How to do - Abdominal Trauma


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How to do - Abdominal Trauma

  1. 1. How To Do…?? Explorative Laparotomy For Abdominal Trauma Presented by: Dr. Khalifa Al-Mulhim GS Consultant KFHU – Khobar – Saudi Arabia 2008
  2. 2. Introduction <ul><li>Conduct of a laparotomy for trauma follows a guidelines that apply irrespective of whether the injury is sustained by blunt or penetrating means </li></ul><ul><li>If patient is stable diagnostic aids required… </li></ul><ul><ul><ul><li>Ultrasounds </li></ul></ul></ul><ul><ul><ul><li>CT scan </li></ul></ul></ul><ul><ul><ul><li>DPL </li></ul></ul></ul>
  3. 3. Introduction <ul><li>If unstable proceed to resuscitative laparotomy without delay as part of the primary survey of ABC </li></ul>
  4. 4. Indications <ul><li>Penetrating or perforating wound (missile or stab) </li></ul><ul><li>Clear clinical evidence of peritonitis </li></ul><ul><li>Unresponsive resuscitation shown by continuing requirement of intravenous fluids with exclusion of bleeding from other system </li></ul><ul><li>Presence of air under diaphragm or evidence of diaphragmatic rupture on erect chest x-ray </li></ul><ul><li>CT evidence of presence of blood and ruptured solid viscera or positive diagnostic peritoneal lavage </li></ul>
  5. 5. <ul><li>All penetrating wounds should be explored as a role but conservative measures could be carried out provided… </li></ul><ul><ul><ul><li>Patient is stable </li></ul></ul></ul><ul><ul><ul><li>Frequent reassessment </li></ul></ul></ul><ul><ul><ul><li>Exploration on the 1 st signs of deterioration </li></ul></ul></ul>
  6. 6. <ul><li>Before exploration… </li></ul><ul><ul><li>Available blood </li></ul></ul><ul><ul><li>Prevent hypothermia </li></ul></ul><ul><ul><li>NGT and Foley’s catheter </li></ul></ul><ul><ul><li>Prophylactic antibiotics </li></ul></ul><ul><ul><li>Two large suction apparatus are ready as well as large </li></ul></ul>
  7. 7. <ul><li>Opening </li></ul><ul><li>Midline Incision </li></ul><ul><li>Clear away as much clot and free blood as possible to identify the specific source </li></ul><ul><li>Organized exploration </li></ul>
  8. 8. <ul><li>Retroperitoneal hematoma… </li></ul><ul><ul><li>Penetrating  explore </li></ul></ul><ul><ul><li>Blunt expanding  explore </li></ul></ul><ul><ul><li>Blunt non expanding or with pelvic fracture  Do not explore </li></ul></ul>
  9. 9. <ul><li>Major vessel bleeding… </li></ul><ul><li>Controlled with pressure while dissecting around the vessel to have control above and below the bleeding and repair using polypropylene </li></ul><ul><li>Small mesenteric vessels… </li></ul><ul><li>Could be oversewn but always examine the distal bowel for viability </li></ul><ul><li>Aorta and Inferior Vena Cava require vascular surgeon assistance for repair </li></ul>
  10. 10. <ul><li>Stomach… </li></ul><ul><ul><li>Oversewing tears </li></ul></ul><ul><ul><li>Doubtful viability of the greater curve if there is longitudinal tear parallel to it then resect </li></ul></ul>
  11. 11. <ul><li>Duodenum… </li></ul><ul><ul><li>Kocherize to examine posterior surface </li></ul></ul><ul><ul><li>Tears require primary repair or with jejunal patch </li></ul></ul><ul><ul><li>Extensive damage needs diversion gastrojejunostomy and T-tube in CBC in addition to the repair or resection </li></ul></ul>
  12. 12. <ul><li>Small bowel… </li></ul><ul><ul><li>Oversew penetrating wounds </li></ul></ul><ul><ul><li>Resect if there is multiple tears in a short segment or if doubtful viability </li></ul></ul>
  13. 13. <ul><li>Large bowel… </li></ul><ul><ul><li>High chance for contamination </li></ul></ul><ul><ul><li>Oversewing small tears < 6hrs old in the right colon </li></ul></ul><ul><ul><li>Right hemicolectomy with 1ry anastomosis </li></ul></ul><ul><ul><li>Resection with anastomosis and colostomy vs. Hartman’s procedure </li></ul></ul>
  14. 14. <ul><li>Liver… </li></ul><ul><ul><li>Tears are often mild </li></ul></ul><ul><ul><li>Major tears sutured with liver needles </li></ul></ul><ul><ul><li>Pringle maneuver if substantial Heg </li></ul></ul><ul><ul><li>Continuing Heg after clamping is common from hepatic veins or IVC </li></ul></ul><ul><ul><li>Major injury may require lobectomy </li></ul></ul><ul><ul><li>Uncontrollable Heg consider DCS </li></ul></ul>
  15. 15. <ul><li>Spleen… </li></ul><ul><ul><li>Best removed if ruptured </li></ul></ul><ul><ul><li>Splenic salvage </li></ul></ul>
  16. 16. <ul><li>Renal trauma… </li></ul><ul><ul><li>Blunt  conservative except ? </li></ul></ul><ul><ul><li>Penetrating  </li></ul></ul><ul><ul><ul><ul><li>Explore </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Kidney oversewing ( conserve as much kidney as possible) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ureter 1ry repair with double J stent </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bladder 1ry repair with suprapubic catheter </li></ul></ul></ul></ul>
  17. 17. <ul><li>Check List… </li></ul><ul><ul><li>Hemostasis </li></ul></ul><ul><ul><li>Visceral viability </li></ul></ul><ul><ul><li>Diaphragmatic injury </li></ul></ul><ul><ul><li>Drains </li></ul></ul><ul><ul><li>Stoma </li></ul></ul><ul><ul><li>Instrument count </li></ul></ul>
  18. 18. <ul><li>Closure… </li></ul><ul><ul><li>Single layer using One Nylon </li></ul></ul><ul><ul><li>Entry-exit missile wounds derided and left open </li></ul></ul>
  19. 19. <ul><ul><ul><ul><ul><li>Conclusion… </li></ul></ul></ul></ul></ul><ul><li>Laparotomy for trauma could save injured patients by controlling bleeding </li></ul><ul><li>Never start laparotomy without available blood </li></ul><ul><li>Ask for HELP when needed </li></ul><ul><li>Consider DCS if injuries are beyond repair </li></ul><ul><li>Make thorough exploration so not to miss any intraperitoneal injury </li></ul>
  20. 20. Thank You