1. Abdominal injuries Yoram Klein MD

2. Introduction  Suture repair of bowel - the 15th century.  Routine exploration not employed until WW I. – mortality 70-75%.  WW II – mortality 50%.

3. Introduction  Diagnostic challenge.  Importance of prompt management (?!).  Evolution in surgical management: Damage control. Staged repair. Colo-rectal repair. Duodenal repair.

4. Decisions  What is the systemic condition?  Is there an abdominal injury?  Can the systemic condition be related to the abdominal injury?

5. What is the systemic condition?  Oxygenation.  Hemodynamic stability.  Neurological status.

6. Is there an abdominal injury?  Mechanism of injury.  Physical examination.  FAST.  Plain X-ray.  CT.  DPL.

9. Physical examination Blunt  Hemodynamic status.  Abdominal wall hematoma.  Seat-belt sign.  Peritoneal irritation.  GI bleeding.  Confounding factors. Penetrating   Hemodynamic status.   Location of the wound.   Evisceration.   Peritoneal irritation.   GI bleeding.   Confounding factors.

10. FAST Focused Assessment Sonography for Trauma Advantages  Free fluid in the peritoneal or pericardial cavity?  Quick.  Bedside.  Repeatable. Disadvantages   False sense of security.   Retoperitoneum.   Hollow viscous injury   Penetrating trauma.   User dependant.

11. Plain X-ray Blunt  CXR.  Pelvic. Penetrating   CXR.   KUB in GSW.

12. CT Blunt  The gold standard.  Hemodynamic stability.  Normal FAST? Penetrating   RUQ low-energy missiles.   Triple-contrast for flank and back wounds.

13. DPL Blunt  Free fluid with no organ injury in the CT. Patient’s examination unreliable.  Discrepancy between FAST and physical finding. Penetrating   Violation of the anterior abdominal fascia --- stab wounds.

14. Emergency laparotomy  Hemodynamic instability and abdominal injury.  Hemodynamic instability and positive FAST.  Diffuse peritoneal irritation.  Significant evisceration.  Imaging study suggesting hollow viscous injury.  GI bleeding.

15. Management of penetrating injury GSW  85% need surgical repair.  Low energy RUQ.  Tangential wounds.

16. Management of penetrating injury stab wounds Anterior abdomen  local wound exploration.  Violation of anterior fascia – DPL. Flank and back  Triple contrast CT. Left thoraco-abdominal  Surgical evaluation of the diaphragm. Right thoraco-abdominal  CT.

17. Management of blunt injury  CT.  Free fluid with no organ injury in the CT. Patient’s examination unreliable --- DPL.  If signs of arterial bleeding - angiogram?

18. Hollow viscous injuries  Diagnostic challenge.  Importance of prompt management (?!).  Evolution in surgical management: Damage control. Staged repair. Colo-rectal repair. Duodenal repair.

19. Evolution in surgical management  Non-operative management.  Damage control.  Staged repair.  Colo-rectal repair.  Duodenal repair.

20. Non-operative treatment  No indication for emergency surgery.  Spleen – OPSI in pediatric surgery.  Liver – non bleeding CT diagnosed injuries.  Penetrating injuries – good outcome with stable patients and unavailable OR.

21. Damage control

22. Physiological failure On-going coagulopathy acidosis hypothermia

23. Damage control  Bleeding control.  Contamination control.  Temporary abdominal closure.

24. Damage control  Bleeding control.  Contamination control.  Temporary abdominal closure.

25. Damage control  Bleeding control.  Contamination control.  Temporary abdominal closure.

26. Surgical approach  Hemorrhage control.  Primary exploration and temporary control of spillage.  Thorough exploration and definitive spillage control.  Irrigation. ------------------------------------------  Reconstitute continuity.  Definitive abdominal closure.

27. ???