F. Al-Mashat

Dep of Surgery

Kauh

BOWEL INJURY

TYPES :

1. Blunt

2. Penetrating: Stab, Gunshot

3. Operative

Mechanism:

1. Crushing: Compression 2. Shearing: Sudden Deceleration 3. Bursting: Abdominal Pressure

Causes:

1. Motor – Vehicle: 75%

2. High – Speed Vehicular

3. Fall from Heights

4. Seat Belt

Unrecognized : frequent cause of preventable death

Symptoms and Signs:

Unreliable

Often Masked:1. Head Injury 2. Major Fractures3. Alcohol

Signs:

1. Echymosis & Abrasions 2. Tender ribs

3. Peritonitis

a. Tenderness and Guarding : 75%

b. Rebound and Rigidity: 28%

4. Pelvic Fracture

5. DRE

6. Urethral blood

7. Tests, Perineum , Vagina

Investigations:1. CBC

2. U&E’s

3. LFT’s

4. Amylase

5. Clotting Profile

6. ABG

7. Urinalysis

8. CXR : A-P

9. KUB

10. DPL : 95 % Accurate

11. Contrast

12. CT

13. U/S

14. IVU /Contrast CT

15. Double – Contrast CT

16. Aortography : Embolization

 The most frequently involved in penetrating (90%)

The 3rd in blunt

Penetrating: Gunshot: > 80%

Stab: 30%

Occurs in 5-15% of blunt

Small Bowel Injuries

Penetrating:

1. History 2. Examination

Not Sufficient

Blunt :“High Index of Suspicion”

Physical signs: Non Specific 1. associated injury2. Alcohol 3. Neutral PH & bacteria – minimal

inflammation

Delay

Laparotomy: 1. Four: Quadrant Survey

2. Control Enteric Contamination

3. Exploration ??

1. Haematoma & Laceration : Lembent, Transverse

2. Mural haematoma <1cm: Inversion

3. Small perforation : Close transverse

4. Adjacent perforations:divide, close transverse

5. Resection: A. Enterroraphy ½ diameter

B. Multiple injuries

C. Devascularized

Single, Double, Stapler

High Bacteria in terminal S. Bowel: repair in a distal to proximal fashion

Mesentry

Haematoma & Lacerations: >2cm, expanding, uncontained, near root mesentomy

Lesser Sac

Proximal Control Root Mesentry

Mattox

Evacuation

Ligation/SMA repair – saphenous vein/ graft

Second look 24H

Injury distal SMA

Bowel Resection +

Enteroenterostomy

Colon Injuries

• Majority: Penetrating

• Mortality: < 5%

Risk Factors :

• Shock: Sustained hypotensionmortality significantly

• Duration from injury to surgery morbidity not up to 12 H

• Faecal Contamination Quantity ? Major: > one Quadrant Class II & III: Major -- Sepsis

• Associated injuries:Class I, II, & III: > 2 organs -- Sepsis PATI > 25, FSS > 25 , Flint >11Class I: Greater # of associated organ

injury

Mortality & Sepsis

But : NO Contraindication to 1º repair of non destructive

• Anatomic Location: – Class I , II , & III: NO Significant

difference in complications between right & Left for 1º repair

• Blood Transfusion: 4 units critical > 4 → ↑ morbidity

Flint Severity Score:

• Isolated colon injury, minimal contamination, no shock, minimal delay.

• Perforation, lacerations, moderate contamination

• Severe tissue loss, devascularization, heavy contamination

Methods of Repair:

Primary Repair: The Standard Safe Right & Left (I, II, III)

Prospective Colostomy : Safe, conservative, acceptable

Closure: 10% Morbidity W. Infection I. Obstruction Fistula Incisional Hernia

Exteriorization:

a. Healing: 5 – 10 days

b. Colostomy

Abandoned: Failure & Complications

1. Drains : NO W. Infection Sepsis

2. Peritoneal Irrigation3. Wound:

Definitiona: Open: Significant

Contamination b: Delayed primary closure: 7 days

1. Class I & II: Single Pre - OP

aerobic & Anaerobic

2.Class I & II: 24 H hollow viscus

3. Shock : dose 2 – 3 folds

Prophylactic Antibiotics

Type: Single = Combination Aminoglycocide + Clindamycin

orAminoglycocide + metroindazole

Duration:Class I & II: 24 H

Optimal Dose: Fluid Shift High Dose Aminoglycocide: 3mg/Kg

Loading

Recommendations:

1. Class I & II: Non Destructive: 1º repair (Peritonitis º)

2. Destructive: 1º repair if:1 – Haemodynamic stable 2 – Shock °3 – Significant underlying disease º4 – Minimal associated injuries 5 - Peritonitis º

3. Complex: Shock + substantial contamination or trauma to other organs

Resection + proximal diversion

Colostomy/ Ileostomy

Mucous Fistula

Hartmann’s

Pregnancy

1. Blood Volume 2. Lax Abdominal Muscles

3. Enlarged Uterus

4. Pulse, BP, Haematocril, WBC, HCO3

5. Compressed Uterus: peripheral venous Pressure

6. GIT motility

Diagnostic Procedures: Same

1. Limit Radiation/ Shielding

2. Avoid Anaesthesia

3. DPL: Open

4. IVU: Single exposure

5. DIC

6. Early Mobilization of fracture

Special

1. Fetal Heart: Doppler (12w)2. U/S3. Placental Separation: Fetal cells in maternal blood

Treatment: Vigilant

Mother must be saved first

Options: as non pregnant 1. Uterine Injuries

2. Termination

In Majority: non injured uterus – V. Delivery at term

Injured uterus – repair

Indicators for C –Section :

1. Uterine rupture

2. Worseness fetal distress

3. Exposure of rectum, great vessels

4. Maternal Thoracolumbar spine fracture

5. DIC

6. MOF

Maternal death

Immediate Delivery

Poor infant survival if maternal death >15 minutes

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