Mattox Maneuver

Anatomy and Physiology

In trauma surgery, the abdominal retroperitoneal space is divided into 3 zones: central, lateral, and pelvic. Each zone is defined by distinct anatomical boundaries and characteristic contents.

Zone 1 (central retroperitoneum) extends superiorly to the diaphragmatic, esophageal, and aortic hiatuses and inferiorly to the sacral promontory, with the psoas muscles forming the lateral borders. Principal contents include the abdominal aorta, IVC, pancreas, and portions of the duodenum.

Zone 2 (lateral or perirenal retroperitoneum) spans from the diaphragm superiorly to the iliac crests inferiorly, bounded medially by the psoas muscles. Structures within this zone include the kidneys and renal vessels, ureters, ascending and descending colon, and the hepatic and splenic flexures.

Zone 3 (pelvic retroperitoneum) is bounded anteriorly by the space of Retzius, posteriorly by the sacrum, and laterally by the bony pelvis. Contents include the pelvic cavity and wall, rectosigmoid colon, iliac vessels, and portions of the urogenital organs.[4][5]

Indications

The primary indication for the Mattox maneuver is exploration of the left and central retroperitoneal spaces to evaluate adjacent organs and major vascular structures. This approach is commonly employed in abdominal trauma involving zone 1 or zone 2 injuries accompanied by hemodynamic instability. Retroperitoneal tumors, sarcomas, and malignant metastases also constitute indications for the Mattox maneuver.[6] Indications for retroperitoneal exploration are determined by the mechanism of injury and the anatomic zone involved.

Zone 1 hematomas require exploration regardless of mechanism, ie, blunt vs penetrating trauma, because of the high risk of life-threatening vascular injury. Key structures in this zone include the abdominal aorta, IVC, and major visceral branches.

Zone 2 hematomas from penetrating trauma warrant surgical exploration. Blunt trauma is managed nonoperatively unless hematoma expansion, ongoing hemorrhage, or hemodynamic instability develops. The lower incidence of major vascular injury in blunt trauma supports selective exploration. This zone contains the kidneys, renal vessels, and ureters.

Zone 3 hematomas are generally not explored for either blunt or penetrating trauma. Management relies on pelvic stabilization, preperitoneal packing, and angioembolization, as bleeding in this zone is typically venous or osseous and poorly controlled by open exploration.[7] This zone contains the iliac vessels, pelvic venous plexus, and the bony pelvis.

Contraindications

No absolute contraindications are recognized for performing the Mattox maneuver to achieve left lateral retroperitoneal exposure during abdominal exploration in individuals with traumatic injuries. Certain patients in profound shock may benefit from aggressive initial resuscitation prior to operative intervention.

The Mattox maneuver may be inappropriate when injuries do not involve the left retroperitoneum, necessitating consideration of alternative exposure techniques. Options include the Cattell–Braasch maneuver for right-sided retroperitoneal injuries and supraceliac aortic exposure to achieve proximal control of abdominal hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA) can provide temporary hemorrhage control as a bridge to surgery.[8]

Preexisting splenic or pancreatic pathology increases the risk of intraoperative complications and should inform postoperative management. Operative management should not be delayed when the risk–benefit assessment favors urgent operative intervention.

Preparation

Preparation for the Mattox maneuver requires anticipation of severe abdominal bleeding, as mandated in trauma center protocols. The surgical and operating room teams coordinate to minimize the procedure start time. Comprehensive involvement of the emergency, intensive care, general and trauma surgery, anesthesia, and clinical support teams ensures readiness for management of significant intra-abdominal hemorrhage.

Exploratory laparotomy is performed under general anesthesia after establishing adequate intravascular access. A nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and bladder, reducing aspiration risk and permitting urine output monitoring. The sterile operative field extends from the chin to above the knees and between the posterior axillary lines, with both arms fully abducted. This configuration provides unobstructed access to the abdomen, chest, groin, and both upper extremities, while allowing the anesthesia team access to the head, neck, and arms.

Technique or Treatment

The Mattox maneuver is a surgical technique designed to mobilize the left and central abdominal organs and viscera medially while preserving their structural integrity. Successful execution relies on identifying and following the appropriate avascular plane for dissection and mobilization.

Dissection begins with the mobilization of the left and sigmoid colon by incising the white line of Toldt. This line represents a lateral avascular reflection of the visceral peritoneum covering the colon and its mesentery over the lateral abdominal wall, transitioning into the parietal peritoneum. Incision along this line opens the retroperitoneal plane, allowing blunt dissection and progressive organ mobilization.

The splenic attachment to the diaphragm is sharply dissected, while attachments to the colon and stomach are preserved. Most dissections and mobilizations are performed bluntly, with minimal use of sharp instruments or cautery. Dissection continues medially along the same avascular plane, remaining superficial to the posterior abdominal muscles. Sequential mobilization of the left colon mesentery with its primary vessels, the left kidney and its pedicle, the spleen, stomach, and pancreatic tail proceeds until full exposure of the aorta is achieved.[9]

Given the extensive anatomy encountered during this exposure, discussion of technical pearls and potential pitfalls is essential. Key technical considerations include early identification and protection of the left ureter, blunt dissection along the avascular plane of the white line of Toldt, and complete mobilization of the left kidney to prevent obstruction of aortic exposure by the anterior renal fascia. Preservation of the splenocolic and gastrosplenic attachments, when feasible, reduces the risk of splenic injury.

Common pitfalls include inadequate medial rotation limiting aortic visualization, excessive traction causing splenic avulsion, unrecognized avulsion of lumbar veins from the left renal vein, and inadvertent pancreatic injury from aggressive dissection. Incomplete mobilization of the kidney increases the risk of ureteral injury and compromises vascular control.

Left-sided medial visceral rotation for aortic exposure in elective vascular surgery predates the Mattox maneuver. A critical anatomical distinction exists: the Mattox maneuver always retracts the left kidney. Leaving the kidney in place interposes the anterior renal fascia between the dissection plane and the aorta, obstructing access to the anterior aortic surface and increasing ureteral injury risk. This variant, performed with the kidney remaining in the Gerota fascia, is sometimes referred to as the “modified Mattox maneuver.”

Complications

Complications associated with the Mattox maneuver are potentially serious. Contributing factors include the severity and acuity of the underlying trauma, the rapid pace required in unstable patients, and the manipulation of multiple organs and their associated vasculature. Although risks are present, the maneuver proves lifesaving in severe abdominal aortic injuries through definitive hemorrhage control, rendering potential complications acceptable in critical cases.

Complications may arise from the procedure itself, inadvertent injury, or progression of the primary trauma. Documented adverse events include splenic injury, which represents the most common iatrogenic complication; avulsion of the descending lumbar vein from the left renal vein; pancreatitis; and gastrointestinal ischemia secondary to retraction or arterial congestion.[10]

Clinical Significance

Controlling traumatic intra-abdominal hemorrhage is critical for survival in severely injured patients. The severity and urgency of such injuries demand prompt and precise surgical intervention. Hemorrhage originating from easily accessible intra-abdominopelvic structures may be controlled straightforwardly.[11] Bleeding from major vessels or multiple branches of a large vessel presents greater challenges, primarily due to the anatomical location of the abdominal aorta. Complete execution of the Mattox maneuver is required to expose the aorta and achieve lifesaving hemorrhage control.

Upon entering the abdominal cavity, temporary hemostasis with packing is considered initially. Suspected major or retroperitoneal bleeding warrants classification of the vascular site according to the 3 retroperitoneal zones described in the anatomy section. This zonal classification aids in guiding management decisions and selecting the appropriate surgical approach.

Midline supramesocolic and inframesocolic injuries in zone 1 from blunt or penetrating trauma warrant surgical exploration due to the high likelihood of injury to the aorta, the IVC, or their major branches. Perirenal blunt hematomas in zone 2 are typically managed nonoperatively, whereas perirenal hematomas resulting from penetrating trauma require surgical exploration.

Retroperitoneal hemorrhage in the pelvis (zone 3) frequently occurs in association with pelvic fractures. This injury complex carries a mortality rate of up to 30% and usually involves bleeding from smaller vessels, the venous plexus, and bone fragments.[12] Management requires an interprofessional team, comprising trauma surgeons, interventional radiologists, and orthopedic surgeons at a level 1 trauma center.[13]

Patients with injury patterns necessitating retroperitoneal exploration often present with profound physiologic derangement. Definitive exploration may be deferred in favor of damage-control laparotomy with temporary abdominal closure, which may be achieved with devices such as a Wittmann patch.[14] This approach is particularly valuable in the presence of contaminated wounds or severe physiologic instability, allowing continued resuscitation and optimization prior to definitive repair.[15]

Enhancing Healthcare Team Outcomes

Interprofessional teamwork is critical for optimizing patient care in high-acuity settings such as trauma.[16] Surgeons function as team leaders, but effective communication across the entire healthcare team is necessary to improve outcomes. Thorough anatomical knowledge and procedural expertise are essential for the safe performance of the Mattox maneuver. Emergency laparotomy for traumatic hemorrhage provides lifesaving hemorrhage control. Retroperitoneal injuries require formal exposure for definitive control and repair.[17]

Emergency medicine clinicians, radiologists, critical care nursing teams, pharmacists, and physical therapists contribute to injury identification, perioperative decision-making, postoperative management, and rehabilitation. Coordinated, team-based care across the trauma continuum enhances efficiency, reduces complications, and improves patient outcomes. A well-organized system staffed with experienced interprofessional personnel is essential to maximize survival in patients with traumatic injuries.