Discusses abdominal injuries and the various surgical interventions

1. Abdominal Injuries
BY DR. EKE

2. Table of Contents
Abdominal Injuries
Aetiology
Clinical features
Investigations in Abdominal Injuries
Specific Organ Injuries and Treatments

3. Abdominal Injuries
Abdominal injury occurs worldwide and the
incidence is likely to increase everywhere with the
rising frequency of high speed travel and social
violence. In most instances abdominal injury is one
of the injuries in a polytraumatized patient.

4. Aetiology
A. Blunt Abdominal Injuries
In these injuries there is no penetration of the abdominal cavity, the
visceral injuries resulting mainly from crushing force.
•Road Traffic accidents
•Falls from heights
•Direct blows – fist, football, kick
•Crushing injuries
The spleen is the most frequently injured organ in blunt abdominal
injuries.

5. Aetiology Cont’
B. Penetrating Abdominal Injuries – Here there is penetration
of the abdominal cavity.
Sharp objects – Knives, arrows and spears.
Gun shot.
The abdominal cavity is most frequently breached from
external wound in the anterior abdominal wall but injuries can
also occur from penetrating wounds in the thorax, the loin, the
buttocks or the perineum.

6. Clinical features
Hx of abd trauma – mechanism of injury should be enquired.
This may provide a clue to possible visceral lesions.
Compression steering wheel (drivers) type injury is known to
produce diaphragmatic rupture or pancreatic trauma.
Abdominal pain and tenderness are regular features, with
signs of peritoneal irritation – guarding, rigidity, rebound
tenderness and rectal tenderness. These sign are more
pronounced when the peritoneum is irritated by gut contents
than by blood.
, B.P – these ones can be subjected to further investigation.

7. Shock- some patients present in shock – dizziness, feeble
pulse, tachycardia, low B.P, cold clammy extremities. These
patients need immediate operation.
Haemodynamically unstable – some present with unstable
B.P, they also need immediate surgery.
Haemodynamically stable, normal pulse

8. Investigations in Abdominal Injuries
These investigations as are appropriate are done only in the
haemodynamically stable patients.
1. PCV, Blood Group, FBS/RBS, serum amylase. Serial PCV or HB checks
which shows a steady fall leads to a suspicion of haemorrhage.
Serum amylase level may occur in pancreatic injury but also occurs in
rupture of the stomach, duodenum or small intestine.
2. X-ray – in those who are stable.
Abdominal X-ray – you may see ground grass appearance.
CXR – may see air under the diaphragm in case of ruptured hollow
organ.
Bowel in the chest in the case of ruptured diaphragm.

9. Investigations in Abdominal Injuries Cont’
3. Abdominal Ultrasound
Free fluid in the peritoneal cavity
Solid organ – spleen, kidney, liver etc.
4. CT Scan
5. Angiography – to assess vessels, solid organ. Also for embolisation of bleeding
vessels within these organ so as to avoid laparotomy.
6. Intravenous Urography
Patients with suspected renal or ureteric injuries as they show leakage of dye, or
non-functioning kidney. Also shows the condition of the other kidney.
7. Laparoscopy

10. Investigations in Abdominal Injuries Cont’
8. Abdominal paracentesis – has been used for years but has become controversial.
Needs large volume of blood to be positive, also in the obese it may be negative
due to fat.
9. Diagnostic Peritoneal Lavage (DPL)
More accurate than abdominal paracentesis and is very useful in the unconscious
patient.
Instill 500mls of Ringer lactate into the peritoneal cavity and examine the contents
for blood, WBC, faeces or food particles, serum amylase.
10. Exploratory laparotomy where doubts still persist after investigations or in areas
with lack of facilities. Negative laparotomy rate is high but many patients can be
saved through this.

11. Specific Organ Injury
Spleen – commonest organ to be injured in blunt abdominal injury.
Classification of Spleen Injury
Grade Types of Injury
Grade I Subcapsular haematoma < 10% surface area.
Laceration capsular tear < 1cm deep
Grade II Subcapsular haematoma 10 – 50% surface
area
Intra parenchymal haematoma < 5cm Laceration
1 – 3cm without vessel involvement

12. Specific Organ Injury Cont’
Grade III Subcapsular haematoma > 50% surface area
or expanding
Intraparenchymal haematoma > 75cm
Laceration <3cm or with trabecular vessels
involvement
Grade IV Laceration of segmental or vessels causing major
devascularization > 25% of the spleen.
Grade V Shattered Spleen.
Injury of hilar vessels with completely
devascularized spleen.
Rupture of pathological spleen e.g. SS

13. Presentation
Ultra urgent splenic injury – presents in shock. Needs immediate
laparotomy.
Gradual deterioration - Majority of patients presently like this -
initially normal but gradually deteriorates.
Delayed Rupture - occurrs after days, weeks or even months due to
subcapsular haematoma which eventually ruptures - to the
peritoneal cavity, or digestion of initial clot by enzymes released
from concomitant damage to pancreatic tail or due to delayed
recognition of splenic injury when minimal signs are present.

14. Treatment
-Splenorrhaphy for minor injuries
- Segmental resection
- Splenectomy for major injuries.

15. Complications of Splenectomy
1. Injury to surrounding structures – stomach, colon, pancreases.
Pancreatitis, pancreatic abscess, pancreatic fistula.
2. Gastric dilatation – NGT
3. Paralytic ileus
4. Disturbance of immune system
- OPSI – overwhelming post splenectomy infection especially in infants
and children especially pneumococus, Neisseria Meningitidis, H.
Influenza
- Lowered immunity to malaria
5. Thrombo – embolism due to increased activity of the bone marrow
following splenectomy – Increased platelets.

16. Liver Injuries
Liver injuries are usually due to severe forces and 80% of them are
associated with injuries in other organs.
Liver injuries range from:
Simple laceration
Tissue Fractures
Penetrating injuries due to bullet wounds with its cavitation effects.
Haematoma
Vascular injuries.
Liver injuries are categorized into six grades (I-IV).

17. Treatment
Minor liver injuries like subcapsular haematoma,
lacerations constitute 80-90% of all cases. Require
minimal or non-operative Rx like suturing.
Major injuriesrequire, operative Rx like simple drainage
debridement, suturing and drainage and resection of
parts of the liver.
Gauze packing is no longer much used.
Antibiotics.

18. Complications of Liver Injuries
1. The thorax is involved in nearly 50% of hepatic injuries
therefore pulmonary complications:
-Atelectasis
- Pleural effusion
-Empyema
-Bronchopneumonia
2. Haemorrhage, wound infection, intra abdominal
collection
3. Coagulopathy

19. Complications of Liver Injuries Cont’
4. Hypoglycaemia
5. Jaundice
6. Liver Failure
7. Biliary leakage
8. Haemobilia
9. Transient hyperbilirubinaemia – lasts 2-3weeks due to obstruction
of the ducts from oedema.
Mortality: 10 – 15% - due to bleeding, sepsisand other injuries.

20. Extrahepatic Biliary Tract
Uncommon wounds.
Gallbladder injuries – Cholecystectomy if patient is fit,
Cholecystostomy if patient is unfit.
Damaged ducts – simple suture over a T-tube
If there is loss of tissue (duct) – do Choledochojejunal
Anastomosis

21. Pancreatic Injury
Uncommon. Also classified into 5 grades.
1. Serum Amylase – elevated in 2 hours
2. Contrast Radiography – in the stable patient may
show widening of the C-loop.
3. USS –Shows haematoma
4. CT Scan

22. Pancreatic Injury Cont’
Rx. 1. Conservative Rx – in patients with blunt injuries, minor, and are
stable and no peritoneal signs. Monitor them clinically, laboratory
and radiological monitoring.
2. Surgery – In penetrating injuries and blunt injuries with peritoneal
signs. These require kocherization of the duodenum and examination
of the lesser sac.
Surgery include:
-Drainage for contusion
-Suturing of simple laceration with non- absorbable.Drainage too.
-Debridement, distal pancreatectomy.

23. Complications of Pancreatic Injury
1. Pancreatic Fistulae
2. Pseudocyst of the pancreas
3. Pancreatitis
4. Sepsis
Stomach
Treatment - suturing in two layerts.

24. Duodenum
Difficult to diagnose because of its
retroperitoneal position.
Rx Contusion– NGT x 1-2/52
Lacerations - Closure in 2 layers
Loss of tissue – resection and anastomosis

25. Complication of Duodenal injuries
•Infection
•Fistula
Small Intestine
Laceration – two layer closure after debridement.s multiple perforation
that are closeby – resection and end to end anastomosis.
Peritoneal lavage, drainage, Antibiotic.
Complications
•Faecal fistula
•Adhesions

26. Mesenteric Injuries
Longitudinal tears – close
Transverse and long tears – may cause bowel
ischaemia,mm do resection and end to end
anastomosis.
Complications of Mesenteric Injuries
- Haemorrhage
- Bowel Ischaemia

27. Large Intestine
Management
IVF
Antibiotics
RightSided– Simple laceration – debridement and
closure in two layers.
Right hemicolectomy and ileotransverse anastomosis
for ones unsuitable for simple closure.

28. Peritoneal Lavage
Drain
Left sided – If simple laceration and no peritoneal
contamination do simple closure in 2 layers.
If there is peritoneal contaminations, do colostomy with
mucous fistula or Hartman’s procedure.
Complication of Injuries
•Wound infection
•Intra peritoneal sepsis
•Fistula (entero-cutaneous).

29. Retro Peritoneal Haematoma
Difficult
Watch out in pts with hypotension but no
peritoneal sign following abd trauma and no
obvious source of harmorrhage.
Tender mass in the flanks.

30. Retro Peritoneal Haematoma
Rx Two Opinions
1. Leave alone
2. Exploration of all retroperitoneal haematoma especially
near retroperitoneal viscera e.g. duodenum, ascending or
descending colon in case of retroperitoneal perforation.
Pulsatile or expanding haematoma is due to injury to the
major vessels of the retro peritoneum and should be
explored.

31. Genito Urinary Injury
Presentation
Haematoma (Macro or microscopic)
Blood at urethral meatus
Peritoneal or genital swelling
Inability to pass urine
Loin mass, supra pubic mass, injury
Treatment
Conservative or surgical depending on severity of injury.

32. Thank you for listening!!!