medis

1. Wifanto Saditya J
Digestive Division Department of Surgery
Cipto Mangunkusumo Hospital and
Jakarta

2. } In the past : Abdomen was a “Black Box”:
“It is impossible to know what specific
injuries have occurred at initial evaluation”
} Nowadays : Many tools to evaluate organ
specific injury
} The Causes of Abdominal:
◦ Blunt trauma
◦ Penetrating trauma
◦ Blast/gunshot trauma

3. Anatomy and Topography correlated to Organ Involvement

6. } Primary Survey : A-B-C-D
} Rapid identification and control of major
haemorrhage
} Think site of bledding :
◦ Thorax
◦ Abdomen
◦ Pelvis
◦ Femur fracture
◦ Retroperitoneum

7. } Immediate explorative of the abdomen:
◦ Major haemorrhage from abdominal source
◦ Signs of peritonitis
◦ Evisceration
◦ Chest radiographic evidence of diaphragmatic
rupture
◦ Abdominal impalement
◦ ALL gunshot wounds to the abdomen

8. } Blunt trauma-
unstable
} Retroperitoneal
hematoma
} Ileum perforation

9. } Blunt trauma-stable
} Perforation of
jejunum

10. } Abdominal wound
with evisceration of
omentum or
intestine

11. } History of Illness
◦ Mechanism of Injury
◦ Injury sustain
◦ Time of injury
} Type of injury
◦ Blunt injury
◦ Penetrating injury
◦ Gunshot/blast injury
◦ Combination/multiple trauma

12. } Physical examnination
◦ Inspection : general-local conditon
◦ Palpation : tenderness, peritonitis
◦ Percussion : dull, fluid, free air
◦ Auscultation : bowel sound
} Digital Rectal Examination
} Genital/perineal inspection
◦ Blood, hematoma,
◦ Swelling etc.
} Laboratory

13. } Ultrasonography – FAST
◦ Focused Assessment Sonography on Trauma
} Diagnostic Peritoneal Lavage (DPL)
} Computed Tomography (CT Scan)
} Diagnostic laparoscopy

14. } Assest solid organ
injury
} Intraabdominal fluid
or blood
} Huang et al (1994) :
Prediction of fluid
amount

15. ◦ To
diagnose
free
intraperitoneal
fluids
a2er
blunt
trauma
◦ Four
areas:
– Perihepa9c
&
hepato-­‐renal
space
(Morrison’s
pouch)
– Perisplenic
– Pelvis
(Pouch
of
Douglas/rectovesical
pouch)
– Pericardium
(subxiphoid)
◦ Sensi9vity
60
to
95%
for
detec9ng
100
mL
-­‐
500
mL
of
fluid
Trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009

16. } Morrison’s
pouch
(hepato-­‐renal
space)
Rosen’s Emergency Medicine, 7th ed. 2009

17.
} Perisplenic
view
trauma.org Rosen’s Emergency Medicine, 7th ed. 2009

18. } Retrovesicle
(Pouch
of
Douglas)
} Pericardium
(subxiphoid)
trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009

19. Huang MS, Liu M, Wu JK, Shih HC, Ko TJ, Lee CH. Ultrasonography for the evaluation of
hemoperitoneum during resuscitation: a simple scoring system. J Trauma. 1994;36(2):173-7.
B. Philippi, H Siahaan : FAST Evaluation in RSCM 2012

20. } Advantages :
◦ Fast-bedside
◦ Sensitive to hemoperitoneum (82-97%)
◦ Non invasive
◦ No radiation/contrast
} Disadvantages
◦ Operator dependent
◦ Not as good for solid parenchymal damage,
retroperitoneum, or diaphragmatic defects.
◦ Limited by obesity, substantial bowel gas, and free air.
◦ Can’t distinguish blood from ascites.

21. } Advantages :
◦ Fast
◦ Sensitive and objective
} Disadvantages :
◦ Specialized training
◦ Invasive – Need streril equipments
◦ Not injury specific
◦ Miss retroperitoneal and diaphragm injury
} Not recommended if prior to laparotomy

24. } Advantages
◦ Very specific and sensitive
◦ Good for evaluating back
and retroperitoneal injuries
◦ Allow staging of blunt organ injury
} Disadvantages
◦ Require time and patient transport
◦ Patient must in stable condition

25. } Rationale
◦ Exploratory laparotomy in trauma patient with
suspected intra-abdominal injury can be NEGATIF
LAPAROTOMY with increasing morbidity and
mortality
◦ Diagnostic Laparoscopy can perform to decrease
negatif laparotomy
(10-20% no significant organ injury)

26. } Improved diagnostic accuracy compared to
◦ FAST: poor specificity
◦ DPL: poor specificity, invasive, not informative for
retroperitoneal injuries
◦ CT: hollow viscus injuries difficult to identify
} Reduction of non therapeutic laparotomy
rates
} Reduction of short and long-term morbidity –
↓ ICU stay, ↓ overall LOS
Risk future adhesive bowel obstruction

29. } Indication :
◦ Highly suspected intra-abdominal injury after negatif
initial examination
◦ Abdominal stab wound through fascia/peritoneum
◦ Gunshot wound suspected through abdomen
◦ Diagnosis diafragm injury
◦ Transdiafragm pericardial window in heart injury
} Contraindication (absolut or relative)
◦ Unstable Hemodinamic
◦ Peritonitis
◦ Significant Intra-abdominal injury
◦ Posterior stab wound with suspected colon injury
◦ Limited skill to perform laparoscopy

30. } Contraindication (absolut or relative)
◦ Unstable Hemodinamic
◦ Peritonitis
◦ Significant Intra-abdominal injury
◦ Posterior stab wound with suspected colon injury
◦ Limited skill to perform laparoscopy

34. PF
normal
PF
tak
jelas/tak
dapat
dipercaya/
tidak
di
follow
up
Peritonitis
Pemeriksaan
Serial
Hemodinamik
Stabil
Hemodinamik
Tidak
Stabil
Trauma
Tumpul
Abdomen
FAST
Positif
Negatif
Trauma
abdomen
tidak
jelas
Trauma
abdomen
jelas
FAST
Negatif Positif
Laparotomi
Evaluasi
ulang:-­‐
organ
lain-­‐
penyebab
lain
Penanganan
Selektif
Laparotomi

35. cedera
organ
(+)
cedera
organ
(+)
cedera
organ
jelas
cedera
organ
(+)
tembus
(-­‐)
tembus
(+)
cedera
diafragma
Repair
Laparotomi
cedera
organ
(-­‐)
cedera
organ
tidak
jelas
Tembak
Trauma
Tembus
Abdomen
Indikasi
Laparotomi:
Syok,
Peritonitis
,
Eviserasi,
Tertancap,
Udara
bebas,
Darah
di
oriMisium/selang,
Tidak Ya
Tusuk
Abdomen
Depan
Flank/
belakang
Torako-­‐
abdominal
Laparoskopi
CT
Scan
+
Kontras
Eksplorasi
lokal
luka
Laparoskopi
Observasi
cedera
organ
(-­‐)
tembus
(+)
Laparoskopi
Tutup
luka
Observasi
/
Rawat
jalan

36. } Abdominal trauma is a complex situation
needing prompt and thorough approach
} Primary survey : controlled abdominal
bledding
} Specific examination à accurate treament
} FAST is useful for initial assestment of blunt
abdominal trauma
} Laparoscopic surgery : good visualization in
specific injury