This document provides a comprehensive overview of the diagnosis and management of hollow viscus injuries, particularly focusing on penetrating and blunt abdominal trauma. It details specific injuries to the stomach, small bowel, and colon, outlining diagnostic procedures, injury scales, and treatment protocols. Emphasis is placed on the importance of early diagnosis and tailored management strategies to improve patient outcomes.

1. Hollow Viscus Injury:
The Evil that Lurks - –
‫يتوارى‬ ‫يستتر‬ ‫يتخفى‬
‫يهدد‬Within
(the Abdomen)
HAMED RASHAD
Professor of Surgery -Egypt

2. Diagnosis
Penetrating abdominal trauma
Blunt abdominal trauma
Diagnostic Workup
Indications for Laparotomy

3. Penetrating Abdominal Trauma Diagnosis
• Immediately to OR if:
•Diffuse abdominal tenderness
•No diffuse tenderness but hemodynamically labile
without other injuries
•No diffuse tenderness, hemodynamically stable, left
or right anterior thoracoabdominal injury
» Laparoscopy

4. Penetrating Abdominal Trauma Diagnosis
• Hemodynamically
stable
• Observe stab wounds
• Consider CT in gun
shot wounds and act
accordingly
• Hemodynamically
labile
• DPL
– If positive, to OR
• Resuscitation

5. Blunt Abdominal Trauma Diagnosis
• Immediately to OR if:
•Diffuse abdominal tenderness

6. Blunt Abdominal Trauma Diagnosis
• Hemodynamically
stable
• FAST (Focused
Abdominal Sonogram
for Trauma) AND
• CT
• Act according to
findings
• Hemodynamically
labile
• FAST
– If positive, to OR
• DPL
– If positive, to OR
• Resuscitation

7. Overview of Specific Injuries
Stomach
Small Bowel
Colon
Management

8. Management:
Stomach

9. Management:
Stomach
Gastric Injury Scale
I Contusion or hematoma
Partial thickness laceration
II Laceration in GE junction or pylorus < 2cm
In proximal 1/3 of stomach, <5 cm
In distal 2/3 of stomach, <10 cm
III Laceration > 2 cm GE jxn, >5 cm proximal, >10 cm distal
IV Tissue loss or devascularization < 2/3 of stomach
V Tissue loss or devascularization > 2/3 of stomach

10. GE jxn:
Divide L triangular ligament,
mobilize L lobe of liver
(watch vagus, anomalous L hepatic
in gastrohepatic ligament)
Fundus:
Short gastrics
(to get high on fundus)
Posterior:
divide gastrocolic ligament along greater curvature
(don’t injure transverse mesocolon / middle colic)
Management:
Stomach
Exposure

11. In an anterior hole is discovered, search for a second one
Greater curvature, lesser curvature, posterior can hide holes
Air insufflation through NG tube
Gastrotomy and internal inspection
Also look for nearby injuries
President William McKinley, 1901
GSW to abdomen
Successful repair of multiple gastric wounds
Lived for 8 days (mortality was >80% at this time)
BUT… pancreatic injury missed (this did not happen at
Hopkins)
Management:
Stomach
Operative Treatment

12. Grade I, II: Two layer primary closure
Inner running licked vicryl (hemostatic)
Outer interrupted seromuscular silk
Grade III: Primary hand-sewn or stapled closure
Attention to avoidance of GE or pyloric
stenosis
Grade IV: Proximal or distal gastrectomy
Bilroth I or II reconstruction
May require roux-en-Y
Based on other injuries found
Management:
Stomach
Operative Treatment

13. Management:
Small Bowel

14. Much less common in blunt than
penetrating
Nonetheless, 3rd
most common blunt
abdominal injury
Mechanism:
* Crushing of bowel against the spine
* Sudden deceleration sheering of the
bowel
from its mesentery at a fixed point
* Bursting of “pseudo-closed-loop” from
sudden increase in intraluminal pressure
Management:
Small Bowel
Small Bowel Injury

15. Management:
Small Bowel
Small Bowel Injury Scale
I Hematoma Contusion without devascularization
Laceration Partial thickness, no perforation
II Laceration <50% circumference
III Laceration >50% circumference without transection
IV Laceration Transection of small bowel
V Laceration Transection with segmental tissue loss
Vascular Devascularized segment

16. Management:
Small Bowel
Treatment Grade I

17. Management:
Small Bowel
Treatment Grade II
Transverse
closure preferred
(if possible)

18. Management:
Small Bowel
Treatment Grade III
No difference in hand-swen vs. stapled (Witzke, J Trauma, 2000)
No difference in 1 vs. 2-layer anastomosis (Burch, Ann Surg,
2000)

19. Management:
Small Bowel
Treatment Grade IV
Damage
Control:
Can staple both
ends, control other
intra-abdominal
damage, resuscitate
in ICU, and return to
OR in 24-48 hrs for
delayed primary
anastomosis
(Carillo, J Trauma,
1993)

20. Management:
Small Bowel
Treatment Grade V

21. 24 hrs perioperative abx if this is the only injury
NG decompression until ileus resolves:
* Multi-injured patients have slower return of bowel fxn
* Can decompress stomach if jejunal feeds used (Am Surg
1996)
* Moderately to severely injured patients (ISS between 16
and 25) do better with enteral feeds started 24-48 hrs
postop (Moore, Ann Surg, 1992, many other papers)
High risk of abscess (10-20%), almost always drain
percutaneously
10% postop bowel obstruction, wait 10-14 days and r/o
abscess by CT scan before re-exploring (Pickleman, Ann
Management:
Small Bowel
Postoperative Care

22. Management:
Colon

23. Gordon-Taylor G. Br J Surg 1942.
Most colonic injuries can be fixed primarily, avoid resection,
proximal colostomies possibly for extensive injury or
descending colon injury. 50% Mortality.
Ogilvie WH. Surg Gynecol Obstet 1944.
Colostomy for colon injuries. 60% Mortality.
Led to Circular Letter #178, Office of the Surgeon General
of the United States, mandating colostomy for all colonic
injuries.
Improvement in postoperative care towards the end of WWII
led to 5-20% mortality, credited incorrectly to use of
colostomy.
Woodhall, Ochsner. Surgery 1951. Re-introduced primary
Management:
Colon
Historical Notes – Backwards as Usual

24. Management:
Colon
Colonic Injury Scale
I Hematoma Contusion without devascularization
Laceration Partial thickness, no perforation
II Laceration <50% circumference
III Laceration >50% circumference without transection
IV Laceration Transection of colon
V Laceration Transection with segmental tissue loss
Vascular Devascularized segment

25. Injuries distributed evenly throughout the colon
Sometimes even difficult to diagnose intra-
operatively
Explore all:
Blood staining / hematoma on colonic wall
Injured mesentery in proximity to colonic wall
(may even need to divide one or two terminal
mesenteric vessels for exposure)
Mobilize all colon in injured areas
Follow trajectories if possible
Management:
Colon
Intraoperative Diagnosis

26. Management:
Colon
Suture Repair

27. Management:
Colon
Resection and Primary Repair

28. Management:
Colon
End colostomy

29. Management:
Colon
Exteriorization

30. Management:
Colon
Factors Determining Optimal Tx
Shock (preoperative BP < 80/60)
Hemorrhage (blood loss > 1L)
Multiorgan injury (>2 organ systems)
Significant peritoneal soilage
Delayed operation (>8 hrs post injury)
Nonviable colon (wall destruction or ischemia)
Major loss of abdominal wall (close range blast
injury)
Location of injury (distal vs. proximal to middle
colic)

31. Management:
Colon
Sample Algorithm
Resection required?
NO YES
Suture Repair Proximal to
MCA?
YES
NO
Resection and
ileocolostomy
Evaluate Local
Conditions:
Resection and
Colocolostomy
vs. Hartmann’s

32. Summary
Diagnosis of hollow viscus injury is difficult,
challenges even modern diagnostic modalities,
and requires a high degree of suspicion
Nonoperative management is still possible but
requires compulsive patient monitoring
Outcomes improve if the “evil that lurks within
the abdomen” is diagnosed and treated early
Summary

33. THANK YOU