Chapter 4: Abdominal injury Blunt abdominal injury: secondary to motor vehicle accidents, motorcycle accidents, falls, assaults The

he spleen is the organ most often injured, liver is the 2nd most commonly injured intraabdominal organ, and the intestine is the most likely hollow viscus to be damaged. Mechanisms of Blunt Abdominal Injury: Sudden rises in intra-abdominal pressures created by outward forces can cause rupture or burst injury of a hollow organ the compression of abdominal viscera between the applied force to the anterior wall and the vertebral column produces a crushing effect acceleration and deceleration forces affecting both hollow and solid viscera causes organs and vascular pedicles to shear, especially at relatively fixed points of attachment. Penetrating abdominal injury: The instruments include knives, handguns, rifles, shotguns, flying glass, scissors, arrows,etc Small intestine, colon, and liver are the most likely to sustain injury after penetrating trauma. Physical Examination: Mental status Respiratory rate Heart rate Blood pressure Inspection: Contusions or subcutaneous haematoma The length and depth of the Wound evisceration palpation: abdominal tenderness peritoneal irritationperitonitis Abdominal mass Percussion: Shifting dullness Auscultation: decreased or absent bowel soundsintestinal paralysis?) Laboratory: Hematocrit white blood cell chemical values Urine routine

Plain Radiographs: lower rib fractures Foreign bodies and missiles free intraperitoneal air Ultrasound: free intraperitoneal fluid evaluate the liver and the spleen Advantage: Portable ,noninvasiveness, cheap Disadvantage: It is technically compromised by the uncooperative, agitated patient, as well as by obesity, substantial bowel gas, and subcutaneous air. Abdominal Computed Tomography: most frequently used method to evaluate a stable blunt abdominal trauma patient evaluates both solid and hollow organ injury The retroperitoneum is best evaluated by CT Three-dimensional reconstructions may help in the identification of bowel thickening, small bubbles of free air Diagnostic Peritoneal Lavage: (DPL) is a procedure where, after application of local anesthesia, a vertical skin incision is made one third of the distance from the umbilicus to the pubic symphysis. The linea alba is divided and the peritoneum entered after it has been picked up to prevent bowel perforation. A catheter is inserted towards the pelvis and aspiration of material attempted using a syringe. If no blood is aspirated, 1 litre of warm 0.9% saline is infused and after a few (usually 5) minutes this is drained and sent for analysis DPL can promptly reveal or exclude the presence of intraperitoneal hemorrhage and can serve as an indication for laparotomy. (incision through the flank or, more generally, through any part of the abdominal wall.) DPL comprises two interrelated steps. The first is the attempted aspiration of free peritoneal blood. The recovery of 10 or more milliliters of uncoagulated blood from the peritoneum is a strong predictor of intraperitoneal injury, and the procedure is then terminated. If aspiration findings are negative, lavage is conducted in which the peritoneal cavity is washed with saline. This fluid is introduced by catheter, recovered by gravity drainage, and analyzed. Criteria for positive DPL: 10 mL gross blood on aspiration, or >100,000 red blood cells/mm3 , or >500 white blood cells/mm3, or Bacteria, or Bile, or Food particles

Angiography: valuable in confirming significant active bleeding and major disruption of the vascular pedicle of an organ. usually reserved for the unstable patient with blunt trauma and pelvic fracture in whom it can be used to embolize bleeding vessels. Local Wound Exploration: LWE is useful in determining the depth of penetration. wound is infiltrated with local anesthetic containing epinephrine and thoroughly prepared for exploration. The stab wound may be extended if required and then carefully visualized through each successive layer of tissue. If LWE indicates that the peritoneum is violated, further diagnostics are indicated. Likewise, when the end of the wound tract cannot be determined clearly, peritoneal entry must be presumed. Laparoscopy: works best in experienced hands for restricted indications. ability to detect organ injury (including diaphragmatic injury) and simultaneously repair some injuries, thus decreasing negative and nontherapeutic laparotomy rates Diagnosis: Diagnostic effort is appropriately aimed at determining whether surgery is necessary or whether the injury is self-limited and does not require repair measures. purpose is to determine whether the peritoneal cavity has been violated or whether there is intraperitoneal injury requiring operative repair. Tests used for the former purpose include plain films, LWE, US, and laparoscopy. Those most commonly used with the latter intent are DPL, serial Clinical Indications for Laparotomy Following Penetrating Trauma: MANIFESTATION Hemodynamic instability Peritoneal signs Evisceration Diaphragmatic injury Gastrointestinal hemorrhage Implement in situ PREMISE Major solid visceral or vascular injury Intraperitoneal injury Additional bowel, other injury Diaphragm Proximal gut Vascular impalement PITFALL Thorax or mediastinum, causal or contributory Unreliable, especially immediately postinjury No injury in one fourth to one third of stab wound cases Rare clinical, radiographic findings Uncommon, unknown accuracy Comorbid disease or pregnancy creates high operative risk

Intraperitoneal air

Hollow viscus perforation

Insensitive; may be caused by intraperitoneal entry only or be due to cardiopulmonary source

Clinical Indications for Laparotomy after Blunt Trauma; MANIFESTATION Unstable vital signs with strongly indicated abdominal injury Unequivocal peritoneal irritation Pneumoperitoneum (air in peritoneum) Evidence of diaphragmatic injury Significant gastrointestinal bleeding PITFALL Alternative sources, shock Unreliable Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy) Nonspecific Uncommon, unknown accuracy

Management of Abdominal Injury: The first priority in all injured patients is resuscitation, ensuring that there is an adequate airway, effective breathing and a circulation. circulatory volume must be restored rapidly with crystalloid or colloid solutions while blood is being cross-matched and invasive monitoring should be established (urinary catheter and central venous line). A nasogastric tube should routinely be placed Foley catheters are useful in unstable patients Systemic antibiotic therapy active against both aerobes and anaerobes is administered to patients with abdominal injuries. Eviscerations: Penetrating wounds and eviscerations in particular should be covered with sterile dressings.

concomitant damage: Life-threatening injuries such as traumatic brain injury, open or tension pneumothorax, pericardial tamponade should be managed first Abdominal solid organ injury can cause massive hemorrhage, and management of solid organ injury precede hollow organ

Anesthesia: General anesthesia is often used for abdominal injury . Incision: A midline laparotomy is the standard incision for trauma The length of the incision should be individualized and should allow adequate exposure Abdominal Exploration: Upon entering the peritoneal cavity the surgeon has two urgent priorities: Temporary control of any active bleeding followed by temporary control of any intestinal spillage In many cases the source of hemorrhage is known, the surgeon should pack the suspected area and then remove all intraperitoneal blood by a combination of suctioning and manual scooping out In cases where the source of bleeding is not known or suspected, the surgeon should pack all four quadrants and the pelvis The next step is temporary control of any gastrointestinal spillage by applying tissue clamps. After temporary control of bleeding and gastrointestinal content spillage have been achieved the abdominal packs should carefully be removed one by one, and the source of bleeding and extent of organ injury are assessed. Drainage: Closed-suction drains may be needed to monitor intraabdominal bleeding or in patients with high-risk hollow viscus repairs. Closed drains should be used liberally in areas with even minor oozing, especially in the presence of an associated hollow viscus perforation Indications for damage control: Hemodynamic instability Coagulopathy on presentation or during operation (clinical or laboratory) evere metabolic acidosis (pH<7.2 or base deficit>8) Hypothermia on presentation (<35C) Prohibitive operative time required to repair injuries (>90 mins) High-energy blunt torso trauma Multiple penetrating torso injuries Multiple visceral injuries with major vascular trauma Multiple injuries across body cavities Massive transfusion requirements (>10 units packed red blood cells) splenic rupture: The spleen is the intra-abdominal organ most frequently injured in blunt trauma

Spleen Injury Scale GRADE TYPE OF INJURY DESCRIPTION OF INJURY I Hematoma Subcapsular, <10% surface area

Laceration II Hematoma Laceration

Capsular tear, <1 cm in parenchymal depth Subcapsular, 10%-50% surface area; intraparenchymal, <5 cm in diameter Capsular tear, 1-3 cm in parenchymal depth and not involving a trabecular vessel Subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, 5 cm or expanding >3 cm in parenchymal depth or involving the trabecular vessels Laceration involving the segmental or hilar vessels and producing major devascularization (>25% of spleen) Completely shattered spleen Hilar vascular injury that devascularizes the spleen

III

Hematoma

Laceration IV V Laceration Laceration Vascular

Principle of management for splenic rupture: Saving life is the first Preserving spleen is the second Nonoperative treatment: criteria include hemodynamic stability, negative abdominal examination, absence of contrast extravasation on CT, absence of other clear indications for exploratory laparotomy or associated injuries requiring surgical intervention Indication of operation: Hemodynamically unstable (often grade IV or V splenic injuries ) Hepatic injury: frequently injured in both blunt and penetrating trauma. diagnostic modality depends on the hemodynamic status of the patient on arrival in the trauma resuscitation area. hemodynamically stable with a blunt mechanism of injury, CT is preferred. CT is sensitive and specific in stable patients with a clinical suspicion of injury. DPL is sensitive but not specific for liver injuries.

Liver Injury Scale TYPE OF GRADE INJURY I Hematoma

DESCRIPTION OF INJURY Subcapsular, <10% surface area

Laceration II Hematoma

Capsular tear, <1 cm in parenchymal depth Subcapsular, 10%-50% surface area; intraparenchymal, <10 cm in diameter Capsular tear, 1-3 cm in parenchymal depth; <10 cm in length Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, >10 cm or expanding 3 cm in parenchymal depth Parenchymal disruption involving 25%-75% of the hepatic lobe or 1-3 Couinaud segments Parenchymal disruption involving >75% of the hepatic lobe or >3 Couinaud segments within a single lobe Juxtahepatic venous injuries, i.e., retrohepatic vena cava/central major hepatic veins Hepatic avulsion

Laceration

III

Hematoma

Laceration IV Laceration

Laceration

Vascular

VI

Vascular

The criteria for nonoperative management of blunt liver injuries: Hemodynamic stability normal mental status Absence of peritoneal signs Lack of continued need for transfusion for the hepatic injury; low-grade liver injuries (grade I-III). Operative management: hemodynamically unstable or has indications for laparotomy, operative management is required. Exploration is through a long midline incision or bilateral subcostal incision. An extension to a median sternotomy or thoracotomy may be necessary for exposure of the injury. The principles of surgical management: control of bleeding removal of devitalized tissue establishment of adequate drainage Some small nondeep bleeding lacerations are easily controlled with simple suture or the use of hemostatic agents.

Complex liver injuries produce exsanguinating hemorrhage. Rapid, temporary tamponade of the bleeding by manual compression of the liver injury or Pringle maneuver(= use finger to grasp the portal vessels to control bleeding) immediately after entering the abdomen allows the anesthesiologist to resuscitate the patient. After resuscitation, the liver injury can be repaired. More severe liver injuries require more complex procedures, including deep mattress sutures, packing, debridement, resection, mesh hepatorrhaphy, and other measures.

Management of common bile duct injury: Primary repair and placement of a T-tube should be attempted for partial or minor injuries Major injuries or complete transection are best managed by choledochoenteric anastomosis. pancreatic injury: Pancreatic injury is rare caused by penetrating mechanisms Blunt trauma to the abdomen caused by a direct blow or seat belt injury may compress the pancreas over the vertebral column and result in pancreatic disruption. Pancreatic injuries are divided into proximal or distal according to the location on the right or left of the superior mesenteric vessels. Because of its retroperitoneal location, the pancreas is a well-protected organ, and signs and symptoms may appear late, thus delaying diagnosis. Isolated pancreatic injury is uncommon. The diagnosis is difficult to make, and patients may complain of vague abdominal pain radiating to the back several hours after the incident. mild abdominal tenderness develops, with peritoneal signs eventually developing. GRADE TYPE OF INJURY DESCRIPTION OF INJURY I Hematoma Laceration II Hematoma Laceration III IV V Laceration Laceration Laceration Minor contusion without duct injury Superficial laceration without duct injury Major contusion without duct injury or tissue loss Major laceration without duct injury or tissue loss Distal transection or parenchymal injury with duct injury Proximal transection or parenchymal injury involving the ampulla Massive disruption of the pancreatic head

Diagnostic examinations: Serum hyperamylasemia is neither sensitive nor specific. DPL is not reliable in the diagnosis of retroperitoneal injuries but will frequently identify intraperitoneal blood or the presence of associated injuries. CT may identify peripancreatic hematomas but may not identify pancreatic lacerations or even complete transections early in the postinjury period. patients with questionable CT scan

findings, persistent abdominal pain, or elevated serum amylase may benefit from a repeat CT scan. Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatogram (MRCP) can be used to diagnose pancreatic ductal injury in hemodynamically stable patients. Intraoperative diagnosis

Treatment: Suspected pancreatic injuries should be surgically explored Control hemorrhage Debride devitalized pancreas, which can require resection Preserve maximal amount of viable pancreatic tissue Wide drainage of pancreatic secretions with closed-suction drains Feeding jejunostomy for postoperative care with significant lesions Treatment options: Pancreatic contusion or capsular laceration without ductal injury wide drainage Pancreatic transection distal to the SMA distal pancreatectomy Pancreatic transection to the right of the SMA superior mesenteric artery (not involving the ampulla) no optimal operation wide drainage; ligation of both ends of the distal duct and wide drainage; oversewing the proximal pancreas and performing a Roux-en-Y jejunostomy to the distal pancreas Ampulla is located at duodenum Severe injury to both the head of the pancreas and the duodenum may require pancreaticoduodenectomy; Injury of Duodenum: With blunt injury,-mid-epigastric or right upper quadrant pain or tenderness and can have peritoneal signs. Hyperamylasemia occurs in about 50% of patients Retroperitoneal air or obliteration of the right psoas margin may be seen on abdominal x-ray study. The diagnosis is generally made at laparotomy for associated injuries. With penetrating mechanisms, duodenal injury is found at laparotomy. CT findings include paraduodenal hemorrhage and air or contrast leak DPL has a low sensitivity for duodenal injury but will often detect associated injuries Adequate intraoperative exposure is vital Duodenum Injury Scale:
GRADE TYPE OF INJURY I Hematoma Laceration II Hematoma Laceration DESCRIPTION OF INJURY Involving a single portion of the duodenum Partial thickness, no perforation Involving more than one portion Disruption <50% of the circumference

III

Laceration

Disruption 50%-75% of the circumference of D2 Disruption 50%-100% of the circumference of D1, D3, D4

IV V

Laceration Laceration Vascular

Disruption >75% of the circumference of D2 and involving the ampulla or distal common bile duct Massive disruption of the duodenopancreatic complex Devascularization of the duodenum

Management of duodenal injury: For most minor injuries (grades I and II) diagnosed within 6 hours of injury, simple primary repair is suitable. After 6 hours the risk of leakage increases, and any form of duodenal decompression (transpyloric nasogastric tube, tube jejunostomy, or tube duodenostomy) is advisable. Grade III injuries involving major disruption of the duodenal circumference are best treated by primary repair, pyloric exclusion, and drainage or, alternatively, by Roux-en-Y duodenojejunostomy. Grade IV injuries (involving the ampulla or distal common bile duct) are difficult to repair. In this situation, primary repair of the duodenum, repair of the common bile duct, and placement of a T-tube with a long transpapillary limb or a choledochoenteric anastomosis may be attempted when possible. Pancreaticoduodenectomy, though rarely needed, reserved for grade V injuries, including massive disruption of the duodenum and pancreatic head or massive devascularization of the duodenum. Gastric injury: result from penetrating trauma Causes of blunt gastric rupture include vigorous ventilation with inadvertent placement of an endotracheal tube in the esophagus, crushing of the stomach against the spine, cardiopulmonary resuscitation, the Heimlich maneuver, and other causes leading to a sudden increase in intraluminal pressure. Diagnosis of gastric injury: Aspirate of a nasogastric tube is positive for blood DPL or CT of the abdomen may confirm the diagnosis The diagnosis made during surgical exploration. intraoperative evaluation includes good visualization of the esophagogastric junction, examination of the anterior gastric wall, opening of the gastrocolic ligament, and complete visualization of the posterior gastric wall.

Management of gastric injury: Most penetrating wounds are treated by debridement of the wound edges and primary closure in layers. Injuries with major tissue loss may best be treated by gastric resection. Injury of small intestine:

most frequently injured organ after penetrating injuries.

Diagnosis of small bowel injury: mild abdominal pain without peritoneal signs signs of peritoneal irritation Plain films of the abdomen may reveal free air DPL findings generally reveal blood. Positive DPL on the basis of only elevated white blood cell (WBC) count with a negative RBC count is unusual. False-negative DPL findings can occur with small-bowel injury. CT findings suggestive of small-bowel injury: Fluid collections without solid viscus injury Bowel wall thickening Mesenteric infiltration Free intraperitoneal air Operative Treatment: Injuries to the mesentery of the small bowel, must be rapidly controlled Perform laparotomy and repair, and administer preoperative antibiotics Debride simple lacerations and close transversely to avoid stenosis Resect larger injuries and perform an end-to-end anastomosis Injury of colon: generally the result of penetrating trauma. relatively infrequent after blunt trauma Diagnosis of colonic injury: Peritoneal signs on examination or free intraperitoneal air Gross blood on rectal examination Management of colonic injury: antibiotics primary repair or resection include minimal fecal spillage, no shock minimal associated intraabdominal injuries, <8-hour delay in diagnosis and treatment, and <1-L blood loss. contraindications to primary repair include extensive intraperitoneal spillage of feces, extensive colonic injury requiring resection If primary repair cannot be performed safely, a colostomy or resection and anastomosis are options Colostomy : cut the region of colon before the injured site and connect it to the abdominal surface to form a stoma, where feces can be eliminated to healing process. After 3-6 months we anastomose the colon back.

Rectal injuries: can be intraperitoneal or extraperitoneal. rectal examination may reveal blood, or an injury may be palpable. Workup of rectal injuries includes anoscopy and rigid proctosigmoidoscopy. Management of rectal injury:

Perioperative broad-spectrum antibiotics should be administered intraperitoneal rectal injuries are primarily repaired. Treat extraperitoneal rectal tears by diverting sigmoid colostomy,With Presacral drainage

Retroperitoneal hematomas: Management depends largely on location and the mechanism of injury. Generally, all penetrating wounds of the retroperitoneum found at laparotomy require thorough exploration. Blunt trauma produces majority of retroperitoneal hematomas; most are caused by pelvic fracture. Zones of retroperitoneum : I.central-medial retroperitoneal zone , II. lateral retroperitoneal zone, III. pelvic retroperitoneal zone. Management of retroperitoneal hematoma by blunt trauma: nonexpanding lateral (zone II) or pelvic (zone III) hematomas secondary to blunt trauma do not require exploration. Central hematomas (zone I) always require exploration to rule out a major vascular or visceral injury.