trauma abdominal

1. Abdominal injury
and Management
Dr Wong Wai Man
Department of Surgery
NTWC
29 Apr 2009

2. Mechanism
• Blunt abdominal trauma
• Penetrating abdominal trauma
• Overall about 20% require surgical
operation

3. Blunt abdominal trauma
•Motor vehicle crush MVC injury
•Seat belt injury
•Handle bar injury
•Fell from height
•Common in HK

4. Penetrating abdominal injury
• Stab wound – low energy transfer
• Gun shot wound – high energy transfer
• Not common in HK

5. Anatomy
• Between diaphragm and pelvic floor
• Beware of diaphragmatic injury in
penetrating chest injury below the nipples
(5th ICS)
• Mid-axillary line
• Retro-peritoneal spaces – zone I, II & III

6. Anatomy
• Solid organs – liver, spleen, kidney
(blood)
• Hollow organs – blood, bile, urine, food,
digestive juice, air
• Remember the diaphragm which is
neither solid nor hollow organ

7. First step of Management
• Resuscitation of patients with suspected
abdominal injuries – same as other trauma
patients
• ATLS
• Surgical plan

8. Basic plan of Surgical Decision
• Is there any abdominal injury? (PE, Ix)
• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)

9. Assessment and diagnosis
• Normal abdominal finding
• Obvious injury to the abdomen
eg gun shot wound
• Equivocal findings requiring further
investigation and re-assessment
eg blunt abdominal trauma

10. Investigations
• Diagnostic peritoneal lavage DPL
• FAST USG
• CT scan
• (Laparoscopy)
• (DPA)

11. DPL
• Previously the standard investigation
• Replaced FAST
• Detect blood
• Bowel content : bacteria, food particles, bile
• Accuracy up to 98%
• Miss diaphragmatic and retroperitoneal
injury

13. FAST
• Detect fluid (blood) inside peritoneal cavity
• Accuracy comparable to DPL
• Non invasive and repeatable
• Operator dependant
• Miss specific injuries
• Obesity
• Replace DPL in many trauma centre

16. CAT scan
• Document specific organ injury
• Retro-peritoneal organs
• Accurate
• Haemo-dynamically stable patients
• Can still miss diaphragmatic injury and
bowel injury

19. Basic plan of Surgical Decision
• Is there any abdominal injury? (PE, Ix)
• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)

20. Surgical decision
• Normal abdominal finding
• Obvious injury to the abdomen
• Equivocal abdominal findings

21. Normal abdominal finding
• Re-assessment and physical finding by
same experienced surgeon in haemo-
dynamically normal is usually sufficient
• ? CAT scan before other extra-abdominal
surgery in awake and alert patients
• FAST or DPL in unstable patients

22. Surgical decision
• Normal abdominal finding
• Obvious injury to the abdomen
• Equivocal abdominal findings

27. Obvious injury to the abdomen
• Mostly applied to penetrating injury
• Virtually all penetrating abdominal injury
should be “explored” promptly, especially
in the presence of hypotension
• Local wound exploration
• Laparoscopy / laparotomy
• Gun shot wound - laparotomy
• CAT scan

28. Surgical decision
• Normal abdominal finding
• Obvious injury to the abdomen
• Equivocal abdominal findings

29. Equivocal abdominal findings
• Further investigation very much depends
on haemo-dynamic status of the patients
• Haemodynamically normal: reassessment ,
CAT scan, other investigation

32. Equivocal abdominal findings
• Haemodynamically stable : CAT scan
• Whether the patient has bled into the
abdomen
• Whether the bleeding has stopped.
• Detect specific organ injury

35. Equivocal abdominal findings
• What if CT shows free fluid without solid
organs injury in a stable patient?
• Blood, bowel content, bile, urine
• ? Mandatory laparotomy
• But non-therapeutic laparotomy is up to
92% in one of the US multi-centre
prospective study
• Re-assessment

36. Equivocal abdominal findings
• Haemodynamically unstable : DPL or
FAST
• Positive finding : operation
• A negative finding is also important : we
have to focus on the other compartment
(chest, pelvis, long bones) or external
haemorrhage

38. Basic plan of Surgical Decision
• Is there any abdominal injury? (PE, Ix)
• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)

39. Conservative management
• NOM
• Liver injury (esp grade I – III)
• Splenic injury (esp grade I – III, paediatric
group)
• Renal injury
• Interventional radiologist

42. Conservative management
• Beware of concomitant solid and hollow
organ injury
• ~7%
• It is still safe to adopt non operative
management to stable patients with solid
organ injury patients but repeated
assessment is required

45. Basic plan of Surgical Decision
• Is there any abdominal injury? (PE, Ix)
• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)

46. Is urgent surgery required?
• Radiological evidence of intraperitoneal gas
• Radiological evidence of ruptured diaphragm
• Gunshot wounds
• Evisceration
• Positive result on diagnostic peritoneal
lavage
• Rigid silent abdomen or unexplained shock

47. Aim of urgent operation
• Haemorrhage control
• Contamination control
• Anatomical repair

50. Aim of urgent operation
• Haemorrhage control
• Contamination control
• Anatomical repair
• Haemorrhage control + contamination
control – anatomical repair = damage
control surgery

51. Damage control
• US Navy, term used for battle ship
• staged laparotomy, surgical resuscitation,
temporary abbreviated surgical control (TASC)
• Focus on restoring function / physiology
• Defer treatment of structural / anatomical
disruption
• Temporary abdominal closure

52. Damage Control Surgery
• Inability to achieve haemostasis (liver injury)
• Combined vascular, solid and hollow organs
injury
• anticipated need for time consuming procedure
• Demand for other control of other injury
• Inaccessible major venous injury
• Evidence of poor physiological reserve
(acidosis, hypothermia, coagulopathy)

55. Role of laparoscopy
• Both as diagnostic and therapeutic tools
• Particularly good in detecting
diaphragmatic injury
• Operator dependant
• Difficult to do full trauma evaluation – esp
retro-peritoneal space
• Still in infancy, with controversies

56. Role of laparoscopy
• Contraindication : haemodynamically
unstable patient
• Uses in stable patients
1. Stab wound after LWE
2. Fever or raised WBC in patient under NOM,
such as in case of liver laceration
3. In stable patient with evidence of isolated
bowel injury after blunt injury trauma

57. Interventional radiologist
• Work with arteries
• Cannot help in hollow organ injuries except
drainage of post op collection
• Common sites : liver, spleen, pelvis
• Contra-indication : haemodynamically
unstable patients (except after damage
control procedure in some scenario)
• Organ infarction

58. Interventional radiologist

59. Specific organs injury

60. Hepatic injury
• Grade I to VI
• VI – hepatic avulsion
• Contrast CT scan - very accurate in diagnosis
and grading
• Conservative treatment : stable low grade injury
• Angiographic embolization : higher grade injury
with evidence of continuous bleeding
• Surgery : Unstable patients

61. Surgery in hepatic injury
• Pringle manoeuvre (occlusion of both inflow to liver
ie. portal vein and hepatic arteries.)
• Failed to control bleeding => aberrant Lt or Rt
hepatic arteries or retro-hepatic venous injury
• Parenchymal suture
• Peri-hepatic packing
• Consider embolization
• Bile leak

62. Splenic injury
• Grade I – V
• V – shattered spleen or hilar vascular injury
• Conservative treatment (children, stable, no ass
intra-abdominal injury, no significant brain injury)
• Angiographic embolization (even up to 80% in
grade IV to V stable patients in one study, Hann
JM 2005)
• Suturing, wrap, total or partial splenectomy

63. Pancreatic injury
• Grade I – V
• Grade I & II – intact main duct
• blunt injury (steering wheel, handle bar)
• Retro-peritoneal structure => not much
peritoneal sign
• Amylase level not reliable in initial evaluation
• CAT scan (contrast)

64. Pancreatic injury
• CT scan
1. Specific (>90%) but not sensitive (~50%)
2. May require repeated scan
• ERCP to assess main duct integrity (in
EDU or intra-op)

65. Pancreatic injury
• Grade I, II cases => closed suction
drainage (in selected cases NOM)
• Grade III – V => resection.
• Common site of injury at neck which is
compressed against the spine => distal
pancreatectomy with splenic preservation

66. Pancreatic injury

67. Pancreatic injury

68. Pancreatic injury

69. Pancreatic injury

70. Bowel injury
• Bowel perforation (peritonitis, free gas,
bowel content in DPL) should never be
treated by non-operative management
• Small bowel injury – primary anastomosis
• Colonic injury – colostomy or primary
anastomosis +/- second look laparotomy
• Duodenal injury – retroperitoneal sturcture

71. Duodenal injury
• Even perforation, abdominal sign not florid
• May required extensive mobilization of
surrounding structure for repair
• Duodenal haematoma after a blunt injury can
be managed by conservative treatment

74. Renal injury
• Grade I to V
• Haematuria (30%)
• Contrast CAT scan
• Angiographic embolization
• Urinoma, sepsis, hypertension

75. Abdominal compartment syndrome
• Sequestration of fluid and edema of bowel
wall and mesentery
• Increase intra-abdominal pressure =>
decrease perfusion of viscera => further
increase capillary leakage in bowel wall
causing a viscous cycle
• oliguria, increase peak inspiratory pressure,
increase CVP & PAWP (false), decrease
cardiac output

76. Abdominal compartment syndrome
• Indirect measure through Foley catheter
• Normal < 5mmHg
• <25mmHg – fluid resuscitation
• >25mmHg + oliguria with adequate blood
volume => consider decompression
• Bogota bag, sandwich-vacuum closure,
other commercial packs

81. Thank you