Abdominal injuries

Klinika Chirurgii Urazowej GralKlinika Chirurgii Urazowej Gralaa

Abdominal injuriesAbdominal injuries

TypesTypes

DiagnosisDiagnosis

TreatmentTreatment


Types of abd traumaTypes of abd trauma

BluntBlunt Direct blowDirect blow DecelerationDeceleration

Penetrating: Penetrating: GSWGSW Stab woundsStab wounds ImpalementImpalement

Often thoracoabdominalOften thoracoabdominal




DiagnosisDiagnosis Determine the presence of abd injury (history, Determine the presence of abd injury (history,

physical examination, USG, CT, DPL, X-ray) – physical examination, USG, CT, DPL, X-ray) – serial examinations indicatedserial examinations indicated

Altered consciousness Altered consciousness → → major confounding major confounding factor for PEfactor for PE

PE: seat belt sign (ecchymotic area at the lower PE: seat belt sign (ecchymotic area at the lower abd. wall – bladder and bowel perforation, L abd. wall – bladder and bowel perforation, L distraction [chance] fr.), Cullen`s sign distraction [chance] fr.), Cullen`s sign (periumbilical ecchymosis indicative of (periumbilical ecchymosis indicative of intraperitoneal hemorrhage), Grey Turner sign intraperitoneal hemorrhage), Grey Turner sign (flank ecchymoses indicative of retroperitoneal (flank ecchymoses indicative of retroperitoneal hemorrhage)hemorrhage)

Indications for laparotomy: Indications for laparotomy: is it the cause of hypotension?is it the cause of hypotension?

is peritonitis present?is peritonitis present? Posible nonoperative treatment of diagnosed Posible nonoperative treatment of diagnosed

intraabdominal injuriesintraabdominal injuries


Diagnosic peritoneal Diagnosic peritoneal lavage – DPLlavage – DPL

OpenOpen and blunt technique: and blunt technique:decompress UB and stomachdecompress UB and stomachgross blood gross blood laparotomy laparotomy1l warmed normal saline 1l warmed normal saline gentle gentle agitation of abd. agitation of abd. wait 10min. wait 10min. drain drain fluid fluid macroscopic evaluation macroscopic evaluation ev. lab ev. lab testing (positive > 100th RBC/mmtesting (positive > 100th RBC/mm33, 500 , 500 WBCs/mmWBCs/mm33))

Interpretation in context of clinical Interpretation in context of clinical condition (positive DPL does not mandate condition (positive DPL does not mandate laparotomy in stable patient)laparotomy in stable patient)

In pelvic fractures supraumbilical entry, In pelvic fractures supraumbilical entry, safe distance from postoperative scarssafe distance from postoperative scars

Complications: false positive, bowel Complications: false positive, bowel perforation, UB perforation, perforation, UB perforation, haemorrhage, wound infectionhaemorrhage, wound infection

Contraindications: advanced pregnancy, Contraindications: advanced pregnancy, clotting disorders, obvious indications to clotting disorders, obvious indications to laparotomy, planned FASTlaparotomy, planned FAST


ER US


FASTFAST - - Focused Assesement Focused Assesement with Sonography for Trauma with Sonography for Trauma

LLimited ultrasound examination imited ultrasound examination directed solely at identifying the directed solely at identifying the presence of free intraperitoneal or presence of free intraperitoneal or pericardial fluidpericardial fluid

In the context of traumatic injury, In the context of traumatic injury, free fluid is usually due to free fluid is usually due to haemorrhage and contributes to the haemorrhage and contributes to the assessment of the circulationassessment of the circulation


FASTFAST - - Focused Assesement Focused Assesement with Sonography for Traumawith Sonography for Trauma

Perihepatic & hepato-renal space Perihepatic & hepato-renal space Perisplenic Perisplenic Pelvis Pelvis Pericardium Pericardium Pleural spacePleural space


FASTFAST - - Focused Assesement with Focused Assesement with Sonography for TraumaSonography for Trauma

hhaemodynamic instability and free intra-peritoneal fluid aemodynamic instability and free intra-peritoneal fluid mandates a laparotomy for intra-abdominal haemorrhage. mandates a laparotomy for intra-abdominal haemorrhage.

iin the presence of haemorrhagic shock but a negative FAST n the presence of haemorrhagic shock but a negative FAST examination, other sites of haemorrhage must be sought examination, other sites of haemorrhage must be sought and controlledand controlled t thoracic haemorrhage may require horacic haemorrhage may require thoracotomy, pelvic haemorrhage angiographic thoracotomy, pelvic haemorrhage angiographic embolisationembolisation; r; retroperitoneal haemorrhage from vascular etroperitoneal haemorrhage from vascular injury remains a possibility with a negative FAST.injury remains a possibility with a negative FAST.

sserial FAST examinations may be required. erial FAST examinations may be required. positive examination relies on the presence of free

intraperitoneal fluid, detects a minimum of 200 mL of fluid; injuries not associated with hemoperitoneum may be missed (not reliable for excluding hollow visceral injury).

cannot be used to reliably grade solid organ injuries - detection of solid organ injury with FAST - 41% (consider CE (consider CE US).US).

(in the hemodynamically stable patient a follow-up CT scan should be obtained if nonoperative management is contemplated). more cost-effective when compared with DPL or CT.


Abd CT


Abd. CTAbd. CT recommended for the evaluation of hemodynamically

stable patients with:equivocal findings on PEassociated neurologic injurymultiple extra-abdominal injuries

under these circumstances, patients with a negative CT scan should be admitted for observation

is the diagnostic modality of choice for nonoperative management of solid visceral injuries

in hemodynamically stable patients, DPL and CT scanning are complementary diagnostic modalities

notoriously inadequate for the diagnosis of mesenteric injuries and hollow visceral injuries (DPL is a more appropriate test)

unique ability to detect clinically unsuspected injuries and ability to evaluate the retroperitoneal structures

requires a cooperative, hemodynamically stable patient that must be transported out of the trauma resuscitation area to the radiographic suite, need for specialized technicians and the availability of a radiologist for interpretation


CT 2006CT 2006 One abdominal CT is the equivalent of 500 chest x-One abdominal CT is the equivalent of 500 chest x-

rays and will increase the lifetime risk for cancer by rays and will increase the lifetime risk for cancer by 1 in 2000. 1 in 2000.

Oral contrast is not helpful in liver or spleen Oral contrast is not helpful in liver or spleen injuries, with free fluid or bony injuries. injuries, with free fluid or bony injuries.

Oral contrast is not helpful in detecting hollow Oral contrast is not helpful in detecting hollow viscus injuries or duodenal injuries. Instead, adds viscus injuries or duodenal injuries. Instead, adds costs, time delay, and the risk for aspiration.costs, time delay, and the risk for aspiration.

Additional intangible costs include the risks Additional intangible costs include the risks associated with contrast, electrolytes to check for associated with contrast, electrolytes to check for renal function, longer time in the ED (although CT renal function, longer time in the ED (although CT scanning does save time in complete spinal scanning does save time in complete spinal evaluations), and the cost of working up incidental evaluations), and the cost of working up incidental findings which may in turn lead to more radiation findings which may in turn lead to more radiation exposure.exposure.


Special diagnostic studiesSpecial diagnostic studies

CategoryCategory USUS CTCT DPLDPL RapidRapid ++++ ++ PortablePortable ++++ ++ Non-invasiveNon-invasive ++++ ++ IIntegration in resuscitationntegration in resuscitation ++++ ++ SensitivitySensitivity ++ ++++ SpecificitySpecificity ++ ++++ QuantitativeQuantitative ++ ++++ ++ Injury localisationInjury localisation ++ ++++ Evaluation of retroperitoneum+Evaluation of retroperitoneum+ ++++ Evaluation of pericardiumEvaluation of pericardium ++++ ++ Ease of interpretationEase of interpretation ++ ++++ Ease of repetitionEase of repetition ++++ ++ Radiation exposureRadiation exposure ++++ ++++ Patient acceptancePatient acceptance ++++ ++ CostCost ++++ ++


Indications for laparotomyIndications for laparotomy

BAT with positive DPL, US, CTBAT with positive DPL, US, CT BAT with recurrent hypotension despite adequate BAT with recurrent hypotension despite adequate

resuscitationresuscitation PeritonitisPeritonitis PAT with hypotension, or violation of peritoneum PAT with hypotension, or violation of peritoneum

esp. in patients with altered consciousnessesp. in patients with altered consciousness PAT with bleeding from the rectum, GU tract or PAT with bleeding from the rectum, GU tract or

stomachstomach GSW (except selected flank wounds)GSW (except selected flank wounds) EviscerationEvisceration On X-ray: retroperitoneal free air, diaphragmatic inj.On X-ray: retroperitoneal free air, diaphragmatic inj.

Be overaggressiveBe overaggressive



Diaphragmatic injuriesDiaphragmatic injuries

Difficult to estabilish the diagnosis (CT, DPL, US, Difficult to estabilish the diagnosis (CT, DPL, US, chest Xray – miss 30%)chest Xray – miss 30%)

Pysical exam: false neg result in 20-45%Pysical exam: false neg result in 20-45%Explorative laparotomyExplorative laparotomyExplorative thoracoscopy?Explorative thoracoscopy? Poor healing (chronic hernias): constant motion, Poor healing (chronic hernias): constant motion,

relative thinness, pressure gradient (intrathoracic relative thinness, pressure gradient (intrathoracic transposition of abd viscera)transposition of abd viscera)

Potentially catastrophic consequences (usual Potentially catastrophic consequences (usual delay up to 8 years): strangulation of abd viscera delay up to 8 years): strangulation of abd viscera through the defect (20-50% mortality rate)through the defect (20-50% mortality rate)

Usually posterolateral left diaphragmUsually posterolateral left diaphragm Chest X-ray: elevation, blurring, hemothorax, abn. Chest X-ray: elevation, blurring, hemothorax, abn.

gas shadow obscuring the diaphragmgas shadow obscuring the diaphragm


Rupture of the left diaphragmRupture of the left diaphragm



Rupture of the right diaphragmRupture of the right diaphragm


SpleenSpleen Receives 5% of cardiac output (splenic a., short gastric aa.)Receives 5% of cardiac output (splenic a., short gastric aa.) Accesory s. (between stomach and pancreas) 20%Accesory s. (between stomach and pancreas) 20% Functions: removal of aged and deformed RBCs, platelet Functions: removal of aged and deformed RBCs, platelet

storage, phagocytosis of bacteria (25% of bodys fixed storage, phagocytosis of bacteria (25% of bodys fixed tissue macrophages), production of IgM (main source) and tissue macrophages), production of IgM (main source) and IgG, opsonins (tuftsin, properdin)IgG, opsonins (tuftsin, properdin)

Postsplenectomy complications: atelectasis (drainage, Postsplenectomy complications: atelectasis (drainage, pulmonary toilet), thrombocytosis (up to 3mill, aspirin pulmonary toilet), thrombocytosis (up to 3mill, aspirin above 1), granulocytosis, subphrenic abscess, pancreatitis, above 1), granulocytosis, subphrenic abscess, pancreatitis, pancreatic fistula, gastric perforationpancreatic fistula, gastric perforation

OPSI – lifetime risk, majority within first 2ys (flulike OPSI – lifetime risk, majority within first 2ys (flulike symptoms rapidly progressing to fulminant sepsis with symptoms rapidly progressing to fulminant sepsis with consumptive coagulopathy and death within 12-48h)consumptive coagulopathy and death within 12-48h)

mortality 50-60%mortality 50-60%encapsulated bacteria (Str. pneum.,Neisseria encapsulated bacteria (Str. pneum.,Neisseria mening.,H.infl.) are causative – post op. immunizationmening.,H.infl.) are causative – post op. immunizationloss of splenic reticuloendothelial cells (clear particulate loss of splenic reticuloendothelial cells (clear particulate antigen in the absence of antibody), opsonin synthesis, antigen in the absence of antibody), opsonin synthesis, decrease in lymphocyte T4-T8 ratio decrease in lymphocyte T4-T8 ratio → → limited responce to limited responce to infectioninfectionsupportive management, high dose 3rd gen. cephalosporinssupportive management, high dose 3rd gen. cephalosporins


Splenic injury CTSplenic injury CT


Mesh splenorrhaphyMesh splenorrhaphy


Splenic laceration


Liver traumaLiver trauma

Most commonly injured organ (possible massive Most commonly injured organ (possible massive haemorrhage)haemorrhage)

Initial hemostasis: mobilisation, bimanual Initial hemostasis: mobilisation, bimanual compression, Pringle maneuver (oclusion compression, Pringle maneuver (oclusion time<45min.) time<45min.) → → nono↓ → ↓ → retrohepatic v. cava or retrohepatic v. cava or hepatic v. inj. hepatic v. inj. → → atriocaval shunt (Schrock shunt), atriocaval shunt (Schrock shunt), Folley catheter, perihepatic packing Folley catheter, perihepatic packing

Definitive hemostasis: electocautery, parenchymal Definitive hemostasis: electocautery, parenchymal sutures (horisontal mattress stitches), hepatotomy sutures (horisontal mattress stitches), hepatotomy with selective ligation (finger fracture technique), with selective ligation (finger fracture technique), topical hemostatic agents, omental packing, topical hemostatic agents, omental packing, resectional debridement, hepatic artery ligation resectional debridement, hepatic artery ligation

Damage controlDamage control DrainageDrainage Blunt trauma: nonoperative approach (observation, Blunt trauma: nonoperative approach (observation,

selective embolisation).selective embolisation).


Posttraumatic bilomaPosttraumatic biloma





Liver GSWLiver GSW


Mesh hepatorraphyMesh hepatorraphy


Femoro-caval Femoro-caval (cavo-caval) (cavo-caval)

shuntingshunting


DuodenumDuodenum Usually unrestrained driver-frontal impact, Usually unrestrained driver-frontal impact,

direct blow (eg.bike handlebars)direct blow (eg.bike handlebars) Bloody gastic aspirate, retroperitoneal air, Bloody gastic aspirate, retroperitoneal air,

leftward scoliosis and blurring of psoas leftward scoliosis and blurring of psoas schadow on X-ray, contrast CTschadow on X-ray, contrast CT

Slow evolution of abd symptoms: back or Slow evolution of abd symptoms: back or flank painflank pain

LaparotomyLaparotomy Kocher maneuver, transverse, double layerKocher maneuver, transverse, double layer closureclosure Whipple procedure in d. devascularisation Whipple procedure in d. devascularisation

with complex bile duct and pancreatic with complex bile duct and pancreatic head injury (high complication rate)head injury (high complication rate)


Duodenal rupture Duodenal rupture (750cc blood in ng tube,>50% circumferential tear)(750cc blood in ng tube,>50% circumferential tear)


Duodenal acces, incision of the Duodenal acces, incision of the lig. of Treitzlig. of Treitz


PancreasPancreas

In 0.2% of BAT - direct epigastric blow (compression against In 0.2% of BAT - direct epigastric blow (compression against VC) and 1.1% of PAT. Penetrating pancreatic injury is VC) and 1.1% of PAT. Penetrating pancreatic injury is usually diagnosed at laparotomy and carries a high usually diagnosed at laparotomy and carries a high mortality because of associated injuries of neighboring mortality because of associated injuries of neighboring major blood vessels. Blunt pancreatic injury is complicated major blood vessels. Blunt pancreatic injury is complicated by difficulty in establishing the diagnosis, which can lead to by difficulty in establishing the diagnosis, which can lead to delay in diagnosis and increased morbidity.delay in diagnosis and increased morbidity.

Serum amylase levels nondiagnosticSerum amylase levels nondiagnostic DPL, US, CT often nondiagnosticDPL, US, CT often nondiagnostic ERCPERCP Celiotomy – associated stomach and liver involvement, Celiotomy – associated stomach and liver involvement,

Kocher maneuver and gastrocolic and gastrohepatic Kocher maneuver and gastrocolic and gastrohepatic ligament dissectionligament dissection

Determine presence of ductal injury: L to s. mesenteric Determine presence of ductal injury: L to s. mesenteric vessels vessels → → distal pancreatectomy with splenctomy, R → distal pancreatectomy with splenctomy, R → closure of proximal end + distal drainage (Roux-en-Y closure of proximal end + distal drainage (Roux-en-Y pancreaticojejunostomypancreaticojejunostomy

Extensive injury to the head of pancreas, duodenum, biliary Extensive injury to the head of pancreas, duodenum, biliary tree tree → → pancreaticoduodenectomy (Whipple procedure)pancreaticoduodenectomy (Whipple procedure)

Parenchymal lesions → drainageParenchymal lesions → drainage


Pancreatic injury BAT CTPancreatic injury BAT CT


Acces to the pancreasAcces to the pancreas


Small bowelSmall bowel

Seat belts, direct blow or Seat belts, direct blow or penetrating penetrating traumatrauma

Minimal bleedingMinimal bleeding Peritoneal signs (intoxicated or deeply Peritoneal signs (intoxicated or deeply

unconsious patients – absent)unconsious patients – absent) US, CT nondiagnosticUS, CT nondiagnostic Diagnosis - DPL and laparotomy Diagnosis - DPL and laparotomy Primary repair or segmental resection and Primary repair or segmental resection and

anastomosis, close mesenteric defectsanastomosis, close mesenteric defects


Blunt bowel injuryBlunt bowel injury


Blunt bowel injuryBlunt bowel injury


Large bowel injuriesLarge bowel injuries

No physical findings or imaging modalities, no clinically useful combination

of findings that would reliably predict colonic injury.

ColonColon1.1. Usually penetrating traumaUsually penetrating trauma Diagnosis at laparotomy (although BCI is rare, it Diagnosis at laparotomy (although BCI is rare, it

ranks 4th among injuries found at laparotomy in ranks 4th among injuries found at laparotomy in BAT and is an independent predictor of hospital BAT and is an independent predictor of hospital and ICU LOS)and ICU LOS).

Debridement, drainage, wide spectrum Debridement, drainage, wide spectrum antibiotic + : primary 2 layer closure, excision, antibiotic + : primary 2 layer closure, excision, diverting colostomy and Hartmann`s pouch diverting colostomy and Hartmann`s pouch considered in long operative delay, severe fecal considered in long operative delay, severe fecal contamination, large transfusion requirements contamination, large transfusion requirements (>4U), prolonged shock, high velocity GSW(>4U), prolonged shock, high velocity GSW

RectumRectum1.1. Historic 3Ds: distal rectal washout, diverting Historic 3Ds: distal rectal washout, diverting

colostomy, presacral drainage – battlefield colostomy, presacral drainage – battlefield injuriesinjuries

2.2. Civilian trauma: primary repair, colostomy Civilian trauma: primary repair, colostomy



RPHRPH Penetrating trauma – require exploration Penetrating trauma – require exploration

(uncontained)(uncontained)temoporary control: packing, cross clamping of temoporary control: packing, cross clamping of supraceliac aortasupraceliac aortagain acces: division of gastrohepatic lig., L medial gain acces: division of gastrohepatic lig., L medial visceral rotation (Mattox maneuver), R visceral visceral rotation (Mattox maneuver), R visceral rotation (Catell maneuver) with Kocher maneuverrotation (Catell maneuver) with Kocher maneuverdirect repair, rarely graftingdirect repair, rarely grafting

Blunt trauma – CT, US or laparotomy for diagnosisBlunt trauma – CT, US or laparotomy for diagnosismanagement determined by location and stabilitymanagement determined by location and stability

Z I RPH (supramesocolic) – Mattox m.Z I RPH (supramesocolic) – Mattox m.Z II RPH (flank) – unless pulsatile, expanding or Z II RPH (flank) – unless pulsatile, expanding or ruptured do not exploreruptured do not exploreZ III RPH (pelvic) – as above, packing or Z III RPH (pelvic) – as above, packing or angiographic embolisation if requiredangiographic embolisation if required


Cattel maneuverCattel maneuver


Mattox maneuverMattox maneuver

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Abdominal injuries

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