritoneal reflection, where the incision would be made to access the retroperitoneum. The possibility of surrounding the cecum and directing the incision at the base of the mesentery is indicated, allowing the elevation of the right colon and the small intestine, to expose in addition to the vena cava, the right iliac vessels and the infra-renal aorta. B) Identification of the peritoneal reflection line of the ascending colon. C) The surgeon has mobilized the hepatic flexure of the colon (Co) and is entering the retroperitoneum posterior to the duodenum (Du). St Stomach D) Mobilization of the hepatic flexure of the colon (Co) and exposure of the first three duodenal portions (Du) and the head of the pancreas (Pa). Li liver, Gb gallbladder, St stomach. E) Mobilization of the duodenum (Du) and the head of the pancreas (Pa), to expose the suprarenal vein cava (Ca). Li liver, Gb gallbladder, St stomach. F) Mobilization of the right colon (Co) and duodenum (Du), to expose the entire vena cava (Ca). Li liver, Gb gallbladder, Ap caecal appendix. 

The existence of a posterior (mirror) injury will force the surgeon to broaden the anterior wound to repair it from the inside or to carefully rotate the vessel to expose it from behind without injuring the lumbar tributaries. Medial rotation of the right kidney will expose the posterior side of the juxtarenal cava. Other treatment methods include reconstruction with a venous or peritoneal patch and, rarely, anastomosis or insertion of a graft. In the damage control setting, ligation can expeditiously resolve the injury ¹⁹ (Figure 9).

Figure 9 Trauma of the infrarenal vena cava. A) Exposure of the vein with medial mobilization of the right colon. B) Infrarenal vena cava ligation.  

Its use has been reported in percentages as low as 5% and as high as 63%. For example, in an analysis of 1,316 patients with IVC injuries registered in the United States National Trauma Database (NTDB), ligation was reported in 34% of cases ⁴⁵.

Matsumoto et al., compared 310 patients with injury to the IVC in which ligation was performed, with an equal number of repaired cases, matched for the probability of being ligated, identified in the NTBD. Patients treated with ligation had greater severity of trauma and greater physiological deterioration. After matching, they found mortality to be similar, with increased risk of extremities compartment syndrome, thromboembolic events, pneumonia, and longer ICU and hospital stay in those with ligation ⁴⁵. Byerly et al., selected the isolated IVC trauma cases from the NTDB and compared 104 ligated patients with 339 repaired patients. The multivariate analysis found that ligation was not associated with a higher risk of death or amputation but with a higher probability of acute kidney injury, venous thrombosis, and fasciotomy ⁴⁶. The usual recommendation in wounds of the infrahepatic segment is to avoid its ligation. There are isolated reports of survival after ligation ^47,48. This is preferable to death due to prolonged repair attempts.

The decision to ligate the vessel, resembling the decision to perform damage control, should be made promptly. When taken as a last resort, loss of time and blood occur, with greater physiological derangement and a considerable increase in the risk of death.

Injury to the suprahepatic vessels or the retrohepatic vena cava presents as a severe hemorrhage in the suprahepatic location or as a hepatic wound with dark bleeding that persists despite clamping of the hilum ⁴⁹. When a stable hematoma is present or bleeding is controlled with packing, the surgeon should avoid any effort to mobilize the liver to expose and repair the injured vessel ⁵⁰. In a second stage, a surgical team that includes a hepatic surgeon returns to the operating room after the patient has been stabilized and the perfusion, hypothermia and coagulopathy alterations have been corrected. Occasionally the removal of the packing is performed in several sequential procedures, allowing the healing of the vascular lesion without a surgical repair (Figure 10). In these cases, imaging of the patient and endovascular treatment is also possible.

Figure 10 Patient with exsanguinating suprahepatic hemorrhage and injury to the right lower lobe. Wound in the suprahepatic area (segment IV) with hemorrhage that was not controlled with clamping of the hepatic hilum. Due to the need to resolve the intrathoracic bleeding, the surgeon packed the liver injury achieving control of the hemorrhage. A) Chest X-ray, Day 1. Laparotomy pads are observed on the chest and abdomen. B) Chest X-ray, Day 3, After chest unpacking and closure and partial abdominal unpacking. C) Chest X-ray, Day 10, after completing abdominal unpacking and closing the fascia.  

If perihepatic packing is unsuccessful, one group member applies pressure to the injury to temporarily achieve bleeding control, while the rest of the team performs hepatic vascular exclusion as vascular control. This can be carried out by placing a REBOA in zone I and an intra-cava balloon (REBOC), inserted through the right femoral vein, taking it to the retrohepatic vena cava and make the total isolation by endovascular methods ^51,52. If this resource is not available, liver isolation is performed with a Pringle maneuver, occlusion of the supra celiac aorta, occlusion of the infrahepatic inferior vena cava, and control of the inferior intrathoracic cava through a sternotomy or thoracotomy. Only under these conditions is possible to perform a repair with suture of the retrohepatic vena cava, or proximal and distal ligation of the vessel or a transfixing suture of a suprahepatic vein (Figure 11).

Figure 11 Wound on the medial area of the retrohepatic cava. Hepatic exclusion was performed by intravascular occlusion of the aorta in zone 1, of the vena cava in its retrohepatic portion, and clamping of the hepatic hilum. The left liver lobe has been mobilized to the right and the surgeon's finger controls the bleeding, in preparation for its suture (arrow) 

The use of atrio-cava or cavo-atrial shunts is successful in the hands of some groups ^53-55. However, its execution is time-consuming and, in the experience of most surgeons, mortality does not change. Therefore, the approach with hepatic exclusion as described is preferred ⁵⁶. The use of a centrifugal pump to preserve the venous return of the lower half of the body while the injury is being repaired has been reported, but the availability of these devices is limited ^57,58.

Iliac vessels: Iliac vessel trauma usually presents as a lateral pelvic hematoma. Less frequently as a flank hematoma. Proximal vascular control requires mobilization of the right or left colon, and occasionally distal repair requires dissection of the common femoral vessels in the thigh ⁵⁹. Injuries to the internal iliac are almost always managed with ligation, whereas injuries to the common iliac and external iliac are preferred to preserve blood flow to the lower extremity, which in damage control situations, temporary shunts are usually used ^39,60 (Figure 12).

Figure 12 Placement of a temporary shunt in a lesion of the right iliac artery. A). Proximally and distally repaired artery. B) The graft (LeVin 16 Fr probe segment) has been installed sideways. C) The graft has been completely installed. Notice the firm ties that fix it. Courtesy Dr. Diego Rivera. 

Porta Vein: Porta vein injuries may manifest as bleeding in the area of the hepatic hilum or as a hematoma in right zone II ³⁵. In the first scenario, the clamping of the hepatic hilum achieves control of the hemorrhage. In the second, the Catell-Braasch maneuver with medial rotation of the duodenum and the head of the pancreas may be insufficient. Therefore, the section of the neck of the pancreas may be necessary. Lateral repair is reserved for small injuries in stable patients. However, ligation, when it is not left as a last resource, can be life-saving in unstable subjects. Stone et al. reported a reduction in mortality from 87% to 20% when they changed their decision to ligate the portal vein as the last choice procedure after failed attempts, to a first-line procedure in the group of unstable patients ⁶¹ and Pachter reported a low incidence of portal hypertension after vessel ligation for traumatic injuries ⁶². More recently, Sabat et al. ⁽⁶³, compared 103 patients with traumatic portal vein injuries managed with ligation with 304 individuals treated with a repair. The treatment method was not associated with higher mortality, while race, the severity of the trauma, presence of coma on admission, and coexistence of another vascular lesion were associated with a higher risk of death. Bowel complications and hospital stay were similar in both groups.

The principles of management of superior mesenteric vein injuries are similar to those described for the portal vein (Figure 13, Table 5).

Figure 13 Blunt trauma with multiple intestinal and mesentery injuries. Severe instability requiring aortic clamping. A). Ligated distal end of the superior mesenteric vein. B) Proximal stump ligated. C) Day 5. Six reoperations were require due to progressive necrosis of the small intestine. Massively swollen and congestive intestine. D) A mesenteric-caval bypass was performed. After this the intestinal congestion resolved and the intestine could be anastomosed in subsequent procedures. 

Step 5. Temporary cavity closure

After managing the vascular lesion and controlling the sources of contamination, the surgeon verifies the absence of active bleeding and readjusts the laparotomy pads. He then proceeds to perform the unconventional closure of the abdominal cavity.

Closure of the fascia or skin with sutures or towel clamps is not recommended as it increases the risk of abdominal hypertension and compartment syndrome ⁶⁴. The suggested method is one that allows to increase the volume of the abdominal cavity and, if possible, that uses the principle of negative pressure because it simplifies nursing care, allows monitoring of persistent bleeding and potentially favors closure of the fascia ^65,66.

There are doubts about exacerbation of bleeding with negative pressure systems. The authors' observations demonstrate that pressure is not transmitted beyond the site where the pads or foams are placed ⁶⁷. In addition, the experience of those who handle a certain volume of trauma patients allows to safely suggest the use of negative pressure devices from the first procedure.

Step 6. Reoperations and vascular reconstruction

The group of patients with vascular injuries treated with damage control procedures often require emergency reoperations due to persistent bleeding or ischemic complications.

If this is not the case, patients should be reoperated as soon as hypothermia, coagulopathy and hemodynamic alterations have been restored to reconstruct the arterial vessel if a temporary bypass was used and to verify intestinal viability in the patients managed with ligation of the portal vein or superior mesenteric vessels.