From 1978 through 1984, 22 patients with 20 penetrating and two blunt injuries to the proximal superior mesenteric artery were treated. Patients presented with exsanguinating hemorrhage (19), midline hematomas (two), or 'black bowel' (one). Two other patients developed 'black bowel' during operation. Direct cutdown through the mesentery was the approach in 11 patients, and three survived; a Mattox maneuver was used in ten patients, and three survived. Arteriorrhaphy was the repair performed in ten patients, and five survived. Complex bypass or grafting procedures were performed in nine patients, and two survived. Ten of 15 deaths were secondary to hemorrhagic shock; two of five late deaths were related to problems with the vascular repair in patients with multiple injuries. Interposition grafting near a major pancreatic injury may lead to catastrophic postoperative problems. Bypass grafts from the distal aorta should have retroperitoneal tissue coverage of the suture line.