What is the modified Mattox maneuver?

September 23, 2025 •

4 min read

First developed in the 1970s, the original Mattox maneuver revolutionized the approach to severe abdominal trauma involving the aorta. What is the modified Mattox maneuver, a modern variant of this vital surgical technique designed to enhance patient safety during life-threatening emergencies?

This maneuver represents a crucial adaptation for trauma surgeons addressing injuries in the retroperitoneal space.

Quick Summary

The modified Mattox maneuver is a left-sided medial visceral rotation, a surgical procedure used in severe trauma and vascular emergencies to expose the abdominal aorta and its major branches. This is achieved by mobilizing abdominal organs medially while leaving the left kidney in place to mitigate the risk of traction injury, a key distinction from the original technique. The maneuver provides critical access for controlling life-threatening retroperitoneal bleeding.

Key Points

Core Concept: The modified Mattox maneuver is a surgical technique for exposing the retroperitoneal aorta in trauma cases.
Key Distinction: Unlike the original maneuver, the modified version leaves the left kidney in place to prevent traction injury.
Primary Indication: It is used for life-threatening bleeding from the aorta, typically in Zone I of the retroperitoneal space following major abdominal trauma.
Procedure: It involves a left medial visceral rotation, where the colon, spleen, and pancreas tail are moved toward the midline to access the retroperitoneum.
Risk Mitigation: The renal-sparing approach minimizes the risk of damage to the kidney and its blood supply, which is a significant complication of the original technique.
Teamwork: This complex procedure requires a skilled trauma or vascular surgeon and a coordinated multidisciplinary team in a specialized trauma center.

Understanding the Mattox Maneuver

The Mattox maneuver, or left medial visceral rotation, is a technique that allows surgeons to gain extensive access to the retroperitoneal space, the area behind the abdominal lining. This is particularly vital in trauma cases involving injuries to the aorta or its main branches, which can cause severe, life-threatening internal bleeding. In the original procedure, the spleen, left kidney, and tail of the pancreas, along with other viscera, are mobilized and rotated toward the midline to expose the aorta from the diaphragm down to the iliac arteries.

The crucial modification: protecting the kidney

The key difference between the original and modified Mattox maneuver is the treatment of the left kidney.

Original Mattox: The left kidney is mobilized medially along with the other structures. This provides the most complete exposure of the entire aorta but carries a risk of injury to the renal pedicle, the bundle of vessels supplying the kidney, from excessive traction.
Modified Mattox: The left kidney is deliberately left in place within its fascial covering, Gerota's fascia. While this can slightly hinder access to the anterior aorta, it significantly reduces the risk of traction-related injury to the left kidney and its vessels, improving patient safety. Trauma surgeons weigh this trade-off based on the specific injury location and the patient's stability.

Indications for performing the modified Mattox maneuver

This procedure is not performed lightly and is typically reserved for critical, life-threatening situations. The main indications include:

Abdominal trauma: Particularly blunt or penetrating injuries causing central retroperitoneal bleeding in Zone I, the midline area containing the aorta.
Hemodynamic instability: When a patient is in shock from uncontrolled bleeding and needs immediate surgical control of the major vessels.
Vascular injury: Direct trauma to the abdominal aorta or its large branches that necessitates rapid exposure and repair.
Elective vascular surgery: In some cases, to provide access to the aorta for procedures, though often other techniques are used.

The surgical procedure in detail

Preparation and initial access

Exploratory laparotomy: The procedure begins with a wide abdominal incision to assess the extent of the injury.
Control of initial bleeding: Initial bleeding may be controlled temporarily with packing to stabilize the patient.
Visualization: The small bowel is moved to the right side of the abdomen to provide a clear view of the posterior abdominal wall.

The medial visceral rotation

Incision of the peritoneum: The surgeon makes an incision along the white line of Toldt, the lateral peritoneal attachment of the left colon.
Mobilization: Using blunt and gentle sharp dissection, the surgeon begins to mobilize the left colon, splenic flexure, and spleen. The splenic attachments are carefully divided.
Renal sparing: Crucially, unlike the original procedure, the surgeon works around the left kidney, leaving it in place within its fascial envelope. This protects the delicate renal vessels from traction.
Full medial rotation: The spleen, stomach, pancreas tail, and left colon are then rotated toward the patient's right side, exposing the full length of the abdominal aorta.

Potential risks and complications

Given the high-acuity nature of the cases where it's used, the modified Mattox maneuver has associated risks, including:

Splenic injury: The spleen is a fragile organ and susceptible to damage during mobilization, which can lead to life-threatening bleeding and necessitate splenectomy.
Pancreatitis: Traction on the tail of the pancreas can cause inflammation or injury.
Gastrointestinal ischemia: Disruption of blood supply to the bowel can lead to tissue damage.
Vascular injury: Although the modified technique minimizes renal pedicle injury, other vessels are still at risk. Avulsion of the descending lumbar vein is a known complication.

Comparison with the original Mattox maneuver


Feature	Original Mattox Maneuver	Modified Mattox Maneuver
Left Kidney	Mobilized medially along with other viscera	Left in place within Gerota's fascia
Aortic Exposure	Provides most complete exposure of the entire aorta	Access to anterior aorta can be somewhat hindered
Risk to Kidney	Higher risk of renal pedicle traction injury	Lower risk of traction injury to the kidney and its vessels
Primary Use	High-acuity trauma requiring maximum aortic exposure	Trauma cases where risk of renal injury must be minimized

The surgical team and post-operative care

This complex procedure is typically performed by a trauma surgeon or vascular surgeon within a Level I trauma center. A multidisciplinary team including anesthetists, nurses, and other specialists is vital for a successful outcome, especially with hemodynamically unstable patients. Post-operative care follows standard protocols for major abdominal surgery, with a focus on recovery, monitoring for complications, pain management, and gradually increasing activity.

Conclusion

The modified Mattox maneuver is a testament to the evolution of surgical technique in response to clinical experience. By adapting the classic approach to protect the left kidney, surgeons have refined a life-saving procedure to be safer in specific traumatic scenarios. It remains a powerful tool in the trauma surgeon's arsenal for controlling major vascular hemorrhage and ensuring patient survival.

For more in-depth medical information on surgical maneuvers, consult reputable medical databases like the National Center for Biotechnology Information (NCBI) Bookshelf.

Frequently Asked Questions

The main difference is the management of the left kidney. In the original Mattox maneuver, the left kidney is mobilized medially with the other organs. In the modified version, the left kidney is intentionally left in its fascial space to protect it from injury during traction, a change that prioritizes renal safety.

It is used to gain rapid and controlled access to the abdominal aorta and other major vessels in the retroperitoneal space, particularly when a patient is experiencing life-threatening hemorrhage from a severe traumatic injury.

The modified Mattox maneuver exposes the left and central retroperitoneal spaces, providing a clear view of the abdominal aorta and its major branches, particularly in Zone I where midline bleeding is a concern.

Potential complications include splenic injury from traction or dissection, pancreatitis, bleeding from other vessels like the lumbar veins, and bowel ischemia. The risk of renal injury is specifically reduced in the modified version.

This maneuver is performed by highly skilled surgeons, typically trauma surgeons or vascular surgeons, often in a Level I trauma center due to the complexity and urgency of the cases.

Recovery involves careful monitoring in an intensive care setting, followed by general post-operative care for major abdominal surgery. This includes managing pain, supervising mobility, and ensuring proper wound healing and organ function.

While primarily a trauma procedure, left medial visceral rotation techniques can sometimes be adapted for elective vascular surgeries or for addressing specific retroperitoneal tumors. However, its use in trauma for immediate hemorrhage control is its most well-known application.

Medial visceral rotation is a broad surgical term referring to the mobilization and rotation of abdominal organs toward the midline to expose the structures in the retroperitoneal space. The Mattox and modified Mattox maneuvers are specific examples of left medial visceral rotation.