Abdominal

Trauma

Diagnosis and treatment of

intraabdominal injuries

Alhmoud Faiez
Consultant Surgeon
Albashir Hospital. MOH
Amman - Jordan
 Where is the abdomen?
External Anatomy
Thoracoabdominal area:
Any penetrating
Transverse nipple line toinjury
costal to any of these
areas,
margin or that may have traversed this
volume, shouldCostal
Anterior abdomen: be considered as a
margin to groin crease to
potential
anterior axillaryabdominal
lines bilaterallyinjury, and evaluated
as such.
Flank area: Between anterior
and posterior
Special Careaxillary lines from
6th intercostals space to iliac
Wounds to thoracoabdominal junction
•crest.
zone
Back: Medial to posterior
Flank
•axillary ortipback
lines, wound
of scapula to
iliac crests & gluteal skin
Wound
•crease to buttock or perineum
inferiorly
 Torso: All the above
 The Abdomen
Cardiac Box

Mediastinum

Thoracoabdominal area

The external appearance of wound doesn’t

determine the extent of internal injuries
Classification of injuries
 Blunt trauma
 Penetrating trauma
 Iatrogenic trauma
 When should you suspect
intra-abdominal injury?
Diagno
Blunt sis and treatment
Penetrating of

intraabdominal injuries
● Speed ●Weapon
● Point of impact ●Distance
are essential to avoid
● Involvement ●Number and
location of
● Safety devices wounds
●preventable
Position morbidity
and death.
● Ejection
 Primary Survey-ATLS Approach

 A – Intubation may be required if pt. is

shocked, hypotensive or unconscious or in need
for ventilation
 B – Watch for hemo-pneumothorax in both
blunt and penetrating thoracoabdominal
injuries
 C – Start with 2 L crystalloid (If active bleeding
you MUST FIND & STOP THE BLEEDING)
 D – May see associated thoracolumbar #es
 E – Watch for other injuries
 Diagnosis & Treatment
Priorities
Patients with abdominal
First: recognize injury
presence tend to
of shock or fall into 4 major
intraabdominal
categories:
bleeding
Second: start resuscitative
Presentation measures
Injury Type for shock
Management/ priority
bleeding
Pulseless Major vascular injury Emergency laparotomy
Consider ED thoracotomy
Third: determine if abdomen is source for shock or
Hemodynamically Vascular and/or solid organ Identify & control
bleeding
unstable injury AND/OR hemorrhage
Hemorrhage from other sites
Fourth: determine if emergency laparotomy is needed
Hemodynamically solid organ injury Resuscitation
Fifth: complete secondary
stable survey, lab, and
Hemorrhage<750cc Gradingradiographic
studies to determine if “occult” abdominal injury is
present
Hemodynamically
Normal
Hollow viscus injury
Pancreas or renal
Identify presence of
gastrointestinal,
Sixth: conduct frequent reassessments diaphragmatic or
 Estimation of blood
loss
-Hemorrhage is a
concern with
abdominal trauma.
-Estimation of blood
volume lost is difficult.
-Signs and symptoms
depend on:
• Volume of blood
lost
• Rate of loss
Base deficit & lactate
 Resuscitation

Biggest concern

Positioning for comfort.

Apply high-flow oxygen.
Treat for shock.
 Resuscitation
 Upper extremity large bore i.v cannulae
and i.v fluids with RL or N/S should begin
immediately with Blood sampling
 If your patient sustained blunt trauma, as
in a motor vehicle crash (MVC), keep his
neck and spine immobilized until X-rays
rule out a spinal injury.
 Control the patient’s pain
 Next, perform a rapid secondary survey
 Resuscitation
 An early rapid assessment of the
abdomen
 Rectal examination
 Catheteres and tubes
 Administer tetanus prophylaxis and
antibiotics as indicated.
 Damage control
resuscitation
It’s an alternative resuscitation approach to hemorrhagic
shock which involves:
1.Rapid control of surgical bleeding
2.Early and increased use of red blood cells, plasma and platelets
in a 1:1:1 ratio
3.Limitation of excessive crystalloid use
4.Prevention and treatment of hypothermia, hypocalcemia and
acidosis
5. Permissive hypotension. (Hypotensive resuscitation strategies)
Damage control resuscitation can be applied to
unstable patients who are with life-threatening
hemorrhage & going to need massive transfusion.
 Initial Resuscitation
Identify where is the bleeding?

“4 & On the floor”

 Chest – CXR
 Intraperitoneal abdomen-FAST
 Retroperitoneal abdomen CT scan
 Extremities – (femur #s)-XRs

Then stop it:

 OR
 Angioembolization
 Pressure
 Reduction & stabilization
 Secondary Survey
History
History for all trauma patients:
Not necessary making an accurate diagnosis
S.A.M.P.L.E
S: Symptoms: Pain, vomiting, hematuria, hematochezia,
dyspnea, respiratory distress…..
A: Allergies
M: Medications
L: Last meal
E: Events: Mechanism of injury is important factor
 Physical Examination
How Good is our Physical Exam?
What is the primary objective?

• Accuracy only 60-65%

• Serial physical examination has the best sensitivity
and negative predictive value of all modalities for the
evaluation of penetrating abdominal trauma
• The primary objective of the physical examination in
abdominal trauma is to rapidly identify the patient
who needs a laparotomy….
• Pulse, blood pressure, capillary refill and urine
output—hypovolemia + abdominal signs
• Then the most important is to detect peritonitis
 Physical Examination

 Inspection: abrasions, contusions, lacerations,

deformity, entrance and exit wounds to determine
path of injury…………..
(Grey-Turner, Kehr, Balance, Cullen, seat belt sign….)
 Palpation: elicit superficial, deep, or rebound
tenderness; involuntary muscle guarding
 Percussion: subtle signs of peritonitis; tympany in
gastric dilatation or free air; dullness with
hemoperitoneum.
 Auscultation: bowel sounds may be decreased(late
finding).
 Physical Exam: Eponyms

 Grey-Turner sign: Bluish Seat Belt Sign Grey-Turner sign

discoloration of lower flanks, lower
back; associated with retroperitoneal London’s sign. Fox sign
bleeding of pancreas, kidney, or
pelvic fracture.
 Cullen sign: Bluish discoloration
around umbilicus, indicates peritoneal
bleeding, often pancreatic Cullen sign
hemorrhage.
 Kehr sign: shoulder pain while
supine; caused by diaphragmatic Labia and Scrotum
irritation (splenic injury, free air,
intra-abdominal bleeding)
Kehr sign
 Balance sign: Dull percussion in
LUQ. Sign of splenic injury; blood
accumulating in subcapsular or
extracapsular spleen. Balance sign
 Radiological and Ancillary
diagnostic procedures
 Plain x-ray chest,abdomen,and pelvis
 FAST
 Diagnostic peritoneal lavage – Aspiration
 Local Wound Exploration
 Contrast studies, CT scan.
 Urethro-Cysto-graphy
 IVU
 Angiography
 Plain films
 Pneumotharax, Haemothorax
 Free air under diaphragm
 Retroperitoneal stippling associated duodenal
injury
 Nasogastric tube, bowel loops in the chest
 Elevation of the both /Single diaphragm
 Lower Ribs # -Liver /Spleen Injury
 In penetrating trauma, injuring trajectory
 Ground Glass Appearance =
Massive Hemoperitoneum
 Obliteration of Psoas Shadow=Retroperitoneal
Bleeding
 Vertebral fracture
 Focused assessment with
sonography for trauma (FAST)
-To diagnose free intraperitoneal
fluid.
-Evaluate solid organ hematoma
-Four areas:
1. Pericardium (subxiphoid)
2.Perihepatic & hepato-renal space
(Morrison’s pouch)
3.Perisplenic
4. Pelvis (Pouch of
Douglas/rectovesical pouch)
sensitivity 60 to 95% for The larger the hemoperitoneum, the
detecting 100 mL - 500 mL of higher the sensitivity. So sensitivity
fluid increases for clinically significant
 (E-FAST): hemoperitoneum.
 Add thoracic windows to look for
How much fluid can FAST detect?
pneumothorax. Sensitivity 59%,
250 cc total
specificity up to 99% for PTX
100 cc in Morison’s pouch
 FAST……

 Advantages
• Portable (bedside), fast (<5 min) and ability to repeat
• No radiation or contrast
• Noninvasive
• Less expensive
• Rapid results, Hemodynamically unstable pt who cannot go to CT

 Disadvantages
• Not good for acute parenchyma damage, retroperitoneal, or diaphragmatic defects.
• Limited by obesity, distended bowel loops and subcutaneous air.
• High (30%) false-negative rate in detecting hemoperitoneum in the presence of
pelvic fracture
• Operator dependent
• Particularly poor at detecting bowel and mesentery damage (44% sensitivity)
• Limited in detecting <200 cc intraperitoneal fluid
 Ct scan
 Accurate for solid visceral lesions and its grading and
intraperitoneal hemorrhage. Guide nonoperative
management of solid organ damage.
 Sensitivity for solid organ is >95% but for enteric & for
diaphragmatic 60% & for pancreatic 30% (organ specific)
 Noninvassive
 Disadvantages :
-Contrast allergies
Contraindications
-Time consuming
Indications; Clear indication for exploratory
trauma
Blunt-Relatively expensive laparotomy
Hemodynamically stable patient Hemodynamically unstable
-Intravenous
Normal or unreliableiodinated
physical contrast
patient risk
-Poor for bowel and pancreas
examination Contrast allergic patient
 Diagnostic peritoneal lavage
A Dying Art?
DPL is indicated in both blunt and a selective group of
penetrating abdominal injuries.
 Blunt abdominal trauma where CT or FAST is not available or
where imaging is equivocal
 Anterior abdominal stab wounds with violation of peritoneum
on local wound exploration
 Unreliable abdominal exam (i.e. altered mental status,
intubated, spinal cord injury) with negative or equivocal
imaging
 Changes in abdominal exam or vitals in observed patients with
negative initial imaging
 Patients with blunt or penetrating trauma who cannot be safely
transported out of the resuscitation bay (i.e. CT scanner,
interventions for other injuries)
 Contraindications of DPL

 Absolute :
 Peritonitis
 Gunshot wound
 Injured diaphragm or evisceration
 Extraluminal air by x-ray
 Significant intraabdominal injury by CT scan
 Intraperitoneal perforation of the bladder by cystography
 Relative :
 Previous abdominal operations (because of adhesions)
 Morbid obesity
 Gravid Uterus
 Advanced cirrhosis (because of portal hypertension and the risk of
bleeding)
 Preexisting coagulopathy
DPL Procedure
 Complications of DPL

Perforation of
 Small bowel,
 Mesentry and
 Bladder.

 Limitations
 Gives no information about retroperitoneal organ
status
 No determination of which organ has been damaged.
IF RBC COUNT>100,000/ML the INCIDENCE OF VISCERAL INJURY= 95%
20,000-100,000ML = 15-25%
<20,000ML < 5%
 Comparison of DPL,FAST
and CT
DPL FAST CT
DOCUMENTS: BLEEDING FLUID ORGAN
BP STATUS: LOW LOW NORMAL
SENSITIVITY: 98% 82% -97% 92%-98%
SPECTIFITY: LOW(MID80) (MID 90) (HIGH 9O)
DISADVANTAGES:Invasive Op. depended Cost & time
 Local Wound Exploration
A Dying Procedure?

 Formal evaluation of a stab wound under local

anaesthesia
 This procedure is usually performed in the
operating room
 Penetration of the anterior fascia is considered
a positive LWE
 When LWE is used alone to determine
laparotomy, there will be a high non-
therapeutic laparotomy rate
 LAPAROSCOPY

 Most useful to evaluate penetrating wounds to

thoracoabdominal region in stable patient
 Spec. for diaphragm injury: Sensitivity 87.5%, specificity 100%
 Can repair organs via the laparoscope
(diaphragm, solid viscera, stomach, small bowel.)
 Disadvantages:
 Poor sensitivity for hollow visceral injury and
retroperitoneum
 Complications from trocar misplacement.
 Exploratory Laparotomy
• Diagnostic capabilities have reduced the number of negative
laparotomies and established the priorities
The indications for exploratory laparotomy are:
Either…….Clinical
a. Obvious peritoneal signs on physical examination
b. Hypotension with a distended abdomen
c. Abdominal GSW with peritoneal penetration
d. Abdominal stab wound with evisceration, hypotension, or
peritonitis
Or………Paraclinical
a. Positive FAST with hemodynamic instability or DPL
b. Findings with any other diagnostic intervention (e.g., chest x-
ray [ruptured diaphragm, pneumoperitoneum], abdominal
ultrasound, abdominal CT, or laparoscopy suggestive of….
 Once the decision is made
to operate:Gen. set-up
• The patient must be rapidly transported directly to the
OR with appropriate airway support
• If possible, informed consent is obtained
• Intravenous lines, tubes, and spinal precautions (at
least two large-bore I.Vs, broad-spectrum antibiotic,
place chest tubes to underwater seal, don’t clamp,
place nasogastric or orogastric tube and a bladder
catheter before laparotomy…..)
• Rapid-infusion system.
• Ascertain that packed RBC are in the OR and plasma
and platelets are available for the patient with active
hemorrhage
You see what you look for
 Procedure ……

1. Incision. Generous midline incision is preferred. Self

retaining retractor systems and headlights are
invaluable.
2. Bleeding control. Scoop-free blood and rapidly
pack all quadrants
3. If packing does not control a bleeding site, this
source must be controlled as the first priority.
4. Contamination control. Quickly control bowel
content contamination
 …Procedure .

5. Systematic exploration. Systematically explore the entire

abdomen, giving priority to areas of ongoing hemorrhage
A. Liver B. Spleen C. Stomach
D. Right colon, transverse colon, descending colon, sigmoid
colon, rectum, and small bowel, from ligament of Treitz to terminal
ileum, looking at the entire bowel wall and the mesentery
E. Pancreas, by opening lesser sac (visualize and palpate)
F. Kocher maneuver to visualize the duodenum, with evidence of
possible injury
G. Left and right hemidiaphragms and retroperitoneum
H. Pelvic structures, including the bladder
I. With penetrating injuries, exploration should focus on following
the track of the weapon or missile.
6. Injury repair 7. Closure
 SPECIFIC ORGAN INJURIES.

• Treatment of an organ
injury is similar whether Specific Organs
the injury mechanism is Trauma:
penetrating or blunt
• An exception to the rule 1.Peritoneal
is a retroperitoneal 2.Retroperitoneal
hematoma. 3.Diaphragm
• Explore all
retroperitoneal
hematomas caused by
penetrating injury.
 1.Diaphragm
• It’s possible in injuries to the thoracoabdominal region
• Can be due to blunt(>85%) or penetrating injury and is larger in
the blunt
• Possible cardiac injury if the penetrating wound is more central
• The weakest point of diaphragm is the Lt.posteriolateral (80%)
• Often missed in multitrauma
• In isolated injury it may go unnoticed and there is often a
delay between the injury and the diagnosis.
• Patients present with non specific symptoms and may
complain of chest pain, abdominal pain, dyspnoea, tachypnoea
and cough
• Rupture with herniation is diagnosed by CXR or CT but
without herniation is difficult to diagnose
• Thoracoscopy or laparoscopy is diagnostic
 Diagnostic modalities
Cl. Examination:
• Chest pain and shortness of breath
• Scaphoid abdomen
• Bowel sounds on auscultation of the hemithorax
Plain radiography:
• Hollow viscus noted in the left hemithorax
• Nasogastric tube in the left hemithorax
 FAST examination: Unreliable
 DPL: Inconclusive; high false-negative
 CT scan: Inconclusive
 Laparoscopy: The diagnostic modality of choice
 Treatment
• Once identified must be repaired because it will not close
spontaneously regardless the size
• Early diagnosis needs abdominal approach using
interrupted nonabsorbable suture and the large defect
(>25cm2)may need nonabsorbable mesh
• In the event of a gross contamination, endogenous tissue can
be utilized for a definitive repair as latissimus dorsi flap, tensor
fascia lata, or omentum.
• There are some who advocate using biologic tissue grafts,
such as AlloDerm (human acellular tissue matrix; Life Cell
Corporation). The durability of such a repair is questionable.
Irrigate the thoracic cavity through the defect in the diaphragm
• Place chest tube on the surgery side at the time of repair
 2.Stomach
• More common in ■ FAST examination
penetrating trauma than – Unreliable
blunt & it’s about 10% of
penetrating injuries of ■ DPL
the abdomen • RBCs
• WBCs
Diagnosis: • Gross contamination
■ Physical examination
– Epigastric tenderness
■ CT scan
– Peritoneal signs – Pneumoperitoneum
– Bloody gastric aspirate
■ Plain radiography in <50% ■ Laparoscopy
–Free air under the diaphragm – Operator dependent
 Stomach:
treatment is according to the severity

• Administer preoperative antibiotics

• Hematoma is evacuated, hemostasis and closure with
nonabsorbable suture
• Small perforations can be closed in one or two layers
• Large injuries near the gr. curvature can be closed by
suture or GIA stapler
• Certain defects may be closed using a TA stapler
• A pyloric wound may be converted to pyloroplasty
• Destructive wound may need proximal or distal
gastectomy
• In rare cases a total gastrectomy and Roux-en-y
esophagojejunostomy are necessary for severe cases
 3.Small Intestine
• The small bowel is the most commonly injured
intraabdominal organ in penetrating trauma; a blunt
trauma cause is less common, but not rare (10%)
• Small isolated perforations probably result from
blowouts of pseudo-closed loops (seatbelt-related
injuries).
• Larger perforations, complete disruptions, and
injuries associated with large mesenteric hematoma
or lacerations are caused by direct blows or
shearing injury or contusion.
• Perforation from blunt injury is most common at the
ligament of Treitz, ileocecal valve, midjejunum, or in
areas of adhesions
 Small Intestine
•Diagnosis is clinical:
• Suspect small-bowel injury with evidence of an
• CT has a significant false negative rate
abdominal wall seat-belt contusion or fracture
in
the diagnosis
of the of small-bowel injury.
lumbar spine.
• CT findings in small-bowel injury include:
• Small-bowel injury is often
• Fluid collections withoutnot solid
diagnosed
viscus oninjury
initial
presentation
• Bowel wall because the patient is less likely to
thickening
have peritonitis on initial examination.
• Mesenteric infiltration
• Free
• This intraperitoneal
delay air
contributes significantly to morbidity
• Oral
and contrast extravasation
mortality.
 Small Intestine
Treatment is operative
1.Administer preoperative antibiotics - Laparotomy
2.Imbricate antimesenteric wall hematomas or serosal injuries
with Lembert stitches to reduce the risk of delayed perforation.
3.Debride simple lacerations and close transversely in one
layer to avoid stenosis. Similarly connect and close adjacent
small lacerations
4.Resect larger injuries and perform anastomosis.
5.Injuries to the mesentery of the small bowel, which can bleed
massively, must be rapidly controlled, with definitive repair of
the small bowel delayed until later in the operation.
6.Injury to the proximal SMA may require a saphenous vein
interposition graft or shunting in a damage control scenario.
7.The outcome is generally good if the diagnosis is made quickly
 Colon and rectum
•Diagnosis
• Peritoneal signs or free intraperitoneal air.
• At laparotomy, small injuries in the wall of the colon can be
missed so explore all blood staining or hematomas of the
colonic wall.
• Consider proctoscopy or proctosigmoidescopy in :
- Gross blood on PR in the presence of a pelvic fracture
- Penetrating abdominal, buttock, thigh or pelvic wound.
- Any patient with a major pelvic fracture if the patient is
stable.
• The location of the injury can be important in planning the
operation. Even if the hole cannot be visualized on
proctoscopy, assume the patient has a colorectal injury, if
there is intraluminal blood.
• In hemodynamically unstable patients, proceed with
laparotomy first.
 Colon and rectum
Treatment is operative
Current operative options include If a primary
• Primary repair of the injury, repair cannot be
• Resection and anastomosis, and performed safely
• Colostomy..
for anatomic
The guidelines for primary repair include reasons (bowel
• Minimal fecal spillage, wall edema,
• No shock (defined as systolic blood pressure <90 mmHg),
• Minimal associated intraabdominal injuries, vascular
• <8-hour delay in diagnosis and treatment, and compromise), a
• <1-L blood transfusion. colostomy may
Traditional contraindications to primary repair include be a safer option.
• Patients with shock, underlying disease, significant associated injuries, or peritonitis
• Extensive intraperitoneal spillage of feces,
• Multisegmental or extensive colonic injury requiring resection, and
• Major loss of the abdominal wall or mesh repair of the abdominal wall;
 Rectum
Intraperitoneal or Extraperitoneal

1.Often, intraperitoneal rectal injuries can be managed as in

colonic injury (primarily repaired).
2.Treat extraperitoneal rectal tears by diverting sigmoid
colostomy. Acceptable options include:
• Hartmann resection with end colostomy,
• End colostomy with a mucus fistula, or
• Loop colostomy with a stapled distal end.
3.If the defect is not readily identified on proctoscopy…..
4.Presacral drainage and irrigation of the distal rectal
stump…..
5.If a colostomy is necessary in a patient with a pelvic fracture
requiring fixation……
6.Perioperative broad-spectrum antibiotics should be
administered for colon and rectal wounds
 Duodenal injury
• Penetrating trauma, predominantly GSW 75% & blunt 25%
• The second portion of the duodenum is most commonly
injured
• Delays in diagnosis in case of isolated injury.
• Up to 98% have associated abdominal injuries(liver,
pancreas, small bowel, colon, IVC, portal vein, and aorta.)
• Retroperitoneal air or obliteration of the right psoas margin
may be seen on abdominal x-ray study
• CT findings include paraduodenal hemorrhage and air or oral
contrast leak.
• Contrast study is helpful
• Bile staining fluids and air in the retroperitoneum, or a
central retroperitoneal hematoma mandates thorough
exploration of the duodenum.
 Duodenal injury
Treatment for hematoma
• Intramural duodenal hematoma is more common in children
than in adults; may be a result of child abuse.
• A “coiled spring” appearance is seen on UGI series. Follow-up
UGI with Gastrografin should be obtained every 7 days, if the
obstruction persists clinically.
• Treated nonoperatively with nasogastric suction and IV
alimentation.
• Operation is necessary to evacuate the hematoma if it does not
resolve after 2 to 3 weeks.
• Treatment of an intramural hematoma found at early laparotomy
is controversial: -One option is to open serosa
-Another option is leaving the intramural hematoma intact and
planning nasogastric decompression postoperatively.
-Consider placement of a jejunal feeding tube
 Duodenal injury
Treatment for perforation
• Longitudinal duodenal injuries can usually be closed
transversely if the length of the duodenal injury is <50%
of the circumference of the duodenum.
• More severe injuries may require repairs using pyloric
exclusion, duodenal decompression, or more complex
operations.
• The (bad prognostic) factors in duodenal injury include:
• Associated vascular injury
• Associated pancreatic injury
• Blunt injury or missile injury
• >75% of the wall involved
• Injury in the first or second portion of the duodenum
• >24 hours since injury
• Associated common bile duct injury
 Duodenal injury
Treatment for perforation
• Pyloric exclusion with gastrojejunostomy. Staple from the
outside or oversew the pyloric outlet through a gastric incision
(absorbable or nonabsorbable suture), using the incision as the
gastrojejunostomy site.
• Vagotomy is usually not performed; the pyloric closure generally
reopens in 2 to 3 weeks.
• If primary closure would compromise the lumen of the
duodenum, use a jejunal serosal patch duodenoplasty
• A three-tube technique may also be used.
• If complete duodenal transection or long lacerations of the
duodenal wall are found, perform debridement and primary
closure or closure of the distal duodenum and Roux-en-Y
duodenojejunostomy proximally may be required.
 Pancreatic injury
• Relatively uncommon; most are caused by penetrating injury
• A major diagnostic challenge, especially in blunt trauma cases
• Associated intraabdominal injury is found in >90% of
pancreatic injuries
• Pancreatic injury should be suspected, based on the
mechanism of injury and the high incidence of associated
intraabdominal injury
• The initial complaints with pancreatic injury may be vague and
nonspecific; 6 to 24 hours after the injury, the patient will
complain of midepigastric and or back pain
• Serum amylase levels are sensitive but not specific. May be =
• DPL is not reliable.
• CT may identify peripancreatic hematomas but may not identify
pancreatic lacerations or even complete transections early
 Pancreatic injury
• (ERCP) or (MRCP) can be used to diagnose pancreatic ductal
injury in hemodynamically stable patients.
• Intraoperative diagnosis depends on visual inspection and
bimanual palpation of the pancreas by opening the gastrocolic
ligament and entering the lesser sac, and by performing a
Kocher maneuver.
• Mobilization of the spleen along with the tail of the
pancreas and opening of the retroperitoneum to facilitate
palpation of the substance of the gland may be necessary to
determine transection versus contusion.
• Identification of injury to the major duct is the critical
issue in intraoperative management of pancreatic
injury.
 Pancreatic injury
• Treatment principles include
• Control hemorrhage (Hemostasis)
• Debride devitalized pancreas, which can require
resection (Debridement)
• Preserve maximal amount of viable pancreatic
tissue (Preservation)
• Wide drainage of pancreatic secretions with
closed-suction drains (Drain)
• Feeding jejunostomy for postoperative care with
significant lesions (Feeding)
 Pancreatic injury
Treatment options
• Pancreatic contusion without ductal injury → wide
drainage.
• Pancreatic transection distal to the SMA → distal
pancreatec-tomy..
• Control the resection line by stapling the pancreatic
stump or closing with horizontal mattress sutures of
nonabsorbable material + closed suction drains.
• Pancreatic transection to the right of the SMA (not
involving the ampulla) → no optimal operation and
wide drainage of the area of injury to develop a
controlled pancreatic fistula;
 Pancreatic injury
Treatment options
• ligation of both ends of the distal duct and wide
drainage; and oversewing the proximal pancreas
and performing a Roux-en-Y jejunostomy to the
distal pancreas (indicated uncommonly). Generally,
wide closed-suction drainage is sufficient acutely
with injury to the head of the pancreas.
• Severe injury to both the head of the pancreas and
the duodenum may require Whipple
pancreaticoduodenectomy); however, this is rarely
indicated. It can be performed in staged, damage-
control fashion.
 Pancreatic Injury in Children

• 10 per cent of cases of blunt abdominal trauma in children

• Usually as a result of a handlebar injury.
• Whether they should be operated upon or managed
conservatively is controversial.
• The current trend for management of solid organ injuries in
children is conservative

• Conservative management is recommended if there are no

signs of clinical deterioration or major ductal injury.

• Although pseudocysts are more likely to develop with

transection injuries, they tend to respond to percutaneous
drainage
 Pancreatic injury
Outcome
• 10-20% incidence of pancreatic fistula as defined as >100 cc/day for >14
days (minor) or >31 days (major).
• Most minor and major fistulae will spontaneously resolve with only <7%
requiring further operative intervention.
• 10-20% incidence of pancreatic abscess.
• Pancreatic duct and colon injury are independent predictors of abscess
formation.
• Post-traumatic pancreatitis should be expected in the patient with persistent
abdominal pain, nausea, vomiting, and hyperamylasemia and complicates
3% to 8% of pancreatic injuries.
• Pancreatic pseudocysts occur in 2% to 4%. Most related to missed or
inadequately treated ductal injuries
• Postoperative hemorrhage may occur in 3% to 10% and requires
reoperation in most.
Overall mortality ranges from 15% to 35% with pancreatic-related
mortality alone ranging from 2% to 3%.
 Liver
Incidence: The liver is the most commonly injured
intraabdominal organ; injury occurs more often in
penetrating trauma than in blunt trauma.

Diagnosis: Physical examination is often unreliable in

the blunt trauma victim.
The appropriate diagnostic modality depends on the
hemodynamic status of the patient.
If the patient is hemodynamically stable with a blunt
mechanism of injury, CT is preferred.
CT is sensitive and specific
 Liver Treatment
The hemodynamically stable patients with blunt injury of
the liver, can be treated nonoperatively, regardless of
the grade of the liver injury.
• This may represent 50% to 80% of patients. The presence of
hemoperitoneum on CT does not mandate laparotomy.
• Arterial blush or pooling of contrast on CT and high-grade
(grade IV and V) hepatic injuries are most likely to fail
nonoperative management.
• Angioembolization has assumed an increasing role
• The criteria for nonoperative management of blunt
liver injuries include:
• Hemodynamic stability.
• Absence of peritoneal signs.
• Lack of continued need for transfusion for the hepatic
injury; bleeding can be addressed with angioembolization.
 Liver Treatment
If the patient is hemodynamically unstable or has indications for
laparotomy, operative management is required.
Management principles include the following four principles:
Hemostasis, adeq. Exposure, Debridement and Drainage
• Adequate exposure of the injury is essential. Complete
mobilization of the liver is performed, including division of the
ligaments.
• Most blunt and penetrating hepatic injuries are grade I and II
(70% to 90%) and can be managed with simple techniques
(e.g., electro-cautery, simple suture, or hemostatic agents).
• Complex liver injuries can produce exsanguinating hemorrhage.
Rapid, temporary tamponade of the bleeding by manual
compression of the liver injury immediately after entering the
abdomen allows the anesthesiologist to resuscitate the patient.
 Liver Treatment
For complex hepatic injuries (Grade III-V):
-Occlude the portal triad with an atrau-matic clamp (Pringle
maneuver).
-Debridement of nonviable tissues
-Fingure fracture of the hepatic parenchyma
-Placement of omental pedicle in the injury site
-Closed suction drainage
• Retrohepatic venous injuries(V) is suggested when bleeding
from the liver is not controlled with Pringle maneuver
• Hepatic vascular isolation with occlusion of the suprahepatic
and infrahepatic venae cavae, as well as application of the
Pringle maneuver, may be required for major retrohepatic
venous injury.
• Cholecystectomy may be required secondary to ischemic
complications from interruption of the right hepatic artery.
 Liver trauma Complications
• With recurrent bleeding (occurs in 2% to 7% of
patients) → return the patient to the OR or, in
selected patients, obtain an angiogram and perform
embolization. Recurrent bleeding is generally caused
by inadequate initial hemostasis. Hypothermia and
coagulopathy must be corrected.
• Hemobilia is another complication of liver injury.
The classic presentation is right upper quadrant pain,
jaundice, and hemorrhage(upper GI); one third of
patients have all three components of the triad. The
patient may present with hemobilia days or weeks
after injury. Treatment is angiogram and
 Liver trauma Complications
• Intrahepatic or perihepatic abscess or biloma can
generally be drained percutaneously. 1.Meticulous control of
bleeding and repair of bile ducts, 2.adequate debridement, and
3.closed-suction drainage are essential to avoid abscess
• Biliary fistulas (>50 mL/day for >2 weeks) usually resolve
non-operatively if external drainage of the leak is adequate and
distal obstruction is not present.
• If >300 mL of bile drains each day, further evaluation with a
radionuclide scan, a fistulogram, ERCP, or a PTC may be
necessary. Major ductal injury can be stented to facilitate
healing of the injury or as a guide if operative repair is required.
Endoscopic sphincterotomy or transampullary stenting may
facilitate resolution
 Extrahepatic biliary tract injury

• It's uncommon & the gallbladder is the most common site &
cholecystectomy is the usual treatment
• Injury to the extrahepatic bile ducts can be missed at
laparotomy unless careful operative inspection of the
porta hepatis is performed
• A cholangiogram through the gallbladder or cystic duct
stump helps define the injury.
• The location and severity of the injury will dictate the
appropriate treatment:
• Simple bile duct injury (<50% of the circumference) can be
repaired with primary suture repair over T-tube.
• Complex bile duct injury (>50% of the circumference) may
require Roux-en-Y choledochojejunostomy or
hepaticojejunostomy.
 Spleen…Diagnosis
• The patient may have signs of hypovolemia and complain of
left upper quadrant tenderness or Kehr's sign.
• Physical examination is insensitive and non-specific. The patient
may have signs of generalized peritoneal irritation or left
upper quadrant tenderness, dullness or fullness
• Of patients with left lower rib fractures (ribs 9 through 12),
25% will have a splenic injury.
• In the unstable trauma patient, ultrasound or DPL will
provide the most rapid diagnosis of hemoperitoneum
• In the stable patient suffering from blunt injury, CT imaging
of the abdomen allows delineation and grading of the
 Spleen…Treatment
• Management of splenic injury depends primarily on the
hemodynamic stability of the patient
• Other factors include the age of the patient, associated
injuries (which are the rule in adults), and the grade of the
injury.
• Cooperative management of splenic injury is successful in
>90% of children, irrespective of the grade of splenic injury.
• Nonoperative management of blunt splenic injury in adults is
becoming more routine, with approximately 65% to 75%
• If hemodynamically stable, adult patients with grade I or II
injury can often be treated nonoperatively.
• Patients with grade IV or V splenic injuries are usually unstable.
• Grade III splenic injuries (certainly in children, and in selected
adults) can be treated nonoperatively
 Spleen…Treatment
The failure rate of nonoperative management of splenic injuries in
adults increases with grade of splenic injury:
• grade I, 5%;
• grade II, 10%;
• grade III, 20%;
• grade IV, 33%; and
• grade V, 75%. In adults (but not children),
Most failures occur within 72 hours of injury.
Patients with significant splenic injuries treated nonoperatively
should be observed in a monitored unit and have
immediate access to a CT scanner, a surgeon, and an OR.
Changes in physical examination, hemodynamic stability, ongoing
blood, or fluid requirements indicate the need for laparotomy.
Arteriography with embolization has been reported to increase the
success rate.
 Spleen…Treatment
Mobilization of the spleen

• Splenectomy should be performed in unstable patients, and in

those with associated life-threatening injury, multiple sources
for postoperative blood loss (pelvic fracture, multiple long bone
fractures, and so forth), and complex splenic injuries.
• Splenorrhaphy is an option when circumstances permit. At
least one half of the spleen must be preserved to justify
splenorrhaphy.
• Nonbleeding grade I splenic injury may require no further
treatment.
• Grade II to III splenic injury may require the above-mentioned
interventions, suture repair, or mesh wrap
• Grade IV to V splenic injury may require anatomic resection,
including ligation of the lobar artery
• Drainage of the splenic fossa should be avoided
• Autotransplantation of the spleen has been reported
 Spleen…Outcome
• The outcome is generally good; rebleeding rates as low as
1% have been reported with splenorrhaphy.
• The failure rate of nonoperative therapy is 2% to 10% in
children and as high as 18% in adults.
• It has been reported that adults >55 years of age are
especially susceptible to failure of nonoperative therapy
• Pulmonary complications are common in patients treated
operatively and nonoperatively.
• Left subphrenic abscess occurs in 3% to 13% of
postoperative patients and may be more common with the use
of drains or with concomitant bowel injury.
• Thrombocytosis occurs in 50% of patients post splenectomy;
the platelet count usually peaks 2 to 10 days postoperatively.
The elevated platelet count generally abates in several weeks.
 Spleen…Outcome
• The risk of overwhelming postsplenectomy infection (OPSI) is
greater in children than in adults; the risk is < than 0.5%.
• The mortality rate for OPSI approaches 50%.
• The common organisms are encapsulated organisms:
meningococcus, Haemophilus influenzae, and Streptococcus
pneumoniae, as well as Staphylococcus aureus and Escherichia
coli.
• After splenectomy, pneumococcal (Pneumovax), H. influenzae,
and meningococcal vaccines should be administered.
• The timing of injection of the vaccine is controversial.
• Current recommendation is to repeat the pneumococcal
vaccination at 5 years.
• The patient should be discharged from the hospital with a clear
understanding of the concerns about OPSI.
 Retroperitoneal Hematomas

• Blunt trauma produces 70% to 80% of retroperitoneal hematomas; most

are caused by pelvic fracture.
• Management of retroperitoneal hematomas depends largely on location
and the mechanism of injury.
• Generally, all penetrating wounds of the retroperitoneum found at
laparotomy require thorough exploration.
• Some simply observe nonexpanding perinephric hematomas.
• If the hematoma is large, expanding, or proximal to the retroperitoneal
vessels (aorta, iliac artery, and so forth), first obtain proximal and distal
control of the vessels.
• In general, nonexpanding lateral (zone II) or pelvic (zone III) hematomas
secondary to blunt trauma do not require exploration.
• Be certain that the overlying bowel (i.e., colon or duodenum) is intact
• Central hematomas (zone I) always require exploration to rule out a major
vascular or visceral injury
 Rupture of the bladder

Bladder rupture can • For extraperitoneal rupture

be: (Pelvic fracture)
• Extraperitoneal: is –Suprapubic cystostomy;
most commonly (Cystofix). If the rupture is
associated with fracture large, place a drain
of the pelvis • For intraperitoneal rupture
• Intraperitoneal: is (Seatbelt injury)
often the result of a – Close the rupture and a
direct blow to the large urethral catheter or a
bladder or a sudden (Cystofix); if the rupture is
deceleration large, also place a latex drain
 LET’S BE CONCERVATIVE

A negative laparotomy does not increase the

complication rate, but a delayed laparotomy does.
Oxygenate and Resuscitate Before You Operate
 Damage control
The term ‘Damage
PRINCIPLES are: Control Surgery’ has
•yet to reach
Control twenty years
hemorrhage of use as
with packing
•concept
Identification of injury
for the treatment of
• Prevention and control contamination with
exsanguinating truncal trauma patients
temporary closure
& has become model
• Avoid further injury for emergent, life
threatening
• Resuscitationsurgical conditions
in the ICU
incapable of tolerating
• Re-exploration traditional
and definitive repair once
methods .
normal physiology has been restored
 WHEN TO INSTITUTE ?
Parameters as a guideline for instituting damage control(DCS):
• pH less then or equal to 7.2
• Serum bicarbonate level less than or equal to 15 mEq/L
• Core temperature less than or equal to 34⁰C
• Coagulopathy, as evidenced by the development of
nonmechanical bleeding within the operative field, elevation of
both prothrombin time (PT) and partial thromboplastin time
(PTT), thrombocytopenia, hypofibrinoginemia, or massive
transfusion (>10 units packed red blood cells [PRBCs]).
• Total blood replacement more than or equal to 5000 ml
• Total fluid replacement more than or equal to 12 000 ml
If all death
If one DCS
WHEN TO INSTITUTE ?
 APPROACH

Before:
ER → OR → DEATH

Now:
ER→OR → ICU→OR→ICU
DCS
 Initial Laparotomy in DCS
• Identify the main source of bleeding and stop it
• Perihepatic packing (superior and inferior)
• Small gastrotomies and enterotomies can be rapidly
closed
• Resect non-viable bowel and close the ends
• Minor pancreatic injuries not involving duct- no
treatment
• Distal injury including the panceratic duct- distal
pancreatectomy
• NO pancreaticoduodenectomy (drainage)
• Abdominal closure is rapid and temporary- if there is
any doubt about abdominal compartment syndrome, left
it open (Bogota-bag, vacuum-pack technique, towel clip)
 Abdominal Compartment
Syndrome
Definition
“The adverse physiological consequences of
an acute elevation in intra-abdominal pressure”
- Oliguria at IAP > 15-20mmHG
- Anuria at IAP > 30 mmHG
- Increased airway pressures (IAP>15 mm HG)
- Reduced cardiac output (IAP>20mmHg)
 Abdominal Compartment Syndrome:
causes
Causes of raised intra-abdominal pressure (IAP)

Retroperitoneal Intraperitoneal

Oedema in necrotising Haemorrhage

pancreatitis
Pelvic haematoma Visceral oedema

Retroperitoneal haematoma Abdominal packing

Bleeding after aortic surgery Bowel dilatation

Oedema related to Mesenteric venous

resuscitation obstruction
Pneumoperitoneum

Acute ascites
 Abdominal Compartment Syndrome:
At risk patients

•Major trauma
•Damage control surgery
•Laparotomy for bleeding, ischaemia etc
•Re-laparotomy for postoperative complications
•Massive volume resuscitation
 Abdominal Compartment Syndrome

Clinical features
•Abdominal distension
•ELEVATED IAP
•Consequent organ dysfunction
Importance
•Decompression can reverse abnormal physiology
•Probable fatal progression if left untreated
Effects of intra-abdominal hypertension (IAH)
Gut and hepatic effects Renal effects
Cardiovascular effects Respiratory effects
CNS Abdominal wall
 Abdominal Compartment Syndrome

Means of detection
•Intraabdominal pressure >30mmHg
•CT changes
- Narrowing of IVC
- Direct renal compression
- Bowel wall thickening
- “Rounded abdomen”
•Splanchnic hypoperfusion and acidosis
•Abdominal perfusion pressure
 Abdominal Compartment Syndrome –
Management
•Supportive treatment
•Early abdominal decompression of at risk
patients
-Laparotomy
-Percutaneous decompression with peritoneal
lavage catheter
•Abdominal decompression with temporary cover
eg plastic or silicone coverage, skin only closure,
mesh grafts etc

Outcomes: High mortality and morbidity ( 10 – 70 %)

 LET’S BE CONCERVATIVE

A negative laparotomy does not increase the

complication rate, but a delayed laparotomy does.
Oxygenate and Resuscitate Before You Operate
 GOODto JUDGMENT
“Failure COMES
promptly recognize FROM
and treat EXPERIENCE
simple life-
threatening injuries is the tragedy of trauma, not the inability
to handle the catastrophic or complicated injury.”
EXPERIENCE
(F.William Blaisdell) COMES FROM BAD JUDGMENT