ABDOMINAL TRAUMADr. (Brig) P. Krishna murthy

INTRODUCTION Trauma is the most common cause of death below 45

yrs ageIt is 3rd most common cause of death regardless of

ageDeath rate underestimates the magnitude of social tollIncidence of abdominal trauma- 13% of total trauma

cases40% trauma deaths are due to torso traumaIdentification of serious intra-abdominal injuries is

often challenging Many abdominal injuries may not manifest during the

initial assessment and treatment period 

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TRIMODAL DEATH OF TRAUMA

CAUSES OF ABDOMINAL TRAUMA

1. Road traffic accidents- leading cause2. Falls3. Crush injuries4. Stab injuries5. Gun shot wounds6. Blast injuries

MECHANISM OF ABDOMINAL TRAUMABlunt trauma – energy is transferred over wide

areaPenetrating trauma – damage is localised to the

path of knife or bullet

INITIAL MANAGEMENT OF ABDOMINAL TRAUMA( ATLS Protocol) Approach to trauma patient is different from

other patientsC of ABC Determine if patient is in shockWarning signs- Deteriorating consciousness Pallor & cool extremities Tachycardia

INITIAL MANAGEMENT (CONTD.)

-Resuscitate if shock is present 2 large bore peripheral Iv cannulas 1-2 litres of crystalloid-Rapid assessment of source of blood loss “ one on floor and four more”-Investigations- chest x-ray AP view, x-ray pelvis AP view, FAST-Reassess for response to resuscitation i.e, Responders and non responders

FAST focusses only on 4 areas

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EVALUATION OF BLUNT TRAUMAMode of injuryClinical examination- 1/3 patients may not have abd

findingsRepeated examinations may be necessaryInvestigations- X-ray abdomen, chest and pelvis USG abdomen CT scan abdomen Peritoneal tap( 4 quadrant tap) DPL Angiography

CT ScanDone in Hemodynamically stable patientIv contrast / oral contrast is used

Advantages  Retroperitoneal assessment can be madeNonoperative management of solid organ injuryHigh specificity

Disadvantages  cost, radiationHollow viscus injuries, diaphragm injury are not seen

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DPLStandard criteria10cc gross bloodRBC>100,000/mm2 (5% miss)WBC>500/mm2

Amylase>175 IU/dLBile, bacteria, or food

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EVALUATION OF BLUNT TRAUMA

EVALUATION OF PENETRATING ABDOMINAL TRAUMA

GSWHaemodynamically unstable- Entry & exit wounds anterior expl laparotomy to mid axillary lines-

Entry & exit wounds posterior to mid axillary line- CT scan, laparoscopyTangential wounds-

EVALUATION OF PENETRATING ABDOMINAL TRAUMA  (contd…)

         LIVER TRAUMA

grade I  HAEMATOMA: sub capsular, <10% surface area LACERATION: capsular tear, <1 cm depth

grade II  HAEMATOMA: sub capsular, 10‐50% surface area HAEMATOMA: intraparenchymal <10 cm diameter LACERATION: capsular tear, 1‐3cm depth, <10 cm length

grade III HAEMATOMA: sub capsular, >50% surface area, or ruptured with active bleedingHAEMATOMA: intraparenchymal >10 cm diameter  LACERATION: capsular tear, >3 cm depth

grade IV  HAEMATOMA: intraparenchymal rupture with active bleedingLACERATION: parenchymal disruption involving 25‐75% hepatic lobe or involves 1‐3 Couinaud segments (within one lobe)

grade V LACERATION: parenchymal disruption involving >75% hepatic lobe or involves >3 Couinaud segments (within one lobe)VASCULAR: juxtahepatic venous injuries (IVC, major hepatic vein)

grade VI vascular: hepatic avulsion 

 MANAGEMENT 80% of patients with hepatic injuries can be managed

conservatively ( NOMLI )irrespective of grade of injury.

Indications for surgery (1) haemodynamically unstable patient

(2) multiple transfusions required to maintain haemodynamic stability

(3) signs of peritonism, or development of peritonism on serial abdominal examinations

(4) active arterial blush on CT for which interventional techniques ( angiographic embolisation) have failed

OPERATIVE MANAGEMENTOperative management can be summarised in 4 P’s

• PUSH ( Manual compression )PRINGLEPLUGPACK

The liver is packed with laparotomy pads to provide compressionagainst the abdominal wall, diaphragm, and retroperitoneum

Omental pedicle packing

Pringle maneuver:

Gallbladder injuries - cholecystectomy.

Bile duct injuries within the liver parenchyma may generally be managed nonoperatively

Duct transection with tissue loss or extensive injury should be treated with Roux-en-Y choledocho- or hepaticojejunostomy.

                 SPLENIC INJURY            

 GRADING OF SPLENIC INJURY

Management

 Recent trend is  Non‐operative management of splenic injury (NOMSI)

   ‐ hemodynamically stable patients with grade I, II, or III splenic injuries.

Angiography with embolization is a useful adjunct to NOMSI. Indications to Angiographic embolisation include CT evidence of ongoing bleeding with contrast extravasation outside or within the spleen

 Indications for  surgical intervention:o  Hemodynamic instabilityo Grade IV, V splenic injuryo Evidence of continued splenic hemorrhageo Replacement of more than 50 % of the patient’s blood volume or need for more than 4 units of blood transfusions

o Associated intra‐abdominal injury requiring surgery

PANCREATIC TRAUMA

  PANCREATIC INJURIES 1. BODY AND TAIL a. duct intact‐ nonoperative closed drainage b. duct involved‐ distal pancreatectomy/ pancreatico‐jejunostomy 

+ closure of proximal cut end

2. HEAD a. No duct injury‐  closed drainageb. Duct injury‐ CBD injury Roux‐en‐y choledochojejunostomy + closure of 

distal end ‐PANCREATIC DUCT injury central pancreatectomy+ Roux‐en‐

y pancreaticojejunostomyc.   Destructive injuries‐ whipple’s ( pancreatico‐ duodenectomy)

 Injury of  body of pancreas with duct involvement‐ Roux‐en‐Y pancreaticojejunostomy

 INJURIES TO STOMACHPrimary repair is done due to good vascularity

 INJURY TO DUODENUM 1.Small perforations/lacerations‐ primary repair

2. Extensive injuries‐ 1st part‐‐‐Mobilise and end to end anastomosis2nd part‐‐‐patch with vascularised jejunal graft3rd part ( proximal to SMA )‐‐‐closure of distal stump+Roux‐en‐y duodenojejunostomy

3rd part (distal to SMA ), 4th part‐‐‐‐duodenojejunostomy left of SMA

  INJURIES TO SMALL BOWEL Primary repair / resection anastomosis

 INJURY TO COLON

No contamination‐‐‐ primary repairContamination present‐‐‐ colostomy

                 RENAL INJURY

Treatment of renal injuryMost blunt renal injuries, including all grade 1 and

2 and most grade 3 and 4 injuries, can be safely treated conservatively.

Surgical Intervention is required for patients with the following:Persistent bleeding (ie, enough to necessitate

treatment for hypovolemia)Expanding perinephric hematomaRenal pedicle avulsion or other significant

renovascular injuries

 INJURY TO URINARY BLADDERIntra peritoneal rupture‐‐‐ primary repairExtra peritoneal rupture‐‐‐ conservative management

 RETROPERITONEAL TRAUMA

Zones of retroperitoneal injury.  zone I, central (injuries to aorta and caval vein and their main branches as well as duodenum and pancreas) zone II  lateral (injuries to kidney and bowel vssels) zone III  pelvic (injuries to pelvis and iliac arteries and veins)

Zone I :- midline retroperitoneal hematomas “all” need surgical exploration, as they commonly result in injury to vital structures. Zone II :- surgery done if there is expanding

hematomaZone III :- conservative management

DAMAGE CONTROL SURGERYMinimising surgery until the physiological derangements can be corrected.Components          ‐Stopping active bleeding          ‐controlling contamination Decision for damage control surgery to be taken at the earliest in ED or at the beginning of surgery.

DAMAGE CONTROL SURGERY contd..Stages of damage control surgery      1. Patient selection      2. Control of hemorrhage and contamination      3. Resuscitation continued in ICU      4. Definitive surgery      5. Abdominal closure

DAMAGE CONTROL SURGERY contd..INDICATIONS:‐  ANATOMICAL‐  ‐ Inability to achieve hemostasis ‐ Complex abdominal injuries ( ex: liver and pancreas ) ‐ Combined major vascular , solid and hollow organ injuries ( ex: IVC, AORTA etc )

 ‐ Inaccessible major venous injury ( ex: retrohepatic vena cava )

DAMAGE CONTROL SURGERY contd..PHYSIOLOGICAL ‐ Acidosis  (pH<7.2) ‐ Coagulopathy ( PT > 19 sec, PTT> 60 sec ) ‐ Massive blood transfusion ( > 10 units ) ‐ Hypotension ( < 90 mm Hg for more than 1hr )

 

Vac‐pack dressing

(a) covering the bowel with a fenestrated plastic drape, (b) placement of closed‐suction drains and a  towel, ( c ) adhesive occlusive dressing

“Vac‐Pack” dressing :‐(1)A fenestrated plastic sheet is draped over the bowel and extended to the paracolic gutters to keep the bowel from adhering to wound edges.

(2) A towel is placed over the sheet to prevent suction drains from adhering to bowel through the slits in the plastic sheet. 

(3)Drains are placed on top of the towel. (4) Finally, an adhesive drape is placed over the entire wound

  CONCLUSIONAbdominal trauma constitutes an important group of injuries requiring proper assessment and prompt management to decrease the mortality.Operative decisions for blunt trauma abdomen are more challenging than penetrating trauma.Majority of solid organ injuries can be managed conservatively.Surgical team should make a decision for damage control surgery as early as possible.

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