Abdominal Injuries

ABDOMINAL INJURIES Prof.Dr. Turgut İPEK

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Resuscitation and Evaluation   

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Resuscitation Evaluation of the Patient with Blunt Trauma Evaluation of the Patient with Penetrating Trauma

Treatment       

Abdominal wall injuries Liver injuries Splenic injuries Biliary tract injuries Pancreatic injuries Gastrointestinal tract injuries Genitourinary tract  Injuries of to the male genitalia  Uterine injuries  Urethral injuries  Bladder injuries  Kidney injuries

Resuscitation and Evaluation 1 Resuscitation 1. 2.

Does the patient need an abdominal operation? Will the patient tolerate the time required for diagnostic maneuvers before surgery is performed?

Resuscitation and Evaluation 2  Airway  

maneuvers

Endotracheal intubation Tube thoracostomy (pneumothorax, hemothorax)

 Circulation 

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IV lines (upper extremity, neck, thoracic inlet) (jugular, subclavian catheter) Nasogastric tubes (blood) Bladder catheterization Tetanus toxoid, antibiotics

Evaluation of the Patient with Blunt Trauma 1 Difficult: 1. 2. 3.

Multiple injuries (head, extremities, thorax) Acute alcoholic + intoxication, drug abuse Solid organs bleeds slowly

Evaluation of the Patient with Blunt Trauma 2 Clinical Manifestations  

A careful history Physical examination 

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Hypotension or peritonitis

Inspection Fractures in the lower six ribs? Contusion over the lower chest?

Suspect: Liver or Spleen injury 

Palpation

Peritonitis (involuntary guarding, rigidity, rebound tenderness)

Evaluation of the Patient with Blunt Trauma 3 Diagnostic Procedures Radiologic Findings    

Plain X-ray (Free air bubbles in the ruq) Chest X-ray Gross hematuria : IVP Retrograde cystography (blood at the meatus)

Examination and Observation False + (% 43) False – (% 21)

Evaluation of the Patient with Blunt Trauma 4 

DIAGNOSTIC PERITONEAL TAP/LAVAGE (DPL)

Indications    

Altered sensorium from a head injury, drug ingestion, or alcohol intoxication Altered sensation from a spinal cord injury Rib or vertebrae fractures Equivocal findings on physical examination

Relative Contrindications    

Abdominal scars Latter stages of pregnancy Morbid obesity Coagulopathy

Evaluation of the Patient with Blunt Trauma 5 Diagnostic Peritoneal Tap/Lavage (DPL)    

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Local anesthesia, 2-3 cm vertical midline incision, 3-4 cm below the umblicus 20 ml gross blood, feces, bile, food, intestinal fluid (+) 1000 ml normal saline (10+15 ml/kg child) RBC > 100.000 /mm3 WBC> 500 / mm3 + DPL Gram stain 24 h observation and repeated examinations

Evaluation of the Patient with Blunt Trauma 6 Ultrasound 

Liver, spleen, pancreas and kidney injuries

CT 1. 2. 3. 4.

Stable patients with closed head injury Stable patients with an equivocal abd. exa. Patients with hematuria Pelvic fractures

Retroperitoneal structures (pancreas, kidney) Arteriography Laparoscopy 

Evaluation of the Patient with Penetrating Trauma Clinical Manifestations  How did it happen? (the tract)  Physical examination 

Hypotension, distension, peritonitis hematemesis, proctorrhagia, hematuria

Diagnostic Procedures Radiologic Findings Plain X-ray (free air, missile) IVP Observation DPL (anterior abdomen, lower chest or flanks) tangential gunshot wounds

Stab Wounds  Local wound exploration and DPL and examinations  Back wounds (colon?, observation) contranst-enhanced CT enema Gunshot Wound Automatic laparotomy Tangential (observation or DPL) Shotgun Wound Peritoneal penetration by pellets? Observation Lateral X-ray

Frequency of Organ Injury in Blunt ABD Trauma Organ injured Spleen Liver Colon Small Bowel Kidney Pancreas Duodenum Bladder

Frequency % Admission 57.2 46.6 12.8 12.2 9.5 6 5.4 4.3

Frequency % Celiotomy 57.7 44.6 14 14 8.4 6.2 6 3.8

Frequency of Organ Injury in Stab Wounds of the ABD Organ injured Liver Small bowel Diaphragm Colon Stomach Major vascular Kidney Spleen Pancreas Gallbladder Duodenum

Frequency (%) 39.3 31.6 19.6 15.3 12.6 10.3 9 7 6 2.3 1.6

Frequency of Organ Injury in Gunshot Wounds of the ABD Organ injured Small bowel Colon Liver Vascular Stomach Kidney Duodenum Diaphragm Spleen Bladder Gallbladder Pancreas Rectum Other

Frequency (%) 49.3 41.6 29.3 24.6 17.3 17 11 10 7.6 7.3 7 6 3.3 4

Liver Injuries 1  The

most commonly injured organ Mechanism of Injury 

Direct blows, comression or shearing

Clinical Manifestations  

Profound hypotension Marked abdominal distension

DPL, CT

Liver Injuries 2 Treatment Nonoperative Approach 3. Simple hepatic parenchymal laceration or intrahepatic hematoma 4. No evidence of active bleeding 5. Intraperitoneal blood loss < 250 ml 6. Absence of other intraperitoneal injuries requiring operation Subcapsular or Intrahepatic Hematoma Nonoperative management (bed rest, nbm, antibiotics)

Liver Injuries 3 General Principles of operation Pringle Maneuver (Clamping of porta hepatis 10-15 minute is recommended but 30 mn. is acceptable) Mobilization of Lobe Compression, Topical Agents (Surgical, Spongostan) Fibrin Glue Suture Hepatorrhaphy Hepatotomy with Selective Vascular Ligation Omental Pack Resectional Debridement with Selctive Vascular Ligation Resection Selective Hepatic Artery Ligation Perihepatic Packing

Liver Injuries 4 Complications Hemorrhage/Hemobilia Intraabdominal Abscess Hyperpyrexia Biliary Fistulae

Spleen 1 Incidence  The most commonly injured organ in blunt abdominal trauma Mechanism of Injury  Deceleration-type trauma causes capsular tears

Spleen 2 Diagnosis Clinical Manifestations  Hypotension (1/3)  Kehr’s Sign: pain at the tip of the left shoulder in the head down position (% 50)  Leukocytosis (> 15.000)

Spleen 3 Radiologic Findings 2. Elevation of the left hemidiaphragm 3. Enlargement of the splenic shadow 4. Medial displacement of the gastric bubble 5. Widening of the space between splenic flexure and the preperitoneal fat pad

Spleen 4 CT  Extremely useful both in detection and fallowing the healing Treatment Importance of the Spleen  Immunologic importance. The risk of septicemias from encapsulated microorganisms (pneumococcus, meningococcus, and hemoplhilus) in the first 2 years after splenectomy. OPSI (Overwhelming postsplenectomy infection) mortality 30 %

Spleen 5 Nonoperative Approach 1. No hemodynamic instability 2. No peritoneal findings 3. No need more than 2 units of blood Splenectomy Splenorrhpy Partial splenectomy

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Resuscitation and Evaluation   



Resuscitation Evaluation of the Patient with Blunt Trauma Evaluation of the Patient with Penetrating Trauma

Treatment       

Abdominal wall injuries Liver injuries Splenic injuries Biliary tract injuries Pancreatic injuries Gastrointestinal tract injuries Genitourinary tract  Injuries of to the male genitalia  Uterine injuries  Urethral injuries  Bladder injuries  Kidney injuries