Surgical management of retroperitoneal vascular injuries in combat abdominal trauma: Experience at Role 2 facilities during the war in Ukraine

BACKGROUND: Combat-related retroperitoneal vascular injuries are among the most severe and rarely occur in isolation, often resulting in high mortality. This study analyzes their management in combat abdominal trauma at Role 2 during the ongoing war in Ukraine using a damage control surgery approach to minimize organizational and technical errors. METHODS: A retrospective review included 65 cases of retroperitoneal vascular injury among 1,407 patients with combat-related abdominal trauma managed by a Role 2 surgical team in eastern Ukraine in 2023. The severity of anatomical injuries was assessed using the Hannover Polytrauma Score, while the patient's condition was evaluated using the Admission Trauma Score (AdTS). Surgical care followed damage-control surgery principles, including vascular ligation, temporary shunting, pelvic tamponade, and prehospital interventions such as resuscitative endovascular balloon aortic occlusion and the abdominal aortic junctional tourniquet. RESULTS: Retroperitoneal vascular injuries comprised 4.6% of all combat abdominal trauma cases, with 95.4% accompanied by other injuries. The most frequently affected vessels were the inferior vena cava (33.9%) and iliac vessels (50.3%). Ligation was the primary hemostatic method; vessel repair was performed in 58.5% of cases. Mortality peaked at 54.6% within 3 days postinjury because of massive blood loss and hemorrhagic shock. Hemorrhagic shock (classes III and IV) occurred in 77% of patients. Overall mortality was 50.8%. Nonsurvivors had significantly higher Hannover Polytrauma Score (27.0 ± 7.8), AdTS (10.4 ± 2.6), and blood lactate levels nearly three times greater than survivors. CONCLUSION: Retroperitoneal vascular injuries remain highly lethal, emphasizing the need for early hemorrhage control and timely surgical intervention. Resuscitative endovascular balloon aortic occlusion and abdominal aortic junctional tourniquet at the prehospital stage showed potential in stabilizing patients for evacuation. Blood lactate levels and AdTS are valuable tools for triage and treatment decisions at Role 2 facilities. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.