Abdominal injuries lit review Surgery

1. ABDOMINAL INJURIES
• By Senior Clerks of Surgical ward 3

2. CONTENT
• Introduction
• Boundaries of the abdomen
• Types of abdominal injuries
• Assessment of abdominal injury
• Investigations
• Management
• Indications for Laparotomy and specific organ repair

3. INTRODUCTION
• The abdomen can be injured in many types of trauma; injury may be confined to the
abdomen or be accompanied by severe, multisystem trauma. The nature and severity
of abdominal injuries vary widely depending on the mechanism and forces involved,
thus generalizations about mortality and need for operative repair tend to be
misleading.
Injuries can involve: Abdominal wall
Solid organs
Hollow viscus
Vasculature

4. INTRODUCTION
The primary goals in the evaluation of abdominal injury are to:
• To promptly recognize conditions that require immediate surgical exploration.
• To avoid critical error of delayed operative intervention when it is needed.

5. EXTERNAL ANATOMIC BOUNDARIES
• Anterior abdomen: trans-nipple line superiorly, inguinal ligaments and the pubic
symphysis inferiorly, anterior axillary lines laterally.
• Flank: between anterior and posterior axillary lines from 6th intercostal spaces to iliac
crest.
• Posterior: Posterior to posterior axillary lines, from tip of scapulae to iliac crests.

7. INTERNAL ANATOMIC BOUNDARIES
• Upper peritoneal cavity
– Covered by lower aspect of bony thorax.
– Includes diaphragm, liver, spleen, stomach, transverse colon.
• Lower peritoneal cavity
– Small bowel, ascending and descending colon, sigmoid colon, and (in women) internal
reproductive organs.

9. INTERNAL ANATOMIC BOUNDARIES
• Pelvic cavity
– Contains the rectum, bladder, iliac vessels, and (in women) internal reproductive organs.
• Retroperitoneal space
– Posterior to peritoneal lining of abdomen.
– Abdominal aorta, IVC, duodenum, pancreas, kidneys, ureters, and posterior aspects of
ascending and descending colon.

10. AETIOLOGY OF ABDOMINAL INJURY
• Penetrating Trauma
– Low velocity e.g. stab, pistol
– High velocity e.g. rifle, shrapnel
• Blunt trauma
• Iatrogenic injuries

12. PENETRATING INJURIES
• Stab wounds and impalement injuries
– Injuries follow track of impalement
• Gunshot injury
– Low velocity injuries follow tract of injury
– High velocity injuries have cavitation as well as a non-linear pattern

13. PENETRATING INJURIES
• Blast Injuries
– Primary blast wave
– Secondary blast wave
– Shrapnel

14. BLUNT INJURIES
• Compression, crush, or sheer injury to abdominal viscera  deformation of solid or
hollow organs/ rupture (e.g. small bowel, gravid uterus)
• Deceleration injuries
– Differential movements of fixed and non-fixed structures
– e.g. duodenojejunal junction injuries, splenic lacerations at sites of supporting ligaments.

17. BLUNT INJURIES
● Spleen - 26%
● Kidneys - 24%
● Intestine - 16%
● Liver - 16%
● Others - 20%

18. IATROGENIC INJURIES
• Endoscopic (G.I., Urology etc.)
• Gynaecologic
• External Cardiac Message
• Peritoneal Dialysis
• Paracentesis
• Percutaneous Biopsy
• Barium Enema

19. ASSESSMENT OF ABDOMINAL INJURY
The assessment begins with the ABC's of trauma resuscitation.
• Assessment of patients with abdominal trauma can be difficult due to
–Altered sensorium (head injury, alcohol)
–Altered sensation (spinal cord injury)
–Injury to adjacent structures (pelvis, chest)

20. ASSESSMENT OF ABDOMINAL INJURY
• Initial evaluation and resuscitation occur simultaneously
• Do not obtain a detailed history until life-threatening injuries have been identified and
therapy initiated.

21. ASSESSMENT OF ABDOMINAL INJURY
• Admit patient
• Secure airway and immobilize c-spine (multi-trauma patient)
• Breathing – 100% oxygen
• Circulation – 2 wide bore I.V. cannulae
• Take blood samples for FBC, toxicology, pregnancy
• Vigorous infusion of IV fluids (crystalloids)
• Monitor patient vitals - respiratory rate pulse and blood pressure is useful for initial assessment and continuous evaluation quarter
hourly.

22. HISTORY
• Duration, symptoms
• Mechanism:
– RTA:
• Speed
• Type of collision (frontal, lateral, rear)
• Types of restraints
• Deployment of air bag
• Patient’s position in vehicle
– PAI:
• Type of weapon: gun, knife, scissors, etc.

23. ASSESSMENT OF ABDOMINAL INJURY
• Suspect intra-abdominal injury whenever penetrating trauma to the chest, abdomen,
flanks, back or buttocks has occurred.
• Do not forget to inspect the entire skin surface, including the back, buttocks, and flank
for cuts and bruises which may point to organ damage.

24. PHYSICAL EXAMINATION
• Inspection: pain, abrasions, contusions (seat belt sign), lacerations, deformity. Grey-
Turner’s sign, Cullen’s sign, Kehr sign, abdominal distension, entry and exit wounds in
gunshot injuries (trajectory too)
• NB: Grey Turner and Cullen sign are usually delayed for several hours to days
• Palpation: tenderness, guarding, rigidity and rebound tenderness : suggestive of peritoneal
irritation by blood or contents of perforated bowel.
• Percussion: dullness with haemoperitoneum, tympany in gastric dilatation.
• Auscultation: bowel sounds in the thorax may indicate the presence of a diaphragmatic
injury

25. PHYSICAL EXAMINATION
• Hypotension is a predictor of more significant intra-abdominal injuries.
• Accuracy increases if the patient is examined repeatedly and at frequent intervals.

26. Cullen sign
Grey-Turner’s sign
Seat belt sign

27. ASSESSMENT OF ABDOMINAL INJURY
• Ryles’s tube useful for monitoring continuous bleeding from the gut, prevent
aspiration in an unconscious patient and to decompress the bowel.
• Self retaining urinary catheter is also useful to monitor perfusion and detect any
bleeding from possible damage to genitourinary structures.
• . Maintain a high index of suspicion for occult vascular and retroperitoneal injuries,
which may be responsible for significant continuing hemorrhage.

28. INVESTIGATIONS
• Abdominal Paracentesis
• Diagnostic peritoneal lavage when abdominal examination is
equivocal
• FAST: Focused Abdominal Sonogram for Trauma

29. INVESTIGATIONS: IMAGING
• Chest x-ray
• Abdominal X ray
• CT Scan
• MRI
• IVU

30. ABDOMINAL PARACENTESIS
• This is useful when there is a large amount of intra-peritoneal blood
• The blood should be non-clotting as the enzymes in the peritoneum would have acted
on the blood digesting the clotting factors
• If the blood is clots, it signifies the tap was from a blood vessel
• Pregnancy is a contraindication

31. DIAGNOSTIC PERITONEAL LAVAGE
• This test improves the accuracy of paracentesis and it is most useful in the unconscious
patient in whom physical examination is not helpful and ultrasound has not been
helpful or is unavailable
• It is not helpful retroperitoneal injuries
• It is considered more sensitive than FAST but less specific
• Instill 500ml of Ringer’s lactate under LA into peritoneal cavity
• Examine the contents for; frank blood > 5- 10ml, pink perfusate or 105 RBCs per 𝑚𝑚3,
500 WBC/𝑐𝑚3, presence of faecal or food particles and increased levels of amylase.

32. FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
For identifying hemoperitoneum in blunt abdominal trauma:
 Sensitivity 76 - 90%
 Specificity 95 - 100%
The larger the hemoperitoneum, the higher the sensitivity. So
sensitivity increases for clinically significant hemoperitoneum.
It can detect;
 250 cc total
 100 cc in Morison’s pouch

33. FAST: STRENGTHS AND LIMITATIONS
Strengths
• Rapid (~2 mins)
• Portable
• Inexpensive
• Technically simple, easy to train (studies show competence can be
achieved after ~30 studies)
• Can be performed serially
• Useful for guiding triage decisions in trauma patients
Limitations
• Does not typically identify source
of bleeding, or detect injuries that
do not cause hemoperitoneum
• Requires extensive training to
assess parenchyma reliably
• Limited in detecting <250 cc
intraperitoneal fluid
• Particularly poor at detecting
bowel and mesentery damage
(44% sensitivity)
• Difficult to assess retroperitoneum
• Limited by habitus in obese
patients

34. INVESTIGATIONS CONTD…
• Supportive Investigations
• Hb and Hematocrit
• Grouping and crossmatching
• BUE & Cr
• Urinalysis
• Serum Amylase
• Pregnancy test

35. • The single most important initial study is a chest x-ray if the
patient is stable. Hemo- or pneumothorax, widening of the
mediastinum or air within the mediastinum, evidence of
diaphragmatic trauma, and free air below the diaphragm are
all significant findings.

36. MANAGEMENT

37. PENETRATING INJURY
• Cover penetrating wounds with sterile dressings.
• Prophylactic antibiotics – to decrease risk of intraabdominal sepsis.
• Pain relief
• In general leave foreign bodies in and remove in theatre. They should be
protected from excessive movement.
• Patients present in one of three ways:
– Pulseless
– Haemodynamically unstable
– Haemodynamically stable

38. PENETRATING INJURY
• The pulseless patient
– Emergency laparotomy: quickly send to the theatre for on-going bleeding to be
stopped.
– Second option: emergency room thoracotomy and cross clamp the aorta –
ideally done in theatre.
• Haemodynamically unstable (transient or not responding to resuscitation.
– Emergency laparotomy
– May do a FAST to confirm abdomen as the source of bleeding.
• Haemodynamically stable
– Can be investigated for the appropriate intervention.

39. INDICATIONS FOR LAPAROTOMY

40. INDICATIONS FOR LAPAROTOMY
• Control bleeding
• Identification of injury
• Control of contamination
• Protection from further injury eg. Abdominal compartment syndrome

41. SPLEEN- CONTRAINDICATION TO
SPLENIC PRESERVATION
• Hilar avulsion injuries.
• Rupture of grossly pathological spleen e.g .. splenomegaly syndromes, leukemia or SC
disease.
• Multiple associated injuries.
• Gross intra-abdominal contamination especially from colonic perforations. 5. Blast
injuries to the left side of the abdomen

42. SPECIFIC ORGAN REPAIR
• Spleen: Emergency splenectomy
• Liver: Tractotomy and direct ligation
• Extra biliary: Cholecystectomy Simple suture with decompression by cholecystostomy
• Pancreas: Pancreatectomy

43. SPECIFIC ORGAN REPAIR
• Stomach: Primary suture with two rows of catgut dexon coupled with adequate
peritoneal toileting
• Duodenum: Duodenojejunostomy
• Small bowel: Resection with end to end anastomoses

44. SPECIFIC ORGAN REPAIR
• Large bowel:
 Primary end to end anastomoses
Hartman’s pouch
Right hemicolectomy with ileotransverse anastomoses