This document describes a case of a 22-year-old male who presented with abdominal pain after a blunt injury and was diagnosed with a transected pancreas and duct disruption based on exploratory surgery findings. The patient underwent primary pancreatic duct repair with stenting and drainage. He recovered uneventfully and was discharged on post-op day 15. Pancreatic injuries can be difficult to diagnose due to their protected location and often subtle early symptoms. A high index of suspicion is needed to identify such injuries.

1. DR.E.KAUSHIK KUMAR
DEPT.OF GENERAL SURGERY
STANLEY MEDICAL COLLEGE

2.  குறள் 393:
 கண்ணுடையர் என்பவர் கற்ற ோர் முகத்திரண்டு
புண்ணுடையர் கல்லோ தவர்
 கண்ணில்லோவிடினும் அவர் கற் வரோக
இருப்பின் கண்ணுடையவரோகறவ
கருதப்படுவோர். கல்லோதவருக்குக் கண்
இருப்பினும் அது புண் என்ற கருதப்படும்.

4.  The pancreas-relatively protected
position high in the retroperitoneum,
 Many blunt pancreatic injuries are not
immediately recognized
 Consequently end up causing higher
morbidity and mortality rates than
observed in injuries to other
intraperitoneal organs

5.  Penetrating abdominal trauma
frequently causes pancreatic injury
 Even physical visualization and
examination of the pancreas in the
operating room may miss an isolated
ductal injury to the pancreas

6.  A delayed diagnosis of pancreatic
injury, mild or severe, is easy to diagnose
but becomes a major therapeutic
challenge to the surgical team and a
potentially disastrous situation for the
patient.
 To consider a pancreatic injury, a
trauma that occurred from a significant
force is usually required.

7.  22 year male suffered a blunt injury
abdomen-Had no external injuries
Primary Health care had pain
abdomen in epigastrium and back next
day Admitted and evaluated and
diagnosed as Blunt Injury Abdomen with
retroperitoneal haematoma
 ? Pancreatic Injury

9.  Taken up for exploratory laparotomy
 Findings
› Minimal hemoperitoneum
› Transection of pancreas at the level of neck
and body with duct disruption
› All other organs- Normal

12.  Procedure done
› Primary repair of pancreatic duct over a
stent and pancreatic anastamosis and drain
of pancreatic bed with Feeding Jejunostomy

13.  Patient was referred for post op care
 Tachypnoea,tachycardia,intermittent
fever
 Conservatively managed
 Uneventful
 Post-operative imaging-satisfactory
 Discharged on 15th POD

15.  Approximately 20-30% of all patients with
penetrating traumas
 10% in blunt traumas
 The proximity of the larger vessels (eg,
portal vein), the abdominal aorta, and
the inferior vena cava (IVC) to the
pancreatic head increases the risk of
exsanguinating hemorrhage
accompanying pancreatic penetrating
injury

16.  Amylase detected in diagnostic
peritoneal lavage (DPL) fluid is much
more sensitive and specific for
pancreatic injury
 CT scans provide the best overall
method for diagnosis and recognition of
a pancreatic injury-Retroperitoneal
hematoma, retroperitoneal fluid, free
abdominal fluid, and pancreatic edema

17.  Conservative
› Stable hemodynamics and CT scans showing no evidence
of pancreatic parenchymal fracture, parenchymal
hematoma, parenchymal edema, fluid in the lesser sac, or
retroperitoneal hematoma may be observed but should
not be considered to be cleared for pancreatic injury for
at least 72 hours
 Damage-control techniques
 Operative repair
 Resection
 Factors
› Hypothermia
› Dilutional coagulopathy
› Other fatal or near-fatal injuries

18.  Pancreatic injury can be frighteningly symptom
free early in the postinjury time frame and even
silent in many cases
 Symptoms of injury to other structures
commonly mask or supersede that of
pancreatic injury, both early and late in the
hospital course
 A high degree of clinical awareness is
necessary to ensure that pancreatic injuries are
not overlooked or missed, either early in the
course of trauma or later in the ICU when the
patient is not clinically improving as expected

20.  A 26 year male brought to emergency
room by 108 people
 No specific reliable history
 Stomach eviscerated in epigastrium
 Patient under alcohol intoxication
 There was a laceration over his scalp.

21.  On examination
 GCS – 12/15 (E 3 V 4 M 5).
 PR- 112/min.
 BP- 100/60mmHg.
 Stomach eviscerated with bluish hue.
 Rest of abdomen-flat,tenderness not
elicitable.
 No guarding/rigidity. BS +.
 No other extremity injuries or spinal injury

22.  Patient resuscitated initially with iv fluids
 Coagulation profile assessed and blood
taken for cross matching
 Shifted to Operating room for
exploratory laparotomy.

24.  Stab injury in epigastrium causing
perforation of body of stomach in
anterior and posterior wall.
 Omental contusion +
 Hemoperitoneum about 50 ml.
 No other bowel or solid organ injury.
 No diaphragmatic injury.

26.  Procedure done: Omental patch closure
with feeding jejunostomy.

27.  Post Op: Uneventful and discharged on
POD 7.
 Follow up : normal

28.  Penetrating trauma causing Gastric
evisceration is less than 2 %
 Absolute indication of Laparotomy
 Associated major vessel/organ injury to
be searched
 Damage control/definitive repair

29.  Aware about uncommon injuries
 Proper clinical evaluation serially
 Communication within and between the
surgical and allied teams
 Treatment individualised