General

Management of
Penetrating
abdominal Trauma

Dr. Muhammad Asad Parvez

Postgraduate Resident General Surgery
Allied Hospital, Faisalabad
 Definition

 Potential penetrating abdominal injuries are wounds located between

 the nipple line (T4) and the groin creases anteriorly
 from level of T4 to the curves of the iliac crests posteriorly
 A projectile can cause a penetrating abdominal injury via a wound in any part of the bod
Epidemiology
Evaluation of the patient

 As is with any trauma case presenting to the E.R, initial

management is according the ATLS protocols.
 Patients can be classed into one of the 3 following
categories:
physiologically ‘normal’
physiologically ‘non-compromised’
physiologically ‘compromised’
 Evaluation of the patient
(continued)

Patients presenting with abdominal trauma can be classed into one of the 3
following categories and managed accordingly
 physiologically ‘normal’ – investigation can be completed before treatment
is planned
 physiologically ‘non-compromised’ – investigation is more limited; it is
aimed at establishing whether the patient can be managed non-
operatively, whether angioembolization can be used or whether surgery is
required
 physiologically ‘compromised’ – investigations need to be suspended as
immediate surgical correction of the bleeding is required
Initial Management and
Resuscitation

 As mentioned earlier, initial management of any patient presenting to the ED with trauma
is based on the ATLS protocol. Points or tidbits of particular important in the abdominal
trauma patient include, but are not limited to:
 Early establishment of venous access with 2x wide bore IV lines
 Laboratory samples should be sent at the same time as the establishment of venous
access and should include:
 Cross match and blood grouping (MOST Important)
 Complete blood count (Hct fall may indicate massive hemorrhage, WBC count
indicates sepsis or reactive leucocytosis)
 RFTS (pre-renal AKI), LFTS, Serum electrolytes, BSR, Lactate, Serum Amylase (gut or
pancreatic injury), Serum Lipase
 PT/aPTT
 ABG’s
 Urinalysis (for hematuria)
Initial Management and
Resuscitation (continued)

Resuscitation with blood products in 1:1:1 ratio of

pRBC:FFP:Platelets
Cover penetrating wounds and eviscerations with sterile
dressings
Give prophylactic antibiotics to reduce risk of intra-abdominal
sepsis
Leave foreign bodies in place to be removed in theatre
 History

The following points are important in the history of a patient with penetrating
abdominal trauma:
 AMPLE
 Allergies
 Medications
 Prior illnesses and operations
 Last meal
 Environment and events surrounding injury
 Physical Examination
Inspection
o Abrasions, Contusions, Lacerations, Deformity, Entrance and
exit wounds, Abdominal Distension
o (Grey turner, Cullen, Seat belt sign)
o Important to undress and fully examine for exit and entry
wounds.
o Blood at the urethral meatus may indicate genitourinary tract
injury.
Palpation
o May elicit Superficial, deep or rebound tenderness, involuntary
muscle guarding
Percussion
o Tympany in gastric dilatation or free air
o dullness with hemoperitoneum
Auscultation
o Bowel sounds may be decreased (late findings)
DRE Figure showing Grey Turner’s
o DRE may reveal fresh blood per rectum, high riding prostate (in sign
 Imaging Studies

 CXR:
A chest x ray is essential in all patients
with penetrating abdominal trauma to rule
out penetration of the chest cavity. In
addition a chest x ray can reveal:
 Hemothorax
 Pneumothorax
 Irregularities of cardiac silhouette
indicating cardiac or great vessel injury
 Diaphragmatic injury
 Lower rib fractures
 Air under the diaphragm indicates
A chest x-ray showing Diaphragmatic rupture with
peritoneal penetration or hollow viscus
herniation of abdominal contents into thoracic cavity
injury
 Imaging Studies (Continued)

 Abdominal X-rays:
o Erect, supine and lateral decubitus views
should be obtained.
o Sites of external wounds should be marked
by metal markers (e.g bent paper clips).
o These radiographs may help to identify
projectile emboluses (Absence of a
projectile in the presence of only an
entrance wound).
o May help predict pattern of injury based on
location and trajectory of projectiles.
 Imaging Studies (Continued)
 FAST (Focused assessment
with sonography for
trauma
To diagnose free intraperitoneal fluid and
evaluate solid organ hematoma.
Four areas evaluated:
o Pericardium (subxiphoid)
o Perihepatic and hepatorenal space
(morrison’s pouch)
o Perisplenic area
o Pelvis (pouch of douglas/rectovesical
pouch)
FAST Showing free fluid in the splenorenal recess
 Advantages and Disadvantages of FAST
Advantages Disadvantages

1. Imaging
94-98% specificity Studies (Continued)
for abdominal injury 46-67% sensitivity for abdominal injury in
in penetrating abdominal trauma penetrating abdominal trauma

2. Portable, fast, repeatable, can be Solid parenchymal injuries, retroperitoneal

performed at bedside, cheap injuries, diaphragmatic injuries may be
missed

3. No radiation or contrast involved Low sensitivity in comparison to CT,

especially in hemodynamically stable patients

4. Non-invasive Cannot comment on nature of free fluid in

peritoneal cavity (blood, ascites or urine)

5. Rapid results, especially in context of <100cc free fluid cannot be accurately

hemodynamically unstable patients detected
6. Is operator dependent
Imaging Studies (continued)

 So, in conclusion, (in context of penetrating abdominal

trauma)
A positive FAST indicates peritoneal penetration (high
SPECIFICITY)
A negative FAST does not rule significant injury and
should be combined with other investigations before
reaching treatment decisions (low SENSITIVITY),
especially in hemodynamically unstable patients
 Imaging Studies (continued)

CT scan
o It is the “gold standard” investigation
for intra-abdominal diagnosis of injury in
the stable patient.
o CT scanning with IV and Oral contrast is
used commonly, rectal contrast maybe
added in suspected colorectal injury.
o Images are reviewed for evidence of
peritoneal penetration and visceral
injuries.
o Detects and identifies injuries to solid CT Abd showing Splenic Contusion with
and hollow organs and also source of subcutaneous emphysema due to rib fracture
 Advantages and Disadvantages of CT Scan
Advantages Disadvantages
Imaging Studies (continued)
1 Very high specificity and sensitivity, especially Lack of sensitivity in diagnosing mesenteric, hollow
for solid visceral lesions and intraperitoneal visceral, and diaphragmatic injuries
hemorrhage

2 ability to evaluate the entirety of the abdomen, Cost and time

retroperitoneum and pelvis

3 Excellent delineation of tract of injury following Transport of patient required

penetrating trauma

4 Non invasive Not rapidly repeatable

5 Can be used to reliably predict patients Radiation and contrast exposure

with solid organ and pelvic injury who may
benefit from
angioembolization

6 Limited utility in the hemodynamically unstable patient

Diagnostic Procedures

Nasogastric intubation:
Can help detect gastric injury by presence of blood in the
nasogastric tube
Foley’s Catheterization:
 Enables monitoring of fluid resuscitation
 Can help indicate injury to the urogenital system by the
presence of blood
 Diagnostic Procedures (Continued)

 Diagnostic Peritoneal Lavage/Aspiration

A cannula is inserted below the umbilicus, directed caudally and
posteriorly.
The cannula is aspirated.
The aspirate is considered to show positive findings if > 10 mL of blood
is aspirated. If < 10 mL is withdrawn, a liter of normal saline is instilled.
The effluent is withdrawn via gravity siphoning and sent to the
laboratory for analysis.
 Diagnostic Procedures (Continued)

Criteria for a positive DPL (in penetrating abdominal trauma) [Ref. Schwartz]

1. RBC count >100,000/ml

2. WBC count >500/ml

3. Amylase level >19IU/L

4. Alkaline phosphatase >2IU/L

5. Bilirubin level >0.01mg/dL

6. Presence of bile, fecal matter or food particles

7. Passage of lavage fluid from Foley’s catheter, Nasogastric tube, or chest tube
 Diagnostic Procedures (Continued)

 Indications for DPL:

 Hemodynamically unstable patient with an equivocal FAST scan
 No FAST available
 Thoracoabdominal stab wounds (diaphragmatic injury)
 Especially useful in the hypotensive, multiply injured, unstable patient as
means of excluding intra-abdominal bleeding
 Hemodynamically stable patient with tangential gunshot wounds
o Contra-indications for DPL:
 It is contra-indicated when immediate laparotomy is indicated
Diagnostic Procedures (Continued)

 Graze / tangential wounds: the bullet strikes the skin at a shallow angle, producing
a superficial wound
 Advantages and Disadvantages of DPL
Advantage Disadvantage

1. Diagnostic Procedures (Continued)

Very high sensitivity for the presence of hollow
Low specificity
viscus injury and mesenteric injury

2. Fast, repeatable, can be performed at bedside, Potential for organ injury

cheap

3. No radiation or contrast involved Increased technical difficulty in obese patients

or those who have undergone previous
abdominal surgery

4. Especially useful to investigate diaphragmatic Technical errors can lead to false positive and
injury in patients whom it is suspected, and negative results
FAST and CXR are negative.

5. Rapid results, especially in context of Invasive

hemodynamically unstable patients

6. Cannot detect injuries to retroperitoneum

 CT
Comparison Category USG (incl. FAST) DPL CT
Speed 2-5 Minutes 20 minutes 20-60 minutes
Cost Low Low High
Bedside test +++ +++ -
Blunt Trauma +++ +++ +++
Penetrating Trauma ++ ++ +++
Unstable Patient ++++ + -
Identifies bleeding +/- - ++
site
Non-operative ++ - +++
management
Retroperitoneum/ ++ - +++
renal
Pancreas +/- + ++++
Pelvic Fracture +/- - ++++
 Diagnostic Procedures (Continued)
 Local wound exploration
o Under universal precautions, Local anesthesia is
injected at the wound site, wound tract is
followed through layers of the abdominal wall or
until its termination
o Goal is to identify the end point of the tract
which may require extension of the wound to
allow adequate visualization
o A positive result is the identification of
penetration of the posterior rectus fascia (or the
transversalis fascia if the wound is not central).
o Stab wounds are well suited for this purpose,
indication is less clear for gunshot wounds and
wounds produced by sharp instruments such as
an icepick. Picture showing a penetrating midline wound
 Diagnostic Procedures (Continued)

 Indications for Local Wound Exploration

Abdominal stab wound exploration is indicated in a patient who presents with a
 stab wound to the anterior abdomen
 normal vital signs
 no signs of peritonitis,
 no evidence of evisceration
 no other concurrent injury requiring laparotomy

o Contraindications for Local Wound Exploration

LWE is contra-indicated if immediate laparotomy is indicated.
 Diagnostic Procedures (Continued)

Advantages and Disadvantages of Local Wound Exploration

Advantages Disadvantages
1. Reported sensitivity and specificity of Excessive fat tissue, dense muscle, or the presence
LWE (performed by general surgeon in of multiple wounds or other injuries can
the emergency department) for compromise LWE
peritoneal violation were both 100
percent.
2. Fast, repeatable, can be performed at Not as useful in exploration of gunshot wounds and
bedside, cheap those produced by thin instruments such as an ice
pick
 Diagnostic Procedures (Continued)

 Diagnostic Laparoscopy
Laparoscopy or thoracoscopy may be a valuable
screening investigation in physiologically non-
compromised patients with penetrating trauma to
detect or exclude peritoneal penetration and/or
diaphragmatic injury.
Laparoscopy may be divided into:
● screening: used to exclude a penetrating injury
with breach
of the peritoneum;
● diagnostic: finding evidence of injury to viscera;
● therapeutic: used to repair the injury
 Treatment

 The management of abdominal trauma varies according to the following factors:

 Mechanism and location of injury
 Hemodynamic and neurologic status of the patient
 Associated injuries
 Institutional resources
 As mentioned earlier, when indications for immediate laparotomy are present, the patient should
immediately be explored in the OR.
 When such indications are not present, the first management decision is whether there is violation
of the peritoneum or retroperitoneum. For anterior abdominal wounds, peritoneal penetration is
the key decision point. This can often be determined by local wound exploration (LWE), but advanced
imaging studies are sensitive and specific when LWE is difficult.
 Indications for Immediate
Laparotomy

 All gunshot wounds

 All eviscerations even with a small tag of
protruding omentum
 Non responders to fluid resuscitation
(hemodynamically unstable patients)
 Stab wounds with significant blood loss and
peritonitis
 Signs of lower extremity ischemia suggestive
of vascular injury.
 Signs of peritonitis
 Hematemesis or gross blood per rectum
Treatment (continued)
 Treatment (continued)

Selective nonoperative management

Selective nonoperative management of patients with abdominal
GSWs may be appropriate for select patients. The following criteria are
necessary for this strategy:
 Patient remains hemodynamically stable throughout their care
 No hollow visceral or major vascular injury exists
 Frequent, careful patient reassessment can be performed and continued
for a minimum of 24 hours
 Rapid transport to the operating room can be accomplished if concerning
clinical signs develop.
Treatment (continued)

 Principles of Trauma Laparotomy:

1. Management of bleeding
2. Quick identification of any serious injury
3. Rapid control of contamination
4. Reconstruction when possible
 Treatment (continued)

Brief description of exploratory laparotomy in trauma

1. Generous midline incision preferred. Self retraining retractor systems and headlights are
invaluable
2. Bleeding control: Scoop free blood and rapidly pack all quadrants. If packing does not
control a bleeding site, this must be controlled as a first priority
3. Contamination control Quickly control bowel content contamination
4. Systematic exploration: Systemeaticallyexplore the entire abdomen, giving priority to
areas of ongoig hemorrhage
A. Liver B. Spleen. C. Stomach D. Right Colon, transverse colon, descending colon, sigmoid
colon, rectum and the small bowel
B. From the ligament of treitz to terminal ileum, looking athe the etire bowel wall and the
mesentery
C. Pancreas, by opening lesser sac (Visualize and palpate)
D. Kocher maneuever to visualize the duodenum with evidence of possible injury
E. Left and right hemiddiahpragms and retroperitoneum H. Pelvic structure including the
bladder
F. I. With penetrating injuries, exploration should on following the track of the weapon or
 Treatment (continued)

 Once the abdomen is opened obvious blood and clot I removed and all four quadrants
are packed with sponges. These sponges are then sequentially removed to localize
sources of bleeding and/or contamination. Once all areas of active haemorrhage are
identifed they can be repacked for temporary control. Additional inflow occlusion can
beaccomplished by clamping the aorta at the diaphragmatic hiatus (Figure 14.26)..
Retroperitoneal haematomas should be left intact if not ruptured and investigated only
once all intra-abdominal catastrophes have been addressed. The major abdominal
vessels are all centrally located and, because of this, all central retroperitoneal
haematomas should be surgically explored. Lateral and pelvic haematomas are more
likely to be caused by non-surgical bleeding or injury to the kidneys, small unnamed
vessels or veins; because of this, lateral and pelvic retroperitoneal haematomas should
only be explored if they are expanding, pulsatile or due to penetrating trauma.
Role of Damage Control Surgery

Defined as tailoring the process according to physiology of patient and doing definitive
surgery later on to prevent physiological exchaustion.
Goal is to prevent patient developing the lethal triad (acidosis, hypothermia, and
coagulopathy)
Stage 1 = Patient Selection (Indications given in next slide)
Stage 2 = Control Hemorrhage and Contamination (alongwith temporary closure of the
abdomen)
Stage 3 = Physiological Resuscitation in the ICU (Correction of body temperature, clotting
profile, electrolyte anomalies, repletion of blood and components, monitoring for ACS)
Stage 4 = Definitive Surgery
Stage 5 = Abdominal Wall reconstruction
Indications for Damage Control
Surgery
Management of Specific Injuries
(Brief)
Management of Specific Injuries
(Continued)

 Management of Stomach
Injuries
Full evaluation of stomach involves examination of its
anterior and posterior walls, which necessitates entry
into the lesser sac.
Hematomas within the wall should be evacuated to rule
out perforation
Followed by control of bleeding and closure with non
absorbable sutures.
Stapler can also be used for this purpose.
Full thickness injuries should be debrided before closure.
Highly destructive injuries may require partial or total
gastrectomy with Bilroth 1 or 2 gastroenterostomy or
Roux-en-Y esophagojejunostomy depending upon extent
of the resection.
Management of Specific Injuries
(Continued)
Management of Specific Injuries
(Continued)
Management of Specific Injuries
(Continued)

Destructive = Grade IV or V, Nondestructive = Grade I, II or III

Management of Specific Injuries
(Continued)
Management of Specific Injuries
(Continued)
Management of Specific Injuries
(Continued)
Management of Other Injuries

 Gallbaldder injuries – usually cholecystectomy

 CBD Injuries – Intraoperative cholangiography and Repair over T-tube
 Great Vessel Injury – Repair or ligation
 Retroperitoneal hematomas – All hematomas (regardless of Zone) should be explored
in penetrating abdominal trauma and injuries managed accordingly.
Thank You