Br Med Bull 1999 Brooks 844 55

Blunt abdominal injuriesAdam J Brooks and Brian J RowlandsSection of Surgery, Queen's Medical Centre, University Hospital, Nottingham, UK

The management of blunt abdominal injury (BAI) has undergone quitesignificant changes over recent years. The emphasis is now on the recognitionand limitation of the underlying metabolic insult associated with severeabdominal injury. The concepts of damage control and non-operative manage-ment while seeming diametrically opposed have both found favour in selectedpatient groups. The interventional radiologist has opened a new dimension inthe control of inaccessible bleeding and is able to contribute to non-operativeapproaches. The complimentary use of the methods of investigation availablefor BAI will also improve the accuracy and specificity of diagnosis allowing moreappropriate management. Embracing these new concepts of management by allinstitutions dealing with trauma victims will hopefully reduce the morbidity andmortality of BAI.

In 1988, the Report of The Royal College of Surgeons of England on TheManagement of Patients with Major Injuries* identified intra-abdominalinjury as a significant cause of preventable deaths. Since then newconcepts and techniques have been introduced in the surgical managementof blunt abdominal injury (BAI). Some have been widely accepted bythose dealing with trauma on a frequent basis, whilst other approachesand technical 'advances' remain contentious. This chapter will reviewthose main developments diat have found approval including: (i) damagecontrol; (ii) non-operative management of solid organ injury; (iii)interventional radiology; and (iv) organ injury scales.

In addition, a balanced account will be given of some of the otherareas and procedures which remain open for debate: (1) investigation ofBAI; and (ii) therapeutic laparoscopy.

Correspondence toProf. Brian J Rowlands,

Section of Surgery,Queen's Medical Centre,

University Hospital,Nottingham

NG7 2UH, UK

Damage controlThe acceptance by trauma surgeons of the 'abbreviated' or 'damagecontrol' laparotomy has been a significant development in surgery forabdominal injury. It is not a new concept to terminate operativeprocedures for a deteriorating patient to allow further resuscitation and

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restoration of physiological reserve. Its origins can be traced back toHalsted's original description of the control of bleeding by packing inthe management of liver injuries in 1908. In the 1980s, Stone et ahrepopularised this approach by advocating abdominal packing andclosure in the approach to major intra-operative coagulopathy.Subsequently, this technique has become referred to as either 'damagecontrol'3 or the 'abbreviated laparotomy'4. Rotondo et aP refined thetechnique and published a prospective study of 46 severely injuredpatients comparing definitive laparotomy with damage control. Theyshowed a survival advantage m the damage control group amongst thesepatients with major vascular and multiple visceral injuries.

The principles of resuscitation and the objectives of surgery in thetrauma patient remam unchanged. The aim of resuscitation is to correctand maintain oxygenation and tissue perfusion. The surgical approachinvolves control of haemorrhage, limitation of contamination andrestoration of continuity. The concept of damage control is based on therealisation that patients with hypothermia, acidosis and coagulopathyare in metabolic exhaustion and have a high risk of death. The finalobjective of surgical intervention remains unaltered, but the emphasis ontiming has changed in damage control. Surgical techniques must beperformed to minimise the metabolic insult rather than merely restoringanatomical continuity.

There are three key factors that interact to produce the downwardmetabolic spiral5. They are: (i) hypothermia despite warming; (ii) clinicallydetectable coagulopathy (non-surgical bleeding); and (iii) persistent severeacidosis. Trauma patients are at high risk of hypothermia during theprehospital phase and during resuscitation and operative procedureswhere heat loss sometimes occurs at rates of 8cC/h6. Hypothermia inhibitsblood clotting, induces vasoconstriction, impairs myocardial performanceand increases myocardial irritability. The effect of hypothermia onmortality is marked in severe injury. Jurkovich7 reported a significantdifference in mortality in hypothermic patients from a cohort of 71injured patients. There were no survivors amongst the patients whodeveloped a core body temperature less than 32C. The trauma team mustbe aware constantly of the risks of heat loss and take measures tominimise it. Rewarming using rapid blood warming infusion devices,warm air convection blankets or thermal reflective sheets should bestarted early in resuscitation and assessment.

Coagulopathy may develop despite aggressive blood and componentreplacement because of dilution of clotting factors from resuscitationfluids and hypothermia. Cosgriff8 showed that hypothermia andmetabolic acidosis were predictors for life-threatening coagulopathy in astudy of 58 severely injured patients. Likewise, persistent acidosisincreases cardiac instability and decreases the response to catecholamines.

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The recognition of patients who have metabolic decompensation ordysfunction is the first stage in the damage control approach. No control-led trials exist to determine the optimum timing of damage control or therecognition of the interdependence of the key factors. It has beensuggested that the procedure should be terminated rapidly when hypo-thermia is progressive or a temperature of 34C is reached; acidosis witha pH of < 7.2 develops despite adequate volume replacement and ofperoperative coagulopathy is recognised as non-surgical bleeding9.Prehospital stability, resuscitation requirements, pre-existing medicalconditions and injury pattern recognition all impact on the decision toinstitute damage control.

Once recognised, the procedure is rapidly terminated using standardsurgical techniques, packing and closure. This is followed by secondaryresuscitation in the critical care unit to correct physiological exhaustionand restore reserve. Definitive laparotomy follows within 48 h on restor-ation of normal physiology3. In the patient with continuing instability, thistechnique may have to be employed a number of times to deal with all theinjuries.

The components of the damage control laparotomy are control ofhaemorrhage and contamination. Haemorrhage may be controlled initiallyby four-quadrant packing, followed by ligation, repair or temporary shuntof vessels. Development of non-surgical bleeding will require packing ofthe abdomen to produce tamponade. Care must be taken to avoid furtherinjury during this process and some institutions recommend covering packswith Op Site to prevent adherence to tissues. Initially, entericcontamination can be temporarily controlled with Babcock clamps or softbowel clamps. This may be followed by ligation, suturing or stapling ofbowel injuries leaving definitive anastomosis to re-establish bowelcontinuity until subsequent laparotomy.

In the intensive care unit, fluid therapy and monitoring continue theresuscitation that began in the emergency room. The core principles areinvasive monitoring and cardiopulmonary support, aggressive rewarming,and replacement of blood and clotting factors to correct coagulopathyand the correction of the acid-base imbalance. The decision to return totheatre for definitive surgery can usually be made within 24 h, but mustbe made at a time when there is correction of key factors, restoration ofreserve and cardiovascular stability.

Abdominal compartment syndrome and techniques ofwound closure

Damage control, like any procedure, has its complications. It may resultin the abdominal compartment syndrome (ACS) and complex wound

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Table I Adverse effects of raised intra-abdommal pressure

Abdominal pressure Adverse effects

>15 mmHg Fall in cardiac outputIncrease in airway pressuresDecreased pulmonary complianceDecreased blood flow to intra-abdominal organsOhguna

> 30 mmHg Fatal organ failure

closure. ACS is defined as adverse physiological consequences caused byan acute increase in intra-abdominal pressure10.

Following crystalloid resuscitation and prolonged laparotomy, theremay be progressive and sustained oedema and distension of the bowel.This increase in volume coupled with slow haemorrhage from on-goingcoagulopathy and the insertion of abdominal packs, may lead to anincrease in the intra-abdominal pressure following closure of the fascia- the abdominal compartment syndrome. The increased intra-abdominal pressure (IAP) leads to adverse effects on the cardiac output,respiratory function and renal function (see Table I)11.

The indication for abdominal decompression depends on the responseto raised IAP. IAP can be reliably measured using bladder pressuremeasurements, but the development of oliguria/anuria, high airwaypressures or inadequate oxygenation are indications for decompressionof the abdomen.

Numerous techniques of closure of the abdominal wall followingtrauma laparotomy or damage control procedure are described in aneffort to avoid high intra-abdominal pressures and ACS.

Temporary closure can be obtained by either direct suture fascialclosure or simple towel clip closure of the skin with application of aSteri-drape to prevent excessive seepage. Both have the disadvantagethat they do not totally eliminate the possibility of raised intra-abdominal pressure. The use of a temporary silo for closure of the cavityhas been recommended in those patients at risk of raised LAP12. This hasbeen performed successfully using Steri-drape or silastic sheeting or bysuturing a large intravenous or urological irrigation bag to the woundedges - the 'Bogata Bag'. This system alleviates the rise in intra-abdominal pressure, preventing the development of ACS.

Non-operative management of blunt abdominal injuryThe vogue for the non-operative management of solid organ injury hasincreased and found wide acceptance. The use of computerised tomo-graphy (CT) and other modalities of diagnosis (ultrasound, laparoscopy,




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magnetic resonance imaging) in conjunction13, has allowed theassessment of the grade or extent of organ injury and the accuratefollow-up of its resolution. When the latest therapeutic techniques ininterventional radiology14 are also used, an increasing number ofpatients with isolated abdominal solid organ injury can be managedwithout surgical intervention.

Haemodynamic stability is of paramount importance when patientsare considered for non-operative management. Mucha et aP5 suggestedthat adults with splenic injury should only be treated non-operativelywhen they had minimal physical signs, cardiovascular stability andrequired less than 2 units of transfused blood. Two retrospective studiesof the use of CT scan to determine the need for surgery in splenic traumahave recently been published. They looked at the scans from 45patients16 and 70 patients17, respectively, and concluded that, despiteaccurate determination of injury grade by CT scan, clinical criteriashould be used to make the decision about appropriate need for surgicalintervention. 'Non operative management' should not be considered'conservative' management as these injured patients still have greatpotential for rapid deterioration. They should be closely monitored forhaemodynamic instability, fluid and transfusion requirements in a highdependency or intensive care unit.

Accurate assessment of the extent, severity of primary injury andassociated injuries is vital to successful management. Smith18 showed, ina prospective series of 112 patients with blunt splenic trauma, thatyounger patients with less severe injuries (American Association ofSurgeons for Trauma Organ Injury Scale I, II or III), haemodynamicstability and the absence of other abdominal injuries could be managednon surgically with success in 93% of cases. Carillo's19 recent review ofblunt hepatic injury concluded that non-operative management could beconsidered in up to 50% of blunt liver injuries in adults with a 50-80%success rate. Patient selection and accurate CT grading of injury severitywas essential, although the latter could not predict failure. The majorityof renal injuries in the stable patient can be managed non-operativelyunless there is injury to the renal pedicle as determined by CT scan,intravenous urogram or selective arteriogram.

Paediatric surgeons have more readily embraced the concept of non-operative management although there is no definite evidence thatchildren tolerate this approach better than adults. Thaemert20 showedno difference between adults and children in the non-operativemanagement of splenic injury. Smith18 showed a greater success for thisapproach in patients less than 55 years old. In children, non-operativemanagement is recommended in lower grades of splenic and liver21injuries. A recent retrospective study showed a 79% success rate for thisapproach in 123 patients with grade 1 or 2 pancreatic injury22.

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Interventional radiologyThe interventional radiologist has become an integral member of thetrauma team. Their technical expertise has allowed the diagnosis ofinaccessible and unrevealed haemorrhage and brought new therapeuticstrategies into play. Angiography is an important diagnostic adjunct intrauma13'14 especially when used in conjunction with CT. This allowsaccurate diagnosis of bleeding and provides therapeutic options in bothsurgical and non-operative management. Sclafani14 reported 60 patientswith splenic injury who underwent coil embolisation of the proximalsplenic artery following angiography showing contrast extravasation.This technique was successful in stopping bleeding in 93% of patientsallowing non-operative management. Interventional radiology hasadded a new dimension to the treatment of severe liver injuries. Thetechnique is complimentary to traditional surgical techniques andperihepatic packing. Denton23 reported the successful use of acombination of arterial embolisation and transhepatic venous stenting ina multidisciplinary approach to grade V liver injury involving theretrohepatic vena cava. A similar surgical and radiological approachinvolving the placement of a stent in a damaged hepatic vein withsuccessful outcome has also been reported by Burch10. It opens a newavenue for the management of these complex problems, which have ahigh morbidity and mortality.

In abdominal trauma, interventional radiological techniques have foundmost acceptance in the diagnosis and management of haemorrhage fromcomplex pelvic fractures. Different fractures have been shown to beassociated with injuries to specific arteries24 and arteriography andembolisation allows accurate diagnosis and control of bleeding.

Interventional radiological techniques including selective arterialembolisation, temporary balloon occlusion for vascular control and stentplacement have all been successfully reported in the management of headand neck vascular injuries25126. There is potential for applying thesetechniques to BAI both in the acute phase and in the treatment of com-plications, e.g. percutaneous drainage of post injury intra-abdominalabscess and haematoma.

Assessment of organ injury severityIn 1987, the Organ Injury Scaling Committee of the AmericanAssociation for the Surgery of Trauma (AAST) was established. It wascharged with devising injury severity scores for individual organs andbody structures to facilitate clinical research and quality improvement.The classification scheme is a systematic, graded anatomic description




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Table 2 Spleen injury scale (1994 revision)Grade 'Grade Injury description

I Haematoma Subcapsular, < 10% surface areaLaceration Capsular tear, < 1 cm parenchymal depth

II Haematoma Subcapsular, 10-15% surface area, intraparenchymal, < 5 cm in diameterLaceration Capsular tear, 1-3 cm parenchymal depth which does not involve a

trabecular vessel

III Haematoma Subcapsular, > 50% surface area or expanding, ruptured subcapsular orparenchymal haematoma, intraparenchymal haematoma > 5 cm orexpanding

Laceration > 3 cm parenchymal depth or involving trabecular vessels

IV Laceration Lacerationinvolving segmental or hilar vessels producing majordevasculansation (> 25% of spleen)

V Laceration Completely shattered spleenVascular Hilar vascular injury which devasculanses spleen

'Advance one grade for multiple injuries up to grade IIIAfter Moore et aP

scaled from I to VI that differs from the Injury Severity Score as it is notintended to correlate with anticipated patient outcome. The gradesrepresent increasingly complex injuries and grade VI is reserved forinjuries that are beyond repair and are incompatible with survival. Themajority of institutions dealing with trauma on a regular basis haveuniformly accepted this scheme. The organ injury scales provides acommon descriptive language for the comparison of technique and resultsbetween organisations. The organ injury scales for splenic and duodenalinjuries are reproduced in Tables 2 and 327.Table 3 Duodenum injury scale

Grade 'Grade Injury description

I Haematoma Involving single portion of duodenumLaceration Partial thickness no perforation

II Haematoma Involving more than one portionLaceration Disruption < 50% of circumference

III Laceration Disruption 50-75% circumference of D2Disruption of 50-100% circumference of D1, D3, D4

IV Laceration Disruption > 75% circumference of D2Involving ampulla or distal common bile duct

V Laceration Massive disruption of duodenopancreatic complexVascular Devasculansation of duodenum

'Advance one grade for multiple injuries up to grade IIIAfter Moore et aP

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Current debateAbdominal assessment and investigation

Patients with suspected abdominal injuries from blunt trauma could becategorised in to three groups:1 Those requiring immediate surgery on clinical examination alone.2 Those requiring further investigation using appropriate diagnostic test to

determine intra-abdominal injury and assess the most appropriatemanagement.

3 Those with no abdominal injury on clinical examination and where there isa low index of suspicion require only observation and re-examination.The proportion in each group at any institution depends on the

mechanisms of trauma most commonly seen and the severity.There is continuing debate over the most appropriate diagnostic

investigation for patients who fall into the second group where diagnosisof injury is required. The most commonly used modalities for thisassessment are: (i) diagnostic peritoneal lavage; (ii) ultrasound; (iii) com-puterised tomography; (iv) diagnostic laparoscopy; and (v) magneticresonance imaging.

Diagnostic peritoneal lavageOriginal described in 1965 by Root et aP3, diagnostic peritoneal lavage(DPL) has been the gold standard investigation for BAI against whichothers have been compared. Despite the advent of ultrasound and CT,DPL has remained the investigation of choice in many institutionsbecause it is reproducible29, inexpensive and accurate. Powell et al30found an accuracy of 97.3% in a review of collected series with falsepositive and false negative rates of 1.4% and 1.3% only. In blunttrauma, lavage counts of 100,000 red cells/mm3 (RCC) and 500 whitecells/mm3 have been accepted as providing the most appropriate balancebetween false negative and false positive investigations. With equivocalresults (RCC 50,000100,000) the use of a second diagnostic testimproves accuracy. The most recent studies comparing open techniqueswith closed percutaneous techniques have reported equal sensitivity andspecificity between these methods and found the closed technique to befaster and associated with fewer complications31'32.

UltrasoundIn Europe and the US, ultrasound has become the main investigation forblunt abdominal trauma and is most useful in detecting injury to solid




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intraperitoneal and retroperitoneal organs and the presence of freeintrapentoneal fluid or blood. It is common for the surgical residents ortrauma fellows to perform the examination. Accuracy improves with theexperience of the investigator33. Rozycki's34 study evaluated 476 patientsand showed 79% sensitivity and 96% specificity with surgeons per-forming the examination. For the detection of free intraperitoneal fluid,the sensitivity has been reported to be 81 %35 to 88%36 with an accuracyof detecting injury of 99% in McKenny's36 report of 1000 consecutiveultrasounds for BAI.

The focused abdominal sonogram for trauma (FAST) is the technique ofchoice for surgeons using ultrasound to assess the abdomen34. Thisinvolves a limited number of ultrasound windows to detect fluid: rightupper quadrant (Morrison's pouch); left upper quadrant (splenorenalrecess and subdiaphragmatic space); the pouch of Douglas and a peri-cardial window to assess for pericardial effusion. Rozycki37 showed m acollective review of 4941 patients that surgeons using FAST for theinvestigation of BAI had a sensitivity of 93.4%, specificity of 98.7% andaccuracy of 97.5% in detecting both haemopentoneum and visceral injury.

Ultrasound is a fast, non-invasive and portable modality for investig-ations, but is dependent on operator experience. It may be limited byobesity and is poor for evaluation of injuries to the diaphragm and someretroperitoneal structures (e.g. pancreas). Reliability and accuracy isimproved by repeating the procedure over a period of time34. A singlenormal ultrasound examination cannot be taken as a guarantee thatthere is no intra-abdominal injury.

Computerised tomographyIn the stable patient with blunt abdominal injury, CT is the investigationof choice in many institutions. A standard trauma scan with a modernspiral scanner can be acquired in 3-5 min and should includeintravenous contrast. The use of oral contrast is unnecessary in traumapatients38, and many institutions no longer use it. The scans shouldimage from the top of the diaphragm, to visualise intrathoracic haemo-and pneumothoraces, to the pubic symphysis and into the pelvis to aidorthopaedic assessment of suspected pelvic fracture.

The advantages of CT are the capacity to visualise retroperitoneal inaddition to peritoneal structures. The severity of injury and its suitabilityfor non operative treatment17 can also be judged although the correlationbetween CT assessment and operative grading of organ injury has beenreported to be 20 %39. A review of prospective studies from the 1990s usingmodern CT scanners gives a sensitivity of 88% and a negative predictivevalue of 97%40, but has significantly reduced accuracy in the diagnosis ofhollow organ41 and pancreatic injuries42.




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Diagnostic laparoscopyThere is little work to support the use of diagnostic laparoscopy (DL) inblunt abdominal injury. Leppaniemi43 published a collective analysis of 11reports with 355 blunt abdominal injury patients. He found DL to be97% accurate but concluded that it was limited by time and cost whencompared to less invasive bedside investigations. At present it cannot berecommended as a primary investigation in blunt abdominal injury.Salvino44 compared DPL to diagnostic laparoscopy in a prospective studyof 59 patients with BAI. He concluded that alterations in managementand improvement in outcome would occur in only 3 % of cases assessedby DL and, therefore, its routine use could not be justified.

Technically, DL is hampered by the presence of blood and it is difficultto thoroughly assess the spleen and retroperitoneal structures. The rolefor DL in the assessment of BAI is two fold - as an adjunct to otherdiagnostic tests in selected patients, e.g. the assessment of diaphragmaticrupture, and to determine those patients with minor injuries suitable fornon-operative management45'46.

Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI) is unlikely to be used in theassessment of the acute patient. However, this technique may develop arole in patients where presentation is delayed. Specifically, the value ofMR cholangiography in assessing the biliary and pancreatic systemfollowing trauma has yet to be assessed.

No single diagnostic modality is ideal in the investigation of every patientwith BAI. The sensitivity and specificity of the tests vary with DPL beingthe most sensitive but not as specific as CT or ultrasound47. Catre40 andLiu47 have suggested that the methods are complementary and theu: use incombination would improve the overall accuracy and organ specificity.

Therapeutic laparoscopy

The extension of laparoscopic procedures to abdominal trauma in atherapeutic capacity remains largely in the hands of a few enthusiasts.The largest series published to date reports on 28 therapeutic proceduresincluding the repair of diaphragm injuries and a closure of gastro-stomy48. The mean stay in the absence of other injuries was only 2.7days, however the mean time taken for the surgical procedures was 111.8min (range 75-265 min). As a technique in abdominal trauma surgery, itis unlikely to have a major role due to the constraints of theatre time, theinstability of trauma patients and the technical difficulties encounteredwith performing laparoscopic procedures.




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