Abdominal Trauma and Management. Surgical Management of injuries to Abdominal Organs.

1. ABDOMINAL TRAUMA G.Githsuhan

2. ABDOMINAL TRAUMA
1. Blunt Abdominal Trauma
2. Penetrating Abdominal
Trauma
1. Hemodynamically ‘Normal’,
2. Hemodynamically Stable
3. Hemodynamically Unstable

3. ABSOLUTE INDICATIONS FOR A
LAPAROTOMY:
1. Hemodynamic lability – Hypotension with a distended abdomen
2. Peritoneal signs
3. Free air
4. Bleeding from an orifice
5. Impaled object
6. Peritonitis
Local wound exploration is positive – anterior fascial penetration  Laparatomy

4. MANAGEMENT OF ABDOMINAL
TRAUMA
1. ATLS – Advanced Trauma Life Support ABCDE,
2. Classifying Patient as Hemodynamically Normal, Stable and
Unstable.
3. Treatment Based on the patients hemodynamic state and type of
injury.
Note: Blood is not an irritant of the peritoneum and therefore and
does not cause any pain initially!

5. MOST APPROPRIATE
INVESTIGATIONS
•Serial Abdominal Physical Examinations
Radiographic Examinations only in Hemodynamically normal or stable
patients!
•Abdominal CT with contrast
•Plain Abdominal Radiographs
•Diagnostic Peritoneal Lavage (DPL)
•FAST (Focused Abdominal Sonogram for Trauma)
•Diagnostic Laparascopy

6. SUSPECT ABDOMINAL TRAUMA
Injury Below:
 Nipple Line Anteriorly
 Tip of scapula Posteriorly

7. FAST

9. DIAGNOSTIC PERITONEAL LAVAGE
Aspirated, if negative, a liter of NS is infused and aspirated
Positive if:
10 mL gross blood on aspiration
>100,000 red blood cells/mm3
>500 white blood cells/mm3
Bacteria
Bile
Food particles

10. HEMODYNAMICALLY
UNSTABLE

12. GOALS OF TREATMENT
Stop Bleeding and
Gastrointestinal Contamination.
Contamination is controlled by
Clamps or Temporary Sutures
Proceed to clamping if bleeding
visible, packing if not.

13. FOLLOWING CELIOTOMY
Abdominal Packing
If Packing does not control bleeding, source of bleed must be
controlled first!
Massive Transfusion Protocol - >10 pRBC in 24h.
Clamp the mesenteric bleeders
Stop
Blunt injuries- liver, spleen, and mesentery
Penetrating injuries - liver, retroperitoneal vascular structures, and
mesentery, based on trajectory of the weapon or bullets

15. ABDOMINAL VASCULAR INJURY

16. MANAGEMENT
Control Aortic and IVC bleeds before proceeding to solid organs.
Hematomas evacuated after controlling bleeding.
Manually apply pressure when removing pads for examination

17. LEFT SIDED MEDIAL VISCERAL
ROTATION

18. RIGHT SIDED MEDIAL VISCERAL
ROTATION

19. DAMAGE CONTROL SURGERY
Initial operation controlling only hemorrhage and contamination
and allow aggressive resuscitation in the intensive care unit (ICU).

21. ORGAN SPECIFIC
TREATMENT

22. DIAPHGRAM
Hard to Diagnose.
Usually on CT or Laprascopy or
Laparatomy
Future Herniation or
strangulation if not treated.
Treated with non absorbable
sutures or mesh.
Flaps if contaminated, from:
Lat. Dorsi, omentum or biologic
grafts

23. LIVER
4 Ps:
Push – Directly on liver
Pringle
Plug – Visible holes can be
plugged
Pack – Above and below in the
recesses

24. AAST CLASSIFICATION
Grades V, VI most likely to fail Non operative Management

25. BLT – Blunt Liver Trauma
IR - Drainage

26. CRITERIA FOR NOM
•Hemodynamic stability
•Absence of peritoneal signs
•Lack of continued need for transfusion for the hepatic injury;
bleeding can be addressed with angioembolization.

27. BLEEDING CONTROL
If bleeding not controlled by
pringles, suggests hepatic vein
injury,
If within liver – Hepatoraphy or
Resection.
Mobilise Left or Right lobes to
expose vein injury and bleeding
outside the liver.

28. SURGERY:
long midline incision or bilateral
subcostal incision. Right lobe
exploration might require subcostal
extension of midline incision.
Grades I – III : electrocautery,
simple suture, or hemostatic agents
Do not pack directly into liver
lacerations. – Distract or even
exacerbate bleeding
1. Pack around liver.
2. If packing does not stop bleeding
 Pringles maneuver
(10 to 15 minutes on, 5 minutes
off) to reduce hepatic ischemia
3. Hepatoraphy  Finger fracture
technique – ligation of bleeding
vessels
4. Nonanatomic lobectomy with
staplers are safe
5. Delayed anatomic resection if
packing stops bleeding
6. Closed suction drains for grade
III-IV

29. Intraoperative cholangiogram or
saline injection for leaks in bile
tract after major operation on the
liver. This is usually after the
Damage control surgery on the
second operation.
Penetrating wounds of liver –
Bleeding stopped by tamponade
by panrose drains.

30. Arterial Blush in Liver after Trauma

31. COMPLICATIONS OF LIVER INJURY
Recurrent Bleeding
Hemobilia
Intrahepatic or perihepatic abscess
Bilioma
Biliary Fistula
Extrahepatic Bile duct injury uncommon.

32. SPLEEN
Kehrs Sign- Pain referred to Left shoulder
Can be:
 Packed
 Placed in a Mesh Bag
 Repaired
Angioembolism
Splenectomy is safer in an unstable patient with multiple bleeds from
spleen and age >55yo.
Following splenectomy, rising platelet and WBC may indicate sepsis.
Non operative management of pediatric spleen injury is highly successful >90% irrespective of the grade.

34. SPLEEN INJURY MANAGEMENT
Grades I–II: Topical hemostatic agents, argon beam coagulator, or
electrocautery
Grades II-III: Suture repair, or mesh wrap – Suture repair requires Teflon
pledgets
Grades III-IV: anatomic resection with ligation of the lobar artery
Grades V: Splenectomy
*Splenorraphy requires 1/3 of intact spleen.
*Drainage of splenic fossa should be avoided due
to increased risk of subphrenic abscess.
*Vessels in gastrosplenic ligament divided close to spleen

35. STOMACH
Usually with penetrating injuries,
Primary repair with single layer with non-absorbable suture or as a
double-layer closure with an absorbable suture with the first layer
and the second layer with non-absorbable
sutures
Will require copious abdominal lavage.

36. SMALL INTESTINE
Most common following penetrating injuries.
CT can help detect Bowel injury in blunt trauma
Stop Bleeding, Resect intestine if necessary, close enterotomies with
single layer non absorbable suture.
If edges necrosed, debrid prior to closure.
Bowel Decompression for 12 – 24h following surgery.
Antibiotics preoperatively.

37. Proceed to Segmental resection

38. COLON AND RECTUM
Colon injuries closed with primary suture. If extensive damage or not
possible, segmental resection.
proximal segment can be anastomosed to the distal segment
or a proximal ostomy and Hartmann’s procedure can be performed
If distal segment is long – mucosal fistula is made
Rectal injury below peritoneal reflection necissate a diverting
colostomy.
Lower 1/3 injuries might require presacral drainage.

39. PANCREAS
Subtle clinical signs.
Serum hyperamylasemia –Neither
sensitive nor specific
CT scans – repeat if with
hyperamylasemia
Abdominal Pain, tenderness,
ecchymosis – Absence does not
exclude diagnosis
ERCP – Most sensitive but not
clinically applicable

41. AAST CLASSIFICATION

42. INTRAOPERATIVE DIAGNOSIS OF
PANCREATIC TRAUMA
Visual examination and bimanual
palpation.
Pancreas visualized by opening
gastrocolic ligaments and
entering lesser sac
Intraoperative pancreatography
with dueodenotomy is possible
but is not recommended.

43. TREATMENT OF PANCREATIC
INJURY
1. Control hemorrhage
2. Debride devitalized pancreas
3. Preserve maximal amount of
viable pancreatic tissue
4. Wide drainage with closed-
suction drains
5. Feeding jejunostomy with
significant lesions
AAST Grade I to II -
Debridement and external
drainage
AAST Grade III – Distal
pancreatectomy – distal to SMA-
Closed with stapler or Non abs.
suture
AAST Grade IV – V – Wide
drainage or
pancreaticoduodenectomy

44. INDICATIONS FOR
PANCREATICODUODENECTOMY
Massive disruption of the pancreatic head with uncontrolled
hemorrhage
massive hemorrhage from adjacent vascular structures
severe combined duodenal, pancreatic, and biliary injuries.
If pancreaticoduodenectomy is indicated: initial resection and
delayed reconstruction (24 to 48 hours) may facilitate anastomotic reconstruction.

45. DUODENAL INJURY
Diagnosis based on mechanism of injury
CT signs – Paraduodenal hemorrhage, air or contrast leak
Upper Gastrointestinal studies – X-rays with water soluble contrast.
DPL – Has low sensitivity

46. Intraduodenal hematoma- UGI study with gastrograffin q7 days.
 nasogastric suction and IV alimentation
If noted on laparotomy hematoma can be evacuated through serosa.
Duodenal Perforation is treated operatively:
 Transverse primary closure
 Duodenal decompression by retrograde jejunostomy or lateral tube duedonostomy.

47. 3TUBE TECHNIQUE
• Gastrostomy tube to
decompress the stomach,
• Retrograde jejunostomy to
decompress the duodenum
• Antegrade jejunostomy to feed
the patient

48. PYLORIC EXCLUSION
For duodenal injury or pancreatic
injury

49. RENAL INJURIES
For Hemodynamically Stable patients – Non operative management
for all Grades of injury.
Operative exploration in Grades IV and V and in unstable patients.
An IVP can be performed before exploration in case a nephrectomy
becomes necessary.
Vascular control by midline transperitoneal approach.
Urinomas and abscesses are drained percutaneously.

52. URETERAL INJURIES
Ureteroureterostomy
ureteropyelostomy
Ureterocalicostomy
Transureteroureterostomy
Boari bladder flap

53. BOARI BLADDER FLAP

54. RETROPERITONEAL HEMATOMAS
Zone I – Mandatory Exploration
retroperitoneal hematoma
any zone requires exploration for
all penetrating injuries
Zone II retroperitoneal
hematomas resulting from blunt
trauma
Zone III explored only if
penetrating injury. Blunt trauma
usually causes venous bleeding
which requires fixation.

55. ABDOMINAL COMPARTMENT
SYNDROME
Primary ACS - caused by a condition associated with injury or disease
in theabdominopelvic region that frequently requires surgical or
interventional radiologic intervention, or a condition that develops
following abdominal surgery.
Seconday ACS - caused by conditions that do not originate from the
abdomen such as sepsis with associated capillary leak, major burns,
major soft tissue and skeletal trauma, or other conditions requiring
massive fluid resuscitation.

56. ACS DIAGNOSIS
Bladder Pressure Measurement,
ACS is defined as Sustained IAP of 15 -20 mmHg with or without
Abdominal Perfusion Pressure(APP) <60 mmHg with single or Multi
organ dysfunction

57. ACS MANAGEMENT
Serial Monitoring of IAP,
Sedation, Analgesia to relax abdominal wall muscles
Percutaneous decompression
Fluid Restriction, Diuresis, Hemofiltration
Surgical Decompression
Prepare for reperfusion syndrome – 2/4 Amps of Sodium Bicarbonate
Minimally Invasive Therapy – subcutaneous release of linea alba – mostly for
Secondary ACS
Open abdomen – Temporary closure - VAC, Prosthetic coverage
Decompression if IAP >15mmHg with physiologic decompromise

58. ABX FOR PENETRATING
ABDOMINAL TRAUMA
1st line: Co-amoxiclav 1.2g IV q8h + Metronidazole 500mg IV q8h
2nd: Cefuroxime 750 mg q8h + Metronidazole 500mg IV q8h
Cefoxitin 1.5g q6h or 30 mins prior to surgery or anyother 2nd gen
cephalosporin <24h
Srilankan:
US:

59. BIBILIOGRAPHY
Acute Care Surgery 1st Edition 2012
Tintinallis Emergency Medicine A Comprehensive Study Guide 8th
Edition 2016
Trauma and Acute care surgery 4th Edition 2014
Bailey and Loves Short Practice of Surgery 26th Edition
Srilankan National Antibiotic Guidelines 2016