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Abdominal Injuries Part 2.pptx
- 1. ABDOMINAL INJURIES PART 2 Management of Specific Organ Injuries (30th JANUARY 2023) Dr. M. Yigah
- 2. Splenic Injuries • Most injured viscus in a blunt abdominal trauma. • It can be affected by penetrating injuries especially due to thoraco-abdominal trauma • Syndromes of Presentation • Immediate rupture with continuous haemorrhage • Ultra-splenic injury • Gradual onset of shock and peritonism • Delayed bleeding – (2 weeks to several months) • subcapsular haematoma which later ruptures into the peritoneal cavity. • Temporary localization by omentum • Digestion of the initial clot by enzyme released from injured pancreas
- 3. Splenic Injuries • Clinical History • History of mechanism of injury e.g., a blow to the left hypochondrium • Any previous surgeries especially one that may have resulted in splenectomy • Any pre-existing conditions that might predispose to splenic enlargement. • Physical Examination • Local bruising (ecchymoses) in the left lower chest or LUQ • Local rib pain or tenderness • Localised tenderness in the LUQ or generalised tenderness • Rectal tenderness with a soft boggy mass • Kehr sign – left shoulder tip pain • Ballance sign – non-shifting left flank dullness from perisplenic
- 4. • CT Scan • Haematoma and parenchymal disruptions • Blush of contrast in disrupted parenchyma. • Accumulation of blood in peritoneal cavity • Pseudoaneurysm • Assess adjacent structures • X-rays • Left lower rib fractures. • Triad of splenic rupture • Left hemidiaphragm elevation • Left lower lobe atelectasis • Pleural effusion
- 5. Selective Angiography Distal embolization (curative) of distal arterial bleeding using a microcatheter.
- 6. AAST Grades of Splenic Injury
- 7. Non-operative Management • Patient selection • Haemodynamically stable (without ongoing intravascular support) • No evidence of ongoing haemorrhage • No clinical signs of generalised peritonitis • Free of signs of other abdominal injuries or • Blunt stable injury. • Up to grade 3 injuries (some institutions) • Other Important Consideration • Resources for frequent clinical and radiological surveillance • Rapid mobilization to operating room in case of delayed bleeding or ongoing bleeding • Discharge of patient to well resourced areas where emergent operative procedure may be done
- 8. Non-operative Management • Components of Non-operative management • Most patient should be admitted at the ICU (especially above Grade II) for 24 to 72hrs. • Keep NPO - incase they require rapid operative interventions • Regular monitoring of vitals, serial examinations and haematocrit measurements • Vaccines to prevent streptococcal, meningococcal, and Hemophilus infections • Mechanical thromboprophylaxis • Patient admitted for about 7 days • Follow up CT • Scan if there is persistent abdominal features after a week of observation. • When patient sustained a high-grade splenic injury • Contemplating return to contact sports or other activities (best
- 9. • Laparotomy + Splenic Mobilization • Splenic mobilization is vital for both splenic salvage and splenectomy • Division of the splenophrenic and splenorenal ligament • Mobilize the spleen and tail of pancreas as a unit from lateral to medial. • Location and division of the short gastric arteries • Division of the splenocolic ligament
- 10. • Grade I or II • Direct suturing for laceration • Ruptured capsule – haemostatic agent under absorbable mesh • Mesh sheet is compressed against parenchyma with laparotomy packs • Grade III IV and V - Splenectomy • Grade I • Haemostatic repair • Grade II and III • Suturing • Suture plus pledget material • Partial splenectomy • Wrapping spleen in mesh • Grade IV and V - Splenectomy Damage Control Surgery Definitive Repair
- 11. Splenic Preservation Techniques Suturing Haemostatic agents Reinforcement with Omentum
- 12. Segmental Resection with Stapling device Spleen cocooned in mesh Resection and Suturing with Pledget material
- 13. Spleen Salvage • Contraindications to splenic preservation • Hilar avulsion injury and shattered spleen • Rupture of grossly pathological spleen – e.g., tropical splenomegaly, SCD, leukaemia • Multiple associated injuries • Gross contamination e.g., colonic perforation • Blast injuries to the left upper quadrant of the abdomen. • Unstable and/or the patient over 50 – emphasis is based on rapid haemostasis.
- 15. Liver Injury • One of the most injured from all agents • The force is of the crushing type and associated with serious associated injuries. • The form of liver injury is determined by the type of wounding agent. • Blunt injuries • Simple laceration • Stellate soft tissue fracture • Avulsion of soft tissues • Vibration • Injure the inner core of the liver leaving the superficial areas intact. • Penetrating injuries • Knife wound often produce superficial lacerations • Bullet missiles - ragged through and through injuries with blast
- 16. Liver Injuries • Clinical features – syndromes can be varied • Haemoperitoneum of unspecified origin • Local peritonism in the RUQ • Palpable subcapsular haematoma – occasionally. • Investigations • Peritoneal lavage – helpful but not specific • Abdominal USG for initial assessment of liver injuries • CT – more precise information on injury in stable patients
- 18. Liver Injuries Treatment • Non-operative management • Stable patient with all evidence that bleeding has stopped. • Regular clinical assessment and imaging investigations. • Surgical Intervention is indicated if • acute haemodynamic decompensation, • increased fluid requirement or • a fall in haemoglobin. • Potential complications • Continued bleeding, • haemobilia, • bile leak, • Missing other abdominal injuries and • sepsis.
- 20. Operative Interventions Techniques to halt bleeding Finger fracturing Plugging of Penetrating Injuries Direct Ligation
- 21. Techniques to halt bleeding from Penetrating Wounds
- 22. Liver Injuries Treatment • Definitive Operative management • After resuscitation of haemodynamically unstable patients • Grade I and II - Simple drainage • Argon beam coagulation • Haemostatic agent - microcrystalline collagen application • Grade II and III - Suture and drainage • Grade IV to VI – Hepatic resection • Drainage is very important • leakage of blood or bile is ever present. • Prevent subphrenic collections and peritoneal abscesses.
- 23. Hepatic resection • In practice it is a debridement-resections • Dissection is by finger fracture and individual ligation of vessels. • Control of haemorrhage is a crucial factor in this procedure • Pringle manoeuvre • internal shunt for the IVC
- 24. Extra-hepatic Biliary Tract • It is rare because of its small size and mobility • Penetrating injuries are commoner • Blunt injuries often associated with other visceral injuries • Diagnosis is more difficult for blunt than penetrating • Peritonism may be unremarkable • DPL – Bile-stained effluent is suggestive • CT Scan – modality of choice
- 25. Treatment • Gall bladder injury – cholecystectomy • Gall bladder injury and unfit for surgery – cholecystostomy • Biliary duct – direct suture over a T- tube • Biliary duct injury with tissue loss • Roux-en-Y choledochojejunostomy
- 26. Pancreas • Diagnostically and therapeutically challenging • Locations pancreas makes isolated injuries uncommon. • Liver – 46% • Stomach - 41% • Related great vessels – 28% • Spleen – 26% • Kidney – 22% • Causes pancreatic injuries • Penetrating (commoner) – stab wounds, gunshots • Blunt – high speed RTA, seatbelt injuries, kicks or blows
- 27. Pancreatic Injury • Diagnosis • Usually discovered during surgery (usually caused by penetrating mechanisms) • Requires a high index of suspicion especially in blunt abdominal injury • Persistent abdominal pain and tenderness. • Peritonism may be absent • The serum amylase level is often elevated within 2h of injury • It is non-specific as it is elevated in other upper intestinal lesions • High amylase level with peritonism warrants
- 28. • CT Scan • Fractures or lacerations of the pancreas. • Active hemorrhage from the gland or • Haematoma between the pancreas and splenic vein • Oedema or hematoma of the parenchyma • Poor at evaluating the pancreatic duct • ERCP and MRCP • Both are Indicated in stable patients only • MRCP Is non-invasive and can visualize other structures • Intra-operative duct assessment
- 30. Treatment • Stable preop patient with no indication for exploratory laparotomy • Grade I and II - Non-operative management • There must be no evidence of a pancreatic duct injury. • Frequent clinical, laboratory and radiological monitoring. • pancreatic abscess or pseudocyst are common complications • Indications for Exploratory laparotomy • Haemodynamically unstable patients • Penetrating wounds • Blunt injuries with peritoneal signs • Grade III or more pancreatic injury
- 31. Operative Management • Adequate exposure • Kocherization • Opening of lesser sac. • Grade 1 and 2 • Non-bleeding capsular tears – left alone + drain • Bleeding capsular tears - suture using non-absorbable material and drainage
- 32. Grade III • Exploration may include pancreatography • Distal pancreatectomy + Grade (IV and V) Whipple’s (Pancreaticoduodenectomy) +
- 33. Hollow Viscera Injuries – Stomach • More affected by penetrating than blunt injuries • Full thickness perforation leads to spillage of gastric contents. • Blunt trauma increases gastric intraluminal pressure the ruptures the wall • Diagnosis • Physical signs of localised peritonitis. • Location of penetrating wound may be suggestive • Bloody NG tube aspirate should raise suspicion
- 34. Treatment • Gastric haematomas – Evacuations and seromuscular closure with interrupted 3-0 silk • Gastric perforations or lacerations – 1- or 2-layer closure • 1st layer (inner layer) – continuous locked absorbable suture • 2nd layer (outer layer) - interrupted seromuscular sutures of 3.0 or 4.0 silk • Tissue loss/devascularization • Less than 2/3 of tissue loss – partial gastrectomy with Billroth I or II • More than 2/3 of tissue loss - Total gastrectomy with Roux-en-Y esophagojejunostomy
- 35. Duodenal Injuries • These are uncommon; diagnostically and therapeutically challenging • Most injuries are from penetrating mechanism – stab wounds, gunshots. • Rarely affected by blunt trauma - blunt injury is caused blows to the epigastrium • Steering wheel striking the abdomen • In children - a bicycle handlebar. • Diagnosis • Persistent abdominal pain and tenderness • Persistent epigastric or umbilical pain and tenderness • Elevated serum amylase – raises suspicion
- 36. Abdominal X-rays Retroperitoneal gas Abdominal CT Scan Collection of gas posterior to the 2nd part of the duodenum
- 38. Duodenal Injuries – Treatment • Duodenal haematomas – Non-operative intervention • Prolonged gastric decompression for about 1 to 2 weeks • Distal tube jejunostomy for enteral nutrition • Duodenal laceration – primary closure with absorbable sutures. • Tissue loss at a short segment – Resection and primary anastomosis. • Long segment of injury or area adjacent to ampulla – Roux-en-Y duodenojejunostomy • Protection of repairs in extensive injuries
- 40. Small Bowel and Mesentery • Jejunal and ileal injuries account for 4/5th of bowel injuries • Blunt abdominal injury mechanisms: • Compression against the vertebral • Bursting of bowel from increased intra-luminal pressure • Deceleration injuries • Penetrating injuries - Bullet missiles, stab wounds • Mesenteric and omental injuries may occur alone or in association with the gut. • They are important causes of haemoperitoneum • Transversely-oriented mesenteric tears devitalize the adjoining gut
- 41. Small Bowel and Mesentery Injuries
- 42. Small Bowel and Mesentery • Clinical Manifestation • Type of injuries that raise suspicion - Seat belts, handlebar and blows to the abdomen. • Penetrating injuries – eviscerated bowel or omentum • Features of peritonitis • Investigations • DPL is sensitive and can be done in unstable patients – blood, elevated WBC • Chest X-ray - air under the diaphragm • Abdominal CT Scan – limited in detecting perforations • Pneumoperitoneum, • Gas bubbles close to the bowel wall, • Thickened (>4–5 mm) bowel wall, bowel wall hematoma
- 43. Inversion with seromuscular suturing Minor Contusion < 1cm Partial thickness laceration Debridement and Primary Closure (1- or 2-layer closure) Contusions ≥ 1cm Lacerations < 50% of circumference
- 44. Resection & Anastomosis Multiple close perforation at a segment. Laceration ≥ 50% circumference. Complete transection Segmental tissue loss. Devascularised segment
- 45. Large Intestines • 2nd most affected organ from gunshot wounds (after small bowel) • 3rd most affected organ after the liver and small bowel • Occur in less than 1% of all blunt trauma patients • Penetrating injuries –commoner and includes injuries from instrumentations
- 46. Large Intestines • Clinical features • May first be seen at laparotomy • Signs of peritonitis in grosser injuries • Masked in delayed injuries due to devitalization of the colon due to contusions or ischaemia • Blood on DRE may be suggestive of rectal injury • Investigations • Plain X-ray may reveal the free peritoneal air • Abdominal CT is limited in capability • Proctosigmoidoscopy to visualization of the rectum and distal sigmoid colon
- 47. Large Intestines - Treatment • Simple linear laceration < 50% of circumference – Primary repair • Lacerations ≥ 50% of circumference - Resection and anastomosis • Right sided colonic injuries – Limited right hemicolectomy • Left side colonic injuries – Segmental resection with colo- colic anastomosis • Extensive injuries or patient’s condition is tenuous avoid anastomosis • The proximal end is brough out as a stoma • Distal end also brought out as a fistula or closed off as a Hartmann pouch
- 48. Retroperitoneal Haematomas • Most commonly secondary to penetrating injuries. • Pelvic fractures are usually the cause of retroperitoneal haematoma in blunt injuries • Diagnosis • Tenderness and/or dullness in the flanks • Grey-Turner’s sign • Plain X-ray – pelvic fractures, vertebral fractures • CT Scan – evaluate abdominal vasculature and assess path of penetrating injuries to the back.
- 49. When to Open Into Haematoma Zone 1 • Requires Exploration because they involve aorta, proximal visceral vessels, or IVC Zone 2 • Contains the kidneys and Should be explored only if hematoma is expanding and continuing to lose blood. Zone 3 • Secondary to pelvic fracture bleeding and should not be explored unless exsanguinati ng hemorrhage is obvious
- 50. Securing Haemostasis • Clamps to secure haemostasis • Doubly applied vessel loop • Bulldog clamp • Balloon catheter • Loop ligature • Vascular clamp • Vascular Repair • Suturing: Polyprophylene – 5.0 or 5.0 • Techniques – Ligation, Primary repair, Anastomosis, Grafting, Bypass
- 51. References • Principles and Practice of surgery 5th Edition [BAJA] • Sabiston Textbook of surgery 20th edition • Advanced Trauma Life Support 10th Edition • Trauma 7th Edition • Bailey and Love’s Short Practice of Surgery 27th Edition • Schwartz Principles of Surgery 10th Ed
Editor's Notes
- Review of what was learned Abdominal inuries - 3rd most injured part of the body Anatomy of the abdome - extent and the entery into the abdomen Blunt and penetrating abdominal injuries and the various mechanism Initial management based on the ATLS - adjunct - FAST, DPL, Classification of patients after initial resuscitative attempts Inidcations and approach to trauma laparotomy: and choosing an operative profile Definitive repair or DCS
- Largest lymphatic organ and most delicate and protected by ribs 9 to 11 Red pulp – remove RBC and White pulp – rich in lymphocytes – antibodies and opsonins Temporary store blood Ultras-splenic injury - avulsed hilum or shattered spleen rapid onset of shock within a few min from uncontrollable haemorrhage surgery on unprepared patients (direct ligation of bleeding vessels/splenectomy) Delayed rupture Selective arteriography or CT expedites the diagnosis but unavailable .
- It is known that patients on left side of the car (driver and rear passengers are at risk) Presence of hepatic disease, ongoing anticoagulation, or recent usage of aspirin or non-steroidal anti-inflammatory drugs, also Kehr sign – there is minimal shoulder tenderness and no pain on ROM of shoulder Demonstration of free fluid (depends on extents of bleeding) Tenderness or guarding, depressed bowel sounds FAST and DPL can detect intraperitoneal haemorrhage but not splenic injuries Clinical features maybe inconspicuous and patients with severe splenic may occur after the most trivial of injuries
- X-ray features are non-specific and unreliable CT Scan Findings Hematomas and parenchymal disruption generally show up as hypodense areas. Free fluid accumulates - Morison’s pouch, the paracolic gutters, and the pelvis, loops of small bowel, subphrenic spaces. Presence of a blush (hyperdense) of contrast in disrupted parenchyma – continuous bleeding. Pseudo aneurysm Assessment of adjacent organs: distal pancreas. CT shows a subcapsular hematoma with a splenic laceration extending from the capsule to the hilum with an intraparenchymal hematoma (blue arrow). Within the intraparenchymal and subcapsular hematomas are areas of hyperdensity that represent active extravasation (red arrow).
- Both diagnostic and therapeutic uses Bleeding sites are obstructed by angioembolization Splenic angiography and embolization – Some centres use it to reduce the risk of delayed haemorrhage.
- Grade I - Subcapsular haematoma < 10% surface area and/or Laceration/capsular rear < lcm deep Grade II – Subcapsular haematoma 10 to 50% surface area (or intra-parenchymal haematoma < 5cm) or Laceration 1-3 cm Grade III Subcapsular Haematoma >50% of surface atreas or expanding Ruptured subcapsular or parenchymal haematoma > 5cm or expanding Laceration is >3cm parenchymal depth Grade IV Laceration involving segmental or hilar vessels – devascularizing > 25% of spleen Grade V Completely shattered spleen Hilar vascular injury that devascularize the spleen
- More than 12h after injury Non-operative management has increased because of the advent of CT Scan and the realized importance of the spleen. Appropriate patient selection is the most important element of nonoperative management. Hypotension – when SBP is < 90mmHg or remain hypotensive after initial resuscitative measures Success rate – 50 to 60% can be misleading because it looks at patient who were stable enough to undergo CT Scan Nonoperative management should only be undertaken if it will be possible to closely follow the patient – if not exploratory laparotomy Most failures of nonoperative management occur within the first 6–8 days after injury
- CT findings of continuous bleeding and be treated with angioembolization Continue resuscitative measures and other diagnostic and therapeutic procedures Transfer back to the ward when patient is stable NG tube is not necessary unless for other reasons. Avoid contact sports
- NG tube to decompress the volume of the stomach Midline incision – quicker and one can deal with a lot of variety of different injuries Examine the four quadrant areas especially the upper quadrants for packing Factors that figure into the decision about what to do with the injured spleen after mobilization include the degree of splenic injury, the overall condition of the patient, and the presence of any other intra-abdominal injuries.
- – e.g. fibrin glue Factors that figure into the decision about what to do with the injured spleen after mobilization include the degree of splenic injury, the overall condition of the patient, and the presence of any other intra-abdominal injuries Grade I with minimal bleeding - haemostatic agents e.g. fibrin glue, gelatin sponge. ( Grade II and III Suturing of laceration when capsule is intact. Suturing can be reinforced with pledget material to bolster repair when capsule is
- – e.g. fibrin glue Factors that figure into the decision about what to do with the injured spleen after mobilization include the degree of splenic injury, the overall condition of the patient, and the presence of any other intra-abdominal injuries Grade I with minimal bleeding - haemostatic agents e.g. fibrin glue, gelatin sponge. ( Grade II and III Suturing of laceration when capsule is intact. Suturing can be reinforced with pledget material to bolster repair when capsule is
- realization that splenectomy can lead to overwhelming sepsis in infants and children under 5 and pneumococcal septicaemia in some adults. Resistance to malaria, H. influcnzac and N. meningitidis is also reduced. Spleen salvage should be deeply considered because of effects of splenectomy.
- Autotransplantation of splenic tissue that has been removed is a controversial topic. Splenic tissue has a remarkable ability to survive in ectopic locations even without a clearly identifiable blood supply. Greater or lesser degrees of spontaneous splenosis after splenectomy for trauma are quite common, and patients with splenosis demonstrate some degree of splenic function after splenectomy One of the more common is to cut the spleen into pieces and place the pieces in omental pouchesWhether or not enough of it survives without attachment to the splenic artery in an adequately functioning form to provide adequate protection against postsplenectomy sepsis is an open question
- Splenic injuries are the most frequent following blunt abdominal trauma. Liver is the largest intra-abdominal organ – and the most injured from all causes Indeed 80% of hepatic injuries are accompanied by injuries in other organs.
- disruption of the hepatic parenchyma with perihepatic blood or hematoma and hemoperitoneum. Bleeding can be seen on CT as extravasation of contrast Based on the immediate threat to life from haemorhage, a system of categorization ofliver injuries has been worked out. Grades I and II injuries constitute 80-90 % of all cases and are considered minor and managed non-operatively Grades III- IV lesions are considered severe and usually require operative treatment. Grade VI injuries are incompatible with survival
- As 50-80% of liver injuries stop bleeding spontaneously no tachycardia, hypotension or metabolic acidosis no physical examination evidence of shock There must be no ongoing fluid administration to support the CVS system Follow-up CT Scan – indicated in only for those patients who develop clinical features of hepatic abnormality Resumption of activity – about 4 months (CT Scan evidence of injury resolving) Animal studies – 1 month is (III to V) is enough.
- Manual compression allows anaesthesia to catch up. Pringles can be used for 20min (recent studies it can go as far as 75min) It does not make the field blood less – retrograde flow from vena cava. Packing - The right and left triangular, coronary, and falciform ligaments must be divided Problem with packing is unpacking – soak with NS, non-adherent plastic drape Very good for DCS Suturing Grade III and IV liver lacerations often do not respond to the more topical methods The hepatoduodenal ligament is encircled with a vessel loop or vascular clamp to occlude hepatic blood flow from the hepatic artery and portal vein. This maneuver helps distinguish hepatic arterial and portal venous bleeding from hepatic vein bleeding, which will persist with the hepatoduodenal ligament clamped. In many cases, the liver laceration can then be explored and any actively bleeding vessels controlled with suture ligation
- NB – Some are also definitive management. Direct suturing - Suturing Grade III and IV liver lacerations often do not respond to the more topical methods continuous or if a deeper laceration is encountered, a mattress is preferred. Large, blunt-tipped 0 or 1 chromic suture - prevents the suture from tearing through Glisson’s capsule when tying. This technique is most appropriate for lacerations less than 3 cm in depth Finger fracturing More severe laceration may involve major branches of the portal vein or hepatic artery (Not amenable to suturing) This technique can lead to extensive additional parenchymal bleeding Omental Packing Can be used with finger fracturing Used to pack the dead space
- A Penrose drain is placed over a hollow perforated tube and tied on both ends. The balloon is then placed into the tract and inflated with a contrast agent
- Sump drainage is particularly useful. T-rube drainage Controversies around packing
- Pringle manoeuvre which involves the application ofacemporary soft clamp on the hepatic input in the free edge or the lesser omemum keeping 10 the principal planes of segmental resection of internal shunt which allows continuation of IVC blood flow while isolating the liver by temporary occlusion clamps above and below the hepatic vein
- Penetrating injuries are more obvious but have a higher mortality where the portal vein or hepatic artery are involved. CT Scan Findings include – highly suggest blunt gallbladder injury CT scan revealing a distended gallbladder filled with blood (dark arrow) in a patient with blunt abdominal trauma and virtually no peritoneal signs.
- Minor contusions of gallbladder – non-operatively >> Non-operative management – complication is cholecystitis or delayed rupture 4-0 absorbable suture choledochojejunal anastomoses are preferable to choledochoduodenal anastomose
- Diagnostically and therapeutically challenging Retroperitonal position makes clinical detection difficult Infrequency of injuries leads to inadequate expertise Anatomic and physiologic factors – morbidity is exacerbated by delay in diagnosis and treatment
- Initial approach is to follow the ATLS guidelines Haemodynamically unstable patients require little pre-op evaluation Persistent abdominal pain may be absent in intoxicated patients, brain injury or shock.
- FAST may detect Haemoperitoneum but poor with retroperitoneal bleeding Abdominal X-ray is of limited use >> loss of psoas shadow and trajectory of bullets ECRP is indicated in patients with suspected pancreatic duct injury. Subtle changes on CT, and chemical evidence of pancreatitis but without overt clinical findings mandating laparotomy MRCP -noninvasiveness and the ability to visualize not only the duct, but the pancreatic parenchyma and remainder of the abdomen Secretin, which increases pancreatic exocrine output and distends the pancreatic duct. ERCP can be done in theatre – insufflation may interfere with abdominal wound closure Intra-operative cholangiopancreatography is done
- Managed according to the haemodynamic status and the grade of pancreatic
- Grade I and II - Even capsular tears that are not bleeding are not repaired and may be simply drained with closed suction drainage. Overzealous suturing leads to pancreatic pseudocyst Distal transection or parenchymal injury with main pancreatic duct generally requires surgical management in order to prevent pancreatic ascites or major fistula. DCS – Packing of the head pancreas Parenchymal defects with no duct injury – ignored or filled with omentum Ductal transection – packed or drained
- Grade III – Requires surgical intervention to avoid pancreatic ascites or major fistula. Most ductal injuries can be identified either by preoperative studies in the stable patient or intraoperatively Ductal injuries at or distal to the neck are treated definitively with distal pancreatectomy. In the hemodynamically stable patient, the distal pancreatectomy can often be performed without splenectomy Try to establish enteral access in all cases to avoid TPN Grade IV Resection of greater than 85–90% is associated with a significant risk of pancreatic insufficiency In the rare situation where resection will result in less than 20% of intact pancreatic tissue, the pancreas should be divided, the proximal segment closed, and the distal portion preserved with drainage into a Roux-en-Y pancreaticojejunostomy. Grade IV and V - Debridement of pancreas; Closure of duodenal wound and; Pyloric exclusion by gastro-jejunostomy Major complications are - pancreatic fistulae, pseudocyst, pancreatitis, sepsis and haemorrhage. DCS Parenchymal defects not involving the duct – ignored or filled with omentum (delay insertion of closed suction drain until re-operation) Ductal transection distal to mesenteric vessels are packed or drained ( distal pancreatectomy done at reoperation) Parenchymal or ductal injuries in the head or neck of the pancreas are also packed or drained and Whipple delayed)
- Hollow viscus injury – bleeding and spillage of contents causing peritonitis Usually protected by the lower ribs from blunt injuries Often associated with the liver, spleen pancreas, and small bowel. CT scan evaluation is limited Picture is a
- Closure – an absorbable is used to close the perforation and then a non-absorbable is used to invert it. with Billroth I or II reconstruction Total gastrectomy with Roux-en-Y Oesophagojejunostomy
- Rarely affected by blunt trauma – retroperitoneal location and protection by ribcage Often accompanied by injuries to other organs Diagnostically challenging – retroperitoneal position No spillage into peritoneum Sterile contents delay – sepsis DPL and FAST are of little use
- Abdominal X-ray Retroperitoneal gas is suggestive but not always present CT Scan Finidngs free air and contrast extravasation. More subtle findings - hematoma, or thickening of the bowel wall; surrounding fluid, hematoma, or fat stranding in the retroperitoneum; or intramural gas, should raise suspicion of duodenal injury
- Treatment depends on location of injury and amount of tissue destructions. Haematomas can present with GOO but most heal within 3 weeks Whenever mobilization is difficult for end-to-end anastomosis – a duodeno-jejunostomy anastomosis can be done – Roux-en-Y duodenojejunostomy. DCS – Near transections of the duodenum are stapled shut at reoperation – appropriate reconstruction is done A pyloric exclusion with polypropylene suture + antecolic gastrojejunostomy are added in selected patients with severe duodenal contusion, narrowing after a suture repair, or a combined complex pancreatoduodenal injury.
- Patch of omentum can be used to reinforce any of the repairs Protection of repair from enteric contents in extensive injuries – Pyloric exclusion gastrojejunostomy and external drainage
- 60% of cases are associated with intestinal lacerations
- Diagnosis Peritonism is more obvious Diffuse peritonitis is a regular feature of the late presenting case and is usually responsible for mortalities from this injury
- Careful and thorough inspection Contusions < 1cm – turned in with a row of seromuscular sutures Larger contusions – require resection. Simple linear laceration – suturing in two layers after debridement
- multiple sutures are more liable to leak and obstruction from undue luminal narrowing may occur DCS – A rapid one-layer full-thickness closures using continuous suture polypropylene 3-0 or 4-Multiple large perforation within a short segment – of bowel and colon – segmental resection plus stables Neither anastomosis or colostomy is done until stable
- Iatrogenic injuries – colonoscopy, barium enemas May first be seen at laparotomy prompted by haemodynamic instability or penetrating injuries.
- Suspicion of injury is grounds enough for laparotomy Use of bactericidal antibiotics due to high risk of peritoneal soiling.
- Primary repair with one or two layers Caecal injuries – caecostomy DCS Enterotomies or colotomies from a penetrating wound, a rapid one-layer, full-thickness closure using a continuous suture of 3-0 or 4-0 polypropylene material is appropriate. Multiple large perforations within a short segment of the small bowel or colon are treated with segmental resection, using metallic clips for mesenteric hemostasis and staples to transect the bowel.
- Significant on-going blood loss and haemodynamic instability. DPL is positive in 50% of cases (may be indicative of coexistent intraperitoneal haemorrhage)
- DCS Renal artery – nephrectomy in the presence of a palpable. Zone 1 - central vascular structures, such as the aorta and vena cava. Zone 2 includes the kidneys and adjacent adrenal glands. Zone 3 describes the retroperitoneum associated with the pelvic vasculature