Gig

1. Management of Colorectal,
Pancreaticodoudinal and
Abdominal Vascular Trauma
Moderator – Dr. Shimelis
Consultant General and Hepatobilliary surgeon
Dr. Fikreyohanis S (GSRIII)
Aug,2023

2. Outline
• Colorectal Trauma
• Pancreatic Trauma
• Duodenal Trauma
• Abdominal vascular trauma

3. COLORECTAL TRAUMA

4. Introduction
• The colon is involved in 25% of GSW, 5% of stab
wounds, and 2% of blunt abdominal injuries
• It is expected that this will continue to be a problem
because of the frequency of MVA and availability of
firearms

5. • Colonic trauma can be :-
 Blunt
 Penetrating

6. PENETRATING TRAUMA
• Most colon injuries result from penetrating
wounds to the abdomen. 20 % of are associated
with injury to the large bowel

7. • Septic morbidity is a real danger b/c of the combination
of
- Fecal spillage,
- Soft tissue injury
- Bleeding, all of which predispose to subsequent
infection
• GSW of the colon are associated with more tissue
destruction and increased number of associated injuries
in comparison with stab wounds

8. • Stab wounds of the abdomen, which more than 20 years
ago were frequently managed by routine laparotomy, are
now subjected to selective NOM
• Only patients with diffuse abdominal tenderness or
hemodynamic instability are rushed to the operating
room

9. BLUNT TRAUMA
• Blunt trauma causing colonic injury, in less than 5% of
cases
• Mobile segments of the colon (e.g., cecum, transverse
colon, and sigmoid colon) are more susceptible to injury

10. • Most perforations are found in the sigmoid
colon, that can be explained by
 It’s redundancy
 it’s tendency to form a closed loop
 It is subjected to acceleration/deceleration
forces

11. • These injuries demand special consideration since they can be
devastating
• Approximately 50% of blunt colon injuries are grade III to V,
thus necessitating resection. Typical injuries include extensive
serosal tears, mesenteric rents with devascularization, and
perforations

12. DIAGNOSIS
1. CT
o CT has almost exclusively replaced peritoneal lavage
The results of CT can be -
 presence of free fluid without evident liver or spleen
injury is worrisome
 presence of mesenteric inflammatory change, edema, or
hematoma
 Free air is a pathognomonic sign of hollow visceral
injuries

13. 2. FAST
o Its is quite helpful when it is positive; specificity rate is
high for detecting hemoperitoneum (95 - 100%) vs. (42%
to 87%)
3. Laparoscopy
o It is highly sensitive test for determining peritoneal
penetration. Particularly, Thoraco-abdominal wounds

15. OPERATIVE MANAGEMENT
1. Non destructive colonic wounds
• It includes' AAST grade I and II and selected grade III injuries
• Such injuries are low energy wounds that do not require
significant debridement. There is ample evidence that primary
repair is the optimal treatment

16. Operative Management
2. Destructive Colon Wounds
• Resection and anastomosis is the optimal
treatment for these destructive injuries
• however, whether to perform proximal diversion
or even exteriorization of the injury as an end
colostomy is the subject of debate

17. Fecal Diversion versus Primary Repair
• They found that primary repair was at least as successful
as diversion and stated that all patients with penetrating
colon injuries should undergo primary repair
• A number of other prospective studies have also
demonstrated that primary repair can be successfully
performed in most patients with colon injuries

18. SURGICAL MANAGEMENT
GENERAL PRINCIPLES
o Preoperative broad-spectrum antibiotics for both
anaerobic and aerobic flora should be given early
o Once the decision has been made to perform an
exploratory laparotomy, the abdomen is entered through
a midline incision
o It is important to preserve the area overlying the rectus
muscles in case a stoma is required

19. o Identifying and controlling any source of bleeding
o Controlling spillage of intestinal contents by means of
atraumatic clamps and sponge
o The entire GIT and mesentery are carefully inspected.
Special attention should be given to the number and
location of all wounds

20. • Usually, there is an ‘Even number’ of openings in the
bowel, compatible with a typical through-and-through
injury pattern. However, when an odd number of wounds
is identified, We have to find the “missing hole.”
• The bowel should be carefully reinspected, especially
the region adjacent to the mesentery

21. • When primary repair is attempted, often accomplished in
a Transverse fashion
• Whether a two-layer or a single-layer technique is
employed is a matter of each individual surgeon’s
personal preference
• If diversion of the fecal stream is required, either the
injured segment is brought out to the abdominal wall or a
proximal portion of bowel is selected as a colostomy or
ileostomy

22. DAMAGE CONTROL LAPAROTOMY
• In 1983, H. Harlan Stone described the concept of a
limited laparotomy in unstable patients following initial
control of hemorrhage and GI contamination and then
with temporary abdominal closure and transfer to the
ICU
• This approach has been shown to be beneficial and to
improve survival in patients with hypothermia, metabolic
acidosis, and coagulopathy

24. RECTAL INJURY
• The presence of blood on a DRE is suggestive of an
injury, and careful palpation of the perineal area
• In female patients, a vaginal examination should be
performed. Asking the patient to “tighten up” will help
evaluate the efficacy of the sphincteric mechanism and
whether it is intact

25. Diagnostic Studies
 SIGMOIDOSCOPY
 CT

27. Operative Management
• Intra-peritoneal - penetrating rectal injuries should be
managed the same as those with colon injuries
• Non-destructive wounds - should be repaired primarily
without proximal fecal diversion
• Proximal colostomy is usually the procedure of choice in
patients with blunt injuries because these are often
associated with pelvic fractures or complex perineal
injuries

29. Retroperitoneal rectal
The choices for management -
• primary repair
• proximal colostomy, or
• primary repair and proximal colostomy
 The old concept of distal Rectal washout and presacral
drainage has been generally abandoned because it has
not been shown to yield any significant improvement in
outcomes

30. PANCREATIC TRAUMA

31. Incidence
• 1–5% of BAT & 12% of penetrating trauma
• Morbidity rates - 30–62%
• Mortality rates from - 10 to 30%
• > 50% associated injuries

33. Diagnosis
• ATLS Protocol
• History & P/E - (high Index of suspicion)
• Serum Amylase and lipase
- Lipase - NPV (99.8%) Vs PPV (3%)
- combined lipase & Amylase has Sp and Sn of100%
and 85% for predicting pancreatic injury
- The dx yield of amylase is time sensitive, and a value
obtained after 3 to 6 hrs. has a higher accuracy
• FAST

34. • CT - Overall, has a Sn of 70 to 95% for detecting
pancreatic injuries
• MDCT - has the greatest sensitivity in the detection of
main duct injuries and is 97.9% Sn in the parenchymal
phase and 100% Sn in the portal venous phase
• Specific signs of injury include
- Fractures or lacerations of the pancreas
- Active hemorrhage from the gland
- Edema or hematoma of the parenchyma
• Non-specific findings include peri-pancreatic blood or fat
stranding.

35. • ERCP - Dx & Mx (stent or drain
placement)
• MRCP

36. MANAGEMENT
It depends on :-
o Hemodynamic status
o Injury grade
o Presence or absence of duct injury

38. • Grade I and II
- Non-operative management
- Intra-op finding – drainage and hemostasis

39. Grade III
o Head – Drainage
o Body/Tail - Distal pancreatectomy with or without
spleen preservation
- Stapled Vs Hand sewn
Indicators of ductal injury include -
• Direct visualization of ductal injury
• complete transection of the gland
• laceration of > 50% of the gland
• central perforation, and severe maceration

40. Grade IV
• Damage control techniques
• Close-suction drainage
• Considerations in these situations include -
- packing
- suture ligation, and
- completing a pancreatectomy

41. Grade V
• Damage control
• Staged Pancreaticoduodenectomy
Indication
• Massive unreconstructable Injury to intrapancreatic BD
and proximal MPD
• Avulsion of the ampulla of Vater from the duodenum with
destruction of the 2ND portion of the duodenum

42. EXPOSURE
• Kocher Maneuver
• Cattell-Braasch Maneuver (Right visceral medial
rotation)
• Aird’s Maneuver

43. Complication
- 20-40%
 Pancreatic fistula - 20%
 Pancreatic abscess/necrosis - 10-20%
 Pancreatitis - 8-18%
 Pseudocyst – 5 vs. 20 %
 Pancreatic duct stricture

44. Duodenal Injury

45. Incidence
• 0.2-0.6% of adult trauma
• Penetrating- 77% Vs blunt-22%
• High Morbidity and Mortality(35-45%, 6-25%
respectively)
- MR ↑ to 40% (>24hrs) compare with 11% (<24hrs)

46. Why duodenal injuries is devastating?
• Anatomic: Accompanies major vascular injuries
• Physiologic: The duodenum is intimately attached to the
pancreas, and a combined pancreaticoduodenal injury is
common
• Pancreatic enzymes can lead to devastating infection
and necrosis within the retroperitoneum
• Healing- Duodenal repairs have a higher incidence of
failure
• There is no secure method of repair
• Failure of the duodenal repair can lead to leakage of up
to 6 L of fluid

47. Common site of injury
 1st - 14.4%
 2nd - 33.0%
 3rd - 19.4%
 4th - 19.0%
 Multiple 14.2%

48. DIAGNOSIS
• High index of suspicion
• FAST, Erect CXR
• CECT – Sn 86% & Sp 88%
 wall thickening > 4 mm
 lack of wall continuity
 Peri-duodenal & pararenal space fluid
 Diminished bowel-wall enhancement, and extra-luminal
air or contrast

50. Management
• Hemodynamically unstable – Immediate
surgery
• It depends on grade of injury

51. Grades I and II
Duodenal hematoma:
– Small/Moderate - NG, JFT, TPN
– Large (>50% luminal compromise) -
laparotomy, clot evacuation
Laceration: Primary repair

52. Grade III
 Primary repair
 Roux-en-y duodenojejunostomy reconstruction
 Resection + end-to-end duodenoduodenostomy(?
D2)
 Jejunal Serosal Patch

53. Protecting the Duodenal Repair
• pyloric exclusion - if associated grade III–IV pancreatic
injury and injury to 2nd part of doudinum
• Duodenal diverticulization

54. GRADES IV AND V
• Damage control approach - significant hemorrhage,
acidosis, hypothermia, and coagulopathy
• If repair possible - Primary repair vs. Roux-en-y
duodenojejunostomy reconstruction
• Trauma Whipple

55. Abdominal Vascular Trauma

56. • Its the most common cause of death after PAT
• Accurate diagnosis, rapid surgical exposure and control,
and the definitive management is challenging
• Rapid transportation, early recognition & surgical
intervention, are critical for optimizing patient survival

58. • Incidence of vascular trauma is 14.3% for GSW,10% for
stab wounds, and 3% for blunt injuries
• The most commonly injured abdominal vessel are
 IVC - 25% of injuries
 Aorta - 21%
 Iliac arteries - 20%
 Iliac veins - 17%
 SMV (11%), and SMA (10%)

59. CLINICAL PRESENTATION
• Early presentation – hemorrhage and
hypovolemic shock
- Thrombosis, dissections, and occlusions
• Late presentation - Pseudoaneurysms

60. Retroperitoneal Hematoma
o Penetrating trauma - As a general rule, almost all
hematomas due to PAT should be explored
o Blunt trauma- Retroperitoneal hematomas due to blunt
trauma rarely require exploration except
- Paraduodenal hematoma
- Large expanding hematoma
- Hematoma in the region of the SMA, with ischemic
bowel

61. EXPOSURE
• Exploration of Zone 1
 Supraceliac Aortic Control
 Exposure of the Supramesocolic Aorta and Visceral
Branches - left medial visceral rotation
 Exposure of the Inframesocolic Aorta
• Exploration of Zone 2 -medial rotation of the right colon
with Kocherization or medial rotation Left colon
• Exploration of Zone 3 -dissection of the paracolic
peritoneum and medial rotation of the right or left colon

64. Abdominal Aortic Injuries
• Lateral Aortorrhaphy
• prosthetic patch or tube graft
Mortality
• blunt Vs penetrating trauma - 30% / 67%

65. Celiac Artery Injury
• Exposure - direct dissection through the lesser
sac or by left medial rotation
• The celiac artery can be ligated without ischemic
sequelae to the stomach, liver, or spleen

66. SMA Injury
• Zone 1 & 2 - results in severe ischemia of the small
bowel and right colon
- shunt, Reconstruct
• Zone 3 & 4 - localized ischemia of the small bowel
requiring segmental resection
- Ligation

67. IVC INJURY
• All hematomas due to penetrating trauma should be
explored
• Exposure – Right medial rotation with kocherization
• lateral venorrhaphy, Patch
• Infrarenal IVC – can be ligated
• Suprarenal IVC – renal insufficiency

68. PV/SMV INJURIES
• Exposure -medial rotation of the right colon with Kocher
mobilization
• lateral venorrhaphy
• Ligation of both the PV & HA is not compatible with life
• Complex reconstructive procedures, such as
interposition grafts
• Abdominal compartment syndrome

69. • Renovascular injuries- observation and
Revascularization
• IMA injuries→ Ligation is well tolerated
• Iliac Vascular Injuries→ DON’T Ligate CIA/EIA,
- Lateral venorraphy /Ligation for Iliac Vein

71. Thank you !