1) Abdominal trauma is a major cause of death globally, especially in young adults, due to injuries from motor vehicle accidents. The abdomen has no bony protection and is vulnerable to hemorrhage from solid organs or sepsis from hollow viscus injuries. 2) Evaluation of abdominal trauma involves history, physical exam, focused assessment with sonography for trauma (FAST), and CT scan if stable. Unstable patients may require diagnostic peritoneal lavage or immediate exploratory laparotomy. 3) Management depends on injury type and hemodynamic stability. Nonoperative management is preferred for solid organ injuries while laparotomy is often needed for penetrating injuries or hemodynamically unstable patients to control bleeding.

1. Abdominal Trauma
D IA GN OSIS & MA N A GEMEN T
MODERATOR:
Dr Shekappa C M
PRESENTOR:
Dr Vinayaka S B
DEPT OF GENERAL SURGERY
VIMS Ballari

2. Introduction
• Approx 10 000 people/day die Globally, due to trauma.
• Most of them are Young Adults
• Major burden of injury increasing (adoption of motorised transportation)
• 39% of all trauma deaths are due to major hemorrhage from torso injury
• The abdominal cavity and intra abdominal organs are vulnerable due to no protection
of any bony cage

3. • Mechanism + Patient =
Injury
• Timeline Trauma
System
• Primary Survey: cABC
• Secondary Survey:
MIST, AMPLE, head to
Toe examination
General Trauma
Principles
• Trauma Mechanisms
• Clinical Presentation
• Investigations
• Management
Abdominal Trauma in
General
• Solid Organs
• Hallow Viscus
• Vascular
Specific Organ
Injuries
“injury does not respect anatomical boundaries”

4. Trauma Mechanisms
•Blunt Trauma:
› E.g. RTAs, Fall, Assault
› Can cause (1) Localized injury (direct impact) or (2) Distant injury
(pressure transmission/ indirect impact)
› Common & difficult diagnose
•Penetrating Injury
› By sharp objects: depends on physical properties of object
› By firearms: depends on velocity… (high: lateral effect; low: like sharp
objects injury)

5. Mechanisms: Involvement of Organs
Direct Injury: respective
regional organ injuries occur
Indirect Injury: shearing points & adjacent
organs laceration occur

6. Pathophysiology
• Abdominal trauma leads to
› Hemorrhage
Due to major vascular injury: immediate death;
Due to solid organ injury: early death
› Sepsis
Due to hallow viscus injury: late death

7. Clinical Approach
•History:
› Mode of injury, Time
•Physical Examination:
› Vitals: Pulse-tachycardia, BP-hypotension
› External wounds: abrasions, ecchymosis, lacerations/ peritoneal
breach, evisceration
› Abdominal tenderness, guarding/ rigidity
› Abdominal distension, shifting dullness, bowel sounds (+/-)
› Bleeding PR,
› External genitalia: hematoma, blood at meatus

8. Immediate Management
•Resuscitation:
› Securing wide bore IV cannula, collection of blood sample for Hb, PCV, Blood
Grouping & Cross Matching
› 250 mL of O-Negative blood or Normal saline IV bolus to achieve palpable radial
pulse
› Inj. Tranexamic acid: 1 g IV over 10 minutes, followed by a further 1 g over 8
hours. Should be given within 3 hours of injury
› Minimize mobilization of patient
› Retained foreign bodies in abdominal wall: maintain and avoid excessive movement;
removed only after defining a definitive plan, i.e. surgery
•Monitor:
› Pulse, BP (target SBP 90 mm of Hg),
› Urine output (if needed catheterization), Mental Status (anxiety/ lethargy)
› Abdominal girth monitoring & Ryle’s tube if needed

9. After Resuscitation…..
• Patients are categorized based on their physiological condition after initial
resuscitation:
i. Hemodynamically ‘normal’ –
› investigation can be completed before treatment is planned;
ii. Hemodynamically ‘stable’ –
› investigation is more limited.
› It is aimed at establishing whether the patient can be managed non-
operatively/ angioembolisation or surgery is required;
iii. Hemodynamically ‘unstable’ –
› investigations need to be suspended
› immediate surgical correction of the bleeding is required.

10. Investigations
• Plain Radiographs:
i. Abdominal X-ray:
› Pneumoperitoneum, ground glass appearance – massive hemoperitoneum
› In penetrating injury, detection of trajectory by using external wound metal
markers
i. Chest X-ray:
› Pneumo – hemothorax,
› Raised hemidiaphragm & lower ribs # ---> liver, spleen injury
› Abdominal contents in chest ---> ruptured diaphragm

11. Focused Assessment with Sonar for Trauma (FAST)
• Assess the torso for the presence of
1. Free fluid,
2. Solid organ laceration.
• Assess four areas
1. Perihepatic
2. Perisplenic
3. Pericardium
4. Pelvis
• Patient in Supine position
• USG probe: 3.5 – 5.0 MHz Convex

12. •Disadvantages (FAST)
› To detect, >100 mL of free blood to be present
› Very operator dependent
› In obese or the bowel is full of gas, it may be unreliable.
› Hollow viscus injury and solid organ injury are difficult to diagnose,
› Unreliable for penetrating injury and retroperitoneal organ injuries.

13. Diagnostic Peritoneal Lavage
• To assess the
presence of
› blood or
› contaminants
in the abdomen
• Replaced by
eFAST.
• Useful in the
hypotensive,
unstable patient with
multiple injuries

14. •DPL positive when
› Initial cannula aspiration of blood >10 mL
› The presence of >100 000 red cells/μL
› >500 white cells/μL (this is equivalent to 20 mL of free blood in the abdominal
cavity),
› presence of vegetable fibre
› a raised amylase level.
•In penetrating trauma, a minimum of 1/10th of the above would be regarded
as evidence of peritoneal penetration or intraperitoneal injury.

15. Computed Tomography Scan
• ‘Gold Standard’
• Performed using IV contrast
• The following points are important when performing CT:
› it remains an inappropriate investigation for unstable patients;
› timed to capture the portal venous phase, which best demonstrates the perfusion of
the solid abdominal organs.
› if duodenal injury is suspected from the mechanism of injury, oral contrast may be
helpful;
› if rectal and distal colonic injury is suspected in the absence of blood on rectal
examination, rectal contrast may be helpful.

16. • Advantages (CT Abdomen):
› Sensitive for blood and individual organ injury, as well as for retroperitoneal injury (3D
imaging capability)
› Normal abdominal CT is sufficient to exclude intraperitoneal injury.
› Evolution of the nonoperative management in case of solid organ injury
(determination of injury severity, presence of active bleeding)
• Disadvantages:
› CT is less capable of detecting injuries to the hollow viscera.

17. Management: Blunt Trauma
Abdominal Examination
Peritonitis
Abdominal CT Scan
Hallow Viscus
Injury
Solid Organ Injury
Free Intra-
abdominal Fluid
Exploratory
Laparotomy
Non Operative
Management
Grade 4 – 5,
Hemodynamically
unstable,
Serial abdominal
exams
Monitor vital signs
Repeat laboratory
tests
Yes
Yes
Yes
No
No

18. Management: Penetrating Trauma
• Local wound exploration:
› No fascial penetration ---> considered for
discharge.
› Possible fascial penetration --->
monitored with serial abdominal
examinations and laboratory studies.
› Patients without clinical change after 24
hours ---> a diet instituted and be
considered for discharge.
› Penetrating wounds to posterior to the
midaxillary lines and the back (bcoz of
thickness)---> imaging with CT.
• Gunshot Injuries:
› high rate of intra-abdominal injury
› often taken immediately to laparotomy.

19. DCS v/s ETC
• Early total care (ETC): definitive management of injuries within 36 hours of
injury after a period of initial resuscitation.
› facilitates nursing care,
› allows early mobilization of the patient
› reduces pulmonary complications and length of stay on intensive care.
• Damage control surgery (DCS): simultaneous resuscitation with early rapid
life surgery AND avoiding second hit by deferring definitive repair
• It has only two goals:
› stopping any active surgical bleeding;
› controlling any contamination.

20. Damage Control Surgery
Indications
Stages

21. Trauma Laparotomy
• Primary Objectives including
› Control of hemorrhage,
› Control of contamination from the gastrointestinal tract,
› Identification of all injuries
› Definitive repair or damage control management of identified injuries.
› Indications
› Hemodynamic instability,
› Peritonitis,
› Evisceration,
› Positive or questionable radiographic findings of organ injury,
› A positive diagnostic peritoneal tap (or lavage),
› A persistent fall in hematocrit.
› A gunshot wound

22. • Preparation
› 2 large-bore intravenous access (+ ABG,
PT/aPTT/INR)
› Foley catheter & Ryle’s tube placement
› obtaining blood products,
› temperature control of the room and the patient,
› the administration of perioperative antibiotics.
• Positioning
› supine position with arms fully abducted at a 90°
angle
› Prepping from chin to knees, posterior axillary line
› Surgeon have access to the neck, chest, abdomen,
bilateral groins
Contd…

23. • Gaining Access to the Peritoneum
• a midline incision from xiphoid to pubis.
› enter the abdomen quickly
› wide exposure
› easily be extended
› Sometimes, Sudden decompression occurs after
opening of abdomen because of release of tamponade..
Anaesthesiologist should be well aware of it.
Contd…

24. • Hemostasis and Control of Contamination
› two pooled suction catheters are utilized to rapidly
evacuate blood from the peritoneum.
› The bowel is then eviscerated and hemorrhage
control or directed packing is performed.
› Likely sources of bleeding are bowel mesentery,
solid organs, or the great blood vessels.
› Pause _ _ _ assess
› Specific repair or damage control
Contd…

25. • Exploring the Peritoneal Cavity
• Zones I, II, and III of the retroperitoneum
Contd…

26. • The anterior aspect of the stomach is examined
in its entirety from the gastroesophageal junction
to the pylorus.
• The lesser sac is then opened by dividing the
gastrocolic omentum, and the posterior aspect of
the stomach and the anterior aspect of the
pancreas are inspected.
Contd…

27. •The bowel is inspected in a
methodical fashion,
• DJ junction ---> IC junction --->
rectum
• examining the circumference of
the bowel and identifying any
abnormalities.
• As a segment of small bowel is
lifted for examination, the
corresponding mesentery is also
inspected for hematoma.
Contd…

28. • The liver, spleen, kidneys, and gallbladder are palpated for injury.
• In the pelvis, the genitourinary organs are inspected for injury.
• Finally, the diaphragm is inspected carefully as a site of potential missed
injury.
Contd…

29. Splenic Injuries
• The spleen is the most commonly injured abdominal organ
• Direct compression of the spleen with parenchymal fracture is a
common pathophysiologic mechanism
• May be associated with lower chest trauma

32. • Management of Splenic Injuries
•Treat stable patients who demonstrate active extravasation on CT
imaging (pseudoaneurysm)
• The use of splenic angiography and embolization
• Eliminate blood flow through the injured segment of spleen and reduce the risk of
delayed hemorrhage.
•Reserve nonoperative management for stable grade I, ii, and iii injuries,
with the assistance of angioembolization when the bleeding risk is
more substantial
• Physiologic stability includes a normal blood pressure, lack of tachycardia, no
physical examination findings indicating shock, and absence of metabolic
acidosis.

33. • Splenectomy may be required in the setting of instability at the time of admission
or after failed nonoperative management.
• No need of packing and exploring other injuries but immediate splenectomy
whenever identified splenic injury
• Precaution regarding OPSI and Providing postsplenctomy vaccination

34. Hepatic Injuries
•2nd most common organ involved in blunt trauma
•Mechanisms of blunt hepatic trauma include compression with
direct parenchymal damage and shearing forces, which tear
hepatic tissue and disrupt vascular and ligamentous
attachments.
•Because of the large amount of the abdomen occupied by the
liver, penetrating injuries are common as well

36. •AAST Injury Scoring Scale

37. •Management of Liver
Trauma
1. Pressure
2. Packing
3. Pringle maneuver
4. Plug

38. • Perihepatic compression, packing
• Plugging of penetrating injury handmade balloon catheter

39. •Pringle maneuver: 20:5
•Finger fracture & ligation
•Omental plugging

40. Extrahepatic Biliary Tree injury
›Roux-en-Y
hepaticojejunostomy
›Open cholecystectomy
›T-tube drainage
›End to end anastomosis

41. Gastric injuries
• Penetrating mechanisms are the most common cause
• Blunt trauma occurs in high energy injuries and associated
splenic/hepatic injuries
• Manifest as peritonitis
• repair of gastric injuries is based on the amount of tissue loss
and the injury location.

42. • Hematomas within the gastric wall ---> to r/o perforation --->
evacuate ---> control of bleeding ---> closure of the
seromusculature with nonabsorbable suture.
• Full thickness perforation ---> debride nonviable tissue --->
closed in one or two layers---> inner absorbable suture and then
to invert the suture line with nonabsorbable seromuscular
stitches.
• Highly destructive injuries ---> loss of large portions of the
stomach ---> partial or even total gastrectomy ---> billroth
procedures

43. Duodenal Injuries
• Uncommon; diagnostic and therapeutic challenge --- retroperitoneal
location
• The classic description includes the abdomen’s being struck by a
steering wheel/seat belt or, in children, a bicycle handlebar.
• abdominal CT: a thickened duodenal wall, air or fluid outside the
bowel lumen, or extravasation of contrast material if an oral
contrast agent was administered
• Management
›Hematomas of wall: conservative management
›Small perforation: omental patch repair or two layer repair
›Longer segments of duodenal injury or areas adjacent to the
ampulla may require enteric bypass with a Rouxen-Y
reconstruction.

44. Pancreatic Injuries
• Commonly occur in association with injury to the duodenum
• Delays in diagnosis and management ---> significant morbididty &
mortality rates.
• Abdominal CT: malperfusion of the pancreatic parenchyma,
surrounding fluid, or hematoma and stranding in the adjacent soft
tissue.
• 3 hours after injury occurrence, an elevated serum amylase level
• Imaging of the pancreatic ducts with ERCP or MRCP

45. •Management of pancreatic
injury
•Kocherizati
on

46. •External drainage with closed suction system:
indications
›Damage control surgery
›Contusion
›Laceration without duct injury
›Laceration with duct injury on right side of SMV (Needs
feeding jejunostomy’)

47. •Distal
Pancreatectomy:
›Laceration with duct
injury on left side of
SMV (external drainage)
traumatic
•Pancreaticoduodenectomy:
›Destruction of head of pancreas
(external drainage)

48. Small Bowel Injuries.
• In blunt trauma, bowel
rupture occurs when the
intraluminal pressure
rapidly increases, causing a
blow-out along the
antimesenteric border.
• Occupies more abdomen--->
frequently injured in
penetrating trauma.
• Present as peritonitis
• CT less reliable, diagnosis
mainly clinical ground

49. •Grade I
injuries are
treated by
inversion with
seromuscular
sutures.
•Grade II injuries are
treated by careful
debridement and
primary closure.
•Either a one- or two-
layer closure may be
used.

50. •Adjacent perforations
are treated as a
single defect by
dividing the bridge
of tissue separating
them with
electrocautery.
•Two layer technique
• NOTE: In the setting of multiple
perforations, primary repair can
be safely performed as long as the
injuries are not so close as to
result in narrowing of the bowel
lumen when closed. Otherwise R & A
advised.

51. •Grade III and high grade
small bowel injuries are
usually treated by resection
and anastomoses.
•Damage control for small
bowel injuries includes rapid
closure of perforations to
control contamination with
resection when large
injuries are present.

52. Colo-Rectal Injuries
• 2nd most common organ involved in penetrating injury, blunt trauma rare
• Rectal injuries associated with pelvic #,
• Assessed with bleeding PR
• Management:
› Injuries that involve the colonic wall circumference
› Less than 50% ---> primary repair with one or two layers,
› More than 50% ---> resection anastomosis
› Injuries w. R. T. The middle colic artery
› Proximal ---> right hemicolectomy and ileocolic anastomosis.
› Distal ---> segmental resection with colocolic anastomosis.
› In the setting of shock, immediate anastomosis should be avoided
should be avoided because of an unacceptably high leak rate.

53. •Rectal injuries
•Diversion colostomy ---> fecal diversion ---> healing ---> colostomy
reversed.
•An end colostomy or a loop configuration ---> complete fecal diversion is
achieved.
•Rectal injuries > 50% of the luminal circumference ---> resection of the
rectum above the injury with the creation of an end colostomy.

54. Abdominal Great Vessel Injuries
• Significant ongoing blood loss and hemodynamic instability or
• Retroperitoneal hematoma
• Mortality: Aorta: 50-60%, SMA: 40-80%, IVC: 30%
•Management
› Zone 1 hematomas ---> involve the aorta, proximal
visceral vessels, or inferior vena cava ---> require
exploration
› Zone 2, hematomas ---> the kidneys ---> explored
only when hematoma is expanding & causing
instability
› Zone 3 hematomas ---> secondary to pelvic
fracture bleeding ---> should not be explored unless
exsanguinating

55. •Cattell Braasch maneuver
• Right medial visceral
mobilization
• Exposure of IVC, right renal
and superior mesenteric
artery, right iliac vessels

56. •Mattox maneuver
•left medial visceral
mobilization
•Exposure of aorta, origins
of celiac, superior
mesenteric, and left renal
artery

57. • Different methods of bleeding
control
› Doubly applied vessel loop
› Bulldog clamp
› Balloon catheter
› Loop ligature
› Vascular clamp
•Vascular repair:
› Suture: polyprophylene, 5.0 6.0
› Techniques: Ligation, Primary Repair, Anastomosis, Grafting, Bypass

58. Genitourinary Injuries
• Kidney, ureter, bladder & urethra
› Present as hematuria, blood at meatus,
oliguria, urinary retention, genital swelling
› Investigation: CT abdomen, IVU,
Cystography, retrograde urethrography
• Management:
› Kidney injuries: primary repair, partial or
total nephrectomy
› Ureter injuries: anastomosis, stenting,
autotransplantation
› Bladder injuries: primary repair, SPC,
catheter drainage
› Urethral injuries: SPC & surgical correction

59. Abdominal Compartment Syndrome
• ACS defined as a “sustained IAP >20 mm hg that is associated with new
organ dysfunction/failure.”
• Common manifestations
•The respiratory failure--> diaphragmatic movement --> dyspnea
•Cardiovascular failure --> increased systemic vascular resistance -->
cardiac output
•Renal failure --> blood supply --> oliguria
• Risk factors
•Diminished abdominal wall compliance (ie, abdominal surgery, trauma,
burns);
•Increased intraluminal contents (ie, gastric distension, ileus,
pseudoobstruction);
•Increased intra-abdominal contents (ie, hemoperitoneum; intra-
abdominal infection or abscess);

60. • Measurement of Intra-Abdominal
Pressure (IAP)
› Instillation volume of 25 mL of sterile
saline into bladder
› Pressure transducer at midaxillary
line level
› Measured at end-expiration in the
supine position- with relaxed
abdominal muscles
› Normal: 5-7; IAH > 12; ACS > 20
“opening the abdominal wall to relieve organ failures”

61. Temporary Abdominal Wall Closure
•Indications:
› unable to close the midline incision over an enlarged midgut (avoid
ACS);
› need to perform an early reoperation as a DCS
› loss of or severe injury to abdominal wall
• Closure of the abdomen within 8 days is preferred to reduce complications
from the open abdominal wound

62. • Skin only closure
• By clips or running
suture with nylon
• Bogota bag
• Slide Fasteners
• VAC closure
Temporary
Closure
Techniques

63. New Advances….
•Role of Laparoscopy
› No place for laparoscopy in the unstable
patient
› In stable patient:
› Diagnostic: penetrating trauma, to detect
or exclude peritoneal breach and/or
diaphragmatic injury.
› Screening: Blunt trauma, solid organ
injury ---> NOM ---> avoid negative
laparotomies
› Therapeutic: repair of injury

64. References
• Bailey & Love’s SHORT PRACTICE of SURGERY 27th edition
• Sabiston TEXTBOOK of SURGERY The BIOLOGICAL BASIS of
MODERN SURGICAL PRACTICE, 20th edition
• Ernest Moore’s TRAUMA, 8th edition