ABDOMINAL TRAUMA II

Dr. Wilfredo Sombong Jr.

September 18, 2013
Group 1- N1nja stONEs
Superscripts refer for pictures in the last page
OBJECTIVES
General: To have an overview of the approach to
patients with abdominal trauma
Specific: To know the options in the management of
specific intra-abdominal injuries

I.
II.
III.
IV.
V.

OUTLINE
Review of the Abdomen
Mechanism of Injuries
Organ Injury Scale
Initial Management of the Severely Injured
Traumatic Injuries In The Abdomen
A. Diaphragmatic Injuries
B. Hepatic Injuries
C. Gallbladder Injuries
D. Stomach Injuries
E. Duodenal Injuries
F. Pancreatic Injuries
G. Splenic Injuries
H. Intestinal Injuries
I. Colonic Injuries
J. Rectal Injuries
K. Retroperitoneal Injuries
I.

Review of the Abdomen

4 Quadrant Pattern
9 Region Pattern
(Review the organs located in each quadrants!)
RUQ
LUQ
RLQ
LLQ

Liver and gallbladder

Stomach and spleen
Cecum and appendix
End of descending colon
and sigmoid colon

II.
Mechanism of Injuries
1. Blunt
a. Motor vehicular accidents
b. Motorcycle accidents
c. Falls
d. Assaults
e. Pedestrian struck
2. Penetrating
a. Gunshot wounds
b. Stab wounds
c. Shotgun wounds
3. Surgical Misadventures
- These are injuries sustained by the patient during
a diagnostic procedure (eg. endoscopy,
colonoscopy, or during surgery)
It is an exotic term for iatrogenic injury
- Coding using ICD-10, iatrogenic injury is under
surgical misadventure
Shotgun wounds VS Gunshot wounds
Gunshot and shotgun injuries are separate entities.
They are different in terms of:
1. velocity
2. number of injuries attained by patient
3. extent of injuries
Gunshot wounds are either:
1. high velocity
2. low velocity
- High velocity injuries, even if the mass is small
will cause greater injuries compared to low
velocity gunshot wounds
Shotgun injuries will be dependent on the:
1. Distance from the victim
2. Gauge of the shotgun (12 gauges versus
birdshot)
Close range plus larger gauge = catastrophic
Incidence of Blunt and Penetrating Injuries based on the
Organ Involved
Blunt (%)
Penetrating (%)
Spleen
47
7
Liver/Biliary
51
28
Pancreas or
10
11
Duodenum
Colon
5
23
Stomach/ SB
9
42
Stomach and small bowel has larger incidence of
being injured in penetrating injuries due to the
large area they occupy in the abdomen.
Larger area = sure hit
III.
Organ Injury Scale
Established by the American Society for the surgery
for trauma
Grade injuries from simple (I) to complex (V or VI)

IV.
Initial Management of the Severely Injured
A. Objectives
1. Preservation of life and limb
2. Restoration of individual to as near normal as
possible
Management will differ depending on the grade of
the injury attained
B. Initial Assessment
1. Primary Survey
a. Re-evaluation
b. A, B, C, D, E
2. Secondary Survey
a. Re-evaluation
b. Obtain brief history and identify potentially
lethal often less apparent injuries
c. AMPLE
A Allergies
M Medications
P Past Illness
L Last Meal
E Events Preceding the Injury
d. Serial Physical Examination
C. Definitive Management
- Has the best sensitivity and negative predictive
value for evaluation of penetrating abdominal
injury
PE is not reliable for blunt abdominal trauma
V.

Traumatic Injuries in the Abdomen

A. Diaphragmatic Injuries
Extent of Injuries
Injuries at the level of the nipple will still involve
intra-abdominal organs
Dynamics
a. 3-5 cm bi-directional trajectory
b. At Expiration
Anterior (R) 4th ICS
(L) 5th ICS
Posterior (R & L) 8th ICS
c. Pleuro-peritoneal gradient
There is no such thing as a SMALL diaphragmatic
injury
When there is small injury to the diaphragm and
intra-thoracic suppression is negative -- it will suck in
either the stomach or the intestines or both.
Associated injury is the rule rather than the
exception.
If you have a lower chest injury and the diaphragm is
traversed most likely you will have injury to either
the:
1. Stomach
2. Spleen
3. Large intestine
Diagnosis: Exploratory laparotomy
Management: Repair

Phases of Traumatic Diaphragmatic Hernia and

Corresponding Management
Phase
Features
Management
Intermediate/Acute Acute
Exploratory
symptoms,
laparotomy/
signs, radiologic thoracotomy
findings
Interval/ Chronic

Asymptomatic

Obstruction or
Compromised
Strangulation
vascular supply
Physical Examination
1. Diminished expansion of the chest
2. Impairment of resonance
3. Adventitious sounds
4. Cardiac displacement
5. Circulatory collapse
6. Cyanosis and dyspnea
7. Asymmetry of hypochondrium

Work-up to
identify organ
involved Repair
of defect
Laparotomy/
thoracotomy

B. Hepatic Injuries
Extent of Injuries
Injury to the RUQ or epigastric area or right lower
chest: Could injure the liver as it is a large organ
If there is injury anteriorly, the posterior organs
(biliary tract, stomach, etc) may also be included
The liver can be divided into 8 segments
Management
Penetrating Hepatic Injuries
a. Do operative intervention (current standard of care) if
there is bleeding
b. If it is a solitary liver injury (not bleeding) you can just
wash it.
Complex hepatic injury
a. Portal occlusion
Portal triad: bile duct, hepatic artery, portal vein
75 % of blood supplying the liver comes from the
portal vein
Occlusion of the portal triad will result to:
decrease in blood flow to liver = bleeding
decreases
If portal occlusion has been performed and
bleeding is still present then injury may be coming
from the retrohepatic vena cava or the hepatic
veins
b. Finger fracture
Proposed by the Lin and colleagues, liver
parenchyma is fractured (tear; punitin; gision)
between the forefinger and thumb whilst
identifying and isolating the key vascular and
ductal structures, which could then be ligated and
divided.

c.
d.
e.
f.

Debridement
Placement of Omental Pedicle
Closed Suction of Drainage
Hemostatic methods
1 Deep liver suturing
2 Hepatic resection
3 Mesh hepatorraphy
4 Perihepatic packing
Pack with towels; close the patient and go back at a
later time when acidosis, hypothermia, and
hypotension has been controlled
g. Retrohepatic Caval and Hepatic Vein Injury:
Intracaval shunt
Mortality rate is high when this method [intracaval
shunt] is used; Less than 20% survive
Complications
a. Recurrent bleeding
b. Hemobilia
defined as hemorrhage into the biliary tract
c. Hyperpyrexia
fever with an extreme elevation of body
temperature >41.5 C (106.7 F)
d. Intraabdominal abscess
e. Biliary fistula
f. Arterial-portal venous fistula
Management
1. Manual Compression1
usually the first attempt at controlling bleeding
of the liver
temporarily control the bleeding while the
Pringle Maneuver is being done
2. Pringle Maneuver (Portal Triad Occlusion)2
Occlusion of the portal triad will result to
decrease in blood flow to liver = bleeding
decreases
The portal triad could be approached through
the lesser sac or the foramen of Winslow
3. Pringle Maneuver with Thermometer Probe3
used to monitor the temperature of the liver
while operating. Hypothermia- patient is acidotic
4. Atrio-Caval Tube4
Mortality 50-80%
5. Selective Ligation5
After doing finger fracture of the liver
parenchyma what is left are the blood vessels
and the bile ducts (either repair or ligate them)
6. Omental Packing
The omentum will act as a buttress to prevent
further bleeding and leakage
7. Liver Catheter Tamponade
If continuous bleeding, catheter can be inserted
and inflated to occlude the bleeder and control
the bleeding temporarily
8. Liver Balloon Tamponade
The balloon inflated will create a compression in
the area of the bleeder and hopefully stop

9. Perihepatic Packing
Patient may be hypotensive, hypothermic,
acidotic, no blood available, and with bleeding
liver, just temporarily pack it
Packing is done anteriorly and posteriorly
(creating a sandwich with the liver as the
sandwich spread); hopefully the pressure
created will be hemostatic that will prevent
further bleeding
After addressing the hypotension, acidosis, etc.
patient may then be brought back to the OR for
more definitive procedure (Damage Control
Surgery)
C. Gall Bladder Injuries
1. Disruption
2. Avulsion
3. Contusion
4. Hemobilia
Management
Cholecystectomy & closed suction drainage
Lateral repair with absorbable sutures
(Lateral repair is not recommended by doc)
D. Extrahepatic Biliary Tree Injuries
- Associated vascular injury is common
Management
T-tube stenting
Lateral repair
Roux-en-Y choledochojejunostomy
Intubation and external drainage
E. Stomach Injuries
Management
Repair
Resection and repair
Stomach is so big you can repair it at any direction
(either vertical or horizontal)
No exotic treatment for stomach usually primary
repair is sufficient
F. Duodenal Injuries
When duodenum is injured usually it is not a
solitary problem. Adjacent structures are usually
included (i.e. spleen, kidney, and vena cava)
Duodenal Hematoma
Presents as gastric outlet obstruction
Blunt trauma to the epigastric area may present as
obstruction secondary to hematoma
Diagnosis
UGI Barium
1 Coiled spring
2 Obstruction

Management
Non-operative
1. NGT suction
2. Total parenteral nutrition (for 2 weeks)
Operative
1. Evacuation of hematoma
a. Laparotomy (open technique)*
b. Laparoscopic*
*outcome almost the same
Closure
1. Simple repair or end to end anastomosis
2. Serosal Patch
3. Roux-en-y duodeno-jejunostomy
Operative procedures are done when obstruction exceeds
more than 2 weeks
Resection
Diversion
1. Duodenal diverticulization6
a. Antrectomy
b. Gastrojejunostomy
c. Tube duodenostomy
d. Vagotomy
Peripancreatic drainage
Duodenal diverticulation is not recommended
anymore due to high mortality rate
2. Pyloric exclusion7
Procedure recommended , favored over
duodenal diverticulization
Stomach is opended and pylorus is
closed from the inside
Since injury is in the duodenum and
pancreas, pylorus is closed and stomach
is anastomosed to the small intestine to
divert food from the injured parts
2. Triple tube
a. Gastrostomy
b. Proximal Jejunostomy
c. Distal Jejunostomy
Distal tube can act initially for
decompression and later on for feeding
G. Pancreatic Injuries
[Again] injuries to the pancreas are not solitary.
Anterior structures are injured first before the
pancreas. 8,9,10
Diagnosis: CT Scan
Management:
1. No ductal injury - Drainage or left alone
2. Ductal injury - Exploration
Neck, body and tail
a. Distal pancreatectomy with
splenectomy
b. Distal pancreatectomy without
splenectomy
c. Distal roux-en-y

Determining (diagnosing) Ductal Injury

a) Operative pancreatography
i) Duodenotomy
ii) Tail resection
b) Ductal cannulation via papilla
c) Endoscopic Retrograde Pancreatography (ERCP)
d) Drainage
H. Splenic Injuries
Management
a) Non-operative
b) Operative
i) Repair - Especially in pediatric patients where
post splenectomy sepsis is a complication

ii)
iii)
iv)
v)

Placement of omental pedicle

Mesh repair
Resection11
Splenectomy

Overwhelming Post Splenectomy Infection (OPSI)

1) Estimated risk
a) Adults 0.026%
b) Pedia 0.052%
2) Most Common Pathogens
a) Streptococcus pneumoniae
b) Haemophilus influenzae
c) Neisseria meningitidis
3) Vaccine
For pneumococcus and Haemophilus
Give to patients to prevent OPSI
4) Mortality: >50%
I. Small Intestines Injuries
Mechanism: Blunt Injuries
Crushing injury between the vertebral bodies and
the blunt object
Deceleration shearing at fixed points (e.g. LOT)
Closed loop rupture
Management
Lateral single-layer repair
Resection with end-to-end anastomosis
lumen will be smaller and strictures and
obstruction may develop later on
A full-thickness tear involving less than 50% of the
circumference is treated by primary closure
provided
Blood vessels are protected
Adequate lumen (>30%)
J. Colonic Injuries
1) Primary repair
a) Lateral Repair
b) Resection and Reconstruction
i) Ileocolostomy
ii) Colocolostomy - Especially on the right colon
(not on the left)

2) Colostomy
a) Indications (controversial)
i) Wound involving more than 50% of
circumference
ii) Extensive free peritoneal spill
iii) Associated hypotension
iv) Need for multiple transfusion
v) Three or more associated injuries
vi) Delay of more than 6 hours between injury
and operative intervention
Most accepted indication is if injury enough to cause
resection (at left side)
3) Exteriorized repair
Not accepted method
Complications
1) Intra-abdominal Abscess
2) Fecal Fistula
3) Wound Infection
4) Stomal Complications (5%)
a) Necrosis
b) Stenosis
c) Obstruction
d) Prolapse
K. Rectal Injuries
Organs involved when rectum is injured will depend
upon the sex of the patient
1. Primary closure of extraperitoneal rectal injuries
If injuries are visualized. If not then do not force
the issue.
2. Diverting colostomy
Done when extraperitoneal injuries are not
visualized
Will prevent the passage of fecal material to the
distal rectum where injury is located
3. Distal washout
Flushing of fecal material distal to the injury
4. Pre-sacral drainage 13
With blunt dissection, two fingers are inserted
between the rectum and the hollow of the sacrum.
Penrose drains are inserted and sutured to the skin.
L. Retroperitoneal Injuries
Zones of Retroperitoneal Injuries and Corresponding
Management14
Zone
Management
Zone 1
Penetrating injuries: Explore
Midline
retroperitoneum
Zone 2
Penetrating injuries: Explore
Upper lateral
Blunt trauma: Selective
retroperitoneum
management
( If there is expanding hematoma
explore; if hematoma [secondary
to blunt trauma] is not expanding
then no need to explore)
Renal Exploration: Renal A. and V.
control

Zone
Zone 3
Pelvic retroperitoneum

Management
Large retroperitoneal
hematomas and associated
with pelvic fracture: best
not explored
Ligation of hypogastric
arteries in general, not
effective
May use lap packs for
hemostasis for

Zone 4
Portal Retrohepatic Area
Maneuvers:
1. Cattel Maneuver15
- The right colon is mobilized to expose the right
peritoneal area
2. Mattox Maneuver16
- Mobilize the left colon passing through the white
line of Toldt to expose the left retroperitoneal area
3. Kocher maneuver12
- Reflects the duodenum and the pancreatic head
from the retroperitoneum, allowing access to the
intrahepatic inferior vena cava as well as to the
distal common bile duct, the duodenum, and the
pancreatic head
4. Renal Vessel Isolation

Suggested References
a) Principles of Surgery, Schwartz, 9th ed
b) Surgery, Principles & Practice,ACS
c) Trauma, Mattox 6th ed

Prepared by: Ma. Theresa Monje and Mark Dominic Iwag

Visit:
http://www.aast.org/library/traumatools/injuryscoringsc
ales.aspx#htmlBody (for Organ Injury Scale)
http://www.trauma.org/index.php/main/images/C13/
(For more gross pictures of abdominal trauma.)

Picture Gallery

9 CT scan showing
pancreatic transaction
1 - Manual Compression

2 Pringle Maneuver

4 Atrial Caval Tube

3 Pringle Maneuver with
Thermometer Probe

5 Selective Ligation and

Repair

6- Duodenal
Diverticulization

11 Splenic resection and

repair

10 Distal Pancreatomy
(Spleen preservation)
Resection of the distal pancreas
can be avoided by anastomosing it
[pancreas] to the small bowel

12 Kocher Maneuver

13 Presacral drainage

14 classification of
retroperitoneal hematoma

8 -ERCP shows contrast

leak from main pancreatic
duct
7- Pyloric Exclusion
15 Cattel Maneuver

16 Mattox maneuver