Retroperitoneal/urinary tract injuries Flashcards
what is the weakest portion of the bladder?
The dome where the tracheal remnant fixes the bladder to the lower anterior abdominal wall
what parts of the bladder are covered by the peritoneal reflection?
dome and posterior bladder (can have intraperitoneal injury here)
which parts of the bladder are protected within the bony pelvis?
anterior wall, lateral wall, and base of the bladder (blow out injuries are less frequent, are typically from laceration by bony fragments from pelvic fx)
where are extraperitoneal bladder perforations from?
anterior wall, lateral wall, base of the bladder (no true peritoneal lining)
are a majority of bladder injuries blunt of sharp?
blunt
is injury to the anterior urethra usually blunt or penetrating?
both
is injury to the posterior urethra usually blunt of penetrating
blunt
How do you dx bladder trauma?
retrograde cystography (CT)
what does an extraperitoneal bladder rupture look like?
flame or sunburst contrast pattern
what does an intraperitoneal bladder rupture look like
outlining loops or filling the cul-de-sac
what is the treatment for intraperitoneal bladder perforations?
immediate repair
what is the treatment for uncomplicated extraperitoneal bladder perforations?
foley drainage
what is the treatment for complicated extraperitoneal bladder perforations?
repair at time of exploration for other injuries
how do you repair the bladder?
two layer, water tight closure, with absorbable sutures, foley drainage
no need for suprapubic tube as long as foley can go in
how should you treat urethral distraction injuries?
percutaneous suprapubic tube placement
once stable, can do primary realignment with cystoscopy and foley later
how should you treat penetrating anterior urethral injuries?
exploration, primary closure at time of injury with tension-free, watertight closure w/absorbable sutures, foley
how should you treat blunt anterior urethral injuries
prompt suprapubic tube placement or foley. Immediate operative repair or debridement is not recommended
when should you get a retrograde cystography after foley placement?
10-14 days
what is the MC long term complication of urethral injury?
stricture formation
where does blood supply to the ureter come from?
the great vessels, medially in the abdominal ureter and laterally in the pelvic ureter
what is the mc of injury to the ureter?
iatrogenic (ureteroscopy, hysteroscopy, colectomy)
How do you dx a ureteral/renal injury?
IV enhanced CT (with delayed images for ureteral injury) with retrograde filling
what is a grade I renal injury?
sub capsular hematoma without laceration or contusion
what is a grade II renal injury?
non expanding perirenal hematoma, or lacerations <1 cm deep without urinary extravasation
what is grade III renal injury?
parenchymal laceration >1 cm deep without collecting system injury
what is a grade IV renal injury
laceration extending into the collecting system or vascular injury to the main hisar vessels with contained hemorrhage
what is a grade V renal injury?
completely shattered parenchyma or avulsion of the renal hilum with devascularized kidney parenchyma
Follow up CT for renal trauma should be done for?
grade IV-V injuries or w/clinical signs of complications such as fever, increased pain, distention
medial hematoma suggests
vascular injury
medial urinary extravasation suggests
ureteropelvic junction avulsion
poor renal contrast enhancement suggests
artery laceration and or thrombus
how do you repair a distal ureteral injury?
ureteroneocystostomy with or without posts hitch
how do you repair a proximal ureteral injury (short segment)?
ureteroureterostomy
how do you repair a proximal ureter injury (long segment)?
ureteroneocystostomy with posts hitch if possible, can also do Boari flap if ureter cannot be directly reimplanted into the bladder
how should injuries at the ureteropelvic junction be managed?
dismembered pyeloplasty
how to managed a ureteral injury in damage control surgery?
ureter can be ligated with post op nephrostomy tube or a ureteral stent can be inserted and externalized to drain urine outside the abdomen
what is flank ecchymosis called?
Grey Turner sign
what is umbilical ecchymosis called?
Cullen sign
what is proximal thigh ecchymosis called?
Fox sign
What is scrotal ecchymosis called?
Bryant sign
How would you access the suprarenal inframesocolic aorta?
Left medial visceral rotation (Mattox maneuver)
How would you access the infernal aorta?
reflect the mesocolon cephalic with evisceration of the small bowel to the right and incising through the retroperitoneum overlying the aorta
how to get control of the infra hepatic and suprarenal IVC
kocher manuever
How to control bleeding at the iliac vein bifurcation
division of the right common iliac artery (rare)
how to treat an unstable patient with a renal artery transection with normal contralateral kidney?
nephrectomy
can you do a renal vein ligation without nephrectomy on the left?
yes - collateral venous flow
can you do a renal vein ligation without nephrectomy on the right?
no, must do nephrectomy either at index or second look surgery
