by : Fereshteh Salimi
Department of General & Vascular Surgery
Azar of 1392
e-mail: f_salimi@med.mui.ac.ir
Surgical Anatomy
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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
levator ani muscles.
The anterior border is quite convoluted , extending into
the spaces in between the mesenteries of the small and large
intestines.
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Retroperitoneal Structures
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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 (cysterna
chyli)
 Vagina (upper most)
 Ovaries
 Nerves (lumbar
sympathetics)
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Retroperitoneal space
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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
Retroperitoneal Regions
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Retroperitoneal regions
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Retroperitoneal Hematoma
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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)
Retroperitoneal Hematoma
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 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
Retroperitoneal Regions
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 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 timeconsuming repair.
Retroperitoneal Regions
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 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.
Spontaneous Hemorrhage
Precipitating factors:
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 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
Clinical presentation
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 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.
Cullen Sign
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Diagnostic Images
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 Loss of psoas shadow
 U/S: retroperitoneal hematoma , free fluid
intraperitoneal in 16%.
 C.T Spiral is sensitive in diagnosis
 MRI: is very sensitive
C.T
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C.T
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C.T
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Management
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1. Conservative
2. Endovascular
3. Open surgery
Conservative
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 Admission to ICU
 Monitoring
 IVF Resuscitation
 Blood Transfusion
 Normalization of coagulation factors
Endovascular Treatment
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 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
Open surgery
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 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.abdomional wall defect by Bogota bag
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Retroperitoneal
hematoma
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Large RPH
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Aortic Rupture
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RPH w/Liver injury
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Laparostomy
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conclusion
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 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.
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 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.
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 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.
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 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.
Case Presentation
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 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.
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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
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 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.
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 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
Angiomyolipoma
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 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.
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 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
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 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
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 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
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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.
Spontaneous Retroperitoneal Hematoma:
A Rare Devastating Clinical Entity of a Pleiada of Less
Common Origins
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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%).
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 Tumors, particularly renal cell carcinoma and
angiomyolipoma, are the most common cause of SRH,
occurring in 57–73% of cases
 Aneurysms of the visceral circulation as a cause are rare,
accounting for 0.1–10.4% in autopsy statistics.
 Spontaneous hemorrhage can be seen with inflammatory
erosive processes which explain the association with
necrotizing arteritis in polyarteritis nodosa and
rheumatoid arthritisSpontaneous
 SRH among patients receiving anticoagulation therapy
has been well described and related to warfarin, lowmolecular-weight heparin, unfractionated heparin, or
even clopidogrel
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 Idiopathic retroperitoneal hemorrhage/hematoma is
a relatively uncommon condition with a large
variability and nonspecific presentation in most of
the cases, which may lead to shock and even death
unless it is promptly recognized and treated
appropriately
 Prompt diagnosis and treatment may spare the
patient surgical intervention and improve outcome.
‫هوالبصیر‬
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‫اللهم انی اعتذرالیک من مظلوم ظلم بحضرتی فلم انصره‬
‫خداوندا عذر می خواهم درباره مظلومی که در حضور من مورد ستم واقع شده‬
‫ومن او را یاری نکرده باشم‪.‬‬
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‫صحیفه سجادیه‪ -‬دعای‬
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