Abdominal

Trauma
Diagnosis and treatment
of intraabdominal
injuries
Alhmoud Faiez
Consultant Surgeon
Albashir Hospital. MOH

Where is the abdomen?

External Anatomy
Thoracoabdominal area:
Any
penetrating
Transverse
nipple line toinjury to any of these
areas,
or that may have traversed this
costal margin
Anterior abdomen:
volume,
shouldCostal
be considered as a
margin to groin crease to
potential
abdominal
injury, and
anterior axillary
lines
evaluated
as such.
bilaterally
Flank area:
Between
Special
Care
anterior and posterior
axillary
Wounds
to thoracoabdominal
lines from
6th
junction
zone
intercostals
space
to iliac
crest.
Flank or back wound
Back: Medial to posterior
axillary
Wound
lines,to
tip buttock
of scapula or perineum
to iliac crests & gluteal skin

The Abdomen
Cardiac Box

Mediastin
um

Thoracoabdominal area

The external appearance of wound

doesnt determine the extent of

Classification of
injuries
Blunt

trauma
Penetrating
trauma
Iatrogenic trauma

When should you

suspect intraabdominal
injury?
Blunt
Diagno
sis and Penetrating

Weapon
Speed
Distance
Point of
impact
Number and
Involvement
location of
wounds
Safety
devices
Position
morbidity
preventable
Ejection

treatment of
intraabdominal injuries
are essential to avoid

Primary Survey-ATLS
Approach
A Intubation may be required if pt. is
shocked, hypotensive or unconscious or
in need for ventilation
B Watch for hemo-pneumothorax in
both blunt and penetrating
thoracoabdominal injuries
C Start with 2 L crystalloid (If active

bleeding you MUST FIND & STOP THE

BLEEDING)

D May see associated thoracolumbar

Diagnosis & Treatment

Priorities
Patients
with abdominal
injury tend
to fallor
into 4 major
First: recognize
presence
of shock
categories:
intraabdominal bleeding
Presentation
Injury Type
Management
priority
Second:
start resuscitative
measures
for shock
/
bleeding
Pulseless
Major vascular injury
Emergency laparotomy
Consider ED thoracotomy
Third: determine if abdomen is source for shock
Hemodynamically
Vascular and/or solid organ
Identify & control
or bleeding
unstable
injury AND/OR
hemorrhage
Hemorrhage from other sites
Fourth: determine if emergency laparotomy is
Hemodynamically
solid organ injury
Resuscitation
needed
stable
Hemorrhage<750cc
Grading
Fifth: complete secondary survey, lab, and
Hemodynamically
Hollow viscus
injury
presence of
radiographic studies
to determine
ifIdentify
occult
Normal
Pancreas or renal
gastrointestinal,
abdominal injury is present
diaphragmatic or

Estimation of blood
loss
-Hemorrhage is a
concern with
abdominal trauma.
-Estimation of blood
volume lost is
difficult.
-Signs and symptoms
depend on:

Volume of
blood lost
Rate of loss

Base deficit & lactate

Resuscitation
Biggest

concern

Positioning

for comfort.
Apply high-flow oxygen.
Treat for shock.

Resuscitation

Upper extremity large bore i.v

cannulae and i.v fluids with RL or
N/S should begin immediately with
Blood sampling
If your patient sustained blunt
trauma, as in a motor vehicle crash
(MVC), keep his neck and spine
immobilized until X-rays rule out a
spinal injury.

Resuscitation

An early rapid assessment of the

abdomen
Rectal examination
Catheteres and tubes
Administer tetanus prophylaxis
and antibiotics as indicated.

Damage control
resuscitation
Its an alternative resuscitation approach to
hemorrhagic shock which involves:
1.Rapid control of surgical bleeding
2.Early and increased use of red blood cells, plasma and
platelets in a 1:1:1 ratio
3.Limitation of excessive crystalloid use
4.Prevention and treatment of hypothermia, hypocalcemia
and acidosis
5. Permissive hypotension. (Hypotensive resuscitation
strategies)

Damage control resuscitation can be

applied to unstable patients who are with

Identify where is the

bleeding?
4 & On the floor

Chest CXR
Intraperitoneal abdomen-FAST
Retroperitoneal abdomen CT scan
Extremities (femur #s)-XRs

Then stop it:

OR
Angioembolization
Pressure
Reduction & stabilization

Secondary Survey
History
History for all trauma patients:
Not necessary making an accurate diagnosis

S.A.M.P.L.E
S: Symptoms:

Pain, vomiting, hematuria,

hematochezia, dyspnea, respiratory distress..

A: Allergies
M: Medications
L: Last meal
E: Events: Mechanism of injury is important
factor

Physical Examination
How Good is our Physical Exam?
What is the primary objective?

Accuracy only 60-65%

Serial physical examination has the best
sensitivity and negative predictive value of all
modalities for the evaluation of penetrating
abdominal trauma
The primary objective of the physical
examination in abdominal trauma is to rapidly
identify the patient who needs a laparotomy.
Pulse, blood pressure, capillary refill and urine
outputhypovolemia + abdominal signs

Physical Examination
Inspection: abrasions, contusions, lacerations,
deformity, entrance and exit wounds to determine
path of injury..
(Grey-Turner, Kehr, Balance, Cullen, seat belt
sign.)
Palpation: elicit superficial, deep, or rebound
tenderness; involuntary muscle guarding
Percussion: subtle signs of peritonitis; tympany in
gastric dilatation or free air; dullness with
hemoperitoneum.
Auscultation: bowel sounds may be decreased(late
finding).

Physical Exam:
Eponyms

Grey-Turner sign: Bluish

discoloration of lower flanks,

lower back; associated with
retroperitoneal bleeding of
pancreas, kidney, or pelvic
fracture.
Cullen sign: Bluish
discoloration around umbilicus,
indicates peritoneal bleeding,
often pancreatic hemorrhage.
Kehr sign: shoulder pain
while supine; caused by
diaphragmatic irritation (splenic
injury, free air, intra-abdominal
bleeding)
Balance sign: Dull
percussion in LUQ. Sign of

Seat Belt Sign

Londons sign.

Grey-Turner sign

Fox sign

Cullen sign

Labia and Scrotum

Kehr sign
Balance sign

Radiological and
Ancillary diagnostic
procedures

Plain x-ray chest,abdomen,and pelvis

FAST
Diagnostic peritoneal lavage Aspiration
Local Wound Exploration
Contrast studies, CT scan.
Urethro-Cysto-graphy
IVU
Angiography

Plain films

Pneumotharax, Haemothorax
Free air under diaphragm
Retroperitoneal stippling associated
duodenal injury
Nasogastric tube, bowel loops in the
chest
Elevation of the both /Single diaphragm
Lower Ribs # -Liver /Spleen Injury
In penetrating trauma, injuring trajectory
Ground Glass Appearance =
Massive
Hemoperitoneum
Obliteration of Psoas
Shadow=Retroperitoneal
Bleeding

Focused assessment with

sonography for trauma
-To diagnose free intraperitoneal (FAST)

fluid.
-Evaluate solid organ hematoma
-Four areas:
1. Pericardium (subxiphoid)
2.Perihepatic & hepato-renal
space (Morrisons pouch)
3.Perisplenic
4. Pelvis (Pouch of
Douglas/rectovesical pouch)
sensitivity 60 to 95% for
The larger the hemoperitoneum,
detecting 100mL - 500mL of
the higher the sensitivity. So
fluid
sensitivity increases for

(E-FAST):

clinically significant
hemoperitoneum.

Add thoracic windows to look

for pneumothorax. Sensitivity
59%, specificity up to 99% for How much fluid can FAST detect?
250 cc total
PTX

FAST

Advantages

Portable (bedside), fast (<5 min) and ability to repeat

No radiation or contrast
Noninvasive
Less expensive
Rapid results, Hemodynamically unstable pt who cannot go to CT

Disadvantages

Not

good for acute parenchyma damage, retroperitoneal, or diaphragmatic

defects.

Limited
High

of

by obesity, distended bowel loops and subcutaneous air.

(30%) false-negative rate in detecting hemoperitoneum in the presence

pelvic fracture

Operator

dependent

Particularly

poor at detecting bowel and mesentery damage (44% sensitivity)

Ct scan

Accurate for solid visceral lesions and its grading and

intraperitoneal hemorrhage. Guide nonoperative
management of solid organ damage.
Sensitivity for solid organ is >95% but for enteric &
for diaphragmatic 60% & for pancreatic 30% (organ
specific)
Noninvassive

Disadvantages :
Contraindications
-Contrast allergies
Clear indication for
Indications;
-Time
consuming
Blunt
exploratory laparotomy
trauma
Hemodynamically unstable
Hemodynamically
stable
-Relatively expensive
patient
-Intravenous iodinated patient
contrast risk

Normal or unreliable

Contrast allergic patient

Diagnostic peritoneal
lavage
DPL is indicated in A
bothDying
blunt and aArt?
selective group of
penetrating abdominal injuries.
Blunt abdominal trauma where CT or FAST is not
available or where imaging is equivocal
Anterior abdominal stab wounds with violation of
peritoneum on local wound exploration
Unreliable abdominal exam (i.e. altered mental status,
intubated, spinal cord injury) with negative or equivocal
imaging
Changes in abdominal exam or vitals in observed
patients with negative initial imaging
Patients with blunt or penetrating trauma who cannot
be safely transported out of the resuscitation bay (i.e.
CT scanner, interventions for other injuries)

Contraindications of DPL
Absolute:

Peritonitis
Gunshot wound
Injured diaphragm or evisceration
Extraluminal air by x-ray
Significant intraabdominal injury by CT scan
Intraperitoneal perforation of the bladder by cystography

Relative:

Previous abdominal operations (because of adhesions)

Morbid obesity
Gravid Uterus
Advanced cirrhosis (because of portal hypertension and the risk
of bleeding)
Preexisting coagulopathy

DPL Procedure

Complications of DPL
Perforation of
Small bowel,
Mesentry and
Bladder.
Limitations
Gives no information about retroperitoneal
organ status
RBC
IF
INCIDENCE
OF VISCERAL
No COUNT>100,000/ML
determinationtheof
which organ
has INJURY=
been 95%
20,000-100,000ML
= 15-25%
damaged.

<20,000ML

< 5%

Comparison of
DPL,FAST and CT
DPL

FAST

DOCUMENTS:
BLEEDING
FLUID
BP STATUS:
LOW
LOW
NORMAL
SENSITIVITY:
98%
82% -97%
98%
SPECTIFITY:
LOW(MID80)
(MID 90)
9O)
DISADVANTAGES:Invasive
Op. depended
time

CT
ORGAN

92%(HIGH
Cost &

Local Wound Exploration

A Dying Procedure?
Formal evaluation of a stab wound under
local anaesthesia
This procedure is usually performed in the
operating room
Penetration of the anterior fascia is
considered a positive LWE
When LWE is used alone to determine
laparotomy, there will be a high nontherapeutic laparotomy rate

LAPAROSCOPY

Most useful to evaluate penetrating wounds to

thoracoabdominal region in stable patient

Spec. for diaphragm injury: Sensitivity 87.5%,

specificity 100%

Can repair organs via the laparoscope

(diaphragm, solid viscera, stomach, small bowel.)

Disadvantages:
Poor

sensitivity for hollow visceral injury

and retroperitoneum

Exploratory
Laparotomy

Diagnostic capabilities have reduced the number of

negative
laparotomies and established the priorities
The indications for exploratory laparotomy are:
Either.Clinical
a. Obvious peritoneal signs on physical examination
b. Hypotension with a distended abdomen
c. Abdominal GSW with peritoneal penetration
d. Abdominal stab wound with evisceration, hypotension,
or peritonitis
OrParaclinical
a. Positive FAST with hemodynamic instability or DPL
b. Findings with any other diagnostic intervention (e.g.,
chest x-ray [ruptured diaphragm, pneumoperitoneum],

Once the decision is

made to operate:Gen.
The patient must be
rapidly transported
set-up

directly to the OR with appropriate airway

support
If possible, informed consent is obtained
Intravenous lines, tubes, and spinal
precautions (at least two large-bore I.Vs,
broad-spectrum antibiotic, place chest tubes
to underwater seal, dont clamp, place
nasogastric or orogastric tube and a bladder
catheter before laparotomy..)
Rapid-infusion system.
Ascertain that packed RBC are in the OR and

You see what you look

for

Procedure

1. Incision. Generous midline incision is

preferred. Self retaining retractor systems and
headlights are invaluable.
2. Bleeding control. Scoop-free blood and
rapidly pack all quadrants
3. If packing does not control a bleeding
site, this source must be controlled as the first
priority.
4. Contamination control. Quickly control

Procedure

5. Systematic exploration. Systematically explore the

entire abdomen, giving priority to areas of ongoing
hemorrhage
A. Liver
B. Spleen
C. Stomach
D. Right colon, transverse colon, descending colon,
sigmoid colon, rectum, and small bowel, from ligament of
Treitz to terminal ileum, looking at the entire bowel wall
and the mesentery
E. Pancreas, by opening lesser sac (visualize and palpate)
F. Kocher maneuver to visualize the duodenum, with
evidence of possible injury
G. Left and right hemidiaphragms and retroperitoneum
H. Pelvic structures, including the bladder
I. With penetrating injuries, exploration should focus on

SPECIFIC ORGAN
INJURIES.
Treatment of an
organ injury is similar Specific Organs
whether the injury
Trauma:
mechanism is
1.Peritoneal
penetrating or blunt
2.Retroperitoneal
An exception to the
3.Diaphragm
rule is a
retroperitoneal
hematoma.
Explore all
retroperitoneal

1.Diaphragm
Its possible in injuries to the thoracoabdominal
region
Can be due to blunt(>85%) or penetrating injury and
is larger in the blunt
Possible cardiac injury if the penetrating wound is
more central
The weakest point of diaphragm is the
Lt.posteriolateral (80%)
Often missed in multitrauma
In isolated injury it may go unnoticed and there is
often a delay between the injury and the diagnosis.
Patients present with non specific symptoms and
may complain of chest pain, abdominal pain, dyspnoea,
tachypnoea and cough

Diagnostic
modalities
Cl. Examination:
Chest pain and shortness of breath
Scaphoid abdomen
Bowel sounds on auscultation of the
hemithorax
Plain radiography:
Hollow viscus noted in the left hemithorax
FAST
Nasogastric
tube inUnreliable
the left hemithorax
examination:
DPL: Inconclusive; high false-negative
CT scan: Inconclusive
Laparoscopy: The diagnostic modality of choice

Treatment
Once identified must be repaired because it will not
close spontaneously regardless the size
Early diagnosis needs abdominal approach using
interrupted nonabsorbable suture and the large defect
(>25cm2)may need nonabsorbable mesh
In the event of a gross contamination, endogenous
tissue can be utilized for a definitive repair as
latissimus dorsi flap, tensor fascia lata, or omentum.
There are some who advocate using biologic tissue
grafts, such as AlloDerm (human acellular tissue
matrix; Life Cell Corporation). The durability of such a
repair is questionable. Irrigate the thoracic cavity
through the defect in the diaphragm

2.Stomach
More common in
FAST examination
penetrating trauma
Unreliable
than blunt & its
about 10% of
DPL
penetrating injuries of RBCs
the abdomen
WBCs
Gross contamination
Diagnosis:
CT scan
Physical examination
Pneumoperitoneum
Epigastric tenderness
Peritoneal signs
Laparoscopy
Bloody gastric aspirate
Plain radiography in <50% Operator dependent

Stomach:
treatment is according to the severity
Administer preoperative antibiotics
Hematoma is evacuated, hemostasis and
closure with nonabsorbable suture
Small perforations can be closed in one or two
layers
Large injuries near the gr. curvature can be
closed by suture or GIA stapler
Certain defects may be closed using a TA
stapler
A pyloric wound may be converted to
pyloroplasty
Destructive wound may need proximal or distal

3.Small Intestine
The small bowel is the most commonly
injured intraabdominal organ in penetrating
trauma; a blunt trauma cause is less
common, but not rare (10%)
Small isolated perforations probably result
from blowouts of pseudo-closed loops
(seatbelt-related injuries).
Larger perforations, complete disruptions,
and injuries associated with large mesenteric
hematoma or lacerations are caused by direct
blows or shearing injury or contusion.
Perforation from blunt injury is most common
at the ligament of Treitz, ileocecal valve,

Small Intestine
Diagnosis is clinical:
Suspect small-bowel injury with evidence of
CT has a significant false negative
an abdominal wall seat-belt contusion or
rate
in the
diagnosis
of small-bowel
fracture
of the
lumbar spine.

injury.
Small-bowel
injury
is often not diagnosed
CT findings
in small-bowel
injury on
initial presentation because the patient is less
include:
likely to have peritonitis on initial
Fluid collections without solid viscus
examination.

injury
This
delay
contributes
significantly to
Bowel
wall
thickening

Small Intestine
Treatment is operative

1.Administer preoperative antibiotics - Laparotomy

2.Imbricate antimesenteric wall hematomas or serosal
injuries with Lembert stitches to reduce the risk of
delayed perforation.
3.Debride simple lacerations and close transversely in
one layer to avoid stenosis. Similarly connect and
close adjacent small lacerations
4.Resect larger injuries and perform anastomosis.
5.Injuries to the mesentery of the small bowel, which can
bleed massively, must be rapidly controlled, with
definitive repair of the small bowel delayed until
later in the operation.
6.Injury to the proximal SMA may require a saphenous
vein interposition graft or shunting in a damage

Colon and rectum

Diagnosis

Peritoneal signs or free intraperitoneal air.

At laparotomy, small injuries in the wall of the colon
can be missed so explore all blood staining or
hematomas of the colonic wall.
Consider proctoscopy or proctosigmoidescopy
in :
- Gross blood on PR in the presence of a pelvic
fracture
- Penetrating abdominal, buttock, thigh or pelvic
wound.
- Any patient with a major pelvic fracture if the
patient is stable.
The location of the injury can be important in
planning the operation. Even if the hole cannot be
visualized on proctoscopy, assume the patient has a

Colon and rectum

Treatment is operative
If a primary
repair cannot
be performed
safely for
anatomic
The guidelines for primary repair include
Minimal fecal spillage,
reasons (bowel
No shock (defined as systolic blood pressure <90 mmHg),
wall edema,
Minimal associated intraabdominal injuries,
<8-hour delay in diagnosis and treatment, and
vascular
<1-L blood transfusion.
compromise), a
colostomy may
Traditional contraindications to primary repair include
Patients with shock, underlying disease, significant associated
be a safer
injuries, or
peritonitis
option.
Current operative options include
Primary repair of the injury,
Resection and anastomosis, and
Colostomy..

Extensive intraperitoneal spillage of feces,

Multisegmental or extensive colonic injury requiring resection, and
Major loss of the abdominal wall or mesh repair of the abdominal wall;

Rectum

Intraperitoneal or Extraperitoneal
1.Often, intraperitoneal rectal injuries can be
managed as in colonic injury (primarily repaired).
2.Treat extraperitoneal rectal tears by diverting
sigmoid colostomy. Acceptable options include:
Hartmann resection with end colostomy,
End colostomy with a mucus fistula, or
Loop colostomy with a stapled distal end.
3.If the defect is not readily identified on
proctoscopy..
4.Presacral drainage and irrigation of the distal rectal
stump..
5.If a colostomy is necessary in a patient with a pelvic
fracture requiring fixation
6.Perioperative broad-spectrum antibiotics should be

Duodenal injury
Penetrating trauma, predominantly GSW 75% & blunt
25%
The second portion of the duodenum is most
commonly injured
Delays in diagnosis in case of isolated injury.
Up to 98% have associated abdominal injuries(liver,
pancreas, small bowel, colon, IVC, portal vein, and
aorta.)
Retroperitoneal air or obliteration of the right psoas
margin may be seen on abdominal x-ray study
CT findings include paraduodenal hemorrhage and air
or oral contrast leak.
Contrast study is helpful
Bile staining fluids and air in the

Duodenal injury
Treatment for hematoma

Intramural duodenal hematoma is more common in

children than in adults; may be a result of child abuse.
A coiled spring appearance is seen on UGI series.
Follow-up UGI with Gastrografin should be obtained
every 7 days, if the obstruction persists clinically.
Treated nonoperatively with nasogastric suction and IV
alimentation.
Operation is necessary to evacuate the hematoma if it
does not resolve after 2 to 3 weeks.
Treatment of an intramural hematoma found at early
laparotomy is controversial: -One option is to open
serosa
-Another option is leaving the intramural hematoma intact
and planning nasogastric decompression postoperatively.

Duodenal injury
Treatment for perforation

Longitudinal duodenal injuries can usually be

closed transversely if the length of the duodenal
injury is <50% of the circumference of the
duodenum.
More severe injuries may require repairs using
pyloric exclusion, duodenal decompression, or
more
complex
operations.
The
(bad
prognostic)
factors in duodenal injury
include:
Associated vascular injury
Associated pancreatic injury
Blunt injury or missile injury
>75% of the wall involved
Injury in the first or second portion of the
duodenum

Duodenal injury
Treatment for perforation

Pyloric exclusion with gastrojejunostomy. Staple from the

outside or oversew the pyloric outlet through a gastric
incision (absorbable or nonabsorbable suture), using the
incision as the gastrojejunostomy site.
Vagotomy is usually not performed; the pyloric closure
generally reopens in 2 to 3 weeks.
If primary closure would compromise the lumen of the
duodenum, use a jejunal serosal patch duodenoplasty
A three-tube technique may also be used.
If complete duodenal transection or long lacerations of
the duodenal wall are found, perform debridement and
primary closure or closure of the distal duodenum and
Roux-en-Y duodenojejunostomy proximally may be
required.

Pancreatic
injury

Relatively uncommon; most are caused by penetrating

injury
A major diagnostic challenge, especially in blunt trauma
cases
Associated intraabdominal injury is found in >90% of
pancreatic injuries
Pancreatic injury should be suspected, based on the
mechanism of injury and the high incidence of
associated intraabdominal injury
The initial complaints with pancreatic injury may be
vague and nonspecific; 6 to 24 hours after the injury,
the patient will complain of midepigastric and or back
pain
Serum amylase levels are sensitive but not specific.

Pancreatic
injury

(ERCP) or (MRCP) can be used to diagnose pancreatic

ductal injury in hemodynamically stable patients.
Intraoperative diagnosis depends on visual
inspection and bimanual palpation of the pancreas by
opening the gastrocolic ligament and entering the
lesser sac, and by performing a Kocher maneuver.
Mobilization of the spleen along with the tail of the
pancreas and opening of the retroperitoneum to
facilitate palpation of the substance of the gland may
be necessary to determine transection versus
contusion.
Identification of injury to the major duct is the
critical issue in intraoperative management of
pancreatic injury.

Pancreatic
injury
Treatment principles include
Control hemorrhage (Hemostasis)
Debride devitalized pancreas, which can
require resection (Debridement)
Preserve maximal amount of viable
pancreatic tissue (Preservation)
Wide drainage of pancreatic secretions with
closed-suction drains (Drain)
Feeding jejunostomy for postoperative care
with significant lesions (Feeding)

Pancreatic
Treatment options
Pancreatic contusion
injury
without ductal injury

wide drainage.
Pancreatic transection distal to the SMA distal
pancreatec-tomy..
Control the resection line by stapling the
pancreatic stump or closing with horizontal
mattress sutures of nonabsorbable material +
closed suction drains.
Pancreatic transection to the right of the SMA
(not involving the ampulla) no optimal
operation and wide drainage of the area of
injury to develop a controlled pancreatic fistula;

Pancreatic
Treatment options
injury
ligation of both ends
of the distal duct and

wide drainage; and oversewing the proximal

pancreas and performing a Roux-en-Y
jejunostomy to the distal pancreas (indicated
uncommonly). Generally, wide closed-suction
drainage is sufficient acutely with injury to
the head of the pancreas.
Severe injury to both the head of the
pancreas and the duodenum may require
Whipple pancreaticoduodenectomy);
however, this is rarely indicated. It can be

Pancreatic Injury in
Children
10 per cent of cases of blunt abdominal trauma in
children
Usually as a result of a handlebar injury.
Whether they should be operated upon or managed
conservatively is controversial.
The current trend for management of solid organ
injuries in children is conservative
Conservative management is recommended if there are
no signs of clinical deterioration or major ductal injury.
Although pseudocysts are more likely to develop with
transection injuries, they tend to respond to

Pancreatic
injury

Outcome

10-20% incidence of pancreatic fistula as defined as >100

cc/day for >14 days (minor) or >31 days (major).
Most minor and major fistulae will spontaneously resolve with only
<7% requiring further operative intervention.
10-20% incidence of pancreatic abscess.
Pancreatic duct and colon injury are independent predictors of
abscess formation.
Post-traumatic pancreatitis should be expected in the patient
with persistent
abdominal pain, nausea, vomiting, and hyperamylasemia and
complicates
3% to 8% of pancreatic injuries.
Pancreatic pseudocysts occur in 2% to 4%. Most related to
missed or
inadequately treated ductal injuries
Postoperative hemorrhage may occur in 3% to 10% and requires

Liver
Incidence: The liver is the most commonly
injured intraabdominal organ; injury occurs more
often in penetrating trauma than in blunt trauma.
Diagnosis: Physical examination is often
unreliable in the blunt trauma victim.
The appropriate diagnostic modality depends on
the hemodynamic status of the patient.
If the patient is hemodynamically stable with a
blunt mechanism of injury, CT is preferred.

CT is sensitive and specific

Liver

Treatment

The hemodynamically stable patients with blunt

injury of the liver, can be treated nonoperatively,
regardless of the grade of the liver injury.
This may represent 50% to 80% of patients. The
presence of hemoperitoneum on CT does not mandate
laparotomy.
Arterial blush or pooling of contrast on CT and highgrade (grade IV and V) hepatic injuries are most likely
to fail nonoperative management.
Angioembolization has assumed an increasing role
The criteria for nonoperative management of
blunt liver injuries include:
Hemodynamic stability.
Absence of peritoneal signs.
Lack of continued need for transfusion for the

Liver

Treatment

If the patient is hemodynamically unstable or has

indications for laparotomy, operative management is
required.
Management principles include the following four
principles:
Hemostasis, adeq. Exposure, Debridement and Drainage
Adequate exposure of the injury is essential. Complete
mobilization of the liver is performed, including division
of the ligaments.
Most blunt and penetrating hepatic injuries are grade I
and II (70% to 90%) and can be managed with simple
techniques (e.g., electro-cautery, simple suture, or
hemostatic agents).
Complex liver injuries can produce exsanguinating

Liver

Treatment

For complex hepatic injuries (Grade III-V):

-Occlude the portal triad with an atrau-matic clamp
(Pringle maneuver).
-Debridement of nonviable tissues
-Fingure fracture of the hepatic parenchyma
-Placement of omental pedicle in the injury site
-Closed suction drainage
Retrohepatic venous injuries(V) is suggested when
bleeding from the liver is not controlled with Pringle
maneuver
Hepatic vascular isolation with occlusion of the
suprahepatic and infrahepatic venae cavae, as well as
application of the Pringle maneuver, may be required
for major retrohepatic venous injury.
Cholecystectomy may be required secondary to

Liver trauma

Complications
With recurrent bleeding
(occurs in 2% to 7%
of patients) return the patient to the OR or,
in selected patients, obtain an angiogram
and perform embolization. Recurrent bleeding
is generally caused by inadequate initial
hemostasis. Hypothermia and
coagulopathy must be corrected.
Hemobilia is another complication of liver
injury. The classic presentation is right upper
quadrant pain, jaundice, and
hemorrhage(upper GI); one third of patients
have all three components of the triad. The

Liver trauma
Complications

Intrahepatic or perihepatic abscess or biloma can

generally be drained percutaneously. 1.Meticulous
control of bleeding and repair of bile ducts, 2.adequate
debridement, and 3.closed-suction drainage are
essential to avoid abscess
Biliary fistulas (>50 mL/day for >2 weeks) usually
resolve non-operatively if external drainage of the leak
is adequate and distal obstruction is not present.
If >300 mL of bile drains each day, further evaluation
with a radionuclide scan, a fistulogram, ERCP, or a PTC
may be necessary. Major ductal injury can be stented to
facilitate healing of the injury or as a guide if operative
repair is required. Endoscopic sphincterotomy or

Extrahepatic biliary tract injury

It's uncommon & the gallbladder is the most common
site & cholecystectomy is the usual treatment
Injury to the extrahepatic bile ducts can be missed at
laparotomy unless careful operative inspection of
the porta hepatis is performed
A cholangiogram through the gallbladder or cystic
duct stump helps define the injury.
The location and severity of the injury will dictate the
appropriate treatment:
Simple bile duct injury (<50% of the circumference) can
be repaired with primary suture repair over T-tube.
Complex bile duct injury (>50% of the circumference)
may require Roux-en-Y choledochojejunostomy or
hepaticojejunostomy.

SpleenDiagnosis
The patient may have signs of hypovolemia and
complain of left upper quadrant tenderness or Kehr's
sign.
Physical examination is insensitive and non-specific.
The patient may have signs of generalized peritoneal
irritation or left upper quadrant tenderness,
dullness or fullness
Of patients with left lower rib fractures (ribs 9
through 12), 25% will have a splenic injury.
In the unstable trauma patient, ultrasound or DPL
will provide the most rapid diagnosis of
hemoperitoneum
In the stable patient suffering from blunt injury, CT
imaging of the abdomen allows delineation and

Spleen

Treatment

Management of splenic injury depends primarily on the

hemodynamic stability of the patient
Other factors include the age of the patient,
associated injuries (which are the rule in adults), and
the grade of the injury.
Cooperative management of splenic injury is successful
in >90% of children, irrespective of the grade of splenic
injury.
Nonoperative management of blunt splenic injury in
adults is becoming more routine, with approximately
65% to 75%
If hemodynamically stable, adult patients with grade I
or II injury can often be treated nonoperatively.
Patients with grade IV or V splenic injuries are usually

Spleen
Treatment

The failure rate of nonoperative management of splenic

injuries in adults increases with grade of splenic injury:
grade I, 5%;
grade II, 10%;
grade III, 20%;
grade IV, 33%; and
grade V, 75%. In adults (but not children),
Most failures occur within 72 hours of injury.
Patients with significant splenic injuries treated
nonoperatively should be observed in a monitored
unit and have immediate access to a CT scanner, a
surgeon, and an OR.
Changes in physical examination, hemodynamic stability,
ongoing blood, or fluid requirements indicate the need for
laparotomy.

Spleen

Mobilization of the spleen

Splenectomy should be performed in unstable

patients, and in those with associated life-threatening
injury, multiple sources for postoperative blood loss
(pelvic fracture, multiple long bone fractures, and so
forth), and complex splenic injuries.
Splenorrhaphy is an option when circumstances
permit. At least one half of the spleen must be
preserved to justify splenorrhaphy.
Nonbleeding grade I splenic injury may require no
further treatment.
Grade II to III splenic injury may require the abovementioned interventions, suture repair, or mesh
wrap
Grade IV to V splenic injury may require anatomic
resection, including ligation of the lobar artery

Treatment

SpleenOutcome
The outcome is generally good; rebleeding rates as
low as 1% have been reported with splenorrhaphy.
The failure rate of nonoperative therapy is 2% to
10% in children and as high as 18% in adults.
It has been reported that adults >55 years of age are
especially susceptible to failure of nonoperative
therapy
Pulmonary complications are common in patients
treated operatively and nonoperatively.
Left subphrenic abscess occurs in 3% to 13% of
postoperative patients and may be more common with
the use of drains or with concomitant bowel injury.
Thrombocytosis occurs in 50% of patients post
splenectomy; the platelet count usually peaks 2 to 10

SpleenOutcome
The risk of overwhelming postsplenectomy infection
(OPSI) is greater in children than in adults; the risk is <
than 0.5%.
The mortality rate for OPSI approaches 50%.
The common organisms are encapsulated organisms:
meningococcus, Haemophilus influenzae, and
Streptococcus pneumoniae, as well as Staphylococcus
aureus and Escherichia coli.
After splenectomy, pneumococcal (Pneumovax), H.
influenzae, and meningococcal vaccines should be
administered.
The timing of injection of the vaccine is controversial.
Current recommendation is to repeat the pneumococcal
vaccination at 5 years.

Retroperitoneal Hematoma

Blunt trauma produces 70% to 80% of retroperitoneal hematomas;

most are caused by pelvic fracture.
Management of retroperitoneal hematomas depends largely on
location and the mechanism of injury.
Generally, all penetrating wounds of the retroperitoneum found at
laparotomy require thorough exploration.
Some simply observe nonexpanding perinephric hematomas.
If the hematoma is large, expanding, or proximal to the
retroperitoneal vessels (aorta, iliac artery, and so forth), first
obtain proximal and distal control of the vessels.
In general, nonexpanding lateral (zone II) or pelvic (zone III)
hematomas secondary to blunt trauma do not require exploration.
Be certain that the overlying bowel (i.e., colon or duodenum) is
intact
Central hematomas (zone I) always require exploration to rule out

Rupture of the
bladder
Bladder rupture
can be:
Extraperitoneal:
is most commonly
associated with
fracture of the pelvis
Intraperitoneal:
is often the result of
a direct blow to the
bladder or a sudden
deceleration

For extraperitoneal
rupture
(Pelvic fracture)
Suprapubic cystostomy;
(Cystofix). If the rupture is
large, place a drain
For intraperitoneal
rupture
(Seatbelt injury)
Close the rupture and a
large urethral catheter or a

LETS BE CONCERVATIVE

A negative laparotomy does not increase

the complication rate, but a delayed
laparotomy does.

Oxygenate and Resuscitate Before You

Operate

Damage control
PRINCIPLES
are:
The term Damage
Control
Surgery
Control hemorrhage
with packing
has yet to reach
twenty
years
Identification
of
injury
of use as concept for the
Prevention and control
treatment of exsanguinating
contamination with temporary
truncal
trauma
patients
&
has
closure
become
model
for emergent, life
Avoid further
injury
threatening
surgical
conditions
Resuscitation
in the ICU
incapable
of tolerating
traditional
Re-exploration
and definitive
repair

WHEN TO INSTITUTE ?
Parameters as a guideline for instituting damage
control(DCS):
pH less then or equal to 7.2
Serum bicarbonate level less than or equal to 15 mEq/L
Core temperature less than or equal to 34C
Coagulopathy, as evidenced by the development of
nonmechanical bleeding within the operative field,
elevation of both prothrombin time (PT) and partial
thromboplastin time (PTT), thrombocytopenia,
hypofibrinoginemia, or massive transfusion (>10
units packed red blood cells [PRBCs]).
Total blood replacement more than or equal to 5000 ml
Total fluid replacement more than or equal to 12 000 ml

If all

death

WHEN TO INSTITUTE ?

APPROACH
Before:
ER OR DEATH
Now:
DCS

EROR ICUORICU

Initial Laparotomy

in

DCS

Identify the main source of bleeding and stop it

Perihepatic packing (superior and inferior)

Small gastrotomies and enterotomies can be
rapidly closed
Resect non-viable bowel and close the ends
Minor pancreatic injuries not involving duct- no
treatment
Distal injury including the panceratic duct- distal
pancreatectomy
NO pancreaticoduodenectomy (drainage)
Abdominal closure is rapid and temporary- if
there is any doubt about abdominal compartment
syndrome, left it open (Bogota-bag, vacuum-pack

Abdominal
Compartment
Syndrome

Definition
The adverse physiological consequences
of
an acute elevation in intra-abdominal
pressure
- Oliguria at IAP > 15-20mmHG
- Anuria at IAP > 30 mmHG
- Increased airway pressures (IAP>15 mm
HG)

Abdominal Compartment
Syndrome:
causes

Causes of raised intra-abdominal pressure (IAP)

Retroperitoneal

Intraperitoneal

Oedema in necrotising
pancreatitis

Haemorrhage

Pelvic haematoma

Visceral oedema

Retroperitoneal
haematoma

Abdominal packing

Bleeding after aortic

surgery

Bowel dilatation

Oedema related to
resuscitation

Mesenteric venous
obstruction
Pneumoperitoneum
Acute ascites

Abdominal Compartment
Syndrome:
At risk patients

Major trauma
Damage control surgery
Laparotomy for bleeding, ischaemia etc
Re-laparotomy for postoperative
complications
Massive volume resuscitation

Abdominal Compartment Syndrome

Clinical features
Abdominal distension
ELEVATED IAP
Consequent organ dysfunction
Importance
Decompression can reverse abnormal
physiology
Probable fatal progression if left untreated

Effects of intra-abdominal hypertension (IAH)

Gut and hepatic effects
Renal effects
Cardiovascular effects
Respiratory effects
CNS
Abdominal wall

Abdominal Compartment
Syndrome

Means of detection
Intraabdominal pressure >30mmHg
CT changes
- Narrowing of IVC
- Direct renal compression
- Bowel wall thickening
- Rounded abdomen
Splanchnic hypoperfusion and
acidosis
Abdominal perfusion pressure

Abdominal Compartment
Syndrome Management
Supportive treatment
Early abdominal decompression of at risk
patients
-Laparotomy
-Percutaneous decompression with
peritoneal lavage catheter
Abdominal decompression with
temporary cover eg plastic or silicone
coverage, skin only closure, mesh grafts
etc
Outcomes: High mortality and morbidity ( 10

LETS BE CONCERVATIVE

A negative laparotomy does not increase

the complication rate, but a delayed
laparotomy does.

Oxygenate and Resuscitate Before You

Operate

Failure
promptly recognize
and treat
simple
GOOD to
JUDGMENT
COMES FROM
EXPERIENCE
life-threatening injuries is the tragedy of trauma,
not the inability to handle the catastrophic or
complicated injury.
EXPERIENCE
COMES FROM BAD JUDGMENT
(F.William Blaisdell)