Abdominal trauma can result from blunt force, stab wounds, or penetrating injuries. Diagnosis is challenging as the patient may be unconscious, and other injuries can distract from abdominal issues. Investigations include ultrasound, CT scan, diagnostic peritoneal lavage. Laparotomy is often needed for significant injuries such as liver laceration or small bowel perforation. Management depends on injury type and severity but may involve organ resection, suturing, or drainage. Complications can be serious if not addressed promptly.

1. ABDOMINAL TRAUMA
It can be: Blunt trauma Stab injury Abdominal
wall injury

2. • Abdominal trauma is a major surgical emergency
which most surgeons face.
• It is often associated with head injuries, chest,
pelvic and bone injuries.
• Often patient is unconscious causing diffi culty in
diagnosing the condition.
• Often more importance is given to other system
injuries like of head, thorax and bones whereas
abdominal injury is not addressed properly
causing life-threatening consequences.

3. • When patient is conscious, history related abdominal
trauma is useful. Abrasion over the abdominal skin suggests
the possibility of internal injury (London’s sign).
• Distension, tenderness, rebound tenderness, fullness and
dullness in the flank when present one shouldAbdominal
trauma can be blunt or stab/penetrating or abdominal wall
injuries.
• Spleen is the most common organ involved in blunt
trauma.
• Often in blunt trauma first part of the jejunum or ileocaecal
junction gives way (blow out effect) due to traction often
causing complete transection of bowel horizontally close to
the junction.

4. • . It is due to force of the mobile part of the bowel over the
fixed part.
• Liver is the most common organ involved in penetrating
injuries.
• Injuries of the abdomen may be closed injuries,
compression injuries and penetrating injuries.
• Penetrating injuries may be low velocity injury like stab
injuries or high velocity injury like gunshot injuries.
Penetration of blunt weapon causes less deep trauma than
sharp weapon (sickle, knife).
• In sickle injury tip and sharp edge moves in curved pattern
and so it is often difficult to predict the depth, track and
organs injured

5. • Routinely followed indications for exploration in
abdominal trauma are—hypotension without any
other cause; bleeding through wound;
continuous bleeding in nasogastric tube;
evisceration of abdominal content through the
open wound except in case of protruded
omentum without any hypotension and features
of peritoneal irritation; air under diaphragm in
blunt abdominal injury (not in penetrating injury
as external air gets sucked into the peritoneal
cavity through the wound)

6. Types
• Liver injury.
• ♦ Spleen injury.
• ♦ Gastric/small bowel/colonic injuries
• ♦ Duodenal injuries.
• ♦ Pancreatic injuries.
• ♦ Injuries to kidney/bladder/urethra.
• ♦ Mesenteric injury.
• ♦ Vascular injuries.
• ♦ Associated injuries like of diaphragm, lungs.
• ♦ Abdominal compartment syndrome.
• ♦ Gunshot or blast injuries.

7. General Clinical Features
• Features of shock—pallor, tachycardia, hypo
tension, cold periphery, sweating, oliguria.
• ♦ Abdominal distension.
• ♦ Pain, tenderness, rebound tenderness,
guarding and rigidity, dullness in the fl ank on
percussion.
• ♦ Respiratory distress, cyanosis depending on
the amount of blood loss.
• ♦ Bruising over the skin of the abdominal wall.
• ♦ Features specifi c of individual organ injuries.

8. Investigations
• 1. Ultrasound abdomen. FAST is Focused Abdominal Sonar Trauma:
It is rapid, noninvasive, portable bedside method of investigation
focusing on pericardium, splenic, hepatic and pelvic areas.
• Blood more than 100 ml in cavities can be identifi ed. It is not
reliable for bowel or penetrating injuries. It often needs to be
repeated.
• 2. Diagnostic peritoneal lavage (DPL): It is done in case of blunt
injury abdomen. Through a subumbi lical lavage catheter one litre
of normal saline/Ringer’s lactate is infused into the peritoneal
cavity. Patient is changed to different positions and side-to-side.
Fluid content is aspirated from the abdomen for assessment. It has
got 98% accuracy rate.
• It is the procedure of choice in physiologically unstable patient with
blunt abdominal injury (like with spinal injury, unconscious patient).

9. One of the criterias signifi es positive
lavage
• 10 ml or more of gross blood
• RBC count more than 1,00,000/cumm
• WBC count more than 500/cumm
• Amylase level in the fl uid more than 175
IU/dl
• Presence of bile, bacteria, food particles or
foreign body

10. Contraindications for DPL
• When laparotomy is definitely indicated
• Previous laparotomy
• Pregnancy
• Obesity

11. • 3. CT scan is indicated in assessing
retroperitoneum, solid organ injuries.
• It is noninvasive and highly specific.
• 4. Diagnostic laparoscopy (DL) is valuable
method in stable abdominal trauma patient.

12. Treatment
• Emergency laparotomy.

13. Indications for laparotomy
• Frank haemoperitoneum
• Signifi cant diagnostic peritoneal lavage
• Haemodynamically unstable patient
• U/S or CT scan shows signifi cant intra-
abdominal injuries

14. BLUNT TRAUMA OF ABDOMEN
• BLUNT TRAUMA OF ABDOMEN It is common in
accidents.
• It is often missed or lately diagnosed. Ultrasound/CT
abdomen or diagnostic peritoneal lavage (DPL) is
useful.
• In many cases on clinical grounds directexploratory
laparotomy is done.
• Plain X-ray abdomen may show gas under diaphragm.
• Difficulty arises in deciding about the need for
laparotomy in abdominal trauma in unconscious
patients

15. • . If severity of external injury is out of proportion to the
existing severe shock then exploratory laparotomy is
indicated in an unconscious patient.
• It is also often diffi cult to diagnose bowel injury in
such patients.
• If it is suspected laparotomy should be undertaken in
such patients. Associated spinal injury masks the
abdominal fi ndings.
• Injuries may be of liver, spleen, GIT, pancreas,
mesentery, vascular or diaphragm. Associated chest,
pelvis, skeletal and head injuries should be
remembered.

16. Features of Blunt Trauma
• ♦ Features of profound shock, progressive
distension of abdomen, pain, tenderness,
guarding, rigidity, rebound tenderness, dull flank.
• ♦ Features specific of individual organ injury like
obliteration liver dullness in bowel injury.
• ♦ Bruising of skin over the abdomen—London’s
sign.
• ♦ Respiratory distress, cyanosis.
• ♦ Repeated clinical examination is a must in
blunt trauma.

17. DUODENAL INJURY
• ♦ Its severity depends on the type and extent
of the injury.
• ♦ It can be haematoma or lacerations.
• ♦ Lacerations can cause duodenal disruption,
may be < 50% or > 50% or 75% or more.
• ♦ Laceration may extend into the ampulla,
distal CBD, pancreas or with duodenal
devascularisation.

19. Management
• ♦ CT scan is more relevant investigation.
• ♦ Associated other injuries should be managed
accordingly.
• ♦ Haematoma without extension is managed
conser vatively with nasogastric aspiration,
antibiotics and IV fl uids.
• ♦ Lacerations are sutured surgically with a
stenting or often with bypass like
gastrojejunostomy.
• ♦ ERCP stenting or CBD bypass is also often
required.

20. Complications
• Infection, duodenal leak.
• Peritonitis, haemorrhage.

21. PANCREATIC INJURY
• ♦ It can be in the head or body and tail of the
pancreas.
• ♦ It may be associated with injury to
duodenum or portal or superior mesenteric
veins.
• ♦ It can be contusion or severe lacerations.

22. Management
• ♦ High resolution CT scan is diagnostic.
• ♦ Distal pancreatectomy for injuries distally.
• ♦ Conservative treatment is useful with
antibiotics, IV fl uids.
• ♦ Whipple’s operation or total
pancreatectomy is done as a last resort.
• ♦ Drainage of the pancreatic bed is simple and
often useful method.

23. Complications
• ♦ Pancreatitis, septicaemia.
• ♦ Pancreatic fistula, pancreatic abscess
formation.
• Pancreatic injury has got high mortality (>
45%).

24. SMALL BOWEL INJURY
• ♦ It can be blunt injury or stab injury.
• ♦ Blunt injury causes disruption of either
duodenojejunal region or at ileocaecal region.
• ♦ Presentation is like haemoperitoneum or
features of peritonitis.
• ♦ Monks localising zones in the abdomen signify
the location of the small bowel injury.
• ♦ Presence of pattern bruising over the
abdominal wall signifi es the small bowel injury
and its site. It is called as London’s sign

25. Management
• ♦ Plain X-ray abdomen shows gas under
abdomen with ground-glass appearance.
• ♦ U/S abdomen is useful.
• ♦ Laparotomy and closure of the perforation if it
is small.
• ♦ In presence of extensive bowel injury or
multiple injuries, resection and anastomosis is
done.
• ♦ Any associated injuries should be dealt with
accordingly

26. COLONIC INJURY
• Left sided injury is treated with proximal colostomy with
closure of the wound if it is small, or resection and
anastomosis if it is wider area. Closure of colostomy is done
at later stages after 3-6 months.
• ♦ Small wound over right sided colon can be sutured
primarily.
• ♦ Ileostomy alone or ileostomy with ileo-transverse
anastomosis or right hemicolectomy with ileostomy is
indicated in following situations:
• Extensive peritoneal contamination.
• Colonic vascular injuries.
• Haemodynamically unstable patients.
• Long-term hypotension after trauma

27. LIVER INJURY
• It can be subcapsular haematoma, lacerations,
deeper injuries, lacerations with disruption of
hepatic lobes or segments or liver injury with
vascular injuries like of inferior vena cava or
hepatic veins.
• Present with features of haemorrhagic shock,
dis tension of the abdomen, tenderness,
rebound tenderness, guarding, rigidity.

28. • CT is diagnostic tool
• Liver injury is graded depending on involvement of
hepatic veins, portal system, biliary system and
duodenum
• Often high grade liver injury also can be managed
nonoperatively
• Push (direct compression); Pringle (occluding portal
triad at foramen Winslow with fi ngers temporarily);
plug by embolisation; pack the liver bed; repair of vena
cava or portal vein; stenting of biliary tree and
hemihepatectomy—are the treatment strategies

29. Management
• ♦ Small tear is sutured.
• For larger tears: Deep sutures. Packing. Debridement.
Haemocoagulants.
• ♦ Liver resection is not done (not advisable) usually for
injuries.
• ♦ Pringle manoeuvre—by compressing the porta near
foramen Winslow—to control bleeding (not more than 30
minutes).
• ♦ Blood transfusions.
• ♦ Treatment of associated injuries like of diaphragm, lung,
duodenum, colon.
• ♦ Antibiotics.

30. Complications of Liver Injury
• Haemorrhage, septicaemia, bile leak.
• ♦ Liver failure, haemobilia.
• ♦ Subphrenic abscess, CBD stricture.

31. SPLENIC INJURY
• It can be subcapsular haematoma, laceration
or hilar injury.
• It can be associated with other organ injuries
like left kidney, left lobe of the liver, splenic fl
exure of the colon or pancreas. It can cause
torrential haemorrhage and shock.
• It is the most common organ injured in blunt
injury abdomen.

32. Management
• ♦ U/S abdomen, diagnostic peritoneal lavage
are the investigations. ♦ Blood transfusions. ♦
Splenorrhaphy is done in selected patients so
as to save the spleen. ♦ Splenectomy. ♦
Management of associated injuries.

33. Complications of Splenectomy
• Left lung atelactasis. ♦ Overwhelming
postsplenectomy infection (OPSI). ♦
Pancreatitis and pancreatic fi stula. ♦ Gastric
bleeding. ♦ Subphrenic abscess

34. RENAL INJURY
• It is commonly managed conservatively. ♦ IVU
is the investigation of choice in renal injury. ♦
Surgery is indicated when there is hilar injury,
progressive bleeding, failure of conservative
treatment or perinephric abscess formation.

35. URINARY BLADDER INJURY
• Intraperitoneal bladder injury occurs in
distended bladder. It is treated always by
surgical exploration through transabdominal
approach. Bladder tear is sutured with
keeping a suprapubic cystostomy using
Malecot’s catheter. Extraperitoneal injury can
be treated conser vatively by placing a Foley’s
catheter for 2-3 weeks.

36. ABDOMINAL COMPARTMENT
SYNDROME

38. SEATBELT INJURIES
• ♦ In an individual with seatbelt, during impact
violent deceleration of human body occurs.
Seatbelt impinges heavilyon its point of contact
with trunk and viscera continue to move forward.
• It leads into severe contusion of abdominal
contents; detachment of bowel from its
mesentery due to free forward rapid mobility of
the bowel over a relatively fi xed mesentery.
• Solid organ injury occurs only occasionally.

39. • Two point anchorages causes’ solid organ injuries like of
liver/spleen. Lap-belt causes contusion and bowel injury
commonly.
• ♦ It is often diffi cult to identify the injuries due to
presence of more obvious other injuries. CT chest and
abdomen diagnostic peritoneal lavage (DPL) are very
useful.
• ♦ Petechiae around iliac crest or costal margin are signs
wherein one can suspect seatbelt injuries.
• ♦ Distraction fracture of lumbar spine (chance fracture)
with hyperaesthesia of T12 and L1 level is often associated.
10% of such fractures are associated with intra-abdominal
injuries

40. • ♦ Treatment is immediate laparotomy and
proceed—bowel suturing/resection/suturing
of the organ
injuries/splenorrhaphy/splenectomy