Continuing Education Activity

Surgical maneuvers have been developed over years of experience to enable the surgeon to gain access to injuries of deep abdominal structures, identify these injuries 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. This activity describes how to perform the mattox maneuver and its indications.

Objectives:

• Review how to perform the Mattox maneuver.
• Describe the indications for performing the Mattox maneuver.
• Explain the anatomy of the retroperitoneal space.
• Summarize the importance of interprofessional team members utilizing the Mattox maneuver to improve outcomes in patients who have experienced trauma of the retroperitoneal space.

Introduction

Laparotomy is one of the most common surgical procedures performed for abdominal trauma. The essence of a successful trauma laparotomy outcome relies on a methodical sequence of steps, surgical knowledge of maneuvers, and sound surgical decisions based on evidence and experience. Surgical maneuvers have been developed over years of experience to enable the surgeon to gain access to injuries of deep abdominal structures, identify these injuries 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, also known as a left medial visceral rotation, is a surgical step to explore and handle Zone 1 and 2 retroperitoneal injuries (aorta, left iliac and pelvic vessels). It starts with 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 are mobilized and reflected medially during this maneuver to explore the deeper structures. [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. The patient underwent multiple previous abdominal surgeries and was bleeding into the retroperitoneal space. Dr. Mattox was assisted by a second-year urology resident. They needed to mobilize the viscera and obtain access and control deep retroperitoneal 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 a few more similar cases and presented their data at a national meeting, and hence it has been called the “Mattox maneuver” since then[2].

Anatomy and Physiology

For the purpose of trauma surgery care, the abdominal retroperitoneal space is divided into three zones, the central, lateral and pelvic zones. The following are the zones, boundaries, and contents[3]:

Zone I (central)

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

Zone II (lateral)

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

Zone III (pelvic)

• Anterior boundary: Space of Retzius.
• Posterior boundary: Sacrum.
• Lateral boundary: Bony pelvis.
• Contents: Pelvic cavity, pelvic wall, rectosigmoid colon, iliac vessels, urogenital organs (partial)[4].

Indications

The main indication of Mattox maneuver is to explore the left and central retroperitoneal spaces to assess the organs and blood vessels. A common indication of this exploration is in abdominal trauma and injuries to zone I or II with hemodynamic instability. Retroperitoneal tumors, sarcomas or malignant metastasis are other indications for Mattox Maneuver.

Preparation

1. Preparation for anticipated severe abdominal bleeding is part of trauma centers requirements. The surgeon and the OR team ensures a methodical effort to minimize start time.
2. The emergency team, ICU team, general and trauma team, Anastasia team and nursing staff should be available and involved in providing care for severe intraabdominal bleeding.
3. Exploratory laparotomy is performed under general anesthesia after appropriate intravascular access is obtained. A 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 and monitor urine output.
4. 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 or Treatment

Mattox maneuver is a surgical technique used to mobilize the left and central abdominal organs and viscera medially with their integrity maintained. Knowing and using the avascular appropriate plane of dissection and mobilization is the key to this maneuver. Dissection starts by mobilizing the left and sigmoid colon by incising the white line of Toldt. This line is a lateral avascular reflection of the visceral peritoneum covering the colon and its mesentery over the lateral abdominal wall to become the parietal peritoneum.  This opens the plane of dissection in the retroperitoneal space. Blunt dissection and mobilization can then be started in this plane. The splenic attachment to the diaphragm is then sharply dissected. The rest of the splenic attachments (to the colon and stomach) should be left intact. Most of the rest of dissection and mobilization is done bluntly with minimal sharp or cautery dissection. Dissection continues medially at the same avascular plane just superficial to the posterior abdominal muscles. Mobilization of the left colon mesentery with its main vessels, the left kidney and its pedicle, the spleen, the stomach, and the tail of the pancreas is done sequentially until the entire length of the aorta is explored.[4][5]

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. [2]

Complications

Complications of Mattox maneuver are potentially serious. The severity and acuity of the underlying conditions, the pace of the procedure in the unstable trauma patients, and the multiple organs with their blood vessels handled in the procedure contribute to the occasional complications. The maneuver is considered life-saving in severe abdominal aortic traumatic injury to provide control on the bleeding. Therefore, complications are an acceptable cost for such an important step in serious injuries.

Complications can be due to the procedure and inadvertent injuries or an extension of the main trauma. Some of the known complications are:

1. Splenic injury is the most common iatrogenic complication.
2. Avulsion of the descending lumbar vein from the left renal vein.
3. Pancreatitis
4. GI ischemia related to retraction and congestion of arterial supply.[6]

Clinical Significance

Controlling bleeding in traumatic intra-abdominal bleeding is of paramount importance in saving trauma victims. The severity and urgency of the condition require prompt and skillful surgical intervention. When the bleeding source is accessible inside the abdominopelvic cavity control is relatively easy[7]. But when the bleeding source is a major blood vessel or is diffuse from multiple branches of a major vessel, controlling the bleeding becomes much more challenging mainly due to the anatomic location of the abdominal aorta.  That is why it takes all the necessary steps of Mattox maneuver to expose the aorta and achieve a life-saving bleeding control.

Upon entering the abdominal cavity for severe bleeding, temporary hemorrhage control by packing is first considered. If major or retroperitoneal bleeding is suspected, the bleeding source site should be classified according to the three zones of the retroperitoneum as described in the 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. Peri-renal 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 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. [8] 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 is 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 severe bleeding is life-saving. Retroperitoneal injuries require formal exposure to control them and repair.[9] [Level I] The outcomes after trauma exploratory laparotomy depends on the patient's condition, ICU care, nurses and good physical therapy.