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Surgical Management of Acute Abdominal Injuries Dr. Wifanto S Jeo SpB-KBD Digestive Surgery Division Faculty of Medicine University of Indonesia Cipto.

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Presentation on theme: "Surgical Management of Acute Abdominal Injuries Dr. Wifanto S Jeo SpB-KBD Digestive Surgery Division Faculty of Medicine University of Indonesia Cipto."— Presentation transcript:

1 Surgical Management of Acute Abdominal Injuries Dr. Wifanto S Jeo SpB-KBD Digestive Surgery Division Faculty of Medicine University of Indonesia Cipto Mangunkusumo Hospital JAKARTA

2 Topic of Discussion Abdomen and Abdominal Injuries Decision Making in Abdominal Trauma Trauma Laparotomy Damage Control Surgery

3 Topic of Discussion Abdomen and Abdominal Injuries Decision Making in Abdominal Trauma Trauma Laparotomy Damage Control Surgery

4 Abdomen and Abdominal Injuries One of the five sites of life-threatening hemorrhage in the trauma patient Abdominal cavity : BLACK BOX ! Should be assessed as part of the circulatory assessment in the primary survey Diagnosis of an abdominal injury is very difficult particularly in a multiple injury patient who may have reduced conscious level or distracting injury Emergency in Trauma. Oxford, 2010.

5 Spectrum of emergent operations J Trauma 2005;58:657–662 Emergency Abdominal Surgery in Trauma = 48%

6 Mechanism of Injury BLUNT PENETRATING

7 Common Injuries in Blunt Trauma Trauma Biomechanics 4 th ed. Springer 2014

8 West J Med 1974; 120:

9 Clinical Problems in Abdominal Trauma 1.Intra-peritoneal Hemorrhage 2.Associated Injuries … POLYTRAUMA ? Secondary Abdominal Compartment Syndrome 3.Hollow-organ Perforation Surgeon’s main Question: To OPEN or NOT ?

10 ACUTE CARE SURGICAL CASE PRIORITY

11 Topic of Discussion Abdomen and Abdominal Injuries Decision Making in Abdominal Trauma Trauma Laparotomy Damage Control Surgery

12 Stable patient CT Scan Operative – Solid organ injury, hypotensive – Hollow viscus organ injury – Intraperitoneal bladder injury – Diaphragmatic injury Non-operative management – Observation – Interventional Radiology ? Decision Making

13 Clinical Examination in Abdominal Trauma Unlike penetrating abdominal trauma, where management is largely determined clinically, the diagnosis of blunt abdominal injury by clinical examination is unreliable, particularly in patients with a decreased level of consciousness BMJ 2008;336:938-42

14 Clinical Finding in Abdominal Injuries Likelihood ratios for useful examination and diagnostic tests in blunt abdominal trauma No single clinical finding reliably excludes significant injury in blunt abdominal trauma, but a positive bedside ultrasonographic result confirms injury when clinical suspicion is high Ann Emerg Med Apr;63(4):463-4

15 FAST – initial diagnostic tool DPL – more restricted indication CT scan – modality of choice in haemodynamically stable Afr Health Sci September; 6(3): 187–190. These three modalities are complementary and not competitive These three modalities are complementary and not competitive

16 Summary of Clinical Action HaemodynamicAbdominal SignAction Unstable+Laparotomy UnstableUncertainFAST or DPL Stable+ / UncertainCT Emergency in Trauma. Oxford, ATLS

17 Clinical abdominal scoring system (CASS) International Journal of Surgery 2008; 6: 91e95 *Auxiliary investigations include US, CT, DPL STABILITY LOCAL STATUS “… is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality …”

18 Algorithm for Blunt Abdominal Trauma BMJ 2008;336:938-42

19 Important Notes … Signs of blood loss and hollow viscus injury may initially be subtle A normal FAST does not exclude injury The diagnosis or exclusion of hollow viscus injuries can be problematic BMJ 2008;336: Hollow Viscus ???

20 The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively Am J Emerg Med May;30(4):570-3

21 CT was more sensitive (86% vs 53%) and more specific (88% vs 69%) than physical exam Am J Surg Apr;205(4):414-8.

22 SOP FKUI RSCM

23

24 Laparoscopy Most useful in penetrating trauma to thoraco- abdominal region in haemodynamically stable – esp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscope – diaphragm, solid viscera, stomach, small bowel. Disadvantages: – poor sensitivity for hollow visceral injury, retroperitoneum – Complications from trocar misplacement. – If diaphragm injury, PTX during insufflation Rosen’s Emergency Medicine, 7 th ed. 2009

25 Topic of Discussion Abdomen and Abdominal Injuries Decision Making in Abdominal Trauma Trauma Laparotomy Damage Control Surgery

26 Trauma Laparotomy (Big) Incision (Thorough) Exploration (Adequate) Exposure (Hemorrhage) Control Acute Care Surgery. Springer, 2008

27 (Thorough) Exploration A systematic evaluation of all abdominal contents Sequence of exploration may vary among surgeons – Liver & spleen - root of the mesentery - stomach, duodenum, small bowel, and colon - retroperitoneal structures Acute Care Surgery. Springer, 2008

28 Exposure : R & L medial visceral rotations Acute Care Surgery. Springer, 2008

29 Exposure : Exposure of the pancreas Acute Care Surgery. Springer, 2008

30 (Hemorrhage) Control Apply a Pringle clamp early to control major bleeding from the liver Operative Technique Severe Liver Injury. Springer, 2015

31 Damage Control Surgery The decision to abort operative intervention must be made early, even prior to the arrival of the patient if there is hypotension in transport or in the trauma resuscitation area Phases of DCS: – Ph 0 : Damage control resuscitation – Ph 1 : Abreviated Surgery – Ph 2 : ICU – Ph 3 : Second Operation Damage Control Management in Polytrauma. Springer, 2010

32 Damage Control Resuscitation Must address all three components of the “lethal triad” Integrates permissive hypotension, haemostatic resuscitation, and damage control surgery In trauma patients predicted to require massive transfusion, FFP:PRC:platelets in a 1:1:1 ratio (of individual units) is associated with improved survival BMJ 2009;338:b1778

33 Abreviated Surgery Approx. 60 – 90 minutes If definitive repair is feasible, DO IT ! “Trauma surgery is just general surgery, but faster and under blood.” – Anonymous Damage Control Management in Polytrauma. Springer, 2010

34 Summary Acute abdominal injuries require early surgical consult to assess the need for Surgical Intervention “Damage Control” should begin as early as possible, even from pre hospital period Abbreviated Trauma Laparotomy is the key for successful management


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