Diagnosis and treatment of intraabdominal

injuries

Abdominal Trauma

Alhmoud FaiezConsultant Surgeon

Albashir Hospital. MOH

Amman - Jordan

Thoracoabdominal area: Transverse nipple line to costal marginAnterior abdomen: Costal margin to groin crease to anterior axillary lines bilaterallyFlank area: Between anterior and posterior axillary lines from 6th intercostals space to iliac crest. Back: Medial to posterior axillary lines, tip of scapula to iliac crests & gluteal skin crease inferiorly Torso: All the above

Where is the abdomen?External Anatomy

Any penetrating injury to any of these areas, or that may have traversed this volume, should be considered as a potential abdominal injury, and evaluated as such.Special Care• Wounds to thoracoabdominal

junction zone• Flank or back wound• Wound to buttock or perineum

Thoracoabdominal area

Cardiac Box

Mediastinum

The Abdomen

The external appearance of wound doesn’t determine the extent of

internal injuries

Classification of injuries Blunt trauma Penetrating

trauma Iatrogenic trauma

Blunt●Speed●Point of

impact● Involvement●Safety

devices●Position●Ejection

When should you suspect intra-

abdominal injury?Penetrating●Weapon●Distance●Number and location of wounds

Diagnosis and treatment of intraabdominal injuries are essential to avoid

preventable morbidity and death.

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 injury tend to fall into 4 major categories:

Presentation Injury Type Management priority

Pulseless Major vascular injury Emergency laparotomyConsider ED thoracotomy

Hemodynamically unstable

Hemodynamically stable

Vascular and/or solid organ injury AND/ORHemorrhage from other sites

solid organ injury Hemorrhage<750cc

Identify & control hemorrhage

ResuscitationGrading

Hemodynamically Normal

Hollow viscus injuryPancreas or renal

Identify presence of gastrointestinal, diaphragmatic or retroperitoneal injury

First: recognize presence of shock or intraabdominal bleeding Second: start resuscitative measures for shock / bleeding Third: determine if abdomen is source for shock or bleeding Fourth: determine if emergency laparotomy is needed Fifth: complete secondary survey, lab, and radiographic studies to determine if “occult” abdominal injury is present Sixth: conduct frequent reassessments

Estimation of blood loss

Base deficit & lactate

-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

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.

Resuscitation

Damage control resuscitation

It’s an alternative resuscitation approach to hemorrhagic shock which involves:1.Rapid control of surgical bleeding2.Early and increased use of red blood cells, plasma and platelets in a 1:1:1 ratio3.Limitation of excessive crystalloid use4.Prevention and treatment of hypothermia, hypocalcemia and acidosis5. 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 diagnosisS.A.M.P.L.ES: Symptoms: Pain, vomiting, hematuria, hematochezia, dyspnea, respiratory distress…..A: AllergiesM: MedicationsL: Last mealE: Events: Mechanism of injury is important factor

Physical ExaminationHow 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

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 Examination

Physical Exam: Eponyms

Grey-Turner sign: Bluish discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.

Cullen sign: Bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage.

Kehr sign: shoulder pain while supine; caused by diaphragmatic irritation (splenic injury, free air, intra-abdominal bleeding)

Balance sign: Dull percussion in LUQ. Sign of splenic injury; blood accumulating in subcapsular or extracapsular spleen.

Seat Belt Sign

Fox sign

Grey-Turner sign

Cullen sign

Kehr sign

Balance sign

Labia and Scrotum

London’s 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.Perisplenic4. Pelvis (Pouch of Douglas/rectovesical pouch)sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid

(E-FAST): Add thoracic windows to look

for pneumothorax. Sensitivity 59%, specificity up to 99% for PTX

The larger the hemoperitoneum, the higher the sensitivity. So sensitivity increases for clinically significant hemoperitoneum.

How much fluid can FAST detect?250 cc total100 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 -Time consuming -Relatively expensive -Intravenous iodinated contrast risk -Poor for bowel and pancreas

Indications; Blunt trauma Hemodynamically stable

patient Normal or unreliable

physical examination

Contraindications Clear indication for

exploratory laparotomy Hemodynamically unstable

patient 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 DPLAbsolute :

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 CTDOCUMENTS: BLEEDING FLUID ORGANBP STATUS: LOW LOW NORMALSENSITIVITY: 98% 82% -97% 92%-98%SPECTIFITY: LOW(MID80) (MID 90) (HIGH 9O)DISADVANTAGES:Invasive Op. depended Cost & time

Local Wound ExplorationA 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 prioritiesThe indications for exploratory laparotomy are: Either…….Clinicala. Obvious peritoneal signs on physical examinationb. Hypotension with a distended abdomen c. Abdominal GSW with peritoneal penetrationd. Abdominal stab wound with evisceration, hypotension, or peritonitisOr………Paraclinicala. Positive FAST with hemodynamic instability or DPLb. 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 hemorrhageA. Liver B. Spleen C. StomachD. 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 mesenteryE. Pancreas, by opening lesser sac (visualize and palpate)F. Kocher maneuver to visualize the duodenum, with evidence of possible injuryG. Left and right hemidiaphragms and retroperitoneumH. Pelvic structures, including the bladderI. 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 the injury mechanism is penetrating or blunt

• An exception to the rule is a retroperitoneal hematoma.

• Explore all retroperitoneal hematomas caused by penetrating injury.

Specific Organs Trauma: 1.Peritoneal 2.Retroperitoneal 3.Diaphragm

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

Cl. Examination: • Chest pain and shortness of breath• Scaphoid abdomen• Bowel sounds on auscultation of the

hemithoraxPlain radiography: • Hollow viscus noted in the left hemithorax• Nasogastric tube in the left hemithorax

Diagnostic modalities

FAST examination: Unreliable DPL: Inconclusive; high false-negative CT scan: Inconclusive Laparoscopy: The diagnostic modality of choice

• 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

Treatment

2.Stomach• More common in

penetrating trauma than blunt & it’s about 10% of penetrating injuries of the abdomen

Diagnosis:■ Physical examination– Epigastric tenderness– Peritoneal signs– Bloody gastric aspirate ■ Plain radiography in <50% –Free air under the diaphragm

■ FAST examination– Unreliable

■ DPL• RBCs• WBCs• Gross contamination■ CT scan– Pneumoperitoneum

■ Laparoscopy– 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 abdominal wall seat-belt contusion or fracture of the lumbar spine.

• Small-bowel injury is often not diagnosed on initial presentation because the patient is less likely to have peritonitis on initial examination.

• This delay contributes significantly to morbidity and mortality.

• CT has a significant false negative rate in the diagnosis of small-bowel injury.

• CT findings in small-bowel injury include:• Fluid collections without solid viscus injury

• Bowel wall thickening• Mesenteric infiltration• Free intraperitoneal air• Oral contrast extravasation

Small Intestine Treatment is operative

1.Administer preoperative antibiotics - Laparotomy2.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.

Current operative options include • Primary repair of the injury, • Resection and anastomosis, and • Colostomy..

The guidelines for primary repair include • Minimal fecal spillage, • No shock (defined as systolic blood pressure <90 mmHg), • Minimal associated intraabdominal injuries, • <8-hour delay in diagnosis and treatment, and • <1-L blood transfusion.

Traditional contraindications to primary repair include• 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;

Colon and rectumTreatment is operative

If a primary repair cannot be performed safely for anatomic reasons (bowel wall edema, vascular compromise), a colostomy may be a safer option.

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

RectumIntraperitoneal or Extraperitoneal

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

• 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

• 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.

• 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.

Duodenal injury Treatment for perforation

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.

• 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

• 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 in Children

• 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%.

Pancreatic injuryOutcome

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

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

Liver TreatmentFor 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.

• 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 embolization.

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

Liver trauma Complications

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…TreatmentThe 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• 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

Mobilization of the spleen

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

Bladder rupture can be: • Extraperitoneal: is most commonly associated with fracture of the pelvis • Intraperitoneal: is often the result of a direct blow to the bladder or a sudden deceleration

Rupture of the bladder

• For extraperitoneal rupture(Pelvic fracture) –Suprapubic cystostomy;(Cystofix). If the rupture is large, place a drain• For intraperitoneal rupture(Seatbelt injury) – Close the rupture and a large urethral catheter or a (Cystofix); if the rupture is 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 Control Surgery’ has yet to reach twenty years of use as concept for the treatment of exsanguinating truncal trauma patients & has become model for emergent, life threatening surgical conditions incapable of tolerating traditional methods.

PRINCIPLES are: • Control hemorrhage with packing• Identification of injury • Prevention and control

contamination with temporary closure

• Avoid further injury• Resuscitation in the ICU• Re-exploration and definitive repair

once normal physiology has been restored

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 ?

WHEN TO INSTITUTE ?

Before: ER → OR → DEATH

Now: ER→OR → ICU→OR→ICU

APPROACH

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)

Initial Laparotomy in DCS

Abdominal Compartment

SyndromeDefinition“The adverse physiological consequences

ofan 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:

causesCauses of raised intra-abdominal pressure (IAP)

Retroperitoneal Intraperitoneal

Oedema in necrotising pancreatitis

Haemorrhage

Pelvic haematoma Visceral oedema

Retroperitoneal haematoma

Abdominal packing

Bleeding after aortic surgery

Bowel dilatation

Oedema related to resuscitation

Mesenteric venous obstructionPneumoperitoneum

Acute ascites

• Major trauma• Damage control surgery• Laparotomy for bleeding, ischaemia etc• Re-laparotomy for postoperative complications

• Massive volume resuscitation

Abdominal Compartment Syndrome:

At risk patients

Abdominal Compartment Syndrome

Clinical features• Abdominal distension• ELEVATED IAP• Consequent organ dysfunctionImportance• Decompression can reverse abnormal physiology

• Probable fatal progression if left untreatedEffects of intra-abdominal hypertension (IAH)Gut and hepatic effects Renal effectsCardiovascular effects Respiratory effectsCNS Abdominal wall

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

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

“Failure to promptly recognize and treat simple life-threatening injuries is the tragedy of trauma, not the inability to handle the catastrophic or complicated injury.”(F.William Blaisdell)

GOOD JUDGMENT COMES FROM EXPERIENCE

EXPERIENCE COMES FROM BAD JUDGMENT