Traumatic Retroperitoneal Hematoma

Traumatic Retroperitoneal Hematoma from Sun YaiCheng

Traumatic Retroperitoneal Hematoma Spreads Through the Interfascial Planes
J Trauma. 2005;59:595– 608.

In the early 1980s, Sheldon introduced a treatment principle founded on a location-based classification of traumatic RH as

1. Central-medial (zone I) RH
2. Flank or perirenal (zone II) RH
3. Pelvic (zone III) RH

Traditionally, the retroperitoneal space was believed to comprise only 3 compartments:

1. Anterior pararenal space (APS)
2. Perirenal space (PRS)
3. Posterior pararenal space (PPS)

which are demarcated by 3 well-defined fascias:

1. Anterior renal fascia
2. Posterior renal fascia
3. Lateroconal fascia

Assessment of RH on CT Images
10 component parts of the retroperitoneal space were identified:
 3 compartments

1. Anterior pararenal space (APS)
2. Perirenal space (PRS)
3. Posterior pararenal space (PPS)

4 interfascial planes comprise

1. Retromesenteric plane (RMP)
2. Retrorenal plane (RRP)
3. Lateroconal plane (LCP)
4. Combined interfascial plane (CIP), providing a route for the spread of disease from the abdominal retroperitoneum into the pelvis.

3 other extraperitoneal spaces are

1. Retrohepatic space (rhe)
2. Prevesical space (PV)
3. Presacral space (PS)

New Classification of RH
Each RH was first classified by the component where bleeding originated:

1. Type I derived from the APS or RMP
2. Type II from the PRS, LCP, Rhe, or PPS above the pelvis
3. Type III from the pelvis
4. Type IV from the RRP or CIP

Each type was subdivided according to the degree of extension into subtype

“a” if the RH never exceeded the promontory
“b” if the RH spread beyond the promontory

This Classification Also Indicated The Appropriate Treatment Policy

1. Type I RH requires emergent retroperitoneal exploration, which also affords a good prognosis.
2. Type II RH is treatable with conservative therapy unless renal vein injury is complicated.
3. Type III RH requires TAE, C-clamp, or external fixation but no laparotomy for RH hemostasis.
4. Treatment of Type IV RH is still challenging and requires further investigation.