Overview of Mattox Maneuver
Laparotomy is a type of surgery that is often performed in cases of abdominal injury. An important part of ensuring a successful outcome of this surgery is following a detailed series of steps that have been devised based on evidence and experience. For example, there’s a vital surgical move called the “Mattox maneuver” that has improved the way trauma surgeries are performed since the 1970s.
To put it in simpler terms, the Mattox maneuver, also known as a “left medial visceral rotation”, is a surgical procedure used to examine and treat injuries to a specific part of the abdomen, zones 1 and 2. These zones include the main abdominal blood vessel (aorta), the left iliac and pelvic blood vessels. The procedure begins by making a cut in the parietal peritoneum – the thin, protective layer that lines the abdominal cavity- at the white line of Toldt, which extends from the sigmoid colon to the flexure of the spleen. In the course of this maneuver, the spleen, the pancreas’s tail, the left kidney, and the stomach are moved and turned inward to allow the deeper structures to be examined.
Historically, the Mattox maneuver got its name from Dr. Kenneth L Mattox, a lead surgical resident at the Baylor College of Medicine. The procedure was first designed while he was operating on a patient who had had several surgeries already and was experiencing bleeding into the retroperitoneal space, which is located behind the abdomen. With the help of a second-year urology resident, Dr. Mattox was able to move the organs (viscera) in the abdomen to gain better access to and control over the deep area where the bleeding was suspected to be coming from. The new approach was a success and the patient’s life was saved. Encouraged by the effectiveness of this method, they applied it in other similar cases and presented their results at a national meeting, leading to the method being named the “Mattox maneuver”.
Anatomy and Physiology of Mattox Maneuver
When doctors are treating injuries through surgery, they often think of the area behind the abdominal cavity in three distinct parts: the central, lateral, and pelvic zones. Each of these zones has specific boundaries and contains different organs and structures.
The Central Zone (Zone I) is found between the diaphragm, esophageal, and aorta openings at the top and the sacral promontories at the bottom. It is enclosed on the sides by the psoas muscles. Some of the main structures inside this zone include the large blood vessels of the abdomen (abdominal aorta and inferior vena cava), pancreas, and a portion of the first section of the small intestine (partial duodenum).
The Lateral Zone (Zone II) is the area between the diaphragm at the top and the hip bones (iliac crests) at the bottom. It is also enclosed on the sides by the psoas muscles. It contains organs such as the kidneys and their blood vessels, the ureters (tubes that carry pee from the kidneys to the bladder), and parts of the large intestine (the ascending and descending colon, hepatic and splenic colonic flexure).
The Pelvic Zone (Zone III) is the area between the space in front of the bladder (Space of Retzius) in front, the sacrum at the back, and the pelvis bone on the sides. It contains organs and structures such as the pelvic cavity, pelvic wall, last part of the large intestine (rectosigmoid colon), blood vessels in the hip (iliac vessels), and some of the reproductive and urinary organs.
Why do People Need Mattox Maneuver
The Mattox maneuver is a medical procedure primarily used to examine the areas behind the belly, or the left and central retroperitoneal spaces. It allows doctors to check the condition of organs and blood vessels located in these areas. This is frequently done in cases where a person suffered an abdominal injury, specifically trauma affecting Zone I or II, and this unstable situation affects their blood flow.
Other reasons for performing the Mattox maneuver include the presence of retroperitoneal tumors, sarcomas, or malignant metastasis. These are medical terms for different types of aggressive or malignant growths which could spread and cause further damage to the body if not identified and treated.
Preparing for Mattox Maneuver
When preparing to carry out the Mattox maneuver, a medical procedure often used in cases of severe abdominal bleeding, there are a few important steps that need to be taken:
1. The medical team should always be ready for any severe abdominal bleeding that could result from trauma. This usually involves careful planning by the surgeon and the team to get ready in the quickest time possible.
2. Different medical teams play crucial roles in this process, including the emergency team, the intensive care team, the general and trauma team, the anesthesia team, and the clinical staff. All these teams need to be prepared and on hand to provide the necessary care for severe inner bleeding of the abdomen.
3. Before performing an exploratory laparotomy – a type of surgery to look inside the abdomen – doctors provide general anesthesia once they have ensured that they have proper access to your bloodstream. They also put in a tube through your nose and into your stomach (nasogastric tube) and a tube to help with urination (indwelling urinary catheter). These steps are crucial to avoid complication, such as the stomach contents being breathed into the lungs or monitor the amount of urine being produced.
The area to be prepared and sterilized for this type of procedure extends from the chin to just above the knees, including the area between the back of the armpits, along with both arms being held straight out from the sides. This allows for doctors to easily access the abdomen, chest, and both groin areas for any necessary procedures while still making sure that the team providing the anesthesia can access both of the arms and the head and neck area.
How is Mattox Maneuver performed
The Mattox maneuver is a special surgical method used by doctors to gently move the organs located in the left and middle of your belly while keeping them safe and intact. This technique is about moving the organs without disturbing any major blood vessels. How does it work? The surgery begins by freeing up the left side of the large intestine by cutting through a layer called the Toldt, a natural boundary that separates the lining covering the organs and the side of the belly. This action helps the doctor get to a space behind the intestines for the operation.
Next, the part of the spleen that’s attached to a muscle in your upper belly (diaphragm) is carefully detangled. However, the connections of the spleen to the stomach and intestine are kept unharmed. Most of this movement process uses gentle and careful methods to avoid injuring the internal organs. The doctor further works through that natural boundary line towards the middle of the belly. The big role here is to kindly move and work around each organ, including the large intestine, left kidney, spleen, stomach, and part of the pancreas until the aorta (a major blood vessel) is uncovered.
There’s a similar procedure that surgeons have been using for many years for surgeries involving the aorta. However, one key feature distinguishes the Mattox maneuver from the older method. It’s specific about leaving the left kidney untouched during surgery. Leaving the left kidney where it is, allows a protective sheath covering the kidney to act as a barrier between the natural boundary line and the aorta. It also, importantly, makes sure the tube connecting the kidney and bladder (ureter) is safe from injury during surgery.
Possible Complications of Mattox Maneuver
The Mattox maneuver is a medical procedure sometimes done for serious trauma patients, especially those with severe abdominal injuries like a torn aorta—the body’s main artery. This technique is generally a life-saving measure for controlling intense bleeding, even though it may sometimes lead to some complications. The urgency and severity of a patient’s condition, the pace at which the procedure is performed, and the involvement of various organs and their blood vessels can all contribute to these potential complications.
These complications may result from either accidental injuries during the procedure or complications from the initial trauma the patient experienced. The known complications include:
1. Splenic injury: This is where the spleen gets harmed. Its the most common complication caused by the procedure itself (also known as “iatrogenic”).
2. Avulsion of the descending lumbar vein from the left renal vein: Basically, this is an injury where the vein from your lower back gets torn away from the vein attached to your left kidney.
3. Pancreatitis: This is a condition where the pancreas becomes inflamed.
4. Gastrointestinal ischemia: This means that parts of your digestive system aren’t getting enough blood, often due to the repositioning and congestion caused by the surgery.
Even with these possible complications, the Mattox maneuver is often necessary in life-threatening situations. Therefore, these risks are generally considered justified considering the critical role the procedure can play in managing serious injuries.
What Else Should I Know About Mattox Maneuver?
If a person is seriously injured and their stomach area is bleeding, doctors must act quickly and skilfully to stop the bleeding, which is vital for saving lives. Sometimes, stopping this bleeding can be straightforward if the source of the bleeding is easy to reach. However, if a major blood vessel is injured or several blood vessels are bleeding, this can be much more challenging because of the location inside the body. A surgical technique, known as the Mattox maneuver, is then used to reach and stop the bleeding from these difficult places.
When dealing with severe bleeding in the stomach area, doctors will first try to control it with packing materials. If the bleeding is severe or coming from the back of the abdomen, doctors will identify which of the three possible zones the bleeding is coming from. Knowing the exact location of the injury is very helpful in deciding what steps to take next.
If the injury is in the center of the stomach area, above or below the membrane that separates the stomach and the intestines (zone 1), doctors need to explore the injury, because it could involve major blood vessels. If there are blood collections around the kidneys due to a non-penetrating trauma (zone 2), doctors usually take care of it without surgery. But if a penetrating injury causes these blood collections, surgery will be necessary.
Finally, if the bleeding is in the lower back region of the stomach (zone 3), it often happens along with a pelvic fracture. This can be a very serious condition, with up to a 30% mortality rate, often caused by injuries to smaller blood vessels and bleeding from broken bone pieces. Managing these injuries requires a specialized team of trauma surgeons, intervention radiologists, and orthopedic surgeons typically available in highly-equipped trauma centers.
