Mattox Maneuver

Article Author:
Shekhar Gogna
Article Editor:
Steve Bhimji
Updated:
10/27/2018 12:32:09 PM
PubMed Link:
Mattox Maneuver

Introduction

Laparotomy is the most common operation performed for abdominal trauma. The essence of a successful outcome relies on a methodical sequence of steps and surgical knowledge of maneuvers. They have developed these maneuvers over the years that enable the surgeon to gain access to abdominal injuries, to identify them and address them appropriately. Complete left medial visceral rotation or Mattox maneuver is one such intraoperative surgical innovation which has revolutionized the trauma surgery since the 1970s.

Definition

Mattox Maneuver is also known as a left medial visceral rotation in trauma surgery is a surgical step to deal with Zone 1 and 2 retroperitoneal injuries (aorta, left iliac and pelvic vessels) and is completed by incising the parietal peritoneum at the white line of Toldt from the sigmoid colon to the splenic flexure. The spleen, tail of the pancreas, left kidney, and stomach is reflected medially during this maneuver. [1]

Historical perspective

Dr. Kenneth L Mattox was a chief resident in surgery at Baylor College of Medicine and he was operating on patient early in the morning who underwent multiple abdominal surgeries in the past was bleeding into retroperitoneum. He was assisted by a second-year urology resident and out of necessity for a new approach to control the bleeding which was suspected to be coming from aorta or IVC they developed this maneuver on the table. They could save the patient together. Encouraged by this “new approach” they performed few more similar cases and presented their data at a national meeting and hence called “Mattox maneuver” from then.

Anatomy

There is an anatomic division of the retroperitoneal space into three zones which describes and helps in decision making for treatment of the retroperitoneal injury. The following are the zones, boundaries, and contents[2]:

Zone I (central)

  • Upper: Diaphragmatic, esophageal, and aortic openings.
  • Lower: Sacral promontories.
  • Lateral: Psoas muscles.
  • Contents: Abdominal aorta, inferior vena cava, pancreas, duodenum (partial).

Zone II (lateral)

  • Upper: Diaphragm.
  • Lower: Iliac crests.
  • Lateral: Psoas muscles.
  • Contents: Kidneys and their vessels, ureters and their abdominal parts, ascending and descending colon, hepatic and splenic flexure.

Zone III (pelvic)

  • Anterior: Space of Retzius.
  • Posterior: Sacrum.
  • Lateral: Bony pelvis.
  • Contents: Pelvis in toto, pelvic wall, rectosigmoid colon, iliac vessels, urogenital organs (partial)

Indications

Hemodynamically unstable trauma patients with hemoperitoneum due to blunt or penetrating injuries to Zone I or Zone II on the left side of retroperitoneum.

Contraindications

There are no specific contraindications for this step. 

Equipment

Anesthetic equipment, overhead lights, electro diathermy equipment, and suctioning systems. A standard laparotomy tray along with vascular sutures and silk ties.

Personnel

  1. The chief surgeon who is essentially a team leader directs the movement of personnel and resources all the way from emergency room to the operating room till the safe disposition of the patient to ICU.
  2. An assistant surgeon who can be another attending or surgery resident. Their main goal is to effectively communicate with the team leader and closely monitor the patient’s hemodynamic status; simultaneously carrying out resuscitation.
  3. Circulating nurse supplies the sutures ensures availability of all laparotomy cart and availability of blood in OR.
  4. Scrub nurse who plays a pivotal role with his/her anticipation and assist the surgery team in laparotomy.
  5. ICU team for post-operative care.

Preparation

  1. The less stable the patient, the less time is spent on preoperative preparations. The surgeon and the OR team ensures methodical effort to minimize start time.
  2. Exploratory laparotomy is performed under general anesthesia. Nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the urinary bladder to decrease the risk for aspiration of gastric contents.
  3. The operative field for torso trauma extends from the chin to above the knees, between the posterior axillary lines and with both arms fully abducted. This wide sterile field provides free access to the abdomen and chest and both groins while giving the anesthesia team access to both upper extremities and the head and neck.

Technique

The surgeon begins the maneuver by mobilizing the sigmoid colon by incising the white line of Toldt. White line if Toldt is a lateral avascular reflection of peritoneum over the lateral abdominal wall.  This enables the surgeon to bluntly dissect behind the left colon and rapidly mobilize it from below toward the splenic flexure. The surgeon then bluntly dissects in an avascular plane anterior to the muscles of the posterior abdominal wall allowing to gradually rotate the left kidney spleen, pancreas, and stomach medially and expose the entire length of the abdominal aorta to the diaphragmatic hiatus. The direction of dissection is upwards and medially.

Left-sided medial visceral rotation used for aortic exposure in elective vascular surgery was a known maneuver before Mattox Maneuver. There is one crucial anatomical detail which distinguishes these two. The Mattox maneuver always includes retracting left kidney because leaving it in place interposes the anterior renal fascia between the plane of dissection and the aorta. By leaving the left kidney in place, the left renal vein does not allow access to the anterior aspect of the aorta and predisposes left ureter to injury. [3]

Complications

  1. Splenic injury is the most common iatrogenic complication.
  2. Avulsion of the descending lumbar vein from the left renal vein.
  3. Pancreatitis and
  4. Gut ischemia related to retraction and congestion of arterial supply.[4]

Clinical Significance

Upon entering the abdomen of an exsanguinating patient after gaining temporary hemorrhage control by packing or by manual/ instrumental clamping of bleeding vessels the trauma surgeon should classify the hemorrhage or hematoma into one of the three zones of the retroperitoneum as described in anatomy section above.

This classification is valuable in facilitating decision making about the management approach. Midline supra-mesocolic and infra-mesocolic injuries in Zone I by blunt or penetrating trauma is surgically explored as they imply an injury to the aorta, vena cava, or their major branches.

The perirenal blunt hematomas in zone II are managed non-operatively while perirenal hematomas after penetrating trauma are explored surgically.

Retroperitoneal hemorrhage in the pelvis zone III usually arises in association with a pelvic fracture, and this is a serious injury complex that carries a mortality of up to 30%. It is normally caused by injuries to the smaller vessels and venous plexus and bleeding from bone fragments. [5] This injury needs a multidisciplinary team of trauma surgeons, interventional radiologists and orthopedic surgeons at a level I  trauma center.

Enhancing Healthcare Team Outcomes

Interprofessional teamwork the key to improve the quality of patient management in critical settings such as trauma. While surgeons play the role of team leader, it is important to effectively communicate with emergency room personnel, nurses, anesthesiologist, junior members of the team such as residents to improve the outcome. Thorough knowledge of anatomy and expertise is important in safely performing Mattox maneuver. Emergency laparotomy for trauma to control bleeding is the only means safe life and retroperitoneal injuries require formal exposure to control them and repair.[6] [Level I] The outcomes after trauma exploratory laparotomy depend on the patient's condition, ICU care, nurses and good physical therapy.