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SOLID ORGAN INJURIES

SPLEEN , LIVER , PANCREAS2013

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Abdominal Injuries

• 5 pillars• Solid Organs: Bleed, shock• Hollow Organs: Leak, peritonitis• Retroperitoneum: pancreas, large vessels• Urinary system• Diaphragm

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Mechanism of injuries

• Blunt: • spleen, liver, and small bowel

• Penetrating stab: • liver, small bowel, diaphragm, colon

• Penetrating gun shot: • small bowel, liver, colon

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Splenic Function

• Immunologic filter• Primary remover of non-opsonized bacteria

• Produces tuftsin and properdin• Properdin vital component of alternate

pathway of complement activation• Immunoglobulin production

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Splenic Anatomy

• 100-250 grams• 200 cc/min blood flow• Splenic artery

• 85%-extrasplenic bifurcation• 15%-extrasplenic trifurcation

• Ligamentous attachments• stomach, kidney, diaphragm, colon

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Diagnosis of Splenic Injury• Physical examination - poor sensitivity• Ultrasound - nonspecific• DPL-too sensitive, ? role in nonoperative

management• CT-most common in hemodynamically stable

pts• Laparoscopy-has not found a universal role

AAST SPLEEN INJURY SCALE (1994 REVISION)Grade Injury Description

I Hematoma Subcapsular, nonexpanding, < 1 0% surface areaLaceration Capsular tear, nonbleeding, < 1 cm parenchymal depth

II Hematoma Subcapsular, nonexpanding, 10-50% surface area;intraparenchymal, nonexpanding, < 5 cm in diameter

Laceration Capsular tear, active bleeding; 1-3 cm parenchymal depthwhich does not involve a trabecular vessel

III Hematoma Subcapsular, > 50% surface area or expanding; rupturedsubcapsular hematoma with active bleeding;intraparenchymal hematoma > 5 cm or expanding

Laceration > 3 cm parenchymal depth or'involving trabecular vesselsIV Hematoma Ruptured intraparenchymal hematoma with active

bleedingLaceration Laceration involving segmental or hilar vessels producing

major devaculadzation (> 25% of spleen)V Laceration Completely shattered spleenVI Vascular Hilar vascular injury which devascularizes spleen

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Management of Splenic InjuriesFactors Influencing Decision

• Age of patient- >55yo splenectomy better• Success of non-operative management- 68-83%• Risk of missed injury• Risk of OPSI-0.026-1.0% over lifetime• Risk of blood transfusion-0.014% per unit• Risk of nontherapeutic laparotomy-0.01-6.0%

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Non-Operative Management

• Proper patient selection• Bed rest 2-3 days• Serial physical exams, Hcts x 24-48 hours• Follow-up CT scan at 3-5 days• Overall hospitalization 5-10 days• Severe injuries-3 months no contact sports

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Non-operative management

• Embolisation• Trans-arterial catheter aorta splenic artery

• Partial or total splenic embolization• Splenic immunocompetence is preserved after

splenic artery angio-embolisation

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Operative Management

• Midline incision, pack, examine abdomen • Systematic splenic mobilization• Splenorrhaphy- Cautery, surgicell, pledgetted

sutures, mesh wrapping• Splenectomy- life threatening bleeding • Autotransplantation-experimental• Vaccination-Pneumococcus, H. influenza, N. meningitidis

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Complications

• Pneumonia most common• Subphrenic Abscess 3-13%• Recurrent bleeding - up to 45 days

• 1% re-operative rate (for haematoma, or abscess drainage for example)

• Acute gastric distention- kids usually• Thrombocytosis (very high platelets)

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OPSI

• Nausea, vomiting, confusion, sepsis• Mortality 50-70%• Vaccine provides 60% protection• Best timing of vaccine unknown• Proper counseling a must• Sensitive to malaria

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HEPATIC INJURIES• ANATOMY• INJURY CLASSIFICATION• INITIAL PATIENT MANAGEMENT• OPERATIVE TECHNIQUES• SPECIAL TOPICS

• JUXTAHEPATIC VENOUS INJURIES• SUBCAPSULAR / INTRAHEPATIC HEMATOMAS• EXTRAHEPATIC BILIARY TREE INJURIES

• COMPLICATIONS

• Most commonly injured in stab wounds and blunt injuries• Present as bleeding with hemodynamic instability

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ANATOMY

• LIGAMENTOUS ATTACHMENTS• TRIANGULAR• CORONARY• FALCIFORM

• COUINAUD CLASSIFICATION OF LOBAR / SEGMENTAL DIVISIONS

LIVER INJURY SCALE (1994 REVISION)Grade Injury Description

I Hematoma Subcapsular, nonexpanding, < 1 0 cm surface areaLaceration Capsular tear, nonbleeding, < 1 cm parenchymal depth

II Hematoma Subcapsular, nonexpanding, 10-50% surface area: intraparenchymalnonexpanding< 1 0 in diameter

Laceration Capsular tear, active bleeding; 1-3 cm parenchymal depth, < 1 0 cm in length

III Hematoma Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematomawith active bleeding; intraparenchymal hematoma > 10 cm or expanding

Laceration > 3 cm parenchymal depth

IV Hematoma Ruptured intraparenchymal hematoma with active bleedingLaceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinaud's

segments within a single lobe

V Laceration Parenchymal disruption involving > 75% of hepatic lobe or > 3 Couinaud'ssegments within a single lobe

Vascular Juxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepaticveins)

VI Vascular Hepatic avulsion

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DIAGNOSIS OF LIVER INJURY

• ATLS primary / secondary surveys• Peritoneal signs - exploration • Hemodynamic instability - US or DPL• Stable – CT scan with contrast (embolization)• Non-operative management : hemodynamic stability, no

other suspected injuries, alert patient*, ICU monitoring, accessible for re-examination, minimal transfusions

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LIVER -Penetrating Wounds

• STAB WOUNDS• LOCAL WOUND EXPLORATION• ULTRASOUND• DPL• ? LAPAROSCOPY

• GUNSHOT WOUNDS• EXPLORE• ? ROLE FOR ULTRASONOGRAPHY• ? ROLE FOR LAPAROSCOPY

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OPERATIVE TECHNIQUES

• MANUAL COMPRESSION• EXPOSURE(INCISION + LIGAMENTS)• PRINGLE MANEUVER (32-75 MINUTES)

• Portal vein; hepatic artery: block inflow of blood; find source of bleeding

• TOPICAL HEMOSTATIC AGENTS• BOVIE / ARGON BEAM COAGULATOR• FIBRIN GLUE

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OPERATIVE TECHNIQUES

• Tractotomy / individual vessel and duct ligation

• Omental packing• Resectional debridement• Absorbable mesh wrapping

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OPERATIVE TECHNIQUES

• Drainage (grade III or better)• Laparotomy pad packing - remove before 3

days if possible• *Deep sutures• *Hepatic artery ligation• *Anatomic lobectomy *avoid if possible

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OPERATIVE TECHNIQUES

• HEAT CONSERVATION • BEGINS WITH INITIAL PATIENT CONTACT• LIMIT HEMORRHAGE

• SPEED / EFFICIENCY COUNTS• EQUATES TO PROMPT DECISION-MAKING• DAMAGE CONTROL SURGERY: quick, manage

bleeding and contamination; continue resus in ICU• PREVENT TRIAD OF ACIDOSIS,

COAGULOPATHY AND HYPOTHERMIA (affects clotting mechanism)

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Control of Transhepatic Penetrating Wound

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Juxtahepatic Venous Injury

• Early recognition• Big (chest) incisions (laparotomy and

thoracotomy)• Atrial-caval shunt or caval balloon shunt• Direct attack with or without hepatic

vascular isolation • Packing alone

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Atrial-Caval Shunt

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Subcapsular Hepatic Hematomas

During non-operative treatment , operate for: • On-going hemorrhage• Progressive expansion by ct scan• Signs of infection• Deteriorating transaminase measurementsIntra-operative, if not expanding:• Leave alone in stable patients

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Extrahepatic Biliary Tract Injury

• Rare: 3-5% of all abdominal trauma• Gallbladder (most common)

• cholecystectomy• CBD > RHD> LHD

• <50% circumference - repair with or without T-tube; drain

• >50% circumference - duct enterostomy; drain

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COMPLICATIONS

• Recurrent bleeding - 2% to 7%• Fever - 65% to 75%, grade 3 or more• Abscess - 2% to 10% (increased by shock,

transfusion, colon injury)• Biloma / biliary fistula - 5% to 28%• Hemobilia - extremely rare; 1/3 have jaundice,

upper GI bleed, right upper quadrant pain• Arterial portal venous fistula

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Damage Control Considerations

• Deep suturing• Packing• Omental packing• Drains• Antibiotics• Atrial-caval shunts• CT scan / non-operative management

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PANCREATIC INJURY

• RETRO-PERITONEAL ORGAN• PENETRATING INJURY – IS THE DUCT

INTACT ?• BLUNT INJURY – TRANSECTION OF

GLAND OVER THE VERTEBRAL COLUMN

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PANCREATIC INJURY

• DIAGNOSIS DIFFICULT• HIGH INDEX OF SUSPICION• CLINICAL EXAMINATION NOT HELPFUL• U/S, CT SCAN IF STABLE• SERUM AMYLASE (increased? Duct intact? >>)

• do ERCP

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Diaphragmatic injury

• Traumatic rupture (blunt trauma)• More common on left side (85%)• Tear posterolateral from hiatus• Herniation of stomach, colon, spleen into chest• Penetrating injury usually a small hole, on either

side

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Diaphragmatic injury

• Diagnosis: clinical difficult• Bowel sounds in chest on auscultation• CXR: high diaphragm on left side, or diaphragm

invisible• Confirmation by passing a nasogastric tube,

which can be seen in stomach in chest• Chronic: contrast studies (Ba meal or enema)

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Diaphragmatic injury

• Laparoscopy (or thoracoscopy) for diagnosis• Repair: surgical, via laparotomy (or

thoracotomy), or endoscopic technique• Pitfall: PPV (positive pressure ventilation)

reduced the abdominal organs from chest

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Questions?