Superior mesenteric artery and vein injuries are rare and highly lethal. The association of massive bleeding, difficult anatomic access and possible bowel ischemia are especially challenging. There is also a great deal of debate regarding the best treatment for mesenteric vessels injury. Primary repair, shunting, ligation and complex reconstruction procedures have been advocated. Damage control techniques are frequently necessary in this setting. Furthermore, abdominal compartment syndrome and bowel ischemia are possible lethal complications that deserve special attention.

In this video, authors report the case of a 26 year old man, victim of a car accident, who suffered blunt abdominal trauma. He was hemodynamically stable on admission and had no signs of peritonitis. FAST exam showed moderate amount of blood in the cavity. Liver or splenic injuries were not observed by the CAT scan. The laparotomy was indicated and approximately 1 liter of blood was present within the cavity. A large defect was noticed in the root of the mesentery, with active bleeding. The superior mesentery artery and vein were exposed. A small tear of 0,5 cm was observed at the left lateral wall of the superior mesenteric artery, which was promptly sewn with a running suture of 5-0 prolene. The superior mesenteric vein was dissected, isolated between clamps and a lesion of approximately 2cm was noticed at its left lateral portion. This happened due to the splenic vein avulsion from the superior mesenteric vein. The tear was sewn by a continuous suture of 6-0 prolene. The splenic vein was ligated. The cavity was temporarily closed with sterile adhesive drapes over packs and sterile plastic. The patient was admitted at the intensive care unit and the reoperation was programmed to be performed in 48 hours. During the reoperation, it was noticed that the repair of both vessels were functional and there was no bowel or splenic ischemia. The recovery was uneventful and the patient was discharged eight days after the operation.

Authors discuss many points in this illustrative case, including the approach to blunt abdominal trauma with free fluid within the abdomen and without liver or splenic injury, the options for the treatment of superior mesenteric vein injuries, the necessity of splenectomy after splenic vein ligation, the role of a second look operation to reassess bowel viability after superior mesenteric vessels repair and the possibility of abdominal hypertension after superior mesenteric vessels clamping. There is also a short review of the most important published series about the subject.