Traumatic retroperitoneal hematoma commonly results from injuries associated with falls from heights, crushing incidents, traffic accidents, or damage to retroperitoneal organs such as the pancreas, kidneys, and duodenum. It may also arise from pelvic or lower spine fractures and retroperitoneal vascular injuries. Bleeding can extensively spread within the retroperitoneal space, leading to a large hematoma that may infiltrate the mesenteric area.
The extent and severity of hemorrhage in retroperitoneal hematomas vary, and the condition is often masked by associated injuries. In general, some affected individuals may present with iliolumbar ecchymosis (Grey-Turner sign). Typical manifestations include signs of internal bleeding, lower back and flank pain, and intestinal paralysis. When associated with urinary tract injury, hematuria is often observed. If the hematoma extends into the pelvic cavity, patients may experience tenesmus, and digital rectal examination may reveal a fluctuating bulge in the presacral region. Occasionally, ruptures of the posterior peritoneum may allow blood to enter the abdominal cavity, where abdominal paracentesis or lavage may aid in diagnosis. Imaging studies, such as ultrasound or CT scans, can provide diagnostic support.
Retroperitoneal hematomas are frequently accompanied by major vascular or organ injuries. Aside from managing shock and preventing infection, most cases require exploratory laparotomy. If the posterior peritoneum appears intact during surgery, an initial assessment of the hematoma’s size and extent is made after thoroughly examining and addressing any abdominal organ injuries. If the hematoma shows signs of expansion, the posterior peritoneum should be opened to locate the damaged blood vessels for ligation or repair. In cases where the hematoma remains stable, the posterior peritoneum may remain unopened, as intact posterior peritoneum can act as a compressive barrier to control bleeding, particularly for retroperitoneal pelvic hematomas. Bleeding in these cases often originates from the low-pressure pelvic venous plexus, where spontaneous cessation of bleeding is more likely.
For hematomas located between the outer margins of the psoas muscle on both sides, the diaphragmatic crura, and the sacral promontory, the bleeding may stem from injuries to structures such as the abdominal aorta, celiac artery, inferior vena cava, hepatic veins, the bare area of the liver, pancreas, or retroperitoneal duodenum. Hematomas confined to this region, regardless of whether they expand, generally require opening of the posterior peritoneum for exploration to manage damaged blood vessels and organs. During exploration, efforts are made to locate and control the source of bleeding. If direct bleeding control proves challenging, tamponade with gauze may be employed, which can often successfully halt venous bleeding. Gauze used for tamponade should ideally be removed gradually between postoperative days 4–7 to reduce the risk of infection.
Infection is the most significant complication associated with retroperitoneal hematoma.