1. Abdominal trauma can involve different regions including the anterior abdomen, thoracoabdominal area, flanks, and back. Blunt abdominal trauma is more difficult to diagnose than penetrating trauma and can involve multiple organs. 2. Evaluation of abdominal trauma involves primary and secondary surveys including history, physical exam, diagnostic tests like FAST, CT scans, and exploratory laparotomy if indicated. Common solid organ injuries are to the spleen and liver while the small intestine is the most common hollow viscus injury. 3. Management depends on the specific organ injured and includes non-operative management, angiographic embolization, splenectomy, splenorrhaphy, small bowel resection, and repair of

2. ABDOMINAL TRAUMA
Dr. Mian Muhammad Saad Iqbal
PGR Surgery DHQ Teaching Hospital Sahiwal

3. Regions to consider in abdominal Trauma
Anterior abdomen
— Between the anterior axillary lines; bound by the costal margin superiorly and
the groin crease distally.
Thoracoabdominal area
The area superiorly delimited by the fourth intercostal space (anterior), sixth intercostal
space (lateral), and eighth intercostal space (posterior), and inferiorly delimited by the
costal margin (definitions vary — a pragmatic approach is to use the nipple line as the
upper boundary… in non-obese men at least!). Injuries in the region increase the
likelihood of chest, mediastinal, and diaphragmatic injuries.

4. •Flanks
— From the inferior costal margin superiorly to the iliac crests; bound anteriorly by the anterior axillary
line and posteriorly by the posterior axillary line.
•Back
— Between the posterior axillary lines extending from the costal margin to the iliac crests.

8. Blunt Abdominal Trauma
 “A force to the abdomen that doesn't leave an open wound.”
 Greater mortality than PAT (more difficult to diagnose, commonly
associated with trauma to multiple organs/systems.
 Solid organ injury >> Hollow viscus injury
 Solid Organs: Spleen > Liver, Intestine is the most likely hollow viscus.
 MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%).

9. Pathophysiology Of Blunt Trauma
 Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures.
 Crushing Injury(Solid Organs more Vulnerable )
 Acceleration and deceleration forces → shear injury(liver And Spleen Laceration at the
site of Supporting Ligaments)
 Seat belt injuries
“Seat belt sign” = highly correlated with intraperitoneal injury.

11. Pattern of Injury in Blunt Abdominal
Trauma

12. Penetrating Trauma
 Stabbing 3x more common than firearm wounds.
 Gun shot wound cause 90% of the deaths.
 Small intestine > colon > liver

13. Pathophysiology Of Penetrating Trauma
Stab Wounds
 Knives, ice picks, pens, coat hangers, broken bottles
 Liver, small bowel, spleen
Gunshot wounds
 Small bowel, colon and liver
 Often multiple organ injuries,
 Bowel perforations

14. Primary Survey –ATLS approach
 ABCDE pattern: Airway, Breathing, Circulation, Disability (neurologic status), and
Exposure.
 A - intubation may be required if patient is shocked, hypotensive or unconscious or
in need for ventilation. *with cervical precaution.
 B - watch for hemothorax in both blunt and penetrating thoracoabdominal injuries.
 C - start with 2 L crystalloid (If active bleeding you must find source and stop the
bleeding)
 D – May seen associated with thoracolumbar Fracture.
 E -Watch for other injury

15. Diagnostic
and
treatment
priorities

16. Estimation of Blood Loss

17. Secondary Survey History
 History for all trauma patients:
 It doesn't necessarily making an accurate diagnosis
S.A.M.P.L.E
 S: Symptoms: pain, vomiting, hematuria, hematochezia,dyspnea,respiratory distress…
 A: Allergies
 M : Medications
 L : Last meals
 E : Events (mechanism of injury)

18. Physical Examination
Inspection: abrasions, contusions, lacerations, deformity, entrance and exit
wounds to determine path of injury(Grey-Turner, Kehr, Balance, Cullen, seat belt
sign….)
Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle
guarding
 Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air;
dullness with hemoperitoneum.
Auscultation: bowel sounds may be decreased(late finding).

19. • Grey-Turner sign: Bluish discoloration of lower flanks, lower back;
associated with retroperitoneal bleeding of pancreas, kidney, or pelvic
fracture.
• Cullen sign: Bluish discoloration around umbilicus, indicates peritoneal
bleeding, often pancreatic hemorrhage.
• Kehr sign: shoulder pain while supine; caused by diaphragmatic irritation
(splenic injury, free air, intra-abdominal bleeding)
• Balance sign: Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.

20. Cullen Sign Kuhr Sign Balance Sign
Grey Turner Sign

21. INVESTIGATIONS
• Plain x-rays chest, abdomen,and pelvis.
• FAST
• Diagnostic peritoneal lavage – Aspiration
• Local Wound Exploration
• Contrast studies, CT scan.
• Urethro-Cysto-graphy
• IVU
• Angiography

22. Plain radiographs
Air under diaphragmLower Ribs Facture
Diaphragmatic Hernia

23. FAST
Rapid, accurate, non invasive, inexpensive study and Operator
dependent.
 It Views
1. Pericardium (subxiphoid)
2. Perihepatic &hepatorenal space (morrison’s pouch)
3. Perisplenic
4. Pelvis (pouch of Douglas /rectovesical pouch)
 Suprapubic view (Transverse; before inserting folleys)Sensitivity 60 to
95% for detecting 100 mL - 500 mL of fluid. The larger the
hemoperitoneum, the higher the sensitivity. So sensitivity increases
for clinically significant hemoperitoneum.
 FAST has a low sensitivity (29–35%) for organ injury without
haemoperitoneum. FAST is also unreliable for excluding injury in
penetrating trauma. If there is doubt, the FAST examination can be
repeated.

25. Diagnostic peritoneal Lavage/Tap
DPA - The recovery of 10 cc of frank blood (or more) from the peritoneum is a strong
predictor (90% PPV in blunt trauma) of intraperitoneal injury, and the procedure is then
terminated.
DPL - If aspiration findings are negative, lavage is conducted in which the
peritoneal cavity is washed with saline. RBC count exceeding 100,000/cc
is considered positive and generally specific for injury. Sensitivity 90%.
Method:
A cannula is inserted below the umbilicus, directed caudally and posteriorly. The
cannula is aspirated for blood (>10 mL is deemed as positive) and, following this, 1000
mL of warmed Ringer’s lactate solution is allowed to run into the abdomen and is then
drained out via the same route.

28. Is there still a role for DPA?
FAST has largely replaced DPA, likely due to ease of use.
However, 2 areas where still is warranted:
◦ Hemodynamically unstable and an equivocal FAST
◦ No FAST available
“DPL is safe, sensitive, and reduces the use of CT” (Journal of Trauma 2007)
DPL is especially useful in the hypotensive, unstable patient with multiple injuries as
a means of excluding intra-abdominal bleeding.

29. Local Wound Exploration
• To determine the depth of penetration in stab wounds
• If peritoneum is violated, must do more diagnostics
• Prep, extend wound, carefully examine (No blind probing)
• Indicated for anterior abdominal stab wounds, less clear for other
areas

30. CT Scan
• CT has become the ‘gold standard’ for the intra-abdominal diagnosis of injury in the
stable patient. The scan can be performed using intravenous contrast. CT is sensitive for
blood and individual organ injury, as well as for retroperitoneal injury. An entirely normal
abdominal CT is usually sufficient to exclude intraperitoneal injury.
Indications:
• Blunt trauma
• Hemodynamically stable patient
• Normal or unreliable physical examination
Contraindications
• Clear indication for exploratory laparotomy
• Hemodynamically unstable patient
• Contrast allergic patient

32. Most useful to evaluate penetrating wounds to thoracoabdominal
region in stable patient
 especially for diaphragm injury: Sensitivity 87.5%, specificity 100%.
 Can repair organs via the laparoscope.
• diaphragm, solid viscera, stomach, small bowel.
Disadvantage:
• Poor sensitivity for hollow visceral injury, retroperitoneum
When used in this role laparoscopy reduces the non-therapeutic laparotomy
rate. There is no place for laparoscopy in the unstable patient.
Laparoscopy

33. Which patients need Laparotomy ?
• Blunt abdominal trauma with hypotension with a positive FAST or clinical evidence
of intraperitoneal bleeding.
• Blunt or penetrating abdominal trauma with a positive DPL.
• Hypotension with a penetrating abdominal wound.
• Gunshot wounds traversing the peritoneal cavity or visceral/vascular
retroperitoneum.
• Bleeding from the stomach, rectum, or genitourinary tract from penetrating trauma
• Peritonitis
• Free air, retroperitoneal air, or rupture of the hemidiaphragm
• CECT findings of ruptured GIT, intraperitoneal bladder injury, renal pedicle injury,
or severe visceral parenchymal injury after blunt or penetrating trauma

34. Evaluation of Penetrating Trauma

35. Evaluation of Blunt Trauma

36. 1. Incision. Generous midline incision is preferred. Self retaining retractor systems and headlights
are invaluable.
2. Bleeding control. Scoop-free blood and rapidly pack all quadrants
3. If packing does not control a bleeding site, this source must be controlled as the first priority.
4. Contamination control. Quickly control bowel content contamination.
5. Systematic exploration. Systematically explore the entire abdomen, giving priority to areas of
ongoing hemorrhage
A. Liver B. Spleen C. Stomach
D. Right colon, transverse colon, descending colon, sigmoid
colon, rectum, and small bowel, from ligament of Treitz to terminal ileum, looking at the entire
bowel wall and the mesentery.
E. Pancreas, by opening lesser sac (visualize and palpate).
F. Kocher maneuver to visualize the duodenum, with evidence of possible injury
G. Left and right hemidiaphragms and retroperitoneum.
H. Pelvic structures, including the bladder.
I. With penetrating injuries, exploration should focus on following the track of the weapon or
missile.
6. Injury repair.
7. Closure.
Exploratory Laprotomy

37. Specific Organ
Injuries
1.Peritoneal
2.Retroperitoneal
3.Diaphragm
Treatment of an organ injury is similar whether the injury mechanism is penetrating or
blunt
• An exception to the rule is a retroperitoneal hematoma. Explore all retroperitoneal
hematomas caused by penetrating injury.

38. Spleen
Until the 1970s, splenectomy was considered mandatory for all splenic injuries. Recognition of the
immune function of the spleen refocused efforts on operative splenic salvage in the 1980s.
Management options
• Observation
• Angiographic Embolization (Gd I-III; age < 55y)
• Surgery (Splenectomy/ partial splenectomy/ splenorrhaphy)
 Depending upon
• Hemodynamic status of patient.
• Grade of injury.
• Presence of other injuries.
• Medical co-morbidities.
 Upto 20% patients require early splenectomy.
 Delayed hemorrhage/ rupture can occur weeks after injury

39. Grades Of Splenic Injury
Subcapsular Hematoma Laceration

40. • Hemodynamic stability
• Negative abdominal examination
• Absence of contrast extravasation on CT
• Absence of other clear indication for exploratory laparatomy or
associated injuries requiring a surgical intervention
• Absence of associated health condition that carry an increased risk of
bleeding(coagulopathy, hepatic failure, use of anti coagulant, specific
coagulation factor deficiency)
• Grade 1-3 injury
 > 70 % patients still undergo splenectomy after NOM.
 Higher failure rates of NOM with increasing grades of
Severity.
Criteria for Non Operative Management

41. • Absolute bed rest & NPO
• 6 hourly Hb check in first 24h
• Allowed orally if Hb stable & no surgical intervention likely
• Follow-up CT: Falling Hb, abdominal pain, fever, Lt shoulder pain
• Duration based on
1. Grade of splenic injury
2. Nature & severity of other injuries
3. Clinical Status (Incl peritoneal signs – missed hollow viscus
injury & Hb levels)
• Embolization – 73-97% success rate
Management

42.  Splenectomy (with auto-transplantation)
• Hilar injuries
• Pulverized splenic parenchyma
• GD III and above + coagulopathy/ multiple injuries
 In patients undergoing splenectomy, prophylaxis against Meningococcus,
Pneumococcus, HIb bacteria is provided via vaccines administered optimally at 14
days.
Partial splenectomy – isolated polar injuries
 Splenorrhaphy
Cautery, argon beam coagulator, gelfoam, fibrin glue, collagen, envelopment in absorbable
mesh, pledgeted suture repair
 Bleeding edges – Horizontal mattress sutures + parenchymal
compression
Operative Management

43. Splenic Auto transplantation

45. Its possible in injuries to the thoracoabdominal region.
Can be due to blunt(>85%) or penetrating injury and is larger in the blunt
Possible cardiac injury if the penetrating wound is more central
The weakest point of diaphragm is the left posteriorlateral(80%)
Often missed in polytrauma
In isolated injury it may go unnoticed and there is often a delay between the injury and
the diagnosis
Patients present with non specific symptoms and may complain of chest pain,
abdominal pain, dyspnea, tachypnea and cough.
Rupture with herniation is diagnosed by CXR or CT but without herniation is difficult to
diagnose.
Thoracoscopy or laparascopy is diagnostic.
Diaphragmatic injury

46. Once identified must be repaired because it will not close spontaneously regardless
the size.
Early diagnosis needs abdominal approach using the interrupted nonabsorbable
suture and the large defect(>25cm2) may need nonabsorbable mesh.
In the event of a gross contamination, endogenous tissue can be utilized for a
definitive repair as latissimus dorsi flap, tensor fascia lata or omentum.
There are some who advocate using biologic tissue grafts, such as AlloDerm(human
acellular tissue matrix).The durability of such a repair is questionable.
Place chest tube on the surgery side at the time of repair
Treatment

47. Most stomach injuries are caused by penetrating trauma while The small bowel is
frequently injured as a result of blunt trauma.
Surgical repair is required but great care must be taken to examine the stomach fully,
as an injury to the front of the stomach can be expected to have an ‘exit’ wound
elsewhere on the organ.
 Gastric Wounds – running single layer suture (full
thickness bites)/ stapler
 Partial gastrectomy – for destructive injuries
 Small intestine injury < 1/3rd of bowel circumference transverse running 3-0
PDS
 Multiple injuries/ mesenteric injuries – segmental
resection and anastomosis/ stoma
• Post-op ileus is obligatory
• No enteral feeds for atleast 48 hrs if managing conservatively.
Stomach & Small Intestine

48. For Stomach
• FAST examination:-
unreliable
• DPL: WBC, RBC < Gross
contamination
• CT scan:
pneumoperitoneum
• Laparoscopy:-operator
dependent

49.  Duodenal hematoma – NG aspiration & parenteral
nutrition
 Small duodenal perforation/ laceration – primary single
layer repair
 1st part injuries – debridement & end-to end anastomosis with gastric
antrum/ pylorus
 2nd part injuries – patch with vascularized jejunal graft.
 Injuries b/w Ampulla of vater and SMA- Roux-en-Y
Duodenojujonostomy
 Distal 3rd & 4th part injuries – resection and anastomosis(
Duodenojuonostomy) on Lt side of Superior mesenteric vessels.
 Pyloric exclusion – high risk, complex duodenal repairs
Duodenum

51. Most pancreatic injury occurs as a result of blunt trauma. The major problem is that of
diagnosis, because the pancreas is a retroperitoneal organ. CT remains the mainstay of
accurate diagnosis. Amylase or lipase estimation is insensitive. In penetrating trauma, injury
may only be detected during laparotomy.
Management depends on location of injury to
1. Parenchyma
2. Intrapancreatic CBD
3. MPD
 Contusion (ductal system intact)/ proximal pancreatic injuries (to Rt of SM
vessels)--Non operative/ closed suction drain.
 Distal duct disruption (body & tail) to left of SMA – distal pancreatectomy
with splenic preservation.
 Injury to Head with duct injury – distal duct ligation with Roux-en-Y
choledochojejunostomy.
Pancreas

53.  Primary aim is to arrest bleeding.
 Perihepatic packing is effective most of the times, if
not then perform Pringle maneuver
 Difficult to perform perihepatic packing in Lt lobe Mobilize it and
compress between surgeon’s hands
 Pringle maneuver
• Bleeding stopped => from HA / PV.
• Doesn’t stop => HVs and retrohepatic IVC is the source>Packing
done>Failed>direct vascular repair ± hepatic vascular Isolation.
 Repair the Hepatic artery proper.
 Cholecystectomy if Rt hepatic artery is ligated.
Liver trauma

54. Grades of Liver trauma

56.  Minor lacerations
• Manual compression
• Topical hemostats (cautery, argon beam coagulator, gelfoam, fibrin glue, collagen)
 Shallow lacerations >>> Running PDS suture
 Deep lacerations
• Interrupted Horizontal mattress parallel to edge of laceration
• Omentum to fill large defects (obliterates dead space; source of macrophages)
• Deep recalcitrant hemorrhage>>hepatic lobar arterial ligation.

57. • Repeat laparotomy within 24 hrs for pack removal
• Ongoing hemorrhage – early exploration (<24h h)
• Complex injuries – angioembolization
• Complex injuries – typical ‘liver fever’ upto 5 days post injury.
• Non-anatomical resection – stable without coagulopathy
• GB injury--cholecystectomy
• EHBD Transaction with significant tissue loss>>Roux-en-Y
choledochojejunostomy
• Till then intubate the duct for external drainage
Complications:
Hemorrhage, hepatic necrosis, bilomas,
arterial pseudoaneurysms and biliary fistulas.

58. Basis
• 50-80% of liver bleed stops spontaneously
• Better results of NOM in children
• Significant development of CT scan in liver imaging
 Initially introduced for minor injuries (1972)
 Presently being used for grades III – V also.
Selection criteria
• Hemodynamic stability after initial resuscitation
• No other visceral/ retroperitoneal injuries needing surgery
• Multidisciplinary team – Experienced surgeon, Intensivist, CT scan, 24x7 OT facilities
 Failure rate significantly higher in Grade IV & V than Grade I to III.
 Most common reason for intervention – co-existing abdominal injury (e.g. bleed form spleen or
kidney).
Non Operative Management

59. Predictors of NOM failure
• Advanced age
• Anaemia & HTN
• Active extravasation on CT
• Massive blood transfusion
 CT follow up for Gd I & II not necessary
 Others need clinical and CT follow up

60.  3 methods for colonic injuries
1. Primary repair
2. End colostomy
3. Primary repair with diverting colostomy
Weigh the risk of primary repair Vs colostomy
 Lt colon injuries - Temporary colostomy
 Other high risk pts - Diverting ileostomy with colocolostomy
 Rectal injuries – loop ileostomy/ sigmoid loop colostomy
 Accessible rectal injury – attempt primary repair with diversion
 Extensive rectal injury – End colostomy (Hartmann’s)
Complications:
Intra-abdominal abscess, fecal fistula, infection,stomal complications
Colon & Rectum

61. Injury to the retroperitoneum is often difficult to diagnose, especially in the presence of other injury,
when the signs may be masked. Diagnostic tests (such as ultrasound and DPL) may be negative. The
best diagnostic modality is CT, but this requires a physiologically stable patient. The retroperitoneum
is divided into three zones for the purposes of intraoperative management:
In Blunt Trauma
Zone 1 (central): central haematomas should always be explored, once proximal and distal
vascular control has been obtained.
Zone 2 (lateral): lateral haematomas should only be explored if they are expanding or pulsatile.
They are usually renal in origin and can be managed non-operatively, though they may sometimes
require angioembolisation.
Zone 3 (pelvic): as with zone 2, these should only be explored if they are expanding or pulsatile.
Pelvic haematomas are exceptionally difficult to control and, whenever possible, should not be
opened; they are best controlled with compression or extraperitoneal packing, and if the bleeding is
arterial in origin, with angioembolisation.
In penetrating trauma, every injury should be explored for damage to structures along the
wound track (e.g. ureter), unless preoperative investigation allows non-surgical management of the
injury.
Retroperitonial Hematomas

62. Zones of Retroperitoneum

63.  90 % Renal injuries managed conservatively
• Hematuria resolves in few days with absolute rest
Operative intervention – Hypotension due to
• Renovascular injuries
• Destructive parenchymal injuries
 Persistent gross hematuria – embolization
 Urinoma – Percutaneous drainage
 Renal artery repair
• Success rates very low
• Image guided endostent placement can be attempted.
Renorrhaphy
• Take vascular control for proper visualization
• Preserve renal capsule
• Collecting system is closed separately with absorbable sutures.
• Preserved capsule is closed over collecting system repair
Genitourinary Tract

64. Ureter injuries:
• Primary repair with renal mobilization for tension relief.
• Reimplantation (with psoas hitch) for distal ureter injuries.
• Damage control – B/L ligation + Nephrostomy.

65. Bladder injuries
 Intraperitoneal injuries
• Running, single layer 3-0 absorbable monofilament suture
• Lap repair – if other injuries not needing repair
 Extraperitoneal injuries
• NOM with bladder decompression for 2 weeks
Urethral injuries
• Bridge the defect with Foley’s
• Elective repair for strictures later