MANAGEMENT OF ABDOMINAL TRAUMA.pptx

1. MANAGEMENT OF
ABDOMINAL
TRAUMA
DR ASAD
PG-4 Emergency Medicine

2. CLASSIFICATION OF ABDOMINAL TRAUMA
TRAUMA
BLUNT
CRUSH RTA BLAST INJURY
PENETRATING
STAB GUN SHOT
IATROGENIC

3. BLUNT INJURY
 PRODUCES LEAST VISIBLE SIGNS OF
INJURY
 DECELERATION: INJURY BY CHANGE
IN VELOCITY
 COMPRESSION: ORGANS TRAPPED
BETWEEN OTHER ORGANS
 SHEAR: PART OF ORGAN IS ABLE TO
MOVE WHILE OTHER REMAINS FIXED
CRUSH INJURY
 ENERGY TRANSMITTED TO OTHER
TISSUES
 CAN RESULT IN
 UNCONTROLLED HEMORRHAGE
 ORGAN DAMAGE
 SPILLAGE OF HOLLOW ORGAN
CONTENTS
 MOST COMMON ORGAN AFFECTED:
LIVER
Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the management of penetrating abdominal trauma: the more things
change, the more they stay the same. J Trauma 2003; 55:1095.

4. FREQUENCY OF ORGANS AFFETED
BLUNT TRAUMA
40%
20%
33%
7%
SPLEEN INJURY RENAL INJURY
LIVER INTESTINE
PENETRATING TRAUMA
22%
22%
21%
15%
9%
6%
5%
STOMACH DIAPHRAGM SMALL BOWEL
COLON SPLEEN PANCREAS
KIDNEYS
Boutros SM, Nassef MA, Abdel-Ghany AF. Blunt abdominal trauma: The role of focused abdominal sonography in
assessment of organ injury and reducing the need for CT. Alexandria Journal of Medicine. 2016 Mar 30;52(1):35-41.

5. PrimarySurvey –ATLSapproach

6. Anterior abdomen: Between the anterior axillary lines; bound by the costal margin superiorly
and the groin crease distally.
Thoracoabdominal area: fourth intercostal space (anterior), sixth intercostal space (lateral),
and eighth intercostal space (posterior), and inferiorly delimited by the costal margin
Flanks: From the inferior costal margin superiorly to the iliac crests; bound anteriorly by the
anterior axillary line and posteriorly by the posterior axillary line
Back: Between the posterior axillary lines extending from the costal margin to the iliac crests.

7. DIAGNOSTICAND TREATMENT PRIORITIES
Recognize presence of shock or intra abdominal
bleeding
Start resuscitative measures for shock/bleeding
Determine if abdomen is source for shock
or bleeding
Determine if emergency laparatomy is needed
Complete secondary survey and radiograph studies
to determine if “occult” abdominal injury is present

8. SECONDARY SURVEYHISTORY
 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 meals
 E : Events (mechanism of injury)

9. Physical Examination
Inspection : abrasions, contusion, lacerations, deformity, entrance
and exit wounds to determine path of injury…
(Grey turner, Kehr , balance , Cullen, seat belt sign)
Palpation: elicits 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 decrease ( late finding).

11. Clot collected under left
diaphragm irritates it and the
phrenic nerve( C3, C4)
causing referred pain in left
shoulder 15 minutes after foot
end elevation
Persistent dullness to percussion in the left flank---
due to coagulated blood
shifting dullness to percussion in the right flank---
due to fluid blood
Balance sign

12. Laboratorytests
 Hematocrit – below 30% increases the likelihood of intra-
abdominal injury.
 Leukocyte count
 Pancreatic enzymes – normal serum amylase and lipase concentrations
cannot exclude significant pancreatic injury . and while elevated
concentrations raise the possibility of pancreatic injury,
 Liver function tests – hepatic injury is associated with
elevations in liver transaminase concentrations
 Urinalysis – gross hematuria suggests serious renal injury and
mandates further investigation
Zafar SN, Rushing A, Haut ER, et al. Outcome of selective non-operative management of penetrating abdominal
injuries from the North American National Trauma Database. Br J Surg 2012; 99 Suppl 1:155.

13. Plainradiograph
LOWER RIBS FRACTURE PNEUMOPERITONEUM
DIAGPHRAGMATIC RUPTURE

14. FAST (FOCUSED ASSESMENT WITH
SONOGRAM OF TRAUMA

15. Huang FAST scoring system
• Score >3 cm
– Indicates 1 liter or more hemoperitoneum
– 96 % probability of laparotomy
• Score < 3 cm
– 37 % probability of laparotomy

16. CT IMAGING
Accurate for solid visceral lesions and
intraperitoneal hemorrhage
guide nonoperative management of solid organ
damage
IV not oral contrast
Disadvantages : insensitive for injury of the
pancreas, diaphragm, small bowel, and
mesentery
Inaba K, Okoye OT, Rosenheck R, et al. Prospective evaluation of the role of computed tomography in the assessment o
abdominal stab wounds. JAMA Surg 2013; 148:810.

17. Local WoundExploration
To determine the depth of penetration in stab
wounds
Prep, extend wound, carefully examine (No
blind probing)
Indicated for anterior abdominal stab wounds,
less clear for other areas
Cothren CC, Moore EE, Warren FA, et al. Local wound exploration remains a valuable triage tool for the evaluation of
anterior abdominal stab wounds. Am J Surg 2009; 198:223.

18. Laparoscopy
 Most useful to evaluate penetrating wounds to
thoracoabdominal region in stable pt
 Esp for diaphragm injury:
 Can repair organs via the laparoscope
 Diaphragm, solid viscera, stomach, small bowel.
 Disadvantages:
 Poor sensitivity for hollow visceral injury, retroperitoneum
 Complications from trocar misplacement.
 If diaphragm injury, pnumothorax during insufflation
Ahmed N, Whelan J, Brownlee J, et al. The contribution of laparoscopy in evaluation of penetrating abdominal
wounds. J Am CollSurg 2005; 201:213.
Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating
abdominal trauma. J Trauma 2005; 58:789.

19. Gamanagatti S, Rangarajan K, Kumar A. Blunt abdominal trauma: imaging and intervention. Current
problems in diagnostic radiology. 2015 Jul 1;44(4):321-36.

20. MANAGEMENT

21. 4. Order laboratory work for abdominal trauma patients based on the mechanism of
injury (blunt vs penetrating); labs may include type and crossmatching, complete
blood count, electrolytes, lactate level, directed toxicologic studies, coagulation
studies, hepatic enzymes, and lipase.
3. Administer IV crystalloid fluid to hypotensive abdominal trauma patients. Transfuse
with O-negative or type-specific packed red blood cells as indicated.
2. Administer oxygen as needed, attach cardiac monitoring, and secure two large-
bore IV lines.
1. Initiate standard protocols for evaluation and stabilization of trauma
patients.
Goodman CS, Hur
JY, Adajar MA,
Coulam CH. How
well does CT predict
the need for
laparotomy in
hemodynamically
stable patients with
penetrating
abdominal injury? A
review and meta-
analysis. AJR Am J
Roentgenol 2009;
193:432.

22. 7. For the hemodynamically stable, blunt trauma patient with a positive FAST
examination, further evaluation with CT is required
6. For a stab wound to the abdomen, consider for local wound exploration. If the local
wound exploration demonstrates no violation of the
anterior fascia, the patient can be discharged home.
5. Indications for exploratory laparotomy. When a patient presents to the ED with an
obvious high-velocity gunshot wound to the abdomen, do not delay transport of the
patient to the operating room by performing a FAST examination unless there is a
suspicion for cardiac injury. If organ evisceration is present, cover the wound with a
moist, sterile dressing before surgery.
Goodman CS, Hur
JY, Adajar MA,
Coulam CH. How
well does CT predict
the need for
laparotomy in
hemodynamically
stable patients with
penetrating
abdominal injury? A
review and meta-
analysis. AJR Am J
Roentgenol 2009;
193:432.

23. MANAGEMENT

24. Exploratorylaparotomy
 Potential indications include the following:
 Haemodynamic instability
 Evidence of Peritonitis to achieve control of hemorrhage and
control of spillage (hypotension with distended abdomen)
Traumatic diaphragmatic injury with herniation
Severe solid organ injury (e.g. kidney and spleen)
Infarction due to post traumatic occlusion of the blood supply
Mesenteric tears
Unexplained Moderate to large amounts of free fluid (200-
≥500mls)
Gsw with peritoneal penetration
Plackett TP, Fleurat J, Putty B, et al. Selective nonoperative management of
anterior abdominal stab wounds: 1992-2008. J Trauma 2011; 70:408

25. PROCEDURE
Incision.
Generous midline incision is preferred. Self retaining retractor
systems and headlights are invaluable.
Bleeding control.
Scoop-free blood and rapidly pack all quadrants
If packing does not control a bleeding site,
this source must be controlled as the first priority.
Contamination control.
Quickly control bowel content contamination

26. Systematic exploration. Systematically explore the entire abdomen, giving priority to
areas of ongoing hemorrhage
1. A. Liver B. Spleen C. Stomach
2. Right colon, transverse colon, descending colon, sigmoid colon, rectum, and small
bowel, from ligament of Trietz to terminal ileum, looking at the entire bowel wall and the
mesentery
3. Pancreas, by opening lesser sac (visualize and palpate)
4. Kocher maneuver to visualize the duodenum, with evidence of possible injury
5. Left and right hemi diaphragms and retroperitoneum
6. Pelvic structures, including the bladder
7. With penetrating injuries, exploration should focus on following the track of the weapon
or missile.
Injury repair
Closure
Ertekin C, Yanar H, Taviloglu K, et al. Unnecessary laparotomy by using physical examination and different
diagnostic modalities for penetrating abdominal stab wounds. Emerg Med J 2005; 22:790.

27. DAMAGE CONTROL SURGERY
PRINCIPLES:
• Control hemorrhage with packing
• Identification of injury
• Prevention and control contamination with temporary
closure
• Avoid further injury
• Resuscitation in the ICU
• Re-exploration and definitive repair once normal
physiology has been restored

28. 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 34⁰C
 Coagulopathy, as evidenced by the development of non mechanical 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

29. SPECIFIC ORGAN INJURY
PERITONEAL RETROPERITONEAL DIAPHRAGM
• Treatment of an organ injury is similar whether the injury mechanism is penetrating or blunt
• An exception to the rule is a retroperitoneal hematoma.
• Explore all retroperitoneal hematomas caused by penetrating injury.

30. DIAPHRAGM
 Presentation : chest or abdomen pain, cough, dyspnea,
tachypnea
 Can be due to blunt(>85%) or penetrating injury and is larger in
the blunt
 Often missed in multitrauma
 Possible cardiac injury if the penetrating wound is more central
 The weakest point of diaphragm is the lt.Posteriolateral (80%)
 Rupture with herniation is diagnosed by CXR or CT but
 Without herniation is difficult to diagnose, thoracoscopy or
laparoscopy is diagnostic
Chaudhry HH, Grigorian A, Lekawa ME, Dolich MO, Nguyen NT, Smith BR, Schubl SD,
Nahmias JT. Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated
Diaphragm Injury After Penetrating Trauma. The American Surgeon. 2020 May;86(5):493-8.

31. RADIOGRAPH
Hour glass sign
Herniation of visceras on CT/ MRI/ xray or
barium study
Chaudhry HH, Grigorian A, Lekawa ME, Dolich MO, Nguyen NT, Smith BR,
Schubl SD, Nahmias JT. Decreased Length of Stay After Laparoscopic
Diaphragm Repair for Isolated Diaphragm Injury After Penetrating
Trauma. The American Surgeon. 2020 May;86(5):493-8.

32. CT SCAN
 Discontinuity of diaphragm
 Herniation of abdominal contents in chest
 Abnormal positioning of ng tube (coiled in chest)
 Visceras in direct contact with posterior ribs (liver,
spleen )
Chaudhry HH, Grigorian A, Lekawa ME, Dolich MO, Nguyen NT, Smith BR, Schubl SD,
Nahmias JT. Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated
Diaphragm Injury After Penetrating Trauma. The American Surgeon. 2020 May;86(5):493-8.

33. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
• CONTUSION OR HEMATOMA WITHOUT PERFORATION
• NO SURGICAL INTERVENTION
GRADE 1
• LACERATION LESS THAN 2 CM
• 2/0 OR 1/0 ABSORBABLE SUTURES
GRADE 2
•LACERATOIN 2-9 CM
•FIRST LAYER: 1/0 ABSORBABLE INTERRUPTED
SECOND LAYER: 1/0 RUNNING ABSORBABLE SUTURES
GRADE 3
•LACERATION 10-25 CM
•2/0 NON ABSORBABLE OR 1/0 MONOFILAMENT INTERRUPTED IN 2
LAYERS
•USE OF FASCIA LATA OR ALLOGENIC MATERIAL
GRADE4
•LACERATION OF >25 CM
•USE OF PTFE MESH OR ADVANCEDMENT FLAP
GRADE 5

34. TREATMENT
 Once identified must be repaired because it will not close
spontaneously regardless the size
 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.
 Place chest tube on the surgery side at the time of repair
Chaudhry HH, Grigorian A, Lekawa ME, Dolich MO, Nguyen NT, Smith BR, Schubl SD,
Nahmias JT. Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated
Diaphragm Injury After Penetrating Trauma. The American Surgeon. 2020 May;86(5):493-8.

35. STOMACH
 More common in penetrating trauma than blunt & it’s about 10% of penetrating
injuries of the abdomen
1. Physical examination:
2. Epigastric tenderness
3. Peritoneal signs
4. Bloody gastric aspirate
 Plain radiography in <50%
• –Free air under the diaphragm
Paswan SS, Kumar A, Chitta MR, Sudipta M, Saurabh S. Double Blow
Injury: Diaphragmatic Rupture with Gastric Perforation Following
Blunt Trauma. SN Comprehensive Clinical Medicine. 2020
Jan;2(1):128-31.

36. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
• Contusion/hematoma
• Partial thickness laceration
Grade 1
•Laceration <2cm in GE junction or pylorus
•<5cm in proximal 1/3 stomach
•<10cm in distal 2/3 stomach
Grade 2
•Laceration >2cm in GE junction or pylorus
•>5cm in proximal 1/3 stomach
•>10cm in distal 2/3 stomach
Grade 3
• Tissue loss or devascularization <2/3 stomach
Grade 4
• Tissue loss or devascularization >2/3 stomach
Grade 5

37. TREATMENT
 treatment is according to the severity
 Administer preoperative antibiotics
 Hematoma is evacuated, hemostasis and closure with non absorbable 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
 A pyloric wound may be converted to pyeloroplasty
 Destructive wound may need proximal or distal gastrectomy
 In rare cases a total Gastrectomy and Roux-en-y Esophagojejunostomy are
necessary for severe cases
Paswan SS, Kumar A, Chitta MR, Sudipta M, Saurabh S. Double Blow
Injury: Diaphragmatic Rupture with Gastric Perforation Following
Blunt Trauma. SN Comprehensive Clinical Medicine. 2020
Jan;2(1):128-31.

38. TREATMENT
Paswan SS, Kumar A, Chitta MR, Sudipta M, Saurabh S.
Double Blow Injury: Diaphragmatic Rupture with
Gastric Perforation Following Blunt Trauma. SN
Comprehensive Clinical Medicine. 2020 Jan;2(1):128-
31.

39. DUODENUM
 Right upper quadrant pain, radiating to back
 Retching or vomiting ( blood in vomitus )
 Abdominal distension specially in right upper quadrant
 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.)
Ratnasekera A, Ferrada P. Traumatic Duodenal Injury: Current Management Update. Current Surgery
Reports. 2020 May;8(5):1-6.

40. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
•Hematoma Involving single portion of duodenum
•Laceration Partial thickness, no perforation
GRADE 1
•Hematoma Involving more than one portion
•Laceration Disruption <50% of circumference
GRADE 2
• Laceration Disruption 50%-75% of circumference
• Disruption 50%-100% of circumference of D1,D3,D4
GRADE 3
• Laceration Disruption >75% of circumference of D2
• Involving ampulla or distal common bile duct
GRADE 4
• Laceration Massive disruption of duodenopancreatic complex
• Vascular Devascularization of duodenum
GRADE 5

41. TREATMENT
Ratnasekera A, Ferrada P. Traumatic Duodenal Injury: Current Management Update. Current Surgery
Reports. 2020 May;8(5):1-6.

42. 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
>24 hours since injury
Associated common bile duct injury
Ratnasekera A, Ferrada P. Traumatic Duodenal Injury: Current Management Update. Current Surgery
Reports. 2020 May;8(5):1-6.

43. SMALL BOWEL
 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, midjejunum, or in areas of adhesions
Guarino J, Hassett JM, Luchette FA. Small bowel injuries: mechanisms, patterns, and outcome.

44. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
• Hematoma Contusion or hematoma without devascularization
• Laceration Partial thickness, no perforation
GRADE 1
• Laceration Laceration <50% of circumference
GRADE 2
• Laceration Laceration > 50% of circumference without transection
GRADE 3
• Laceration Transection of the small bowel
GRADE 4
• Laceration Transection of the small bowel with segmental tissue loss
• Vascular Devascularized segment
GRADE 5

45. MANAGEMENT
 Definitive repair should be deferred until the entire bowel is evaluated.
 Primary repair- Partial-thickness injuries, or full-thickness injuries that that are less than 50% of the
luminal circumference in the small bowel can be repaired primarily. The primary repair could be
accomplished with one or two layers of closure.
 Resection and anastomosis- Multiple injuries within the same vicinity or a single injury greater than 3
cm in the stomach or greater than 50% of luminal circumference in the intestines should be resected
with anastomosis as appropriate.
 Diversion: EAST GUIDELINES recommended against diversion in low-risk patients. In high-risk patients,
which they defined as delay greater than 12 hours, transfusion of more than six units of blood,
contamination, and left-sided injuries, they recommended against mandatory colostomy.
 In high-risk situations, a surgeon can choose between repair and anastomosis, diversion, or damage
control approach with an anastomosis after resuscitation and stabilization. If bowel continuity cannot
be established within 36 hours, then diversion is generally recommended to avoid an increased risk of
anastomotic failure related to the bowel edema.
Chamieh J, Prakash P, Symons WJ. Management of Destructive Colon Injuries after Damage Control Surgery. Clin Colon
Rectal Surg. 2018 Jan;31(1):36-4

46. COLON
 The transverse colon is the most commonly injured segment after gunshot
wounds
 The left colon the most commonly injured segment after stab wounds.
 Stab wounds or low-velocity civilian gunshot wounds usually cause limited
damage and most of them are amenable to debridement and primary repair
 High-velocity penetrating injuries, such as in war-related trauma, cause
major tissue damage and almost always require colon resection
De Robles MS, Young CJ. Outcomes of Primary Repair and Anastomosis for
Traumatic Colonic Injuries in a Tertiary Trauma Center. Medicina. 2020
Sep;56(9):440.

47. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
•Hematoma Contusion or hematoma without devascularization
•Laceration Partial thickness, no perforation
GRADE 1
•Laceration Laceration <50% of circumference
GRADE 2
•Laceration Laceration > 50% of circumference without
transection
GRADE 3
•Laceration Transection of the colon
GRADE 4
•Laceration Transection of the colon with segmental tissue loss
•Vascular Devascularized segment
GRADE 5

48. MANAGEMENT
 Current operative options include
 Primary repair of the injury,
 Resection and anastomosis, and
 Colostomy..
 The guidelines for primary repair include
 Minimal fecal spillage,
 No shock (defined as systolic blood pressure <90 mmhg),
 Minimal associated intra abdominal injuries,
 <8-hour delay in diagnosis and treatment, and
 <1-L blood transfusion.
 Traditional contraindications to primary repair include
 Patients with shock, underlying disease, significant associated injuries, or peritonitis
 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;
De Robles MS, Young CJ. Outcomes of Primary Repair and
Anastomosis for Traumatic Colonic Injuries in a Tertiary Trauma
Center. Medicina. 2020 Sep;56(9):440.

49. PANCREATIC INJURY
 Relatively uncommon; most are caused by penetrating injury
 A major diagnostic challenge, especially in blunt trauma cases
 Associated intra abdominal 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
intra abdominal injury
 The initial complaints with pancreatic injury may be vague and
nonspecific; 6 to 24 hours after the injury, the patient will complain
of mid epigastric and or back pain
 Serum amylase levels are sensitive but not specific
Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN.
Pancreatic Trauma: Imaging Review and Management Update. RadioGraphics. 2021 Jan;41(1):58-74.

50. INVESTIGATIONS
Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN.
Pancreatic Trauma: Imaging Review and Management Update. RadioGraphics. 2021 Jan;41(1):58-74.

51. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
Hematoma Minor contusion without duct injury
Laceration Superficial laceration without duct
injury
HematomaMajor contusion without duct
injury or tissue loss
LacerationMajor laceration without duct
injury or tissue loss
Laceration: Distal transection or parenchymal
injury with duct injury
Laceration: Proximal? transection or
parenchymal injury involving amp
Laceration: Massive disruption of pancreatic head

52. MANAGEMENT
Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPb. 2018 Dec 1;20(12):1099-108.

53. MANAGEMENT
 PROXIMAL INJURIES:
 conservative approach (placement of surgical or percutaneous drains/
ERCP + stent positioning for proximal duct injuries)
 One- or two-stage PD is indicated only in SEVERE cases
 DISTAL INJURIES:
 pancreatic duct is not damaged conservative treatment.
 complete Wirsung duct transection surgical intervention.
 pancreatic parenchyma or spleen contusions/lesions laparoscopic or open distal
pancreatectomy / splenectomy
 complete neck transection with preserved pancreatic parenchyma parenchymal-
sparing surgery
Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPb. 2018 Dec 1;20(12):1099-108.

54. COMPLICATIONS
 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 reoperation in most.
 Overall mortality ranges from 15% to 35% with pancreatic-related
 Mortality alone ranging from 2% to 3%.
Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPb. 2018 Dec 1;20(12):1099-108.

55. LIVER
 Commonly injured intra abdominal organ; injury occurs more often in
penetrating trauma than in blunt trauma
 Hemodynamically stable with a blunt mechanism of injury, CT is preferred.
 The hemodynamically stable patients with blunt injury of the
liver, can be treated non operatively, regardless of the grade of
the liver injury.
 Arterial blush or pooling of contrast on ct and high-grade (grade iv and v)
hepatic injuries are most likely to fail nonoperative management.
 The criteria for nonoperative management of blunt liver
injuries include:
 Hemodynamic stability.
 Absence of peritoneal signs.
 Lack of continued need for transfusion for the hepatic injury;
bleeding can be addressed with angioembolization
Saqib Y. A systematic review of the
safety and efficacy of non-operative
management in patients with high
grade liver injury. The Surgeon. 2020
Jun 1;18(3):165-77.

56. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
Subcapsular hematoma<1cm, superficial
laceration<1cm deep.
Parenchymal laceration 1-3cm deep,
subcapsular hematoma1-3 cm thick.
AAST GRADING SYSTEM
GRADE 1 GRADE 2
WSES
grade I

57. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM
Parenchymal laceration> 3cm deep and
subcapsular hematoma> 3cm diameter.
AAST GRADE 3
WSES grade II

58. Parenchymal/supcapsular hematoma> 10cm
in diameter, lobar destruction
Global destruction or
devascularization of the liver.
Hepatic avulsion
WSES
grade III

59. MANAGEMENT
The World Society of
Emergency Surgery
GUIDELINES 2020

60. Criteria for non Operative Management:
Haemodynamic
stability, or stability
achieved with minimal
resuscitation(1-2 litres
of crystalloid)
Absence of other
abdominal injuries
requiring laparotomy
Preserved
consciousness allowing
serial examination of
abdomen
Absence of peritonism
Absence of ongoing
bleeding on CT scan
Non-operative management (NOM) consists of
admission to a unit and the monitoring of vital signs,
strict bed rest,
frequent monitoring of hemoglobin concentration
serial abdominal examinations
Angio-embolization
The World Society of Emergency Surgery
GUIDELINES 2020

61. Criteria for Operative Management
Any patient who is
haemodynamically
unstable with
suspected liver trauma
Multiple transfusions
required to maintain
haemodynamic stability
Signs of peritonism, or
development of
peritonism on serial
abdominal examinations
Active arterial blush on
CT for which
interventional
techniques have failed
and/or ongoing bleeding
on CT scan with focal
pooling of contrast
Penetrating trauma
Operative management can be summarized as
PUSH
PRINGLE
PLUG
PACK
The World Society of Emergency
Surgery GUIDELINES 2020

62. The pringle maneuver, performed with
a vascular Clamp, occludes the hepatic
pedicle containing the portal vein,
hepatic artery, and common bile duct
• Hepatorraphy A running suture is
used to approximate the edges of
shallow lacerations,
• Deeper lacerations are approximated
using interrupted horizontal mattress
sutures placed parallel to the edge of the
laceration.

63. SURGICAL MANAGEMENT
 Mesh wrapping
 Hepatotomy and selective vascular ligation
 Non-anatomical resection of liver
 Anatomical resection of liver

64. SPLEEN
 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 will provide the most
rapid diagnosis of hemoperitoneum
 In the stable patient suffering from blunt injury, CT imaging of the abdomen
allows delineation and grading of the
Chahine AH, Gilyard S, Hanna TN, Fan S, Risk B, Johnson JO, Duszak Jr R, Newsome J,
Xing M, Kokabi N. Management of Splenic Trauma in Contemporary Clinical Practice: A
National Trauma Data Bank Study. Academic Radiology. 2020 Dec 4.

65. AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA GRADING SYSTEM

66. MANAGEMENT
 Non-operative management of splenic injury (NOMSI)
 Conservative
 Interventional radiology
Splenic angioembolization
 Operative management
 Splenorraphy
procedure to preserve spleen done in past, now replaced by NOMSI
 Splenectomy
Chahine AH, Gilyard S, Hanna TN, Fan S, Risk B, Johnson JO, Duszak Jr R, Newsome J,
Xing M, Kokabi N. Management of Splenic Trauma in Contemporary Clinical Practice: A
National Trauma Data Bank Study. Academic Radiology. 2020 Dec 4.

67. EAST GUIDELINES 2020
Patients who have diffuse peritonitis or who are hemodynamically
unstable(positive FAST examination result) should be taken urgently for
laparotomy.
A routine laparotomy is not indicated in hemodynamically stable patient without
peritonitis presenting with an isolated splenic injury.
In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an
abdominal CT scan with IV contrast should be performed to identify and assess the
severity of injury to the spleen
Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients
with isolated blunt splenic injuries without increasing the failure rate of nonoperative
management

68. EAST GUIDELINES 2020
 Following parameters are NO LONGER contraindications to a trial of
nonoperative management in a hemodynamically stable patient
 The severity of splenic injury (as suggested by ct grade or degree of
hemoperitoneum),
 Neurologic status,(asoc, head injury)
 Age >55
 Number of tranfusions
 Blush on CT and/or
 The presence of associated injuries.

69. EAST GUIDELINES 2020
AAST
grade > III
injuries,
presence of a
contrast blush
moderate
hemoperitoneum
evidence of
ongoing splenic
bleeding
Angiography should be considered for patients with

70. EAST GUIDELINES 2020
Frequency of hemoglobin measurements,Frequency of abdominal examinations, Intensity and duration of monitoring
Is there a true transfusion threshold after which operation or angiography should be considered?
Optimal time to reinitiating oral intake
The duration and intensity of restricted activity (both in-hospital and after discharge)
Optimum length of stay for both the intensive care unit (ICU) and hospital
Necessity of repeated imaging
Timing of initiating chemical deep venous thrombosis (DVT) prophylaxis after a splenic injury
Necessity of postsplenectomy vaccination for patients with severe injuries/or embolized injuries
Is there an immunologic deficiency after splenic embolization
What exactly constitutes a ‘‘failure’’ of nonoperative management?
According to EAST guidelines, there was not enough literature available to make recommendations regarding the
following:

71. SURGICAL MANAGEMENT
 Operative therapy of choice is splenic conservation where possible
to avoid the risk of death from overwhelming post splenectomy
sepsis that can occur after splenectomy for trauma
 Splenorrahphy: parenchyma saving operation of spleen
 In grade 2 and 3 splenic injury suture repair (horizontal mattress) ,
or mesh wrap of capsular defects. Suture repair in adults often
requires teflon pledgets to avoid tearing of the splenic capsule
 Partial splenectomy: grade IV to V splenic injury may require
anatomic resection, including ligation of the lobar artery .
 Auto transplantation: implanting multiple 1-mm slices of the
spleen in the omentum after splenectomy.
Chahine AH, Gilyard S, Hanna TN, Fan S, Risk B, Johnson JO, Duszak Jr R, Newsome J,
Xing M, Kokabi N. Management of Splenic Trauma in Contemporary Clinical Practice: A
National Trauma Data Bank Study. Academic Radiology. 2020 Dec 4.

72. EAST GUIDELINES 2020

73. COMPLICATION
 Bleeding
 Recurrent splenic bed bleeding
 Pancreatitis
 Sub phrenic abscess
 Thrombocytosis
 DVT
 OPSI (1-6 weeks)
Chahine AH, Gilyard S, Hanna TN, Fan S, Risk B, Johnson JO, Duszak Jr R, Newsome J,
Xing M, Kokabi N. Management of Splenic Trauma in Contemporary Clinical Practice: A
National Trauma Data Bank Study. Academic Radiology. 2020 Dec 4.

74. RECENT ADVANCEMENT

75. THANK YOU