EMERGENCY SURGERY for

BLUNT ABDOMINAL TRAUMA

byGOUDA ELLABBAN

Introduction

• Majority of preventable trauma deaths due to unrecognized intra-abdominal haemorrage(West JC, Trunkey DD and Lim RC: System of trauma care: a study of two counties. Arch Surg 1979;114:455)

• 6% of all patients with blunt abdominal trauma will require laparotomy

Mechanism of Injury

• Compression/crushing injuries to hollow viscus

• Deceleration injuries to spleen and liver

• Motor vehicle trauma• Assaults• Falls

Risk factors for significant abdominal injuries

• Major mechanism of injury• History of shock

• Confused• Unexplained blood loss• Abdominal signs - distension, contusion,

peritonitis

Risk factors for significant abdominal injuries

• Other injuries - major chest injury, pelvic fracture

• Haematuria• Significant base deficit

Diagnostic Modalities

• Accuracy of physical examination = 65% (Powel DC, Bivins BA and Bell RM: Diagnostic peritoneal lavage. Surg

Gynecol Obstet, 1982; 155:257)

• Nontherapeutic laparotomy - not necessarily harmless (Prospective study of unneccessary laparotomies ini 254 trauma patients - 41% delevoped complications inc atelectasis, hypotension, pneumothorax, prolonged ileus, pneumonia, wound infection, SBO and UTI : Renz and Feliciano, J Trauma 1995)

Diagnostic Peritoneal Lavage

ADVANTAGE• Can be performed

quickly• Few complications• >90% sensitivity and

specifictiy for detection of abdominal blood

DISADVANTAGE• Does not identify organ

injured• Miss retroperitoneal

injury• False positive from

pelvic fracture• Nontherapeutic

laparotomies

Abdominal CT Scan

ADVANTAGE• Can identify organ

injured and grade severity of injury

• Detects both retro and intraabdominal injuries

• Can estimate intra-abdominal blood loss

• F/U with serial scans

DISADVANTAGE• Need to transfer patient

for CT• Time required • Expensive• Potential for allergic

contrast reactions and aspiration of contrast

Abdominal CT Scan

ADVANTAGE DISADVANTAGE• Insensitive for

intestinal injuries, early pancreatic injury

Focused Abdomnial Sonography(FAST)

ADVANTAGE• Can be performed at

bedside• Quick • Easily repeatable• Noninvasive• Relatively inexpensive

DISADVANTAGE• Insensitive for injuries

that do not produce peritoneal fluid

• Accuracy depends on experience of sonographer

Laparoscopy

• Limited role in blunt abdominal injury• More useful for penetrating abdominal injury

where there is a question of peritoneal perforation or diagphragmatic injury

• Requires GA and risks of tension pneumothorax and air embolus

Investigation

• Unstable patientBedside ultrasound - FASTIf FAST equivocal or unavailable - DPL

• Stable patientCT scan of abdomen with oral and IV contrast

TRAUMA LAPAROTOMY

• Indications:– Unstable patient with obvious intra-abdominal

haemorrhage– Perforated viscus

Damage Control Surgery - Laparostomy

• Technique:Clamping of major bleeding vesselsPacking of bleeding solid organ injuriesStapling/Dividing bowel injuries without reconstructionTemporary closure with mesh/plastic drape

Damage Control Surgery - Laparostomy

• Planned reoperation when hypothermia, coagulopathy and acidosis corrected

Often when patient is returned to OR - bleeding has already stopped, only need irrigation, debridement and formal closure

Damage Control Surgery - Laparostomy

Indications:• Avoidance of irreversible physiologic insult in

a hypothermic, coagulopathic patient by rapid termination of procedure

• Inability to obtain direct haemostasis necessisating indirect control of bleeding by packing and balloon tamponade

• Massive visceral oedema precluding formal closure of abdomen

Laparotomy

• Midline abdominal incisionCan be extended superiorly or inferiorly

• If gross blood encountered, 4 quadrants are rapidly packed. Patient stabilized by anaesthetic team

• Manual compression of abdominal aorta at hiatus for additional BP control

Laparotomy

• Once stable, packs are systematically removed. Aim to uncover most likely injury last

• Bleeding sites controlled with clamps, sutures or repacking

• Gross contamination from GI tract controlled with sutures or staples

Laparotomy

• Once haemorrhage and contamination controlled, systematic inspection is performed:Liver & spleenStomach - ant & post wallEntire large & small bowel(inc duodenum)Diaphragm & gastrohepatic ligamentPancreas - Head, body & tailCentral retroperitoneal haematoma

Nonoperative Management

• Liver injuryInitially tried on blunt liver injuriesSuccess predected by stability of patient and independent on degree of injuries>98% success

• Spleen injuryChildren >90% successAdults with mild-moderate spleen injuries

Summary

• Be aware of possibility of intraabdominal injury in trauma patients

• If unstable - FAST or DPL• If stable - CT scan of abdomen• Systematic approach to laparotomy • Damage control surgery if cold,

coagulopathic and acidotic

Reference

• Knudson F: Blunt abdominal trauma. Definitive Surgical Trauma Care(DSTC) course manual 2000; F5:1-9

Thank you !