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ABDOMINAL INJURIES
Presenter – Atiyya Hussein
Supervisor – Dr. Ayesiga Herman
Outline • Evaluation
• Penetrating vs blunt trauma
• Important CT findings
• General principles of management
• Prophylactic measures
• Emergent abdominal exploration
• Lethal triad
• Damage control surgery
• SICU care
• Abdominal compartment syndrome
• Management of specific injuries and their complications
• Vascular injuries
• Liver and extrahepatic biliary tract
• Spleen
• Stomach and small intestine
• Duodenum and pancreas
• Colon and rectum
2
Evaluation
• Diagnostic black box
• What is necessary at the EMD is to determine whether patient will require
ex-lap
• Undisputed indications:
• Abdominal rigidity
• Hemodynamic instability
3
Penetrating trauma
• All anterior truncal GSWs btn 4th ICS and pubic symphysis that penetrate
peritoneal cavity warrant ex-lap, EXCEPT trauma isolated to RUQ (where
patients are hemodynamically stable and trajectory is confined to liver by
CT)
• If GSW thought to be tangential through subcutaneous tissues as in obese
patients, options to exclude peritoneal violation include CT or laparoscopy
• Possibility of transmitted intraperitoneal hollow visceral injury due to blast
injury
• Triple-contrast CT for GSWs to back or flank 4
• Stab wounds less likely to injure intra-abd organs than GSWs
• Anterior abd stab wounds from costal margin to inguinal ligament and bil
mid-axillary lines should be explored under LA at the EMD to determine
whether fascia violated
• If no → no further evaluation necessary
• If yes → options for further evaluation include:
• Serial examination
• Lab evaluation
• DPL
• CT
5
• Remember occult injury to diaphragm
• Penetrating Rt diaphragm injury may be ignored unless major liver injury w
risk of biliopleural fistula
• Laparoscopy or DPL for penetrating wounds to Lt lower chest to exclude
diaphragmatic injury
DPA positive if >
10ml of blood
aspirated.
If <10ml aspirated,
then 1L is instilled
and effluent
withdrawn to be
sent for lab
evaluation.
6
7
8
Blunt trauma
• Initial evaluation by FAST has supplanted DPL
• FAST not 100% sensitive, so DPA warranted in hemodynamically
unstable patients without defined source of blood loss
• FAST only sensitive for intraperitoneal fluid > 250ml, does not reliably
determine source of hemorrhage or grade of solid organ injuries
• If positive FAST without undisputed indications for ex-lap (peritonitis
or hemodynamic instability) then proceed to CT
• If free intraperitoneal fluid without solid organ injury, serial
examinations to monitor for evolving peritonitis
• If cannot (such as in head injuries) then DPL to exclude bowel injury
9
10
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12
Important CT findings:
• AAST grading scale (will depend on features mentioned below)
• Contrast extravasation, “blush” → active bleeding
• Presence of pseudoaneurysms
• Presence of AV fistulae
• Amount of intra-abd hemorrhage or hemoperitoneum
• Pneumoperitoneum
13
• Lacerations – linear, stellate or branching hypodense areas within solid
organs
• Hematomas – oval or round-shaped if within the parenchyma of solid
organs, crescent-shaped if subcapsular along the margins of solid organs
• Contusions – vague, ill-defined hypodense areas with less perfusion
• Devascularization (infarcts)
• Bowel injury suggested by:
• thickened bowel walls
• “streaking” in the mesentery
• free fluid without solid organ injury
• free intraperitoneal air
14
15
16
General principles of management
Remarkable changes in the past 3 decades
• Non-operative management of solid organ injuries has replaced routine
operative exploration due to CT scans
• Less radical resection techniques such as partial nephrectomy or
splenorrhaphy encouraged where possible
• Primary repair of colonic injuries encouraged where possible (continuous
running single-layer advocated over double-layer)
• Damage control surgical techniques
• Abdominal drains no longer considered mandatory for parenchymal injuries
and anastomoses; fluid collections may be managed percutaneously
• Newer endovascular techniques (stenting, angioembolization)
• Massive transfusion protocols 17
Prophylactic measures
• Pre-op antibiotics
• Tetanus prophylaxis
• LMWH if concurrent injuries to pelvis, lower extremities, head or spinal
cord and if ligation of major abd veins, increased risk in morbidly obese pts
and those > 55yrs
• to be initiated only once bleeding in control and intracranial pathology is stable if
present
• add antiplatelets in high-risk pts
• additional options are removable IVC filters and pulsatile compression stockings
• Thermal protection (remember the lethal triad)
• ambient temp, warm blankets, warmed IVF and blood products, heated inhalation
via ventilatory circuit, arteriovenous rewarming if severe hypothermia (<30⁰C)
18
Emergent abdominal exploration
• Midline incision in adults vs transverse incision in children < 6yrs
• Scalpel faster than diathermy
• IGNORE incisional abd wall bleeding until intra-abdominal sources of
hemorrhage controlled
• Eviscerate bowel then use lap pads to evacuate liquid and clotted
blood to identify source(s) of active bleeding
• Blunt trauma → spleen and liver palpated first, packed if fractured,
then inspect infracolic mesentery for zone I vascular injury
• Penetrating trauma → pursue trajectory of penetrating device
19
•If SBP < 70 upon opening, apply
digital pressure (or clamp) on
supraceliac aorta through hole in
the lesser omentum
• Direct digital occlusion for
vascular injuries vs lap pad
packing for solid organ injuries
•Pringle maneuver if liver source
of bleeding
20
Most likely sources of bleeding in blunt trauma are
LIVER, SPLEEN and MESENTERY
1. Perihepatic packing (above and
below)
2. Rt paracolic gutter
3. Perisplenic packing (lateral and
medial)
4. Lt paracolic gutter
5. Pelvis
21
22
23
• Vascular injuries will require rapid exposure of intra-abd vasculature
• Maneuvers for gaining access to the retroperitoneum
24
Systematic exploration after hemorrhage
control:
1. Infracolic compartment
• run the gut from lig of Treitz to rectum (or
vice versa)
• special attention to post transverse colon,
hepatic and splenic flexures
• control spillage as you go
2. Supracolic compartment
• liver and gallbladder
• Rt and Lt kidneys
• GEJ, stomach, duodenum (Kocher maneuver)
• spleen
• hemidiaphragms
• open lesser sac for posterior aspect of
stomach and pancreas
25
26
• After identification of injuries, determine whether primary repair or
damage control
• Enteral access via gastrostomy or jejunostomy in polytrauma
• Irrigation of abdomen w warm saline
• Closure of fascia w running heavy absorbable suture if indication
• Skin closure selective based on level of contamination
27
28
Bloody vicious cycle a. k. a. LETHAL TRIAD
29
Damage control surgery
• Purpose is to limit operative time so as to allow physiologic restoration in
the SICU and break the vicious cycle
• Indications:
• Refractory hypothermia (< 35⁰C)
• Profound acidosis (arterial pH < 7.2 w base deficit < 15mmol/L)
• Refractory coagulopathy
• Decision may be made intraoperatively
• 2 main goals:
1. CONTROL SURGICAL BLEEDING
2. LIMIT GI SPILLAGE
• Temporary measures used to achieve these goals, w definitive repair
delayed until pt physiologically replete (normalization of above indications)
30
Controlling surgical bleeding
• Aortic injuries → interposition PTFE graft
• Celiac a. injuries → may be ligated but early
insertion of intravascular shunt advocated as
the SMA must maintain flow
• Iliac and infrainguinal a. injuries → intravascular
shunt, w delayed interposition graft placement
• Venous injuries → ligation EXCEPT suprarenal
IVC
• Solid organ injuries → excision rather than
operative repair for spleen or kidney, packing or
balloon catheter tamponade for liver
31
Limiting GI spillage
• Small GI injuries → rapid whipstitch of 2-0 polypropylene
• Complete transection or segmental damage → stapler w resection of
injured segment, alternatively ligate open ends of bowel
• Pancreatic injuries → pack, then delayed evaluation of duct integrity
• Urologic injuries → catheter diversion
32
33
• Temporary closure of abdomen
using antimicrobial surgical
incise drape:
• allows closed suction to control
reperfusion-related ascitic fluid
collection
• provides adequate space for
bowel expansion to prevent abd
compartment syndrome
• allows continued assessment of
bowel status and hemorrhage
control
34
35
SICU care
• During shock resuscitation → Hb > 10 acceptable
• After 1st 24hrs → transfusion trigger is Hb < 7, to limit adverse inflammatory
effects of stored RBCs
• Optimizing crystalloid loading challenging → to balance cardiac
performance against generation of abdominal compartment syndrome and
general tissue edema
• Monitoring volume status (invasive vs non-invasive)
• Inotropic support
• Goals of resuscitation:
• core temp > 35⁰C
• base deficit < 6mmol/L
• normal coagulation indices
• normal lactate within 24hrs
36
Abdominal compartment syndrome
• Pathologic intra-abd HTN (i.e. sufficient to produce physiologic deterioration)
due to:
1. Intra-abd injury → PRIMARY
2. Splanchnic reperfusion after massive resuscitation → SECONDARY
• Sources of increased intra-abd pressure:
• Bowel edema
• Ascites
• Bleeding
• Packs
• Diagnosis not clinical alone, requires measurement of intraperitoneal
pressure via measurement of bladder pressure (unreliable if bladder rupture,
external compression from pelvic packing, neurogenic bladder, adhesions)
37
38
• No specific bladder pressure prompts therapeutic intervention, except
when > 35mmHg
• Therapeutic intervention only when end-organ dysfunction occurs,
timing very important
• Manifestations of end-organ sequelae:
• Decreased urine output
• Increased pulmonary inspiratory pressures
• Decreased cardiac preload
• Decreased cardiac output
• Bedside laparotomy or percutaneous drainage
39
40
• Even patients w an open abdomen can develop recurrent abd compartment
syndrome, should monitor bladder pressure 4hrly to determine whether will
require repeat operative decompression
• Complications of open abdomen:
• 500-2500ml of effluent lost in an open abdomen
• Intra-abd abscess
• Enteric fistulae
• Perforations
• Techniques of fascial closure:
• Approximation w prosthetic or biologic mesh, planned reop later
• Split-thickness skin grafts, then removal and hernia repair 9-12mo later
• Sequential closure technique (every 48hrs) w wound VAC device causing constant
fascial tension
41
Management of specific
injuries
Vascular injuries
Principles of vascular repair
• Initial control by direct digital pressure
• Sharp dissection to mobilize sufficient length for proximal and distal
control
• Fogarty thromboembolectomy done proximally and distally to optimize
collateral blood flow
• Heparinized saline (50U/mL) injected proximally and distally to prevent
small clot formation
• Ragged edges debrided using sharp dissection
• Intravascular shunts in damage control, or when arterial injury expected to
require saphenous vein interposition reconstruction
44
45
• Lateral suture repair → arterial and venous injuries w minimal tissue loss
• End-to-end primary anastomosis → no tension, 1-2cm defects
• bevelling allows larger lumen diameter to avoid postop stenosis
• Interposition grafts → tension despite mobilization
• autogenous options such as GSV, celiac and basilic veins preferred for <6mm
diameter as synthetic options have greater rates of thrombosis
• PTFE preferred over Dacron for larger arteries as decreased rates of infxn
• venous injuries repaired w this method will ultimately undergo thrombosis in 1-2wks,
but this is enough time for dev’t of adequate collateral circulation and will prevent
acute venous HTN; may be used in injuries of suprarenal IVC and SMV
• Transposition → when artery bifurcated and one branch can be safely
ligated
• iliac a. injuries where synthetic interposition grafts may pose a dilemma in the
presence of enteric contamination
46
47
Injuries to abd vasculature
• Penetrating trauma indiscriminately affects all blood vessels
• Blunt trauma most commonly affects renal vasculature and occasionally abd
aorta
• Arterial repair a MUST for injuries to aorta, superior mesenteric, proper
hepatic, renal and iliac a.
• Arteries that tolerate ligation include Rt/Lt hepatic a. and celiac trunk
• Venous repair a MUST for injuries to suprarenal IVC and portal vein (may be
ligated in extreme cases, limit bil LL edema by wrapping w elastic bandages
and elevation)
• SMV and Lt renal vein tolerate ligation, although repair is optimal as resultant
bowel edema in the former will require aggressive fluid resuscitation and abd
pressure monitoring
48
• Vascular injuries will require rapid exposure of intra-abd vasculature
• Maneuvers for gaining access to the retroperitoneum
49
• Decide whether pt has supracolic or infracolic vascular injury
• Supracolic injuries include aorta, celiac trunk, proximal SMA and Lt renal a.
• Best approached using Lt-sided medial visceral rotation (Mattox maneuver)
• Incision done along Lt line of Toldt at distal descending colon and extended along
splenic flexure, posterior aspect of spleen, behind gastric fundus and ending at the
esophagus in the diaphragmatic hiatus
• May then cut Lt diaphragmatic crus laterally allowing blunt dissection around aorta
and access to distal thoracic aorta as high as T6 w/o resorting to thoracotomy
• Allows mobilization of Lt colon, spleen, pancreas and +/- Lt kidney
50
51
• Access to SMA injuries depends
on zone:
• Fullen zone I – posterior to
pancreas, accessed through Lt-
sided medial visceral rotation
• Fullen zone II – from pancreatic
edge to middle colic branch,
accessed through lesser sac along
inferior edge of pancreas at the
base of transverse mesocolon, may
require division of pancreatic body
• Fullen zone III and IV – accessed
directly within mesentery
52
Abd aorta
• Pts w penetrating aortic injuries who survive to reach the OR will have
contained hematoma within retroperitoneum
• Blunt injuries are typically extensive intimal tears of infrarenal aorta w
resultant thrombosis
• Lack of mobility means few injuries amenable to primary repair
• Supraceliac aortic injuries challenging as difficult to obtain proximal control
• Options include 4-0 polypropylene suture or PTFE patches for small lateral
perforations, otherwise PTFE interposition graft most common repair
• Vascular suture lines should be covered w omentum to avoid vascular-enteric
fistulas
• SBP < 120mmHg for 72hrs post-op
53
SMA
• Often encountered in GSWs, blunt avulsions rare but should be considered in
pts w seatbelt sign who have epigastric pain/tenderness and hypotension
• “Black bowel” and supracolic hematoma pathognomonic
• Damage control → Pruit-Inahara shunt
• Definitive repair → RSVG interposition
• No pancreatic injury – from proximal SMA to SMA past the point of injury
• Associated pancreatic injury – distal aorta beneath duodenum to distal SMA
• Temporary closure and 2nd look op to evaluate bowel viability
54
• Venous injuries behind the pancreas, from the junction of SMV, splenic
and portal veins accessed by dividing neck of pancreas
• IVC injuries accessed through Rt-sided medial visceral rotation (3 steps):
1. Kocher maneuver – mobilizes duodenal loop and head of pancreas to visualize
IVC and Rt renal hilum
2. Extended Kocher maneuver – mobilizes Rt colon to visualize infrahepatic IVC, Rt
kidney and renal hilum as well as Rt iliac vessels
3. Super-extended Kocher maneuver (Cattel-Braasch maneuver) – incision carried
around cecum and towards lig of Treitz to allow visualization of entire infracolic
compartment including IVC, infrarenal aorta, D3, D4, superior mesenteric vessels
as well as both renal and iliac vessels
55
56
57
• Injuries to iliac vessels:
• Proximal control at infrarenal aorta for arterial injuries
• Tamponade by lap pads for venous injuries
• May require complete vascular isolation
• Rt common iliac a. obscures bifurcation of IVC and Rt common iliac vein, may
require division for access followed by repair later
58
59
Complications and postop considerations:
• Follow-up imaging 1-2wks after injury to confirm healing
• Routine graft surveillance rarely performed as long-term complications
uncommon
• Long-term administration of antiplatelets and antithrombotics
unnecessary
• Complications may include prosthetic graft infxns (perioperative
antibiotics important), stenosis, pseudoaneurysms
60
Liver and extrahepatic biliary
tract injuries
• Large size makes it most susceptible to blunt trauma and upper torso
penetrating trauma
• If hemodynamically stable + no overt peritonitis + no other indications
for laparotomy → NON-OPERATIVE MANAGEMENT
• ONLY CONTRAINDICATION is hemodynamic instability from
intraperitoneal hemorrhage
• Other factors such as high injury grade, large hemoperitoneum,
contrast extravasation, or pseudoaneurysms ONLY PREDICT
complications or failure of nonoperative management
62
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76
> GRADE II INJURIES:
•Admit to SICU
•Hemodynamic monitoring
•Hemoglobin determination
•Abdominal examination
77
• Adjuncts to nonoperative management:
• Angioembolization
• ERCP
• Primary goal in emergent laparotomy is to ARREST HEMORRHAGE
• PUSH
• PACK
• PRINGLE (also helps delineate source of bleeding)
• PLUG
78
79
• Packing of Lt lobe not as effective as insufficient abdominal / thoracic wall
anteriorly, PUSH better strategy
• If PACK doesn’t work, injury to hepatic artery, portal vein and retrohepatic
vasculature likely
• PRINGLE will delineate source of bleeding as will halt bleeding from hepatic
artery and portal vein BUT NOT hepatic veins and retrohepatic IVC
• Intermittent release of PRINGLE helpful to attenuate hepatic cellular loss
• Indication of PLUG is transfusion of 4 units of RBCs in 6 hours or 6 units of
RBCs in 24 hours attributable to the liver
80
Portal triad vasculature
• should repair proper hepatic artery (end-to-end if cleanly transected, otherwise
temporary shunting followed by interposition RSVG)
• might ligate right or left hepatic arteries in urgent situations (will result in lobar
necrosis that will require delayed anatomic resection)
• if right hepatic artery ligated then also cholecystectomy necessary
• directed packing or Fogarty if blunt avulsion at hepatic plate (flush with liver)
• pancreas must be transected to gain access for hemorrhage control if injury
more proximal (retropancreatic) 81
Hepatic vein or retrohepatic IVC injury
• perihepatic packing
• hepatic vein stent by interventional
radiology
• direct repair with or without hepatic
vascular isolations – suprahepatic and
infrahepatic clamping of the vena
cava and stapled assisted
parenchymal resection, temporary
shunting of the retrohepatic vena
cava, venovenous bypass
82
Hepatic parenchymal hemorrhage
83
Hepatic parenchymal hemorrhage (cont’d)
• manual compression
• electrocautery (100W)
• suturing (blunt-tipped chromic 0)
• running suture for shallow lacerations, interrupted horizontal mattress sutures for deeper
lacerations
• adequate tension is when visible hemorrhage ceases or liver blanches around suture (be cautious to
avoid hepatic necrosis)
• hepatic lobar arterial ligation
• omentum can be used to fill large defects – obliterates dead space, excellent source of macrophages,
buttressing support for parenchymal sutures
• thrombin soaked gel foam sponge, fibrin glue
84
85
Translobar penetrating injuries
• intraparenchymal tamponade with Foley catheter, left inflated for 24-48hrs
then sequential deflation and removal
• hepatotomy w ligation of individual bleeders
• angioembolization
• liver transplants in extraordinary circumstances of hepatic necrosis
86
Injuries of extrahepatic bile ducts
• smaller injuries → T-tube or lateral suturing w 6-0 monofilament absorbable
suture
• significant tissue loss → Roux-en-Y choledochojejunostomy using single-
layer interrupted technique with 5-0 monofilament absorbable suture,
jejunum should be sutured to areolar tissue of hepatic pedicle or porta
hepatis
• stenting via ERCP
• ligation of hepatic duct if opposite lobe normal and injured
87
88
Complications and postop considerations:
• ongoing hemorrhage (falling hemoglobin, accumulation of blood clots under
the temporary abdominal closure device, bloody output from drains,
ongoing hemodynamic instability)
• hepatic ischemia due to prolonged intra-op use of Pringle maneuver
(elevation of liver enzymes with subsequent resolution) and frank hepatic
necrosis due to ligation of hepatic arteries
89
• intermittent “liver fever” for first 5 days after injury
• Bilomas
• loculated collections of bile, may or may not be infected
• should be treated by percutaneous drainage if infected
• small, sterile bilomas are often reabsorbed, but larger collections should be drained
90
• Biliary ascites due to disruption of major bile duct, will require reoperation and
wide drainage
• Pseudoaneurysms
• develop because hemorrhage treated w/o ligating individual vessels
• may rupture into a bile duct → hemobilia (RUQ, upper GI bleeding, jaundice), portal vein →
portal venous HTN w bleeding oesophageal varices
• best treated w hepatic arteriography and embolization
• Biliovenous fistulas
• cause jaundice due to rapid increases in serum bilirubin
• treated by ERCP and sphincterotomy
• Bronchobiliary or pleurobiliary fistulas
• in associated diaphragmatic injuries
• majority require operative closure due to pressure differential
• endoscopic sphincterotomy w stent placement to equalize pressure differential, then fistula
closes spontaneously
91
Spleen
93
94
95
96
97
98
99
100
• Splenectomy was considered mandatory for all patients in the 1970s
• Nonoperative management currently the preferred means of splenic
salvage due to recognition of its immune function
• Selective angioembolization (SAE) warranted in high grade injuries,
especially w contrast extravasation (risk factor for failure of
nonoperative management)
• Patient selection most important cause of failure of nonoperative
management
• Indications for early surgical intervention
• initiation of blood transfusion within 1st 12hrs
• hemodynamic instability
• Delayed hemorrhage or rupture can occur up to WEEKS following injury
unlike hepatic injuries where risk of rebleeding is within 1st 48hrs
101
Surgical options:
1. Splenectomy – significant hilar injuries, pulverized splenic parenchyma, or any > grade
II injury in pt w coagulopathy or multiple life-threatening injuries
• May do autotransplantation of splenic implants in younger patients w/o enteric injuries
102
2. Partial splenectomy – when only superior or inferior pole injured
• hemorrhage from raw splenic edge controlled w horizontal mattress sutures with
gentle compression of parenchyma
3. Splenorrhaphy
103
Complications and postop considerations:
• Postop hemorrhage due to improperly ligated or unrecognized short
gastric artery or from splenic parenchyma if was repaired
• Postop sepsis
• subphrenic abscess
• OPSI due to encapsulated bacteria (require vaccination > 14d post-injury)
• Pancreatic ascites or fistula due to iatrogenic injury to pancreatic tail
• Gastric perforation due to short gastric artery ligation
104
Stomach and small intestine
• Gastric wounds can be repaired using running single-layer suture or stapler
• If the former, FULL THICKNESS bites should be taken to ensure hemostasis
• Most commonly missed gastric injuries:
• posterior wound of a through-and-through penetrating injury
• within mesentery of lesser curvature
• high in the fundus
• Can occlude the pylorus digitally and introduce methylene blue-coloured
saline through NGT or air through NGT w abd filled w saline
• Partial gastrectomy and Billroth reconstruction for destructive injuries,
drainage procedures for injuries to the vagi
106
•Small intestine injuries:
• < 1/3 circumference of bowel → transverse running 3-0 PDS
suture
• > 1/3 circumference of bowel or multiple penetrating injuries
→ segmental resection and end-to-end anastomosis using
continuous single-layer 3-0 polypropylene
• Mesenteric injuries → resection mandatory as may result in
ischemic segment of bowel
107
Complications and postop considerations:
• Postop ileus
• Return of bowel function indicated by decrease in gastrostomy or NGT output
• Nutritional issues
• importance of early TEN in trauma pts, esp for reducing septic complications
• route less important unless upper GIT pathology
• should have evidence of bowel function before initiation as may lead to small
bowel necrosis in pts recovering from profound shock
• keep NPO for 48hrs in solid organ injuries if opted for nonoperative
management
• feasible even in open abdomen → higher fascial closure rates, decreased
complications and decreased mortality in pts w/o bowel injury
108
Duodenum and pancreas
110
• Spectrum of injuries to duodenum:
• hematomas
• perforation
• combined pancreaticoduodenal injuries
• Majority of duodenal hematomas managed nonoperatively w NG suction
and parenteral nutrition
• If deteriorate clinically and retroperitoneal free air or contrast
extravasation on imaging → suspect associated perforation
• Resolution occurs within 2wks and indicated by drop in NGT output, if no
improvement within 3wks then operative evaluation warranted
111
• Small perforations repaired by running single-layer 3-0 monofilament
• Close in a direction that will give largest residual lumen
• Bigger tissue losses
• D1 → debridement and end-to-end anastomosis as mobile and richer blood
supply
• D2 → defects “patched” w Roux-en-Y duodenojejunostomy as tethered to
pancreas and end-to-end anastomosis will give unacceptably narrow lumen
• D3 and D4 → resection, Roux-en-Y duodenojejunostomy and oversewing of distal
duodenum
112
113
• Pancreatic contusions (where ductal system intact) → nonoperative
management or closed suction drainage if undergoing laparotomy for other
indications
• Proximal pancreatic injuries (to the Rt of superior mesenteric vessels) →
closed suction drainage
• Distal pancreatic injuries → will depend upon ductal integrity which is
determined by direct exploration of pancreatic parenchyma, operative
pancreatography, ERCP or MRCP
• distal duct disruption → damage control involves distal pancreatectomy w splenic
preservation, otherwise preservation of the distal transected end w
pancreaticojejunostomy or pancreaticogastrostomy
• pancreatic duct in proximal edge should be individually ligated / stapled / glued
114
• Pancreatic head injuries
• identify whether intrapancreatic CBD disrupted by squeezing gallbladder
and looking for bile leakage from pancreatic wound or cholangiography via
cystic duct
• if CBD disruption → division of CBD superior to D1 w ligation of distal duct
and Roux-en-Y choledochojejunostomy
• if CBD intact but main pancreatic duct disruption → damage control
involves Whipple, otherwise central pancreatectomy to preserve CBD and
mobilize pancreatic body for posterior wall pancreaticogastrostomy or
Roux-en-Y pancreaticojejunostomy
• neither duct disrupted → drains placed 115
116
• Indications of Whipple:
• Transections of both intrapancreatic CBD and main pancreatic duct in
injuries of the pancreatic head
• Avulsions of papilla of Vater from duodenum
• Destruction of entire D2
• Pyloric exclusion to divert GI stream in high-risk, complex duodenal
repairs esp w adjacent pancreatic injuries
• If duodenal repair breaks down will form end fistula
• easier to manage and more likely to close than lateral fistula
• typically heals in 6-8wks w adequate drainage and control of intra-abd
sepsis
117
118
119
Complications and postop considerations:
• Delayed hemorrhage
• rare but may occur w pancreatic necrosis or abd infection
• managed by angioembolization
• Closed suction drains should remain in situ until pt tolerating enteral nutrition
• Pancreatic fistula
• 20% of pts w combined injuries
• diagnosed D5 postop if drain output > 30mL/d and drain amylase 3x serum amylase
• Duodenal fistula
• Pancreatic pseudocysts
• missed injury if managed nonoperatively, ERCP for evaluating integrity of pancreatic duct
• if late, may be complication of operative management
• Intra-abd abscesses → percutaneous drainage 120
Colon and rectum
Methods of repair of colonic injuries:
1. Primary repair
• All suturing and anastomoses performed using running single-layer technique
• Consider possibility of anastomotic leakage
• Patient selection is the dilemma → overall physiologic status rather than local
factors should aid in decision-making
• Safe and effective in virtually all patients w penetrating injuries
2. End colostomy
• Disadvantage is requiring 2nd op
• Devastating Lt colon injuries have 40% leak rate
3. Primary repair w diverting loop ileostomy
122
123
Methods of repair of rectal injuries:
1. Loop ileostomy
2. Loop sigmoid colostomy
• Preferred because quick and easy to perform and provides essentially
total fecal diversion
• Technical elements:
oAdequate mobilization so that tension-free
oMaintenance of the spur (common wall of proximal and distal limbs) above
level of skin using Penrose
oLongitudinal incision in taenia coli
oImmediate maturation in the OR
124
125
• Access to extraperitoneal injuries limited due to surrounding
bony pelvis, therefore indirect treatment w intestinal diversion
required
• If accessible, repair of injury should also be attempted
• If injury extensive → divide rectum at level of injury, oversew or
staple distal rectal pouch then end (Hartmann) colostomy
• Rarely, APR may be necessary to avert lethal pelvic sepsis
126
Complications and postop considerations:
• Intra-abd abscess
• 10% of patients
• Managed w percutaneous drainage
• Fecal fistula
• 1-3% of patients
• Majority will heal spontaneously w routine care
• Wound infection
• Stomal complications
• 5% of patients
• Include necrosis (may lead to necrotizing fasciitis of abd wall), stenosis, obstruction
and prolapse
• Osteomyelitis of adjacent bony structures
127

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Abdominal injuries.pdf

  • 1. ABDOMINAL INJURIES Presenter – Atiyya Hussein Supervisor – Dr. Ayesiga Herman
  • 2. Outline • Evaluation • Penetrating vs blunt trauma • Important CT findings • General principles of management • Prophylactic measures • Emergent abdominal exploration • Lethal triad • Damage control surgery • SICU care • Abdominal compartment syndrome • Management of specific injuries and their complications • Vascular injuries • Liver and extrahepatic biliary tract • Spleen • Stomach and small intestine • Duodenum and pancreas • Colon and rectum 2
  • 3. Evaluation • Diagnostic black box • What is necessary at the EMD is to determine whether patient will require ex-lap • Undisputed indications: • Abdominal rigidity • Hemodynamic instability 3
  • 4. Penetrating trauma • All anterior truncal GSWs btn 4th ICS and pubic symphysis that penetrate peritoneal cavity warrant ex-lap, EXCEPT trauma isolated to RUQ (where patients are hemodynamically stable and trajectory is confined to liver by CT) • If GSW thought to be tangential through subcutaneous tissues as in obese patients, options to exclude peritoneal violation include CT or laparoscopy • Possibility of transmitted intraperitoneal hollow visceral injury due to blast injury • Triple-contrast CT for GSWs to back or flank 4
  • 5. • Stab wounds less likely to injure intra-abd organs than GSWs • Anterior abd stab wounds from costal margin to inguinal ligament and bil mid-axillary lines should be explored under LA at the EMD to determine whether fascia violated • If no → no further evaluation necessary • If yes → options for further evaluation include: • Serial examination • Lab evaluation • DPL • CT 5
  • 6. • Remember occult injury to diaphragm • Penetrating Rt diaphragm injury may be ignored unless major liver injury w risk of biliopleural fistula • Laparoscopy or DPL for penetrating wounds to Lt lower chest to exclude diaphragmatic injury DPA positive if > 10ml of blood aspirated. If <10ml aspirated, then 1L is instilled and effluent withdrawn to be sent for lab evaluation. 6
  • 7. 7
  • 8. 8
  • 9. Blunt trauma • Initial evaluation by FAST has supplanted DPL • FAST not 100% sensitive, so DPA warranted in hemodynamically unstable patients without defined source of blood loss • FAST only sensitive for intraperitoneal fluid > 250ml, does not reliably determine source of hemorrhage or grade of solid organ injuries • If positive FAST without undisputed indications for ex-lap (peritonitis or hemodynamic instability) then proceed to CT • If free intraperitoneal fluid without solid organ injury, serial examinations to monitor for evolving peritonitis • If cannot (such as in head injuries) then DPL to exclude bowel injury 9
  • 10. 10
  • 11. 11
  • 12. 12
  • 13. Important CT findings: • AAST grading scale (will depend on features mentioned below) • Contrast extravasation, “blush” → active bleeding • Presence of pseudoaneurysms • Presence of AV fistulae • Amount of intra-abd hemorrhage or hemoperitoneum • Pneumoperitoneum 13
  • 14. • Lacerations – linear, stellate or branching hypodense areas within solid organs • Hematomas – oval or round-shaped if within the parenchyma of solid organs, crescent-shaped if subcapsular along the margins of solid organs • Contusions – vague, ill-defined hypodense areas with less perfusion • Devascularization (infarcts) • Bowel injury suggested by: • thickened bowel walls • “streaking” in the mesentery • free fluid without solid organ injury • free intraperitoneal air 14
  • 15. 15
  • 16. 16
  • 17. General principles of management Remarkable changes in the past 3 decades • Non-operative management of solid organ injuries has replaced routine operative exploration due to CT scans • Less radical resection techniques such as partial nephrectomy or splenorrhaphy encouraged where possible • Primary repair of colonic injuries encouraged where possible (continuous running single-layer advocated over double-layer) • Damage control surgical techniques • Abdominal drains no longer considered mandatory for parenchymal injuries and anastomoses; fluid collections may be managed percutaneously • Newer endovascular techniques (stenting, angioembolization) • Massive transfusion protocols 17
  • 18. Prophylactic measures • Pre-op antibiotics • Tetanus prophylaxis • LMWH if concurrent injuries to pelvis, lower extremities, head or spinal cord and if ligation of major abd veins, increased risk in morbidly obese pts and those > 55yrs • to be initiated only once bleeding in control and intracranial pathology is stable if present • add antiplatelets in high-risk pts • additional options are removable IVC filters and pulsatile compression stockings • Thermal protection (remember the lethal triad) • ambient temp, warm blankets, warmed IVF and blood products, heated inhalation via ventilatory circuit, arteriovenous rewarming if severe hypothermia (<30⁰C) 18
  • 19. Emergent abdominal exploration • Midline incision in adults vs transverse incision in children < 6yrs • Scalpel faster than diathermy • IGNORE incisional abd wall bleeding until intra-abdominal sources of hemorrhage controlled • Eviscerate bowel then use lap pads to evacuate liquid and clotted blood to identify source(s) of active bleeding • Blunt trauma → spleen and liver palpated first, packed if fractured, then inspect infracolic mesentery for zone I vascular injury • Penetrating trauma → pursue trajectory of penetrating device 19
  • 20. •If SBP < 70 upon opening, apply digital pressure (or clamp) on supraceliac aorta through hole in the lesser omentum • Direct digital occlusion for vascular injuries vs lap pad packing for solid organ injuries •Pringle maneuver if liver source of bleeding 20
  • 21. Most likely sources of bleeding in blunt trauma are LIVER, SPLEEN and MESENTERY 1. Perihepatic packing (above and below) 2. Rt paracolic gutter 3. Perisplenic packing (lateral and medial) 4. Lt paracolic gutter 5. Pelvis 21
  • 22. 22
  • 23. 23
  • 24. • Vascular injuries will require rapid exposure of intra-abd vasculature • Maneuvers for gaining access to the retroperitoneum 24
  • 25. Systematic exploration after hemorrhage control: 1. Infracolic compartment • run the gut from lig of Treitz to rectum (or vice versa) • special attention to post transverse colon, hepatic and splenic flexures • control spillage as you go 2. Supracolic compartment • liver and gallbladder • Rt and Lt kidneys • GEJ, stomach, duodenum (Kocher maneuver) • spleen • hemidiaphragms • open lesser sac for posterior aspect of stomach and pancreas 25
  • 26. 26
  • 27. • After identification of injuries, determine whether primary repair or damage control • Enteral access via gastrostomy or jejunostomy in polytrauma • Irrigation of abdomen w warm saline • Closure of fascia w running heavy absorbable suture if indication • Skin closure selective based on level of contamination 27
  • 28. 28
  • 29. Bloody vicious cycle a. k. a. LETHAL TRIAD 29
  • 30. Damage control surgery • Purpose is to limit operative time so as to allow physiologic restoration in the SICU and break the vicious cycle • Indications: • Refractory hypothermia (< 35⁰C) • Profound acidosis (arterial pH < 7.2 w base deficit < 15mmol/L) • Refractory coagulopathy • Decision may be made intraoperatively • 2 main goals: 1. CONTROL SURGICAL BLEEDING 2. LIMIT GI SPILLAGE • Temporary measures used to achieve these goals, w definitive repair delayed until pt physiologically replete (normalization of above indications) 30
  • 31. Controlling surgical bleeding • Aortic injuries → interposition PTFE graft • Celiac a. injuries → may be ligated but early insertion of intravascular shunt advocated as the SMA must maintain flow • Iliac and infrainguinal a. injuries → intravascular shunt, w delayed interposition graft placement • Venous injuries → ligation EXCEPT suprarenal IVC • Solid organ injuries → excision rather than operative repair for spleen or kidney, packing or balloon catheter tamponade for liver 31
  • 32. Limiting GI spillage • Small GI injuries → rapid whipstitch of 2-0 polypropylene • Complete transection or segmental damage → stapler w resection of injured segment, alternatively ligate open ends of bowel • Pancreatic injuries → pack, then delayed evaluation of duct integrity • Urologic injuries → catheter diversion 32
  • 33. 33
  • 34. • Temporary closure of abdomen using antimicrobial surgical incise drape: • allows closed suction to control reperfusion-related ascitic fluid collection • provides adequate space for bowel expansion to prevent abd compartment syndrome • allows continued assessment of bowel status and hemorrhage control 34
  • 35. 35
  • 36. SICU care • During shock resuscitation → Hb > 10 acceptable • After 1st 24hrs → transfusion trigger is Hb < 7, to limit adverse inflammatory effects of stored RBCs • Optimizing crystalloid loading challenging → to balance cardiac performance against generation of abdominal compartment syndrome and general tissue edema • Monitoring volume status (invasive vs non-invasive) • Inotropic support • Goals of resuscitation: • core temp > 35⁰C • base deficit < 6mmol/L • normal coagulation indices • normal lactate within 24hrs 36
  • 37. Abdominal compartment syndrome • Pathologic intra-abd HTN (i.e. sufficient to produce physiologic deterioration) due to: 1. Intra-abd injury → PRIMARY 2. Splanchnic reperfusion after massive resuscitation → SECONDARY • Sources of increased intra-abd pressure: • Bowel edema • Ascites • Bleeding • Packs • Diagnosis not clinical alone, requires measurement of intraperitoneal pressure via measurement of bladder pressure (unreliable if bladder rupture, external compression from pelvic packing, neurogenic bladder, adhesions) 37
  • 38. 38
  • 39. • No specific bladder pressure prompts therapeutic intervention, except when > 35mmHg • Therapeutic intervention only when end-organ dysfunction occurs, timing very important • Manifestations of end-organ sequelae: • Decreased urine output • Increased pulmonary inspiratory pressures • Decreased cardiac preload • Decreased cardiac output • Bedside laparotomy or percutaneous drainage 39
  • 40. 40
  • 41. • Even patients w an open abdomen can develop recurrent abd compartment syndrome, should monitor bladder pressure 4hrly to determine whether will require repeat operative decompression • Complications of open abdomen: • 500-2500ml of effluent lost in an open abdomen • Intra-abd abscess • Enteric fistulae • Perforations • Techniques of fascial closure: • Approximation w prosthetic or biologic mesh, planned reop later • Split-thickness skin grafts, then removal and hernia repair 9-12mo later • Sequential closure technique (every 48hrs) w wound VAC device causing constant fascial tension 41
  • 44. Principles of vascular repair • Initial control by direct digital pressure • Sharp dissection to mobilize sufficient length for proximal and distal control • Fogarty thromboembolectomy done proximally and distally to optimize collateral blood flow • Heparinized saline (50U/mL) injected proximally and distally to prevent small clot formation • Ragged edges debrided using sharp dissection • Intravascular shunts in damage control, or when arterial injury expected to require saphenous vein interposition reconstruction 44
  • 45. 45
  • 46. • Lateral suture repair → arterial and venous injuries w minimal tissue loss • End-to-end primary anastomosis → no tension, 1-2cm defects • bevelling allows larger lumen diameter to avoid postop stenosis • Interposition grafts → tension despite mobilization • autogenous options such as GSV, celiac and basilic veins preferred for <6mm diameter as synthetic options have greater rates of thrombosis • PTFE preferred over Dacron for larger arteries as decreased rates of infxn • venous injuries repaired w this method will ultimately undergo thrombosis in 1-2wks, but this is enough time for dev’t of adequate collateral circulation and will prevent acute venous HTN; may be used in injuries of suprarenal IVC and SMV • Transposition → when artery bifurcated and one branch can be safely ligated • iliac a. injuries where synthetic interposition grafts may pose a dilemma in the presence of enteric contamination 46
  • 47. 47
  • 48. Injuries to abd vasculature • Penetrating trauma indiscriminately affects all blood vessels • Blunt trauma most commonly affects renal vasculature and occasionally abd aorta • Arterial repair a MUST for injuries to aorta, superior mesenteric, proper hepatic, renal and iliac a. • Arteries that tolerate ligation include Rt/Lt hepatic a. and celiac trunk • Venous repair a MUST for injuries to suprarenal IVC and portal vein (may be ligated in extreme cases, limit bil LL edema by wrapping w elastic bandages and elevation) • SMV and Lt renal vein tolerate ligation, although repair is optimal as resultant bowel edema in the former will require aggressive fluid resuscitation and abd pressure monitoring 48
  • 49. • Vascular injuries will require rapid exposure of intra-abd vasculature • Maneuvers for gaining access to the retroperitoneum 49
  • 50. • Decide whether pt has supracolic or infracolic vascular injury • Supracolic injuries include aorta, celiac trunk, proximal SMA and Lt renal a. • Best approached using Lt-sided medial visceral rotation (Mattox maneuver) • Incision done along Lt line of Toldt at distal descending colon and extended along splenic flexure, posterior aspect of spleen, behind gastric fundus and ending at the esophagus in the diaphragmatic hiatus • May then cut Lt diaphragmatic crus laterally allowing blunt dissection around aorta and access to distal thoracic aorta as high as T6 w/o resorting to thoracotomy • Allows mobilization of Lt colon, spleen, pancreas and +/- Lt kidney 50
  • 51. 51
  • 52. • Access to SMA injuries depends on zone: • Fullen zone I – posterior to pancreas, accessed through Lt- sided medial visceral rotation • Fullen zone II – from pancreatic edge to middle colic branch, accessed through lesser sac along inferior edge of pancreas at the base of transverse mesocolon, may require division of pancreatic body • Fullen zone III and IV – accessed directly within mesentery 52
  • 53. Abd aorta • Pts w penetrating aortic injuries who survive to reach the OR will have contained hematoma within retroperitoneum • Blunt injuries are typically extensive intimal tears of infrarenal aorta w resultant thrombosis • Lack of mobility means few injuries amenable to primary repair • Supraceliac aortic injuries challenging as difficult to obtain proximal control • Options include 4-0 polypropylene suture or PTFE patches for small lateral perforations, otherwise PTFE interposition graft most common repair • Vascular suture lines should be covered w omentum to avoid vascular-enteric fistulas • SBP < 120mmHg for 72hrs post-op 53
  • 54. SMA • Often encountered in GSWs, blunt avulsions rare but should be considered in pts w seatbelt sign who have epigastric pain/tenderness and hypotension • “Black bowel” and supracolic hematoma pathognomonic • Damage control → Pruit-Inahara shunt • Definitive repair → RSVG interposition • No pancreatic injury – from proximal SMA to SMA past the point of injury • Associated pancreatic injury – distal aorta beneath duodenum to distal SMA • Temporary closure and 2nd look op to evaluate bowel viability 54
  • 55. • Venous injuries behind the pancreas, from the junction of SMV, splenic and portal veins accessed by dividing neck of pancreas • IVC injuries accessed through Rt-sided medial visceral rotation (3 steps): 1. Kocher maneuver – mobilizes duodenal loop and head of pancreas to visualize IVC and Rt renal hilum 2. Extended Kocher maneuver – mobilizes Rt colon to visualize infrahepatic IVC, Rt kidney and renal hilum as well as Rt iliac vessels 3. Super-extended Kocher maneuver (Cattel-Braasch maneuver) – incision carried around cecum and towards lig of Treitz to allow visualization of entire infracolic compartment including IVC, infrarenal aorta, D3, D4, superior mesenteric vessels as well as both renal and iliac vessels 55
  • 56. 56
  • 57. 57
  • 58. • Injuries to iliac vessels: • Proximal control at infrarenal aorta for arterial injuries • Tamponade by lap pads for venous injuries • May require complete vascular isolation • Rt common iliac a. obscures bifurcation of IVC and Rt common iliac vein, may require division for access followed by repair later 58
  • 59. 59
  • 60. Complications and postop considerations: • Follow-up imaging 1-2wks after injury to confirm healing • Routine graft surveillance rarely performed as long-term complications uncommon • Long-term administration of antiplatelets and antithrombotics unnecessary • Complications may include prosthetic graft infxns (perioperative antibiotics important), stenosis, pseudoaneurysms 60
  • 61. Liver and extrahepatic biliary tract injuries
  • 62. • Large size makes it most susceptible to blunt trauma and upper torso penetrating trauma • If hemodynamically stable + no overt peritonitis + no other indications for laparotomy → NON-OPERATIVE MANAGEMENT • ONLY CONTRAINDICATION is hemodynamic instability from intraperitoneal hemorrhage • Other factors such as high injury grade, large hemoperitoneum, contrast extravasation, or pseudoaneurysms ONLY PREDICT complications or failure of nonoperative management 62
  • 63. 63
  • 64. 64
  • 65. 65
  • 66. 66
  • 67. 67
  • 68. 68
  • 69. 69
  • 70. 70
  • 71. 71
  • 72. 72
  • 73. 73
  • 74. 74
  • 75. 75
  • 76. 76
  • 77. > GRADE II INJURIES: •Admit to SICU •Hemodynamic monitoring •Hemoglobin determination •Abdominal examination 77
  • 78. • Adjuncts to nonoperative management: • Angioembolization • ERCP • Primary goal in emergent laparotomy is to ARREST HEMORRHAGE • PUSH • PACK • PRINGLE (also helps delineate source of bleeding) • PLUG 78
  • 79. 79
  • 80. • Packing of Lt lobe not as effective as insufficient abdominal / thoracic wall anteriorly, PUSH better strategy • If PACK doesn’t work, injury to hepatic artery, portal vein and retrohepatic vasculature likely • PRINGLE will delineate source of bleeding as will halt bleeding from hepatic artery and portal vein BUT NOT hepatic veins and retrohepatic IVC • Intermittent release of PRINGLE helpful to attenuate hepatic cellular loss • Indication of PLUG is transfusion of 4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours attributable to the liver 80
  • 81. Portal triad vasculature • should repair proper hepatic artery (end-to-end if cleanly transected, otherwise temporary shunting followed by interposition RSVG) • might ligate right or left hepatic arteries in urgent situations (will result in lobar necrosis that will require delayed anatomic resection) • if right hepatic artery ligated then also cholecystectomy necessary • directed packing or Fogarty if blunt avulsion at hepatic plate (flush with liver) • pancreas must be transected to gain access for hemorrhage control if injury more proximal (retropancreatic) 81
  • 82. Hepatic vein or retrohepatic IVC injury • perihepatic packing • hepatic vein stent by interventional radiology • direct repair with or without hepatic vascular isolations – suprahepatic and infrahepatic clamping of the vena cava and stapled assisted parenchymal resection, temporary shunting of the retrohepatic vena cava, venovenous bypass 82
  • 84. Hepatic parenchymal hemorrhage (cont’d) • manual compression • electrocautery (100W) • suturing (blunt-tipped chromic 0) • running suture for shallow lacerations, interrupted horizontal mattress sutures for deeper lacerations • adequate tension is when visible hemorrhage ceases or liver blanches around suture (be cautious to avoid hepatic necrosis) • hepatic lobar arterial ligation • omentum can be used to fill large defects – obliterates dead space, excellent source of macrophages, buttressing support for parenchymal sutures • thrombin soaked gel foam sponge, fibrin glue 84
  • 85. 85
  • 86. Translobar penetrating injuries • intraparenchymal tamponade with Foley catheter, left inflated for 24-48hrs then sequential deflation and removal • hepatotomy w ligation of individual bleeders • angioembolization • liver transplants in extraordinary circumstances of hepatic necrosis 86
  • 87. Injuries of extrahepatic bile ducts • smaller injuries → T-tube or lateral suturing w 6-0 monofilament absorbable suture • significant tissue loss → Roux-en-Y choledochojejunostomy using single- layer interrupted technique with 5-0 monofilament absorbable suture, jejunum should be sutured to areolar tissue of hepatic pedicle or porta hepatis • stenting via ERCP • ligation of hepatic duct if opposite lobe normal and injured 87
  • 88. 88
  • 89. Complications and postop considerations: • ongoing hemorrhage (falling hemoglobin, accumulation of blood clots under the temporary abdominal closure device, bloody output from drains, ongoing hemodynamic instability) • hepatic ischemia due to prolonged intra-op use of Pringle maneuver (elevation of liver enzymes with subsequent resolution) and frank hepatic necrosis due to ligation of hepatic arteries 89
  • 90. • intermittent “liver fever” for first 5 days after injury • Bilomas • loculated collections of bile, may or may not be infected • should be treated by percutaneous drainage if infected • small, sterile bilomas are often reabsorbed, but larger collections should be drained 90
  • 91. • Biliary ascites due to disruption of major bile duct, will require reoperation and wide drainage • Pseudoaneurysms • develop because hemorrhage treated w/o ligating individual vessels • may rupture into a bile duct → hemobilia (RUQ, upper GI bleeding, jaundice), portal vein → portal venous HTN w bleeding oesophageal varices • best treated w hepatic arteriography and embolization • Biliovenous fistulas • cause jaundice due to rapid increases in serum bilirubin • treated by ERCP and sphincterotomy • Bronchobiliary or pleurobiliary fistulas • in associated diaphragmatic injuries • majority require operative closure due to pressure differential • endoscopic sphincterotomy w stent placement to equalize pressure differential, then fistula closes spontaneously 91
  • 93. 93
  • 94. 94
  • 95. 95
  • 96. 96
  • 97. 97
  • 98. 98
  • 99. 99
  • 100. 100
  • 101. • Splenectomy was considered mandatory for all patients in the 1970s • Nonoperative management currently the preferred means of splenic salvage due to recognition of its immune function • Selective angioembolization (SAE) warranted in high grade injuries, especially w contrast extravasation (risk factor for failure of nonoperative management) • Patient selection most important cause of failure of nonoperative management • Indications for early surgical intervention • initiation of blood transfusion within 1st 12hrs • hemodynamic instability • Delayed hemorrhage or rupture can occur up to WEEKS following injury unlike hepatic injuries where risk of rebleeding is within 1st 48hrs 101
  • 102. Surgical options: 1. Splenectomy – significant hilar injuries, pulverized splenic parenchyma, or any > grade II injury in pt w coagulopathy or multiple life-threatening injuries • May do autotransplantation of splenic implants in younger patients w/o enteric injuries 102
  • 103. 2. Partial splenectomy – when only superior or inferior pole injured • hemorrhage from raw splenic edge controlled w horizontal mattress sutures with gentle compression of parenchyma 3. Splenorrhaphy 103
  • 104. Complications and postop considerations: • Postop hemorrhage due to improperly ligated or unrecognized short gastric artery or from splenic parenchyma if was repaired • Postop sepsis • subphrenic abscess • OPSI due to encapsulated bacteria (require vaccination > 14d post-injury) • Pancreatic ascites or fistula due to iatrogenic injury to pancreatic tail • Gastric perforation due to short gastric artery ligation 104
  • 105. Stomach and small intestine
  • 106. • Gastric wounds can be repaired using running single-layer suture or stapler • If the former, FULL THICKNESS bites should be taken to ensure hemostasis • Most commonly missed gastric injuries: • posterior wound of a through-and-through penetrating injury • within mesentery of lesser curvature • high in the fundus • Can occlude the pylorus digitally and introduce methylene blue-coloured saline through NGT or air through NGT w abd filled w saline • Partial gastrectomy and Billroth reconstruction for destructive injuries, drainage procedures for injuries to the vagi 106
  • 107. •Small intestine injuries: • < 1/3 circumference of bowel → transverse running 3-0 PDS suture • > 1/3 circumference of bowel or multiple penetrating injuries → segmental resection and end-to-end anastomosis using continuous single-layer 3-0 polypropylene • Mesenteric injuries → resection mandatory as may result in ischemic segment of bowel 107
  • 108. Complications and postop considerations: • Postop ileus • Return of bowel function indicated by decrease in gastrostomy or NGT output • Nutritional issues • importance of early TEN in trauma pts, esp for reducing septic complications • route less important unless upper GIT pathology • should have evidence of bowel function before initiation as may lead to small bowel necrosis in pts recovering from profound shock • keep NPO for 48hrs in solid organ injuries if opted for nonoperative management • feasible even in open abdomen → higher fascial closure rates, decreased complications and decreased mortality in pts w/o bowel injury 108
  • 110. 110
  • 111. • Spectrum of injuries to duodenum: • hematomas • perforation • combined pancreaticoduodenal injuries • Majority of duodenal hematomas managed nonoperatively w NG suction and parenteral nutrition • If deteriorate clinically and retroperitoneal free air or contrast extravasation on imaging → suspect associated perforation • Resolution occurs within 2wks and indicated by drop in NGT output, if no improvement within 3wks then operative evaluation warranted 111
  • 112. • Small perforations repaired by running single-layer 3-0 monofilament • Close in a direction that will give largest residual lumen • Bigger tissue losses • D1 → debridement and end-to-end anastomosis as mobile and richer blood supply • D2 → defects “patched” w Roux-en-Y duodenojejunostomy as tethered to pancreas and end-to-end anastomosis will give unacceptably narrow lumen • D3 and D4 → resection, Roux-en-Y duodenojejunostomy and oversewing of distal duodenum 112
  • 113. 113
  • 114. • Pancreatic contusions (where ductal system intact) → nonoperative management or closed suction drainage if undergoing laparotomy for other indications • Proximal pancreatic injuries (to the Rt of superior mesenteric vessels) → closed suction drainage • Distal pancreatic injuries → will depend upon ductal integrity which is determined by direct exploration of pancreatic parenchyma, operative pancreatography, ERCP or MRCP • distal duct disruption → damage control involves distal pancreatectomy w splenic preservation, otherwise preservation of the distal transected end w pancreaticojejunostomy or pancreaticogastrostomy • pancreatic duct in proximal edge should be individually ligated / stapled / glued 114
  • 115. • Pancreatic head injuries • identify whether intrapancreatic CBD disrupted by squeezing gallbladder and looking for bile leakage from pancreatic wound or cholangiography via cystic duct • if CBD disruption → division of CBD superior to D1 w ligation of distal duct and Roux-en-Y choledochojejunostomy • if CBD intact but main pancreatic duct disruption → damage control involves Whipple, otherwise central pancreatectomy to preserve CBD and mobilize pancreatic body for posterior wall pancreaticogastrostomy or Roux-en-Y pancreaticojejunostomy • neither duct disrupted → drains placed 115
  • 116. 116
  • 117. • Indications of Whipple: • Transections of both intrapancreatic CBD and main pancreatic duct in injuries of the pancreatic head • Avulsions of papilla of Vater from duodenum • Destruction of entire D2 • Pyloric exclusion to divert GI stream in high-risk, complex duodenal repairs esp w adjacent pancreatic injuries • If duodenal repair breaks down will form end fistula • easier to manage and more likely to close than lateral fistula • typically heals in 6-8wks w adequate drainage and control of intra-abd sepsis 117
  • 118. 118
  • 119. 119
  • 120. Complications and postop considerations: • Delayed hemorrhage • rare but may occur w pancreatic necrosis or abd infection • managed by angioembolization • Closed suction drains should remain in situ until pt tolerating enteral nutrition • Pancreatic fistula • 20% of pts w combined injuries • diagnosed D5 postop if drain output > 30mL/d and drain amylase 3x serum amylase • Duodenal fistula • Pancreatic pseudocysts • missed injury if managed nonoperatively, ERCP for evaluating integrity of pancreatic duct • if late, may be complication of operative management • Intra-abd abscesses → percutaneous drainage 120
  • 122. Methods of repair of colonic injuries: 1. Primary repair • All suturing and anastomoses performed using running single-layer technique • Consider possibility of anastomotic leakage • Patient selection is the dilemma → overall physiologic status rather than local factors should aid in decision-making • Safe and effective in virtually all patients w penetrating injuries 2. End colostomy • Disadvantage is requiring 2nd op • Devastating Lt colon injuries have 40% leak rate 3. Primary repair w diverting loop ileostomy 122
  • 123. 123
  • 124. Methods of repair of rectal injuries: 1. Loop ileostomy 2. Loop sigmoid colostomy • Preferred because quick and easy to perform and provides essentially total fecal diversion • Technical elements: oAdequate mobilization so that tension-free oMaintenance of the spur (common wall of proximal and distal limbs) above level of skin using Penrose oLongitudinal incision in taenia coli oImmediate maturation in the OR 124
  • 125. 125
  • 126. • Access to extraperitoneal injuries limited due to surrounding bony pelvis, therefore indirect treatment w intestinal diversion required • If accessible, repair of injury should also be attempted • If injury extensive → divide rectum at level of injury, oversew or staple distal rectal pouch then end (Hartmann) colostomy • Rarely, APR may be necessary to avert lethal pelvic sepsis 126
  • 127. Complications and postop considerations: • Intra-abd abscess • 10% of patients • Managed w percutaneous drainage • Fecal fistula • 1-3% of patients • Majority will heal spontaneously w routine care • Wound infection • Stomal complications • 5% of patients • Include necrosis (may lead to necrotizing fasciitis of abd wall), stenosis, obstruction and prolapse • Osteomyelitis of adjacent bony structures 127