Presentation on theme: "Surgical Management of Acute Abdominal Injuries"— Presentation transcript:
1Surgical Management of Acute Abdominal Injuries Dr. Wifanto S Jeo SpB-KBDDigestive Surgery DivisionFaculty of Medicine University of IndonesiaCipto Mangunkusumo HospitalJAKARTA
2Topic of Discussion Abdomen and Abdominal Injuries Decision Making in Abdominal TraumaTrauma LaparotomyDamage Control Surgery
3Abdomen and Abdominal Injuries Topic of DiscussionAbdomen and Abdominal InjuriesDecision Making in Abdominal TraumaTrauma LaparotomyDamage Control Surgery
4Abdomen and Abdominal Injuries One of the five sites of life-threatening hemorrhage in the trauma patientAbdominal cavity : BLACK BOX !Should be assessed as part of the circulatory assessment in the primary surveyDiagnosis of an abdominal injury is very difficult particularly in a multiple injury patient who may have reduced conscious level or distracting injuryEmergency in Trauma. Oxford, 2010.
5Spectrum of emergent operations Emergency AbdominalSurgery in Trauma=48%J Trauma 2005;58:657–662
9Clinical Problems in Abdominal Trauma Intra-peritoneal HemorrhageAssociated Injuries … POLYTRAUMA ?Secondary Abdominal Compartment SyndromeHollow-organ PerforationSurgeon’s main Question: To OPEN or NOT ?
11Decision Making in Abdominal Trauma Topic of DiscussionAbdomen and Abdominal InjuriesDecision Making in Abdominal TraumaTrauma LaparotomyDamage Control Surgery
12? Decision Making Stable patient CT Scan Operative Solid organ injury, hypotensiveHollow viscus organ injuryIntraperitoneal bladder injuryDiaphragmatic injuryNon-operative managementObservationInterventional Radiology
13Clinical 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 consciousnessBMJ 2008;336:938-42
14Clinical Finding in Abdominal Injuries Likelihood ratios for useful examination and diagnostic tests in blunt abdominal traumaNo single clinical finding reliably excludes significant injury in blunt abdominal trauma, but a positive bedside ultrasonographic result confirms injury when clinical suspicion is highAnn Emerg Med Apr;63(4):463-4
15These three modalities are complementary FAST – initial diagnostic toolDPL – more restricted indicationCT scan – modality of choice in haemodynamically stableThese three modalities are complementaryand not competitiveAfr Health Sci September; 6(3): 187–190.
16Summary of Clinical Action ATLSSummary of Clinical ActionHaemodynamicAbdominal SignActionUnstable+LaparotomyUncertainFAST or DPLStable+ / UncertainCTEmergency in Trauma. Oxford, 2010.
17Clinical abdominal scoring system (CASS) ScoreAction< 9Clinical Observations9 - 11Auxiliary investigations*> 11Immediate Laparotomy*Auxiliary investigations include US, CT, DPLSTABILITY“… is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality …”LOCAL STATUSInternational Journal of Surgery 2008; 6: 91e95
18Algorithm for Blunt Abdominal Trauma BMJ 2008;336:938-42
19Hollow Viscus ??? Important Notes … Signs of blood loss and hollow viscus injury may initially be subtleA normal FAST does not exclude injuryThe diagnosis or exclusion of hollow viscus injuries can be problematicHollow Viscus ???BMJ 2008;336:938-42
20The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectivelyAm J Emerg Med May;30(4):570-3
21CT was more sensitive (86% vs 53%) and more specific (88% vs 69%) than physical exam Am J Surg Apr;205(4):414-8.
24LaparoscopyMost useful in penetrating trauma to thoraco-abdominal region in haemodynamically stableesp for diaphragm injury: Sens 87.5%, specificity 100%Can repair organs via the laparoscopediaphragm, solid viscera, stomach, small bowel.Disadvantages:poor sensitivity for hollow visceral injury, retroperitoneumComplications from trocar misplacement.If diaphragm injury, PTX during insufflationRosen’s Emergency Medicine, 7th ed. 2009
25Topic of Discussion Trauma Laparotomy Abdomen and Abdominal Injuries Decision Making in Abdominal TraumaTrauma LaparotomyDamage Control Surgery
26(Thorough) Exploration (Adequate) Exposure (Hemorrhage) Control Trauma Laparotomy(Big) Incision(Thorough) Exploration(Adequate) Exposure(Hemorrhage) ControlAcute Care Surgery. Springer, 2008
27(Thorough) Exploration A systematic evaluation of all abdominal contentsSequence of exploration may vary among surgeonsLiver & spleen - root of the mesentery - stomach, duodenum, small bowel, and colon - retroperitoneal structuresAcute Care Surgery. Springer, 2008
28Exposure : R & L medial visceral rotations Acute Care Surgery. Springer, 2008
29Exposure : Exposure of the pancreas Acute Care Surgery. Springer, 2008
30(Hemorrhage) Control Apply a Pringle clamp early to control major bleeding from the liverOperative Technique Severe Liver Injury. Springer, 2015
31Damage 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 areaPhases of DCS:Ph 0 : Damage control resuscitationPh 1 : Abreviated SurgeryPh 2 : ICUPh 3 : Second OperationDamage Control Management in Polytrauma. Springer, 2010
32Damage Control Resuscitation Must address all three components of the “lethal triad”Integrates permissive hypotension, haemostatic resuscitation, and damage control surgeryIn trauma patients predicted to require massive transfusion, FFP:PRC:platelets in a 1:1:1 ratio (of individual units) is associated with improved survivalBMJ 2009;338:b1778
33“Trauma surgery is just general surgery, Abreviated SurgeryApprox. 60 – 90 minutesIf definitive repair is feasible, DO IT !“Trauma surgery is just general surgery,but faster and under blood.” – AnonymousDamage Control Management in Polytrauma. Springer, 2010
34SummaryAcute 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 periodAbbreviated Trauma Laparotomy is the key for successful management