Abdominal injuries

Yoram Klein MD

Introduction

Suture repair of bowel - the 15th century. Routine exploration not employed until

WW I. – mortality 70-75%. WW II – mortality 50%.

Introduction

Diagnostic challenge. Importance of prompt management (?!). Evolution in surgical management:

Damage control. Staged repair.

Colo-rectal repair. Duodenal repair.

Decisions

What is the systemic condition? Is there an abdominal injury? Can the systemic condition be related to

the abdominal injury?

What is the systemic condition?

Oxygenation. Hemodynamic stability. Neurological status.

Is there an abdominal injury?

Mechanism of injury. Physical examination. FAST. Plain X-ray. CT. DPL.

Physical examination

Blunt Hemodynamic

status. Abdominal wall

hematoma. Seat-belt sign. Peritoneal irritation. GI bleeding. Confounding factors.

Penetrating Hemodynamic

status. Location of the

wound. Evisceration. Peritoneal irritation. GI bleeding. Confounding factors.

FASTFocused Assessment Sonography for

Trauma Advantages

Free fluid in the peritoneal or pericardial cavity?

Quick. Bedside. Repeatable.

Disadvantages False sense of

security. Retoperitoneum. Hollow viscous injury Penetrating trauma. User dependant.

Plain X-ray

Blunt CXR. Pelvic.

Penetrating CXR. KUB in GSW.

CT

Blunt The gold standard. Hemodynamic

stability. Normal FAST?

Penetrating RUQ low-energy

missiles. Triple-contrast for

flank and back wounds.

DPL

Blunt Free fluid with no

organ injury in the CT. Patient’s examination unreliable.

Discrepancy between FAST and physical finding.

Penetrating Violation of the

anterior abdominal fascia --- stab wounds.

Emergency laparotomy

Hemodynamic instability and abdominal injury. Hemodynamic instability and positive FAST. Diffuse peritoneal irritation. Significant evisceration. Imaging study suggesting hollow viscous

injury. GI bleeding.

Management of penetrating injuryGSW

85% need surgical repair. Low energy RUQ. Tangential wounds.

Management of penetrating injurystab wounds

Anterior abdomen local wound exploration. Violation of anterior fascia – DPL.Flank and back Triple contrast CT.Left thoraco-abdominal Surgical evaluation of the diaphragm.Right thoraco-abdominal CT.

Management of blunt injury

CT. Free fluid with no organ injury in the CT.

Patient’s examination unreliable --- DPL. If signs of arterial bleeding - angiogram?

Hollow viscous injuries

Diagnostic challenge. Importance of prompt management (?!). Evolution in surgical management:

Damage control. Staged repair.

Colo-rectal repair. Duodenal repair.

Evolution in surgical management

Non-operative management. Damage control. Staged repair. Colo-rectal repair. Duodenal repair.

Non-operative treatment

No indication for emergency surgery.

Spleen – OPSI in pediatric surgery.

Liver – non bleeding CT diagnosed injuries.

Penetrating injuries – good outcome with stable patients and unavailable OR.

Damage control

Physiological failure

On-going coagulopathy

acidosis hypothermia

Damage control

Bleeding control. Contamination

control. Temporary

abdominal closure.

Damage control

Bleeding control. Contamination

control. Temporary

abdominal closure.

Damage control

Bleeding control. Contamination

control. Temporary

abdominal closure.

Surgical approach

Hemorrhage control. Primary exploration and temporary control of

spillage. Thorough exploration and definitive spillage

control. Irrigation.------------------------------------------ Reconstitute continuity. Definitive abdominal closure.

???