Abdominopelvic Trauma Guide

2/8/2017 Abdominopelvic trauma By F/wold T.,ESO II 1

Topic outline
• Introduction
• Brief anatomy
• Classification
• Approach to the patient with abdominopelvic trauma
• Specific injuries to organs of the abdomen and pelvic
• Management & Complications
• References

Introduction, Body Cavities
2/8/2017 3Abdominopelvic trauma By F/wold T.,ESO II

Introduction,Brief anatomy…
o Anterior abdomen:
 trans-nipple line, , anterior
axillary lines, inguinal
ligaments and symphysis
pubis.
o Flank:
 anterior and posterior
axillary line ;sixth
intercostal to iliac crest
o Back:
 posterior axillary line; tip
of scapula to iliac crest

Introduction,Brief anatomy…
• Peritoneal cavity:
– Liver, spleen, stomach, and
transverse colon; lower-small
bowel, sigmoid colon
• Retroperitoneal space:
– Aorta, IVC, duodenum,
pancreas, kidneys,
ureters,ascending and
descending colons
• Pelvic cavity:
– rectum, bladder, iliac vessels
and internal genitalia2/8/2017 5Abdominopelvic trauma By F/wold T.,ESO II

Introduction, Epidemiology
• The abdomen can be injured in many types of trauma
• Injury may be confined to the abdomen or be
accompanied by severe, multisystem trauma.
• Nature and severity of injuries vary widely depending
on the mechanism and forces involved
• Thus , generalizations about mortality and need for
operative repair tend to be misleading.

Introduction, Epidemiology….
• Blunt and penetrating abdominal trauma are the
major causes of morbidity and mortality.
• In blunt abdominal trauma the spleen and liver
are the most commonly injured organs and
contribute to a mortality of 8.5%.
• ¾ s attributable to RTA.
• 2/3rd occur in males with a peak incidence in
age 14 – 30 yrs..

Introduction, Epidemiology ….
• Penetrating injury has a higher mortality of up
to 12% and accounts for 1/3rd of all abdominal
trauma.
• Gunshot and stab wounds account for 90% of
penetrating trauma.
• Abdominal trauma more common in the urban
set.
• Males > females

Classification
• Based on type of structure damaged:
–Abdominal/Pelvic wall
–Solid organ
–Hollow viscus
–Vascular
• By mechanism of injury:
–Blunt Vs Penetrating

Blunt Vs Penetrating abd. trauma
• Blunt trauma may
involve
– Direct blow (kick)
– Impact with an object
(fall on bicycle
handlebars)
– Sudden deceleration
(fall from a height,
vehicle crash).
• Penetrating injuries
– may or may not penetrate
peritoneum and if they do,
may not cause organ injury.
– Stab wounds are less likely
than gunshot wounds to
damage intra-abdominal
structures; in both, any
structure can be affected.
– Penetrating wounds to the
lower chest may cross the
diaphragm and damage
abdominal structures.

Blunt Vs Penetrating abd. Trauma…
• Blunt trauma
– spleen (45%)
– liver (40%)
– Small bowel (10%)
– ..figure
collectionPAT &
BAT.PNG
• Penetrating injuries
– Stab wounds:-
• the liver (40%),
• small bowel (30%),
• diaphragm (20%),
• colon (15%);
– gunshot wounds
• small bowel (50%),
• colon (40%),
• liver (30%), and
• vessels (25%).

Approach to the patient with abdominopelvic trauma
As any trauma follow ATLS
A. Primary
survey and
resuscitation
B. Secondary survey and
definitive management
Trauma Hx & PE
Laboratory IXs
Diagnostic procedures
Imaging

Patient approach, Trauma history
Allergies
Mechanism of injury,
Height of a fall
Fatality at the scene
Vehicle type and velocity
Whether the vehicle rolled
over
Patient's location within the
vehicle
Extent of damage to the
vehicle
Steering wheel deformity
Whether seat belts were used
and, if so, what type
 Number of shots heard
 Type of gun usedPosition of
the patient when shot
 Distance of the patient from
the gun
 What instrument was used?
 How long and how wide
was the instrument?
 How was the patient
positioned during the
stabbing?
 What path did the
implement travel?

Patient approach, Trauma history
Past medical and surgical Hx/pregnancy
Last meal/loss of concousness
Events leading to trauma

Patient approach…..
• Historical data are important
• But mechanism alone cannot reliably predict
the need for emergent laparotomy
• must be coupled with other information such
– physical exam findings,
– diagnostic tests
– Imagings

Patient approach, physical examination
• General
– Inspect the abdomen for evisceration, entry/exit
wounds, impaled objects, and a gravid uterus.
– Check for tenderness, guarding, rebound tendrness,
sign of fluid collection
– Assess pelvic stability.
– Penile, perineum, rectal, vaginal examinations, and
examination of gluteal regions

Patient approach, physical examination…
• Sign
– Seat-belt sign
– Cullen’s sign
– Grey–Turner’s sign
– Kehr’s sign

Patient approach, investigations
• Baseline
– HCT
– BG & RH
– Cross mach
– PITC
– HBSA
– SE
– UA
• Diagnostic
– Serial HCT
– serum creatinine
– serum amylase/lipase
– serum electrolyte

Patient approach, DPL
• Played a major role in the management of
BAT
• Its role has steadily declined in parallel with
the advances made in US and CT.

Patient approach, DPL…
• Indications
– Equivocal P/E
– Unexplained shock
or hypotension
– Hemodynamically
stable
• Contraindications
– Clear indication for
exploratory laparotomy
– Relative CIs:
• Previous exploratory
laparotomy
• Pregnancy
• Obesity
• Infections
• Coagulopathy

• Advantages
– Performed bedside
– Widely available
– Highly sensitive for
hemoperitoneum
– Rapidly performed
• Disadvantages
– Invasive
– Risk for iatrogenic injury
(<1%)
– Low specificity (many
false positives)
– Does not evaluate the
retroperitoneum

• Causes for false negative DPL
– Catheter in preperitoneal space
– Catheter insertion through an abdominal wall
hematoma or inadequate hemostasis
– Fluid in compartment 2 adhesions
– Diaphragmatic tear, so fluid goes into thoracic cavity
– Obstruction of fluid outflow (eg, by omentum)

• Preferred Site of DPL
– Standard adult :Infraumbilical midline
– Standard pediatric: Infraumbilical midline
– 2ed &3ed trimester pregnancy :Suprauterine
– Midline scarring :Left lower quadrant

• Standard criteria for a positive DPL:-
– If > 10 mL of blood is aspirated, the procedure
stops because intraperitoneal injury is likely
• Has a positive predictive value of > 90% for
intraperitoneal injury
– If the DPL detects no or <10 ml of blood
• Performs a lavage of the peritoneal cavity with normal
saline and the effluent is sent for laboratory evaluation

• Criteria of positive DPL for a bloody
lavage effluent:-
• RBC count greater than 100,000/mm3
• WBC >500/mm3
• Amylase value greater than 175 IU/dl
• Detection of bile, bacteria, or food fibers

Plain Radiographs
• CXR
– Air under the
diaphram
– Bowel gas patterns
above the diaphragm
or gastric tube seen
in the chest in case
of diaphragmatic
injury.
– Lower Rib #

Plain Radiographs…
• AXR
– Pneumoperitoneum
– Presence of a foreign body (eg,
bullet, shrapnel)
– Ground glass appearance
– Opacity in left hypochondrium
– Gastric shadow displacement
– Downward displacement of
transverse colon

Focused Abdominal Sonography for Trauma (FAST)
• Advantages
– A rapid bedside screening
study
– Noninvasive
– No radiation
– Can be repeated
– Not time consuming
– Low cost
– 80–95% sensitivity for
intra-abdominal blood
 Positive if free fluid is demonstrated in the abdomen.
• Disadvantages
– Operator dependent
– Low specificity for
individual organ injury
– Lower sensitivity for free
fluid <500 mL
– False-negatives:
Retroperitoneal and
hollow viscus injuries

FAST, four views
Subxiphoid and
parasternal
Morrison’s
pouch (RUQ)
Splenorenal
recess (LUQ)
Pouch of
Douglas(pelvic)

FAST…
Morrison’s pouch Splenorenal recess
Doglas pouch(pelvic) Subxiphoid and parasternal

Abdominal Computed Tomography
• CT is the test of choice for identifying specific intra abdominal
injuries in patients with BAT
• The role in penetrating injury is less well-defined.
• Useful to differentiate patients who need exploration from those
that can be appropriately managed non-operatively
• The retroperitoneum is best evaluated by CT.
• The accuracy ranges from 92% to 98%, with low false-positive and
false-negative rates.

CT…
• Indications
– Blunt trauma
– Hemodynamic stability
– Unreliable PE
– Mechanism: Duodenal
and pancreatic trauma
• Contraindications
– Clear indication for
exploratory laparotomy
– Hemodynamic
instability
– Agitation
– Allergy to contrast media

CT…
Advantages
– Adequate assessment of the
retroperitoneum
– Grading of solid organ
injury
– Non operative management
of solid organ injuries
– Assessment of renal
perfusion
– Noninvasive
– High specificity
Disadvantages
– Specialized personnel
– Not done at bedside
– Inability to reliably
diagnose hollow viscus
injury
– Costy

CT…
• Findings on CT that suggest a gastrointestinal injury are
:
– Pneumoperitoneum (free, retroperitoneal)
– Mesenteric air
– Discontinuity of the hollow viscus wall
– Extraluminal enteric contrast
– Extravasated intravenous contrast
– Bowel wall thickening or edema
– Mesenteric hematoma

Other Diagnostic Modalities
• Laparoscopy
– Best method for evaluating diaphragmatic injuries
after thoraco-abdominal penetrating injuries.
• Angiography
– To evaluate renal artery thrombosis
– To manage pelvic hemorrhage in patients with pelvic
fractures
– To manage bleeding from minor hepatic and splenic
injuries.

General management abdominal injury,BAT
• Conservative management
– Indication
• Hemodynamically stable
• No sign of peritonitis
– Component
• Crystalloids
• Keep NPO
• Abx(optional)
• VS Q 3 Hours
• HCT Q 6 Hours
• Abd.girth Q 6 hours
• Bed side US daily if available
• Follow pt for 48 hours then
decide on subsequent
management
• Operative management
– Indication
• VS drangment
• Increased abdominal girth
• Sign of peritonitis
• de creased serial HCT
– Components
• Crystalliods
• Blood transfusion
• Laparatomy

General management abdominal injury,PAT
Unstable patient
– Crystalloids
– Prepare blood
– Exploratory
laparatomy
Stable patient
• For stab injury
– Local wound exploration under
asceptic technique & local anasthesia
• Fascia breached
– Explore in our setup
– Managed conservatively in ideal setup if
» Laparascopy is –ve
» CT is –ve
» US is –ve
• Fascia intact
– Local wound debridment
• Gun shot injury
– No question to explore the abdomen

Abdominal Wall Injuries
• Injuries from blunt trauma are most often due to shearing
forces, such as being run over by the wheels of a tractor
or bus.
• Devitalization of the subcutaneous tissue and skin may
occur
• If debridement is delayed, a serious necrotizing
anaerobic infection may develop.

Abdominal Wall Injuries…
• The management of penetrating abdominal wall injuries is
usually straightforward.
• Debridement and irrigation are appropriate surgical
treatment.
• Every effort must be made to remove foreign material,
shreds of clothing, necrotic muscle, and soft tissue.
• Abdominal wall defects may require insertion of prosthetic
material ( mesh) or coverage with a myocutaneous flap

Solid organ injury, Liver Injuries
• Brief anatomy
– The liver is a highly vascular
organ
– Located in the RUQ
– Two anatomic lobe
– 8 functional lobe..figure
collectionCapture.PNG

Solid organ injury, Liver Injuries
Diaphragmatic Surface Visceral surface

Liver surface

Liver injuries
• Liver is frequently injured in both blunt and
penetrating trauma
• Most hepatic injuries are relatively minor and heal
spontaneously with nonoperative management which
(observation, arteriography and embolization)
• Depending on the number of associated injuries and
the severity of the injury.
– The overall mortality rate ranges from 8% to 10%
– The overall morbidity rate varies from 18% to 30%
– Associated injuries in 80% of hepatic injury

AAST liver injury grading
• Grade I
– Hematoma:
subcapsular <10%
surface area.
– Laceration: capsular
tear <1 cm
parenchymal depth

…..grading
• Grade II
– Hematoma:
• subcapsular 10 to 50% surface area
• intraparenchymal <10 cm in
diameter
– Laceration:
• capsular tear 1 to 3 cm parenchymal
depth, <10 cm in length

…..grading
• Grade III
– Hematoma:
• subcapsular >50 % of
surface area or ruptured
subcapsular area
• Intraparenchymal
hematoma >10 cm or
expanding.
– Laceration >3 cm in
depth
• Grade IV
– Laceration:
• parenchymal disruption
involving 25 to 75% of
a hepatic lobe, or 1 to 3
Couinaud segments

…..grading
• Grade V
– Laceration: parenchymal disruption of >75% of a hepatic
lobe, >3 Couinaud segments within a single lobe.
– Vascular: juxtahepatic venous injuries (retrohepatic vena
cava, central major hepatic veins)
• Grade VI
– Hepatic avulsion.

Approach to management of liver injuries
• The management strategy:
–operative or non-operative
• Depends upon:
–the hemodynamic status of the patient,
–grade of liver injury, and
–presence of other injuries and medical
comorbidities.

Approach to management…
• Nonoperative Treatment
– More than 80% of patients with blunt hepatic
injury are eligible
– >90% success rate
• Success rate is higher with the use of angiography and
superselective embolization
– Successful nonoperative management requires
• Appropriate patient selection
• Availability of resources
– ICU,Blood bank support,Immediate operating room
– Surgeons and interventional angiographers experienced in
managing hepatic injury.

–Criteria
• Hemodynamically stable
• Normal mental status
• Absence of a clear indication for
laparotomy such as peritoneal signs
• Low grade liver injuries (grade I-III)
• Transfusion requirements of less than 2
units of blood.

–Contraindications
• Hemodynamic instability after initial
resuscitation
• Other indication for abdominal surgery (eg,
peritonitis)
• Penetrating injuries(Gunshot injury)

– Observation
– Supportive care with the adjunctive use of
arteriography and hepatic embolization.

– Benefits
• Risks inherent to surgery and anesthesia are eliminated.
– Risks
• Increased risk of missed intra abdominal injury,
particularly hollow viscus injury
• transfusion-related illness
• risks associated with embolization techniques, such as
hepatic necrosis.

– Complications:
• Failure of nonoperative management
• Hemorrhage (< 5%)
• Biloma
• Intra-abdominal abscess.

• Operative Management
– The operative management of liver injuries can be a
challenge even for experienced surgeons due to
• the complex nature of the liver
• Its size, vascularity, dual blood supply
• difficult-to-access venous drainage.
– The goal of surgery is to control hemorrhage from the
liver, which may require simple or more complicated
surgical techniques depending upon the extent of
injury

– Generally needed for 20% of patients with grade
III or higher injuries
– Hemodynamic instability due to hemorrhage.
– Laparotomy is undertaken through a long midline
incision.

–Options
• Push,pack,Pringle & plug
• Finger fracture of liver to expose damaged
vessels and bile ducts.
• Debridement of nonviable tissue.
• Placement of an omental pedicle (with its
blood supply) at the site.
• Major hepatic resection

• Manual compression(push)
– Manual compression of the
liver between both hands may
help tamponade bleeding from
the raw liver surfaces
– The hands are placed on either
side of the liver fracture and
the liver parenchyma is pushed
together.

• Pack
– Perihepatic packing compresses the liver
tissue from multiple directions
– placing laparotomy pads into the space
between the diaphragm and liver,
between the lateral abdominal wall and
liver, and between the liver and hepatic
flexure of the colon.
– Intrahepatic packing should not be used
because it can extend injury & cause
increased bleeding.

• Portal clamping (Pringle
maneuver)
– A non-crushing vascular clamp can
be placed across the structures in the
porta hepatis
– Interrupting hepatic arterial and
portal venous flow into the liver.

• Finger fracture
– The liver is gently 'finger fractured'
to fully expose any vessels or biliary
radicals asociated with liver injury.
– These are then clipped or tied.

• Direct liver suturing
– The edges of the liver are brought together using p
absorbable suture (#1 or #2 chromic catgut) placed
in a mattress fashion using a large blunt-tip needle.
– It is important to remember that the liver capsule is
thin and easily tears, and thus, undue tension
should be avoided

• Hepatic resection
– Resectional debridement
• Removal of devitalized portions of liver along non-anatomic
planes
– Anatomic resection
• Removal of a segment or lobe of the liver in the anatomic
plane ..figure collectionCapture.PNG

• Perihepatic drainage
– Low-grade injuries (grade I and II, and perhaps even
grade III) do not require drainage.
– We use a selective approach for higher grade (grade IV
or grade V) liver injuries.
– Significant bile leak identified intraoperatively should
be identified and controlled.
– If the leak has not been identified or controlled with
certainty, we place a drain.

– Complications:
• Hemorrhage (5%)
• Hemobilia (1%)
• Hyperpyrexia
• Abscess
• Biliary fistula (7–10%)

Splenic injury
• The spleen is a major lymphopoietic organ,
comprising approximately 25% of the total
lymphoid mass of the body.
• Normal splenic function is important for
opsonization of encapsulated organisms

Spleen, brief anatomy

Splenic injuries
• Splenic injury most commonly occurs following
blunt trauma due to motor vehicle collisions
• However, blunt splenic injury can also result from
falls, sport-related activities, or assault
• Penetrating splenic trauma is less common than
blunt injury and is typically due to assault, but
inadvertent impalement may also occur.
• Iatrogenically may be also injured

Splenic injury grading
• Grade I
– Hematoma: subcapsular,
<10 % of surface area.
– Laceration: capsular tear
<1 cm in depth into the
parenchyma
• Grade II
– Hematoma: subcapsular, 10
to 50 % of surface area.
– Laceration: capsular tear,1-3
cm in depth, but not
involving a trabecular vessel

Splenic injury grading…
• Grade III
– Hematoma:
• Subcapsular, >50 percent of surface area
OR expanding,
• Ruptured subcapsular parenchymal
hematoma OR
• Intraparenchymal hematoma >5 cm or
expanding.
– Laceration: >3 cm in depth or
involving a trabecular vessel.

Splenic injury grading….
• Grade IV
– Laceration involving
segmental or hilar
vessels with major
devascularization
(>25% of spleen)
• Grade V
– Hematoma: shattered
spleen.
– Laceration: hilar
vascular injury which
devascularizes spleen

Management approach,Splenic injury…
• Non-operative management
– More than 70% of all stable patients are currently
being treated by means of a nonoperative approach
– Encompassing both observation and embolization
techniques
– Criteria:
• Hemodynamically Stable
• No evidence of injury to other intra-abdominal organs
• No coagulopathy
• No impairment to physical exam (i.e., head injury)
• Injury grade I to III
2/8/2017
Abdominopelvic trauma By F/wold T.,ESO II
72

• Course of Non-operative management
– Bed rest (2 to 3 days)
– Keep NPO for at least the first 24 hours
– NGT decompression
– Serial exam
– Serial hematocrit 6 hourly
– Resume diet once potential for laparotomy
decreased (when bed rest finished)
– Follow-up CT at 3 to 5 days, or sooner if
deterioration
– Activity restrictions for 3 months

• Operative management:
– Indications:
• Signs and symptoms of ongoing hemorrhage
• Failure of nonoperative management
• Injury ≥ grade III
– Options
• Splenic salvage
– Splenorrhaphy
– Partial splenectomy
• Resection (splenectomy)

• The decision to perform splenectomy versus
splenic salvage is made based upon
– Grade of injury
– Presence of associated injuries
– Patient's overall condition
– Experience of the surgeon.
– The small future risk of overwhelming
postsplenectomy sepsis needs to be balanced
against the more significant risk of recurrent
hemorrhage.

• Indication for splenectomy:
– Source of exsanguination
– Pulverized organ
– Shock
– Associated life threatening injuries
– High-grade splenic injuries > III
– Contraindications to prolonged surgery (severe
coagulopathy, hypothermia, multiple abdominal
injuries),even lesser splenic injuries
– Failed splenic salvage attempts

• Operative management:
– Preparation:
• Have blood available.
• Make sure the patient has multiple large-bore IVs.
• Prophylactic antibiotic
• Prophylactic immunization
– Techinique:..figure collectionsplenectomy-
1.PNG,..figure collectionsplenectomy-2.PNG

• Complications:
– Bleeding
– Pulmonary complications (pneumonia, atelectasis)
– Pancreatitis
– Postsplenectomy thrombocytosis
– overwhelming postsplenectomy infection

Hollow viscus ,gastric injuries
• Gastric injuries often result from penetrating
trauma
• The stomach is partially protected by the rib
cage, thus making blunt injuries rare and
relatively difficult to diagnose

Gastric injuries….
• Blunt gastric trauma ranges from mucosal
lacerations to full-thickness disruption and gastric
necrosis due to avulsion of vascular pedicles
• NGTor CT may confirm the diagnosis
• Good intraoperative visualization to explore the
pathology
• Minor injuries may not be identified and require
distention of the organ with saline or methylene
blue to evaluate for leak.
• Frequently injured after thoracoabdominal
wounds due to its proximity with the diaphragm

• Causes of blunt gastric rupture:
– Vigorous ventilation with inadvertent placement of an
endotracheal tube in the esophagus
– Crushing of the stomach against the spine,
– During CPR
– During Heimlich maneuver
– Other causes leading to a sudden increase in intra-
luminal pressure.

• Management
– Most penetrating wounds are treated by means of
débridement of the wound edges and primary
closure in layers
– Pyloric injury—pyloroplasty.
– Body injury—repair
– Major injury(major tissue loss) —resection.

• Postoperative complications:
– Bleeding, usually from submucosal vessels
– Intra-abdominal abscesses
– Empyema(due to contamination from spillage of
gastric contents)
– Rarely, gastric fistula with peritonitis
• Prognosis
– Morbidity and mortality rates is 27% and 14%,
respectively

Injuries to the Duodenum
• The majority of duodenal injuries are caused by
penetrating trauma
• However, blunt injuries, though infrequent, are
difficult to diagnose because patients may have
subtle findings on admission.
• Steering wheel on the epigastrium is the most
common mechanism of blunt duodenal injury

Injuries to the Duodenum…
• Diagnosis
– Hyperamylasemia occurs in about 50% of patients
with blunt injury to the duodenum
– Plain films of the abdomen
• Obliteration of psoas shadow
• Absence of air in the duodenal bulb
• Coiled spring or stacked coin sign
– Diatrizoate meglumine (Gastrografin)
• Extravasation of contrast material
– Ct scan

Grading of duodenal injuries
• Grade I:
– Hematoma: involving a single portion of duodenum
– Laceration :partial thickness without perforation
• Grade II:
– Hematoma: involving more than one portion
– Laceration : disruption <50% circumference or major
laceration without duct injury or tissue loss
• Grade III:
– Laceration with disruption of 50 to 75% circumference
of 2nd portion or
– Laceration with disruption of 50 to 100 %
circumference of 1st, 3rd, 4th portion

Grading of duodenal injuries
• Grade IV:
– Laceration with disruption >75 percent
circumference of 2nd portion or involving ampulla
or distal common bile duct
• Grade V:
– Massive laceration with disruption of
duodenopancreatic complex or devascularization
of duodenum

Management,duodenal injuries
• 80% to 85% of duodenal wounds can be
repaired primarily.
– Grade I,II & III partially
• The remaining 15% to 20% are severe injuries
that require more complex procedures.
– Grade IV & V

Complications
• Duodenal-cutaneous fistulas
• Abscesses
• Dehiscence
• Sepsis
• Multiple organ failure

Small Intestinal Injuries
• The small bowel is the most frequently injured organ
after penetrating injuries.
• Incidence is 10% after blunt trauma that needs surgical
exploration.
• Mechanisms:
– Crushing injury of the bowel between the vertebral bodies
and the blunt object, such as a steering wheel or handlebars
– Deceleration shearing of the small bowel at fixed points,
such as the ligament of Treitz and the ileocecal valve and
around the mesenteric artery
– Closed-loop rupture caused by a sudden increase in intra-
abdominal pressure

Small Intestinal Injuries ,grading
• Grade I:-
– Laceration: partial thickness no perforation, or heamatoma
without devascularization.
• Grade II:-
– Laceration: < 50% of the circumference
• Grade III:-
– Laceration: = 50% of the circumference without
transection.
• Grade IV:-
– Complete transection of small bowel.
• Grade V:-
– Transection of small bowel with segmental tissue loss or
devascularized segment

Small Intestinal Injuries ,management
• Bowel injury (small)—refresh & repair.
• Short segment destroyed (with one or more
injuries)
– Resection and primary anastomosis.
• Mesentery injured, without ischemia
– Repair
• Mesentery injured, with short segment of
ischemia
– Resection & primary anastomosis.

Postoperative Complications
• Intra-abdominal abscess and sepsis
• Anastomotic leakage
• Wound infection
• Enteric fistulas
• Intestinal obstruction

Injuries to the Colon
• Injuries generally occur via a penetrating
mechanism (75% gunshot wound, 25% stab
wound).
• Blunt injuries are rare but result from MVCs.
• Iatrogenic transanal injuries may also occur.

Injuries to the Colon,management
• Colon injuries are difficult to manage:-
– Peritonitis following them is serous
– Unprepared colon, dificult for anastomosis
– Ascending and descending colon are
retroperitoneal

Injuries to the Colon,management
– Cecal injury
• Tube caecostomy
• Right hemicolectomy
with iliotransvers
anastomosis
– Ascending colon injury
• Repair
• Right hemicolectomy
with iliotransvers
anastomosis
– Transverse colon
injury
• Repair
• Colostomy
• Resection and
anastomosis
– Injury to Splenic
flexure and below
• Resection and
diversion colostomy

Injuries to the Colon,management ….
• Criteria for primary repair
– Early diagnosis (within 4-6 hours)
– Absence of prolonged shock or hypotension
– Absence of gross contamination of the peritoneal
cavity
– Absence of associated colonic vascular injury
– Less than 6 units of blood transfused
– No requirement for the use of mesh to
permanently close the abdominal wall.

Injuries to the Colon,management ….
• Increased complication rates after primary
repair are due to:
– Prolonged hypotension
– Massive intraperitoneal hemorrhage
– More than two associated organs injured
– Significant fecal spillage
– Delayed diagnosis.

• Abscess formation
• Anastomotic leak
• Peristomal hernia
• ECF
• Morbidity and mortality associated with
closure of the colostomy.

Rectal injuries
• Can be intraperitoneal or extraperitoneal
• Two thirds extraperitoneal
• Uncommon
• Mechanism:
– 80% gunshot wound
– 10% blunt
– 6% transanal
– 3% stab wound or impalement
– Iatrogenic ( proctosigmoidoscopy),

Rectal injuries
• Diagnosis:
– DRE:
• Suspicion increased by blood in stool or palpation of defect or
foreign body on exam.
– Rigid proctoscopy:
– Anoscopy
– X-ray
• to look for missiles or foreign bodies or pelvic #

Rectal injuries , Management
Intraperitoneal rectal
injuries
• Primary closure
but not advisable
• Loop colostomy.
• Loop colostomy with
distal limb closure.
• End colostomy/mucus
fistula.
Extraperitoneal rectal
injuries
• Diverting colostomy,
washout of the distal rectal
stump, and wide presacral
drainage

• Sepsis
• pelvic abscesses
• urinary or rectal fistulas
• rectal incontinence and stricture
• loss of sexual function
• urinary incontinence.

Injuries to retroperitoneum organs

• Injury to the retroperitoneum is often difficult to
diagnose, especially in the presence of other
injury, and the signs may be masked.
• Intraperitoneal diagnostic tests (US & DPL) may
be negative.
• The best diagnostic modality is CT scan, but this
requires a physiologically stable patient

• Divided into three zones
– zone 1 (central): central
haematomas should always be
explored.
– zone 2 (lateral): lateral
haematomas are usually renal in
origin and can be managed non-
operatively.
– zone 3 (pelvic): pelvic haematomas
are exceptionally difficult to control
and should, whenever possible, not
be opened.

Pancreatic injury
• Pancreatic injury is rare and accounts for
approximately 10% to 12% of all abdominal
injuries
• Mechanism,Largely penetrating (gunshot wound
>> stab wound).
• 75% of patients with penetrating injury to the
pancreas will have associated injuries to the aorta,
portal vein, or IVC.
• Isolated pancreatic injuries are rare
• Mortality rates range from 10% to 25%, mostly
secondary to associated intra-abdominal injuries

Pancreatic injury….
• Diagnosis
– Difficult
– Inspect pancreas during laparotomies performed
for other indications.
– Check amylase
– CT
– ERCP

Pancreatic injury,grading
• Grade I:
– Minor contusion without duct injury or superficial
laceration without duct injury
• Grade II:
– Major contusion without duct injury or tissue loss, or
major laceration without duct injury or tissue loss
• Grade III:
– Distal transection or parenchymal/duct injury
• Grade IV:
– Proximal transection or parenchymal injury involving
ampulla
• Grade V:
– Massive disruption of the pancreatic head

Pancreatic injury,management
• Determined by the location of the injury and
whether or not the main pancreatic duct is injured
• Distal pancreatic injuries with suspected ductal
injuries were treated by distal resection with or
without splenectomy
• Proximal injury:- Penetrating wounds to the right
of the superior mesenteric vein should be treated
with débridement and direct suture ligation of
areas of bleeding

Pancreatic injury,management
• Nonoperative:
– May follow with serial labs and exam if patient can be
reliably examined.
• Operative:
– No ductal injury: Hemostasis and external drainage.
– Distal transection, parenchymal injury with ductal injury:
Distal pancreatectomy with duct ligation.
– When duodenum or pancreatic head is devitalized,
consider Whipple(radical pancreaticoduodenectomy) or
total pancreatectomy.

• Pancreatic fistula
• Peripancreatic abscess
• Pancreatitis
• Pancreatic pseudocysts

Genitourinary trauma

Introduction
• Injuries to the genitourinary tract are often
clinically unsuspected and frequently
overlooked
• Gross hematuria is the most frequent sign
associated with urinary tract injuries.

Mechanism of injury
• Blunt trauma
– 80 % result from blunt trauma and tend to be less
severe overall
– Fractures of the lower ribs or spinous processes
– Abdominal or pelvic crush injuries
– Direct blows to the back and flanks
– Decelerating injuries such as with falls or MVA
• Penetrating injuries to the back or the flank have
the potential to cause significant renal injury
without obvious clinical manifestations.

Patient approach
• Hx & PE
• Laboratory investigation
• Immagings
– Plain x-rays
– Retrograde urethrogram
– Retrograde cystogram
– Intravenous pyelography
– CT scan
– US

Renal injuries
• kidneys lie in the retroperitoneal space and are protected by
the lower ribs, the back musculature, and the perinephric
fat.
• The kidney is the most commonly injured genitourinary
organ.
• Due to the significant forces required, associated
intraabdominal injuries occur commonly.
• Most renal injuries result from blunt trauma and tend to be
less severe overall, with a lower nephrectomy rate than
those seen with penetrating injuries

Renal injuries…
Blunt renal injuries are generally divided into
minor and major injuries
 Minor renal trauma (85% of cases)-
 Renal contusion or bruising of the parenchyma
 Subcapsular hematoma in association with contusion
 Superficial cortical lacerations .
Major renal trauma (15% of cases)-Deep
 lacerations may extend into the collecting system.
 Large retroperitoneal and perinephric hematomas
 vascular injuries of the renal pedicle

Grading of renal injury
• Grade I
– Contusion with microscopic or gross
hematuria
– urologic studies normal;
– nonexpanding subcapsular hematoma
without parenchymal laceration
– More than 85%

Grading of renal injury…
• Grade II
– Nonexpanding perirenal hematoma
confined to renal retroperitoneum;
– laceration < 1 cm parenchymal depth
of renal cortex without urinary
extravasation
– 6%

Grading of renal injury….
• Grade III
– Laceration > 1cm parenchymal
depth of renal cortex
– No collecting system rupture or
urinary extravasation

• Grade IV
– Parenchymal laceration extending
through renal cortex, medulla,
and collecting system
– Injury to main renal artery or
vein with contained hemorrhage

• Grade V
– Completely shattered kidney
– Avulsion of renal hilum that
devascularizes kidney

Renal injurY,Management
Conservative
• 95% of all blunt renal
injuries are treated
nonoperatively.
• Persistent gross hematuria
can be treated by
embolization.
• Grade I & II injuries
• Grade III IN 90%
• Grade IV with urinary
extravasation alone
Operative
• lesions that do not
respond to these less
invasive measures.
• perinephric hematoma
• All penetrating wounds to
kidneys are explored
• 10% of grade III injuries
• Grade IV & V injuries

Ureteral Injuries
• Injury to the ureter is uncommon and occurs
mostly after penetrating trauma.
• Majority (75%) of ureteral injuries are
iatrogenic
• The remaining 1/3 are inflicted by blunt
trauma & 2/3 due to penetrating trauma
– Most common blunt cause MVC or fall from
height
• More common in children due to the increased
mobility of the vertebral column

Ureteral Injuries,diagnosis
• In the majority of cases, IVP will confirm the
diagnosis.
• In approximately 15% to 20% of ureteral
injuries, retrograde ureterography will be
required to confirm the diagnosis.
• In hemodynamically unstable patients the
diagnosis of ureteral injury may be made at the
time of laparotomy

Ureteral Injuries,grading
• Grade I
– Contusion or hematoma without devascularization
• Grade II
– < 50% transection
• Grade III
– >50% transection but not complete
• Grade IV
– Complete transection with < 2 cm devascularization
• Grade V
– Avulsion with > 2 cm devascularization

Ureteral Injuries,management
• No place of conservative management ,needs
surgical management
• Options
– ureteral repair
– Spatulated anastomosis
– Ureteral stenting
– Drainage
• Ureteroureterostomy
• Percutaneous nephrostomy

Bladder Injuries
• The majority of bladder injuries occur as a
result of blunt trauma
• Association of bladder rupture and pelvic
fractures is extremely high.
• Approximately 70% of patients with bladder
rupture have associated pelvic fractures.
• Hematuria is the most frequent sign
• Bladder rupture may be extraperitoneal or
intraperitoneal

Bladder Injuries,grading
• Grade I
– Contusion, intramural hematoma; partial-thickness
laceration
• Grade II
– Extraperitoneal bladder wall laceration < 2 cm
• Grade III
– Extraperitoneal bladder wall laceration > 2 cm or
intraperitoneal bladder wall laceration < 2 cm
• Grade IV
– Intraperitoneal bladder wall laceration > 2 cm
• Grade V
– Intraperitoneal or extraperitoneal bladder wall laceration
extending into bladder neck or ureteral orifice (trigone)

Bladder Injuries,management
• Intraperitoneal injuries
– Repaired primarily via a
transabdominal approach,
including a three-layer closure.
• Extraperitoneal rupture
– primarily non-operative
– Foley catheter in place for 10 to 14
days, provided that the patient has
no intra-abdominal injuries
requiring surgical exploration

Urethral injuries
• It is found mostly in men,rare in women
• Anterior urethra injuries may be inflicted by
direct blows, straddle injuries, instrumentation, or
in conjunction with a penile fracture.
• Posterior urethral injuries usually occur in the
setting of significant pelvic fractures, often
caused by MVC

Urethral injuries,diagnosis
• Urethral injuries should be suspected
– On the basis of the mechanism of injury,
– Associated pelvic fracture,
– Perineal hematoma or perineal injury,
– Blood at the urethral meatus
– High riding prostate gland.
• A retrograde urethrogram is essential for
diagnosis.

Urethral injuries,grading
• Grade I
– Contusion with blood at urethral meatus and normal urethrography
• Grade II
– Stretch injury with elongation of urethra but without extravasation
of urethrography contrast material
• Grade III
– Partial disruption with extravasation of urethrography contrast
material at injury site with visualization in the bladder
• Grade IV
– Complete disruption with < 2 cm urethral separation and
extravasation of urethrography contrast material at injury site
without visualization in the bladder
• Grade V
– Complete transection with >2 cm urethral separation or extension
into the prostate

Urethral injuries,management
• Bladder decompression via suprapubic
cystostomy and delayed urethroplasty.

Vascular injuries
• Most injuries result from penetrating trauma in
90% to 95% of cases
• Most are associated with other abdominal
injuries
• Much more common after abdominal gunshot
than stab wounds (25% Vs 10%)

Vascular injuries…
• The major abdominal vessels are
retroperitoneal structures that lie posterior to
the content of the peritoneal sac and close to
the midline.
• Major abdominal vascular trauma presents
clinically either as free intraperitoneal
hemorrhage or as a contained retroperitoneal
hematoma

Vascular injuries,diagnosis
• Hx and PE
– Findings on PE generally depend on whether a
contained hematoma or active hemorrhage is
present
– Hematoma:- modest VS drangment
– External hemorrhage:- straightforeward, has
significant hypotension and may have a distended
abdomen on arrival

Vascular injuries,management
• Approach to Retroperitoneal Hematoma
– Any hematoma in zone 1 mandates exploration for
both penetrating and blunt injury
– A hematoma in zone 2 is the result of injury to the
renal vessels or parenchyma and mandates
exploration
– A pelvic retroperitoneal hematoma (zone 3) secondary
to penetrating trauma mandates exploration because
of the likelihood of iliac vessel injury
– Zone 3 hematomas resulting from blunt trauma are
usually associated with pelvic fractures and are not
explored

Maneuvers for Retroperitoneal Exposure
• Mattox maneuver
– Left-sided medial
visceral rotation.
– Exposes the
entire length of the
abdominal aorta and
its branches (except
the right renal artery)

Maneuvers for Retroperitoneal Exposure…
• Kocher maneuver
– Right-sided medial
visceral rotation
– Consists of medial
reflection of the right
colon and duodenum
by incising their lateral
peritoneal attachments
through the line of
toldt

Maneuvers for Retroperitoneal Exposure…
• Cattell-Braasch
maneuver
– Kocher maneuver plus
– Detaching the posterior
attachments of the small
bowel mesentery toward
the duodenojejunal
ligament

References
Townsend: Sabiston Textbook of
Surgery, 18th ed, management of
specific injuries
Oxford Handbook of Clinical Surgery, 3rd
Edition, Chapter 13,Major Trauma,
P.442.
Current Surgical Diagnosis & Treatment,
12th Edition, Management of the
Injured Patient

References
ACS Surgery: Principles & Practice, 2007
Edition, Trauma and Thermal Injury,Initial
Management of Life-Threatening Trauma
Greenfield's Surgery: SCIENTIFIC PRINCIPLES
AND PRACTICE, 4th Edition, Chapter 25 -
Abdominal Trauma
Bailey & Love’s,short practice of
surgery,25 th edition,chapter 26,chest
and abdomen.

References

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