ABDOMINAL TRAUMA

Dr. R. MUTHUKRISHNAN M.S., M.Ch., PROF &HOD DEPT OF SURGICAL GASTROENTEROLOGY & PROCTOLOGY GOVT. RAJAJI HOSPITAL MADURAI MEDICAL COLLEGE MADURAI

ABDOMINAL TRAUMA
BLUNT TRAUMA PENETRATING TRAUMA GUN SPOT KNIVES BULL GORE

PATHOPHYSIOLOGY
I SUDDEN PRONOUNCED RISE OF INTRAABDOMINAL PRESSURE CAUSED BY OUTWARD FORCES CAUSE RUPTURE OF HALLOW VISCUS / BURST INJURY OF SOLID ORGAN. II COMPRESSION OF ABDOMINAL VISCERA BETWEEN THE APPLIED FORCE OF THE ANTERIOR ABDOMINAL WALL AND POSTERIOR THORACIC CAGE OR VERTEBRAL COLUMN CAN PRODUCE A CRUSH INJURY. III ABRUPT SHEARING FORCE CAN CAUSE A TEAR OF ORGAN OR VASCULAR PEDICLES.

PATTERN OF INJURY ENCOUNTERED AT LAPAROTOMY FOLLOWING BLUNT TRAUMA

SPLEEN LIVER MESENTERY UROLOGIC PANCREAS SMALL BOWEL COLON DUODENUM VASCULAR STOMACH GALL BLADDER 46 % 33 % 10 % 9% 9% 8% 7% 5% 4% 2% 2%

Initial Evaluation
Evaluation of vitals and resuscitation should be done concurrently Directed to establishment of 1.airway 2.breathing 3.circulation If the patient is in shock, large bore I.V cannula is inserted at one or two sites and rapid fluid replacement given If the patient is shocked due to concealed intra abdominal haemorrhage IVF shold not be rushed to raise the BP to prepretrauma level,it is enough if the systolic is around 100mmhg. If the BP is raised to pre-trauma level there may be torential prebleeding before the patient is taken to OT


EVALUATION
 

    

HISTORY PHYSICAL EXAMINATION ECCHYMOSIS / ABRASION FRACTURED RIBS TENDERNESS / GUARDING REBOUND TENDERNESS PAIN BLOOD ON RECTAL EXAMINATION LABORATORY INVESTIGATION RADIOLOGY DIAGNOSTIC PERITONEAL LAVAGE ULTRASOUND ABDOMEN, CT DIAGNOSTIC LAPAROSCOPY

Investigation


UrineUrine-albumin -sugar -RBCs-urinary tract injury RBCsBlood -haematocrit value -serial estimation of pcv done at hourly intervalintervala decreasing trend indicates concealed haemorrhage -bleeding & clotting time -serum electrolytes -serum amylase- a rise indicates pancreatic amylaseinjury

Radiological examination
Only if the patient is haemodynamically stable  Plain x-ray abdomen,erect view xair under the diaphragm-hollow viscus injury diaphragmLoss of kidney & psoas shadow-renal injury & shadowretroperitoneal haematoma Air in the retroperitoneal space-injury to the spaceduodenum,ascending & descending colon in their posterior wall Displacement of gastric bubble & indentation of splenic flexure-splenic injury flexure

Intravenous urography only if the patient is stable extravasation of the dye indicates injury to the kidney, ureter & bladder presence of two kidney,if nephrectomy is planned on one side if the patient is unstable, a single shot I.V.U at 20mins can be done Ascending cysto urethrogram for urinary bladder Gastrograffiin contrast duodenography picture taken in right lateral decubitus after Installing 250ml through ryles tube-extravasation tubeindicates duodenal injury

USG abdomen & pelvis

 

Most commonly used Indications of USG -haemoperitoneum -solid organ haematoma Advantages Rapid & cheap NonNon-invasive & safe no radiation Accuracy -98%,in solid organ injury Easily repeatable Portable handset- avaliable for bedside handsetDisadvantages missing a hollow viscus injury

Contrast enhanced CT scan abdomen/pelvis



Indications -haemodynamically stable -delayed cases for more than 12 hours -no overt signs of peritoneal irritation -pelvic fractures -DPL results equivocal -DPL could not be done-obesity, pregnancy, previous donelaparotomy  Contra indication patient in shock

LIVER INJURY SCALE (1994 REVISION)



Gr I Haematoma Laceration

Gr II Heamatoma

Laceration

Subcapsular < 10 % surface area Capsular tear < 1 cm parenchymal depth Subcapsular 10 % 50 % surface area Intra Parenchymal < 10 cm in diameter 1 3 cm Parenchymal depth < 10 cm in length

LIVER INJURY SCALE

Gr III Heamatoma

Subcapsular > 50 % surface area or expanding; Ruptured subcapsular (or) Parenchymal Heamatoma Intra parenchymal Haematoma > 10 cm or expanding > 3 cm parenchymal depth

Laceration

HEPATIC TRAUMA
Gr IV LACERATION PARENCHYMAL DISRUPTION INVOLVING 25 75 % OF HEPATIC LOBE (OR) 1 -3 COUINAUDS SEGMENTS WITHIN A SINGLE LOBE

HEPATIC TRAUMA
Gr V LACERATION PARENCHYMAL DISRUPTION INVOLVING >75 % OF HEPATIC LOBE (OR) > 3 COUINAUDS SEGMENTS WITHIN A SINGLE LOBE JUXTA HEPATIC VENOUS INJURIES (ie.,) RETROHEPATIC VENA CAVA / CENTRAL MAJOR HEPATIC VEINS HEPATIC AVULSION

VASCULAR

Gr VI VASCULAR

HEPATIC TRAUMA DIAGNOSIS

I Diagnostic Peritoneal Lavage - Replaced by U/S and CT - Accuracy 98 %

DRAWBACKS: 1. Lacks Specificity as which organ system has been injured. 2. Too sensitive to detect minute quantities of blood. 3. Inaccuracy in detecting retroperitoneal and diaphragmatic injuries.

HEPATIC TRAUMA II. Ultrasonography

Greater familiarity with the technique. 2. Can be done A+ bed side. 3. Ability to determine the presence of intraperitoneal blood usually within 2 minutes. 4. Relative inexpensiveness of the procedure. Sensitivity 81.5% Specificity 99%
1.

HEAPTIC TRAUMA III. CT SCANNING

1.

2.

3.

Accurately delineate the anatomy of the injury. Volume of retroperitoneal blood can be accurately measured. Status of retroperitoneal structures and Gastrointestinal tract can be assessed.

Non operative Management of Hepatic Blunt injury

50 82 % of all Blunt Hepatic injuries managed by nonnon-operative method. Criteria: 1. Haemodynamic stability. 2. CT Scan delineation of injury. 3. Lack of associated enteric (or) retroperitoneal injuries on CT Scan. 4. Absence of peritoneal signs. 5. Limited number of Hepatic related transfusions during the period of observation. 6. AAST Grade I III

RESUMPTION OF NORMAL ACTIVITIES

Resumption of Normal Activities - After 8 weeks Hepatic Parenchymal wound bursting strength exceeds normal hepatic parenchymal bursting strength in 6 weeks due to proliferative fibrotic process due to healing by secondary intention.

Non Operative Management of Hepatic Blunt Injury

Complication Rate 5 % 1. Bleeding 3.5 % 2. Perihepatic abscess / biloma 3. Missed intra abdominal injuries 4. Biliary ductal disruption and subsequent strictures formation

Operative Management of Hepatic Injuries

Incision Midline for wide Exposure. Manual Compression of Hepatic injury while the anaesthetic team performs intraoperative resuscitation Gr III & IV Hepatic injuries are managed by 1. Portal triad occlusion 2. Finger Fracture of Hepatic Parenchyma (Hepatotomy) to expose lacerated bile ducts and blood vessels to direct ligation or repair.

Operative Management of Hepatic Injuries

3.

4.

5.

6.

Debridement of nonviable hepatic parenchyma. Insertion of a viable omental pedicle into the injury site. Closed Suction drainage for Grade III to IV Hepatic injuries. Perihepatic packing.

PRINGLE MANEUVER (PORTAL TRIAD OCCLUSION)

 

Mean occlusion time 30 minutes. Liver tolerates normo thermic ischaemia upto 90 minutes Topical hypothermia (cooling the liver to 30 to . 32 c) and single intravenous bolus of steroids (30 40 mg/kg of methyl prednisolone succinate) extend normothermic ischaemic time of liver. (Pachter et al)

Intrahepatic Haemostasis Hepatorraphy By the finger fracture techniques

  

Indication in Grade III to IV injuries. Successful in 93.5 % Morbidity 15 %

  

Postoperative Bleeding (1.9 %) Perihepatic / Introheaptic abscess (7.5 %) Biliary Fistula (5.6 %)

PERIHEPATIC PACKING
Necessary in 4 5 % Patients undergoing operative Mangement of hepatic injuries. Indication: 1. Onset of Intraoperative Coagulopathy 2. Failure of other Maneuvers to control Haemorrhage. 3. Presence of Subcapsular haematoma 4. Presence of Bilobar injuries

Perihapatic packs usually removed after 48 72 hours Mean Survival 72 %

Operative Management of Hepatic Injuries

DRAINAGE
-

Closed suction drainage is superior to open drainage No drains advised in Grade I & II injuries Closed suction drains advocated in Grade III to V injuries

Persistent bleeding from deep tears

Bleeding arrested

Bleedding continues

Pringle manoeuvre

Bleeding arrested
Bleeding from portal vein/hepatic artery Do hepatic artery ligation/clamping of porta hepatis

Bleedding continues

Liver resection with/without caval shunt

Stiil bleeding

Temporary liver packing & re-exploration after 24 48 hours

Bear Claw Injury

SPLENIC INJURY SCALE

GRADE I HAEMATOMA SUBCAPSULAR NON EXPANDING < 10 % SURFACE AREA CAPSULAR TEAR NON BLEEDING < 1 CM PARENCHYMAL DEPTH SUBCAPSULAR NON EXPANDING 10 50 % SURFACE AREA INTRAPARENCHYMAL NON EXPANDING < 2 CM IN DIAMETER CAPSULAR TEAR, ACTIVE BLEEDING

LACERATION

II HAEMATOMA

LACERATION

SPLENIC INJURY SCALE

Gr III HAEMATOMA SUBCAPSULAR > 50 % SURFACE AREA (OR) EXPANDING RUPTURED SUBCAPSULAR HEMATOMA ACTIVE BLEEDING INTRAPARENCHYMAL HAEMATOMA > 2 CM (OR) EXPANDING > 3 CM PARENCHYMAL DEPTH (OR) INVOLVING TRABECULAR VESSELS.

LACERATION

SPLENIC INJURY SCALE

Gr IV HAEMATOMA RUPTURED INTRAPARENCHYMAL HAEMATOMA WITH ACTIVE BLEEDING LACERATION INVOLVING SEGMENTAL (OR) HILAR VESSELS PRODUCING MAJOR DEVASCULARIZATION (> 25 % SPLEEN)

LACERATION

SPLENIC INJURY SCALE

Gr V
LACERATION COMPLETELY SHATTERED SPLEEN HILAR VASCULAR INJURY THAT DEVASCULIRIZES SPLEEN

VASCULAR

SPLENIC INJURIES
DIAGNOSTIC METHODS - PLAN X-RAY ABDOMEN X- DIAGNOSTIC PERITONEAL LAVAGE 98 % - ULTRASOUND ABDOMEN 70 % - CT ABDOMEN 85 % - ARTERIOGRAPHY 90 % - SCINTIGRAPHY 70 % - DIAGNOSTIC LAPAROSCOPY 100 %

NON OPERATIVE TREATMENT OF SPLENIC INJURY

 

 

90 % IN CHILDREN SPLENIC CAPSULE IN CHILD IS THICKENED CONTAIN MYOEPITHLIAL CELLS BLUNT TRAUMA WITH ISOLATED SPLENIC INJURY (Gr I, II, III) HAEMODYNAMICALLY STABLE DIAGNOSIS AND DEGREE OF INJURY ASSESSED BY CT PATIENT TO BE MONITORED IN ICU

Surgical management
 

Routine spleenectomy Splenic salvage is planned, espically in young patients to avoid immunosupression a) for grade 1& 2 injuries -electro cautery - argon beam cautery - topical haemostatic agent fibrin glue,gel foam,etc

b) for grade 3 injury - evacuate the haematoma - suture ligation of bleeding vessels - debridement of devitalised tissues - interlocking mattress suture with no.1 size chromic catgut over teflon pledges c) for grade 4 injury - segmental resection - ligate segmental arteries in the hilum - then excise the injured segment - capsular suture - pedicled omentum cover

d) for grade 4 injury

- splenectomy - reimplantation of 5 small fragement of spleen (40 x 40 x 3 mm size) in the greater omentum - no drain - post operatively, poly anti-pneumoccocal antivaccine

SPLENECTOMY
INDICATED
-

IN PATIENTS REMAIN SHOCK AFTER CONTROL OF SPLENIC PEDICLE IN PATIENTS WITH OTHER LIFE THREATENING PROBLEMS SUCH AS HEAD TRAUMA, THORACIC TRAUMA IN PATIENTS WITH MEDICAL CONTRAINDICATION FOR PROLONGED SURGERY IN PATIENTS > 30 YRS Gr V INJURY

SPLENIC TRAUMA COMPLICATIONS

       

ATELECTASIS PNEUMONIA LT. PLEURAL EFFUSION LT. SUBPHRENIC ABSCESS 3 13 % OPSI DEEP VIEN THROMBOSIS, PUL. EMBOLISM POST OP. BLEEDING POST TRANSFUSION HEPATITIS 7-50 % 7-

CT showing contained haematoma

Resolved splenic haematoma

PANCREATIC TRAUMA
MORTALITY 10 25 % MORBIDITY 30 40 % MECHANISM OF INJURY - High energy crushing force applied to upper abdomen - 60 % due to impact with steering wheel - 8 % pancreatic trauma reveals hyper amylasemia

INVESTIGATIONS
 

CT ABDOMEN / MRCP INTRA OPERATIVE PANCREATOGRAM

PANCREATIC INJURIES
MANAGEMENT IS BASED ON 1. ASSOCIATED ORGAN INJURY PARTICULARLY DUODENUM. 2. DEGREE OF PANCREATIC PARENCHYMAL DISRUPTION. 3. INTEGRITY OF THE MAIN PANCREATIC DUCT AND AMPULLA.

PANCREATIC TRAUMA MANAGEMENT

1.

2. 3.

4.

Control Haemorrhage and contain Bacterial contamination Debride devitalized pancreatic tissue Preserve atleast 20 to 50 % Functional pancreatic tissue whenever possible Provide adequate internal (or) External drainage of pancreatic injuries or Resection

PANCREATIC TRAUMA
TYPE I CONTUSSIONS & LACERATIONS WITHOUT DUCT INJURY
-

60 % OF PANCREATIC INJURIES HAEMOSTASIS & SIMPLE EXTERNAL DRAINAGE LOW FAT HIGH PH ELEMENTAL DIET NEEDLE CATHETER JEJUNOSTOMY / FEEDING TUBE JEJUNOSTOMY

PANCREATIC TRAUMA
TYPE II DISTAL TRANSECTION AND DISTAL PARENCHYMAL INJURY WITH DUCT DISRUPTION - DISTAL PANCREATECTOMY TYPE III PROXIMAL TRANSECTION OR INJURY WITH PROBABLE DUCT DISRUPTION - DISTAL PANCREATECTOMY - ROUX-EN-Y PANCREATICO JEJUNOSTOMY. ROUX-EN-

TYPE IV COMBINED PANCREATICO DUODENAL INJURIES

1.

2.

3.

CBD & AMPULLA INTACT DUODENAL INJURY REPAIR PRIMARILY WITH OR WITHOUT TUBE DUODENOSTOMY SEVERE INJURY TO DUODENUM & PANCREAS DUODENAL DIVERTICULIZATION (OR) PYLORIC EXCLUSION. MASSIVE INJURY DUODENUM & HEAD OF PANCREAS WITH DISRUPTION OF CBD, AMPULLA & PANCREATIC DUCT PANCREATICO DUODENECTOMY.

PYLORIC EXCLUSION
LESS MORBID FIRST DONE BY VAUGHAN - SUTURE CLOSURE OF PYLORIC RING WITH ABSORBABLE (OR) NON ABSORBABLE SUTURES - GASTRO JEJUNOSTOMY

DUODENAL DIVERTICULIZATION
SUMMERS 1904 BERNE PRIMARY CLOSURE OF DUODENAL WOUND ANTRECTOMY, VAGOTOMY AND GASTROJEJUNOSTOMY TTUBE COMMON BILE DUCT DRAINAGE TUBE DUODENOSTOMY

PANCREARTIC TRAUMA COMPLICATIONS

MORBIDITY 20 35 % MORTALITY 10 20 % - PANCREATIC FISTULA - ABSCESS - SECONDARY HAEMORRHAGE - PSEUDOCYSTS - PANCREATITIS

CT PANCREATIC INJURY
PANCREATIC HEAD INJURY

PANCREATIC NECK INJURY

PANCREATIC TAIL INJURY

ERCP PANCREATIC INJURY

PANCREATIC HEAD INJURY

PANCREATIC DUCT INJURY

PANCREATIC DUCT INJURY

(STENTING DONE)

M.R.C.P


Valuable in evaluating pancreatic duct Unreliable early after injury Useful for delayed diagnosis & management

GRADE I PANCREATIC INJURY

GRADE IV PANCREATIC INJURIES

(GUN SHOT)

DISTAL PANCREATECTOMY WITH SPLENIC PRESERVATION

GRADE III PANCREATIC INJURY

Roux-en-y- Pancreatico jejunostomy

DISTAL PANCREATECTOMY WITH SPLENIC PRESERVATION

ROUX-EN-Y- PANCREATICO JEJUNOSTOMY

GRADE V INJURIES
Pancreatico duodenectomy

PYLORIC EXCLUSION (VAUGHN)

  

For grade III injuries Repair of duodenal wound Gastrostomy in dependent portion of stomach Pylorus closed with non absorbable suture material through the gastrostomy site Followed by gastro jejunostomy

DUODENAL DIVERTICULIZATION (BERNE)



      

For major duodenal injury or combined pancreatico duodenal injury Gastric antrectomy Closure of duodenum Billroth II gastro jejunostomy Vagotomy Duodenal laceration closed Tube duodenostomy T tube in CBD / tube cholecystostomy

DUODENAL INJURY
INCIDENCE 3.7 % MECHANISM OF INJURY CRUSHING / BURSTING / SHEARING FORCE SERUM AMYLASE 50 % RADIOGRAPHY:
-

INTRAPERITONEAL / RETROPERITONEAL AIR AIR IN THE BILIARY TREE, SCOLIOSIS OBLITERATION OF PSOAS SHADOWS RETROPEROTONEAL AIR AROUND KIDNEY

GASTROGRAFFIN STUDY CT WITH ORAL CONTRAST

EVOLUATION OF SEVERITY OF DUODENAL INJURY

MILD AGENT SIZE SITE INJURY REPAIR INTERVAL (HR) ADJACENT INJURY STAB < 75 % WALL III & IV PART < 24 HOURS NO CBD

SEVERE BLUNT (OR) MISSILE > 75 % WALL I & II PART > 24 HOURS CBD

DUODENAL INJURY REPAIR

-

SIMPLE REPAIR - (DUODENORRAPHY) SEROSAL PATCH ROUXROUX-Y DUODENO JEJUNOSTOMY DIVERTICULIZATION PYLORIC EXCLUSION PANCREATICO DUODENECTOMY

GASTRIC INJURIES
50 80 % PRESENTS WITH PERITONEAL IRRITATION OR SHOCK MORBIDITY 27 % MORTALITY 14 % WOUNDS MOST LIKELY MISSED AREAS 1. GASTROOESOPHAGEAL JUNCTION 2. GREATER CURVATURE AT THE OMENTAL AND SPLENIC ATTACHMENTS 3. LESSER CURVATURE AT THE GASTRO HEPATIC LIGMENT 4. POSTERIOR WALL OF STOMACH

GASTRIC INJURIES MANAGEMENT

WOUND DEBRIDEMENT AND REPAIR 2 LAYER CLOSURE

GASTRIC INJURIES COMPLICATION

      

INTRA ABDOMINAL ABSCESS DISRUPTION OF THE GASTRIC REPAIR FISTULA FORMATION EMPYEMA MISSED INJURIES HAEMORRHAGE OBSTRUCTION

Small gut injury



Grading

I -hematoma intra mural

- no devasularisation of bowel - laceration- partial thickness only laceration- no perforation II laceration tear involving < 50% of the circumference

III -laceration - tear involving > 50% of the circumference - no transection IV - transection of the gut ;no tissue loss V -laceration transection with segmental tissue loss - vascular gangrene of the bowel

SMALL BOWEL INJURIES

PRINCIPLES DURING LAPAROTOMY


THROUGH EXAMINATION BY SURGEON AND ASST. FROM LIG OF TREITZ TO ILEOCAECAL VALVE MESENTRIC HAEMATOMA ADJACENT TO BOWEL TO BE OPENED AND EXAMINED THOROUGHLY DEBRIDE OR RESECT ANY BOWEL OF QUESTIONABLE VIABILITY BOWEL RESECTION IS INDICATED IF THE LENGTH OF AN ENTERORRAPHY EXCEEDS ONE HALF THE BOWEL DIAMETER/MULTIPLE INJURIES OCCUR IN PROXIMITY OR A SEGMENT OF BOWEL IS DEVASCULARISED

SMALL BOWEL INJURIES COMPLICATIONS

     

HAEMORRHAGE WOUND INFECTION ANASTOMOTIC FAILURE FISTULA ABSCESS OBSTRUCTION

PRINCIPLES OF REPAIRS OF COLON INJURY

1.

2.

3.

4.

PRIMARY REPAIR IS SAFE IN CAREFULLY SELECTED CASES COLOSTOMIES SHOULD NOT BE ABANDONED BECAUSE OF FEAR OF THE MORBIDITY ASSOCIATED WITH ITS CLOSURE THE DIFFERENCE BETWEEN INJURIES ON THE RIGHT AND LEFT COLON IS QUESTIONABLE EXRERIORIZED REPAIR FREQUENTLY REQUIRES CONVERSION TO COLSOTOMY

PRINCIPLES OF REPAIR OF COLON INJURY

5.

6.

7.

SHORT TERM PERIOPERATIVE SINGLE ANTIBIOTIC COVERAGE IS SUFFICIENT USE OF DRAINS CANNOT BE SUPPORTED IN MOST INSTANCES WOUNDS ARE BEST LEFT OPEN IN PATIENTS WITH SIGNIFICANT CONTAMINATION.

COLON INJURIES - METHODS OF REPAIR

  

PRIMARY REPAIR EXTERIORIZED REPAIR COLOSTOMY

COLON INJURIES
1. 2.

3.

4. 5. 6.

AGE MECHANISM OF INJURY NO. OF BLOOD TRANSFUSION ASSOCIATED INJURIES SHOCK FAECAL CONTAMINATION

7. 8.

9.

10.

11. 12.

WOUND CLOSURE DELAY BETWEEN INJURY AND REPAIR SEVERITY OF COLON INJURY LOCATION OF COLON INJURY DRAIN ANTIBOTICS

Retroperitoneal hematoma
Sub division of retroperitoneal spaces zone:1zone:1- central (midline & paramedian area around the I.V.C & aorta) zone:2zone:2- lateral (flanks) perinephric area zone:3zone:3- pelvic  Aetiology zone:1zone:1- injury to pancreas,duodenum,I.V.C,aorta zone:2zone:2- injury to colon,kidney zone:3zone:3- fracture pelvis


Indication for surgical exploration zone:1zone:1-always zone:2zone:2- expanding hematoma - adjacent to colon - evidence of kidney injury zone:3zone:3- never,in Indication for surgical exploration blunt abdominal trauma because torrential bleeding will occur once the posterior peritoneum is incised annd the tamponade action is released.so threapeutic embolisation only is indicated

Blunt injury abdomen in children



Unfavourable features: - poorly developed abdominal wall musculature - smaller antero-posterior diameter of abdomen antero- urinary bladder is intra abdominal - intra thoracic abdomen is negligible.all the abdominal viscera are more vulnerable for injury - clinical unco-operation unco- unco-operation for investigations like CT scan unco- poor physiological response to trauma  Favourable features: - ribs are pliable;hence do not fracture easily

Thank u Thank u