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Use of the Rokitansky Incision in Retroperitoneal Trauma

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Introduction

Injury to the retroperitoneum occurs with both blunt and penetrating abdominal injuries. The retroperitoneal organs are somewhat protected by the organs that lie within the peritoneal cavity, and as such, injury to the retroperitoneal organs is often associated with injury to the organs of the peritoneal cavity. Once the decision is made to perform an exploratory laparotomy, the surgeon must be prepared to inspect all of the abdominal contents, for a missed injury is inexcusable.

Method

Abdominal Wall Incision

For the purpose of this study, an unembalmed male cadaver was provided by the University of Texas - Houston Human Structure Facility. The abdominal wall incision should be made with the intent that the entire abdomen will be explored, and the most suitable incision for exploratory laparotomy is a long midline incision.

The length of the incision should be based on the individual circumstances. A transverse incision may be used, and although not considered optimal, it should be wide enough to provide adequate exposure. If there is a suspicion of retrohepatic caval injury, then a right transverse incision between the 7th and 8th ribs can be made.

Peritoneal Exploration

Once the peritoneal cavity has been entered, the first priority of the surgeon should be to control life-threatening hemorrhage. If the source of hemorrhage is the bowel wall or mesentery, then immediate evisceration should be performed and the bleeding controlled. Next, any contamination from bowel perforation should be removed. The entire bowel should be inspected using a flip-flop method. The liver and spleen must also be inspected, and any injuries should be dealt with.

Retroperitoneal Exploration

If a retroperitoneal hematoma is present, or there is suspicion of an injury to one of the retroperitoneal organs, then the retroperitoneal space must be entered. All retroperitoneal hematomas above the pelvis must be explored, but only after proximal and distal vascular control has been established. There are several approaches used to gain access to the retroperitoneum, but the Mattox maneuver provides the widest exposure and requires very little time.

The Mattox maneuver is a method for gaining rapid access to the retroperitoneum. The basic incision is a Rokitansky-type incision along the lateral peritoneal reflection. On the left, the incision extends from the sigmoid colon to the splenic flexure. The spleen should be carefully mobilized, and the viscera reflected medially.

Using blunt dissection along the surface of the quadratus lumborum and psoas muscles, visualization of the abdominal aorta, the posterior surface of the kidney, and the ureter is possible. Care must be taken in order to avoid damaging the subcostal, iliohypogastric, ilioinguinal, lateral femoral cutaneous, genitofemoral, and femoral nerves. On the right, the peritoneal reflection is incised and the viscera mobilized medially, allowing the vena cava to be inspected, as well as the right kidney and ureter. The iliac vessels should also be inspected for injury.

If injury to the ureter is suspected but not grossly apparent, then 10% indigo carmine IV can be given and the ureter observed for spillage. The duodenum and head of the pancreas can be explored with a Kocher maneuver.

Discussion

With the high number of civilian gun shot wounds and motor vehicle injuries, the incidence of retroperitoneal injury is quite high, and surgeons should be comfortable with exploration of the retroperitoneum. In one series looking at abdominal injuries in an urban environment, stab wounds accounted for 25%, gun shot wounds were 35%, and blunt injuries made up about 10%, with motor vehicle accidents accounting for over 60% of blunt injuries. In fact, nearly three- quarters of retroperitoneal hematomas were caused by motor vehicle accidents. Many surgeons perform Rokitansky-type incisions in the setting of retroperitoneal trauma, however, a survey of the major trauma atlases failed to disclose this procedure in a step-by-step fashion. It can be performed quite rapidly, and is mastered without great difficulty. This procedure may be helpful in gaining access to the abdominal aorta from the diaphram to its bifurcation, the inferior vena cava, the dorsal surface of the kidneys, and the ureters. When the incision is made using electrocautery, there should be minimal blood loss, as the peritoneal reflections are not heavily vascular. Once the lateral peritoneal reflection has been incised and the viscera reflected medially, the surgeon has a wide view of the entire hemiretroperitoneum, thus allowing for a thorough survey and easy surgical access.

References:

Delany, H., R. Jason, Abdominal Trauma: Surgical and Radiologic Diagnosis, 1981.

Mattox, K., E. Moore, D. Feliciano, Trauma, 1988.

McMurty, R., B. McLellan, Management of Blunt Trauma, 1990.

Weiner, S., J. Barrett, Trauma Management for Civilian and Military Physicians, 1986.

Acknowledgements:

I would like to thank the help of the following fine people:
Ernest Gonzales
Steve Rodriguez

Author:

Chuck Scoggins, MS IV
UT Department of Neurobiology and Anatomy