1. Abdominal injury and Management
Dr Wong Wai Man
Department of Surgery
NTWC
29 Apr 2009

2. Mechanism Blunt abdominal trauma Penetrating abdominal trauma
Overall about 20% require surgical operation

3. Blunt abdominal trauma
Motor vehicle crush MVC injury
Seat belt injury
Handle bar injury
Fell from height
Common in HK

4. Penetrating abdominal injury
Stab wound – low energy transfer
Gun shot wound – high energy transfer
Not common in HK

5. Anatomy Between diaphragm and pelvic floor
Beware of diaphragmatic injury in penetrating chest injury below the nipples (5th ICS)
Mid-axillary line
Retro-peritoneal spaces – zone I, II & III

6. Anatomy Solid organs – liver, spleen, kidney (blood)
Hollow organs – blood, bile, urine, food, digestive juice, air
Remember the diaphragm which is neither solid nor hollow organ

7. First step of Management
Resuscitation of patients with suspected abdominal injuries – same as other trauma patients
ATLS
Surgical plan

8. Basic plan of Surgical Decision
Is there any abdominal injury? (PE, Ix)
Is intervention required? (conservative treatment + close monitoring +/- serial Ix)
Is surgery required? (interventional radiology)
Damage control or definitive surgery (correct physiology then anatomy)

9. Assessment and diagnosis
Normal abdominal finding
Obvious injury to the abdomen eg gun shot wound
Equivocal findings requiring further investigation and re-assessment eg blunt abdominal trauma

10. Investigations Diagnostic peritoneal lavage DPL FAST USG CT scan
(Laparoscopy)
(DPA)

11. DPL Previously the standard investigation Replaced FAST Detect blood
Bowel content : bacteria, food particles, bile
Accuracy up to 98%
Miss diaphragmatic and retroperitoneal injury

13. FAST Detect fluid (blood) inside peritoneal cavity
Accuracy comparable to DPL
Non invasive and repeatable
Operator dependant
Miss specific injuries
Obesity
Replace DPL in many trauma centre

16. CAT scan Document specific organ injury Retro-peritoneal organs
Accurate
Haemo-dynamically stable patients
Can still miss diaphragmatic injury and bowel injury

19. Basic plan of Surgical Decision
Is there any abdominal injury? (PE, Ix)
Is intervention required? (conservative treatment + close monitoring +/- serial Ix)
Is surgery required? (interventional radiology)
Damage control or definitive surgery (correct physiology then anatomy)

20. Surgical decision Normal abdominal finding
Obvious injury to the abdomen
Equivocal abdominal findings

21. Normal abdominal finding
Re-assessment and physical finding by same experienced surgeon in haemo-dynamically normal is usually sufficient
? CAT scan before other extra-abdominal surgery in awake and alert patients
FAST or DPL in unstable patients

22. Surgical decision Normal abdominal finding
Obvious injury to the abdomen
Equivocal abdominal findings

27. Obvious injury to the abdomen
Mostly applied to penetrating injury
Virtually all penetrating abdominal injury should be “explored” promptly, especially in the presence of hypotension
Local wound exploration
Laparoscopy / laparotomy
Gun shot wound - laparotomy
CAT scan

28. Surgical decision Normal abdominal finding
Obvious injury to the abdomen
Equivocal abdominal findings

29. Equivocal abdominal findings
Further investigation very much depends on haemo-dynamic status of the patients
Haemodynamically normal: reassessment , CAT scan, other investigation

32. Equivocal abdominal findings
Haemodynamically stable : CAT scan
Whether the patient has bled into the abdomen
Whether the bleeding has stopped.
Detect specific organ injury

35. Equivocal abdominal findings
What if CT shows free fluid without solid organs injury in a stable patient?
Blood, bowel content, bile, urine
? Mandatory laparotomy
But non-therapeutic laparotomy is up to 92% in one of the US multi-centre prospective study
Re-assessment

36. Equivocal abdominal findings
Haemodynamically unstable : DPL or FAST
Positive finding : operation
A negative finding is also important : we have to focus on the other compartment (chest, pelvis, long bones) or external haemorrhage

38. Basic plan of Surgical Decision
Is there any abdominal injury? (PE, Ix)
Is intervention required? (conservative treatment + close monitoring +/- serial Ix)
Is surgery required? (interventional radiology)
Damage control or definitive surgery (correct physiology then anatomy)

39. Conservative management
NOM
Liver injury (esp grade I – III)
Splenic injury (esp grade I – III, paediatric group)
Renal injury
Interventional radiologist

42. Conservative management
Beware of concomitant solid and hollow organ injury
~7%
It is still safe to adopt non operative management to stable patients with solid organ injury patients but repeated assessment is required

45. Basic plan of Surgical Decision
Is there any abdominal injury? (PE, Ix)
Is intervention required? (conservative treatment + close monitoring +/- serial Ix)
Is surgery required? (interventional radiology)
Damage control or definitive surgery (correct physiology then anatomy)

46. Is urgent surgery required?
Radiological evidence of intraperitoneal gas
Radiological evidence of ruptured diaphragm
Gunshot wounds
Evisceration
Positive result on diagnostic peritoneal lavage
Rigid silent abdomen or unexplained shock

47. Aim of urgent operation
Haemorrhage control
Contamination control
Anatomical repair

50. Aim of urgent operation
Haemorrhage control
Contamination control
Anatomical repair
Haemorrhage control + contamination control – anatomical repair = damage control surgery

51. Damage control US Navy, term used for battle ship
staged laparotomy, surgical resuscitation, temporary abbreviated surgical control (TASC)
Focus on restoring function / physiology
Defer treatment of structural / anatomical disruption
Temporary abdominal closure

52. Damage Control Surgery
Inability to achieve haemostasis (liver injury)
Combined vascular, solid and hollow organs injury
anticipated need for time consuming procedure
Demand for other control of other injury
Inaccessible major venous injury
Evidence of poor physiological reserve (acidosis, hypothermia, coagulopathy)

55. Role of laparoscopy Both as diagnostic and therapeutic tools
Particularly good in detecting diaphragmatic injury
Operator dependant
Difficult to do full trauma evaluation – esp retro-peritoneal space
Still in infancy, with controversies

56. Role of laparoscopy
Contraindication : haemodynamically unstable patient
Uses in stable patients
Stab wound after LWE
Fever or raised WBC in patient under NOM, such as in case of liver laceration
In stable patient with evidence of isolated bowel injury after blunt injury trauma

57. Interventional radiologist
Work with arteries
Cannot help in hollow organ injuries except drainage of post op collection
Common sites : liver, spleen, pelvis
Contra-indication : haemodynamically unstable patients (except after damage control procedure in some scenario)
Organ infarction

58. Interventional radiologist

59. Specific organs injury

60. Hepatic injury Grade I to VI VI – hepatic avulsion
Contrast CT scan - very accurate in diagnosis and grading
Conservative treatment : stable low grade injury
Angiographic embolization : higher grade injury with evidence of continuous bleeding
Surgery : Unstable patients

61. Surgery in hepatic injury
Pringle manoeuvre (occlusion of both inflow to liver ie. portal vein and hepatic arteries.)
Failed to control bleeding => aberrant Lt or Rt hepatic arteries or retro-hepatic venous injury
Parenchymal suture
Peri-hepatic packing
Consider embolization
Bile leak

62. Splenic injury Grade I – V
V – shattered spleen or hilar vascular injury
Conservative treatment (children, stable, no ass intra-abdominal injury, no significant brain injury)
Angiographic embolization (even up to 80% in grade IV to V stable patients in one study, Hann JM 2005)
Suturing, wrap, total or partial splenectomy

63. Pancreatic injury Grade I – V Grade I & II – intact main duct
blunt injury (steering wheel, handle bar)
Retro-peritoneal structure => not much peritoneal sign
Amylase level not reliable in initial evaluation
CAT scan (contrast)

64. Pancreatic injury CT scan Specific (>90%) but not sensitive (~50%)
May require repeated scan
ERCP to assess main duct integrity (in EDU or intra-op)

65. Pancreatic injury
Grade I, II cases => closed suction drainage (in selected cases NOM)
Grade III – V => resection.
Common site of injury at neck which is compressed against the spine => distal pancreatectomy with splenic preservation

66. Pancreatic injury

67. Pancreatic injury

68. Pancreatic injury

69. Pancreatic injury

70. Bowel injury
Bowel perforation (peritonitis, free gas, bowel content in DPL) should never be treated by non-operative management
Small bowel injury – primary anastomosis
Colonic injury – colostomy or primary anastomosis +/- second look laparotomy
Duodenal injury – retroperitoneal sturcture

71. Duodenal injury Even perforation, abdominal sign not florid
May required extensive mobilization of surrounding structure for repair
Duodenal haematoma after a blunt injury can be managed by conservative treatment

74. Renal injury Grade I to V Haematuria (30%) Contrast CAT scan
Angiographic embolization
Urinoma, sepsis, hypertension

75. Abdominal compartment syndrome
Sequestration of fluid and edema of bowel wall and mesentery
Increase intra-abdominal pressure => decrease perfusion of viscera => further increase capillary leakage in bowel wall causing a viscous cycle
oliguria, increase peak inspiratory pressure, increase CVP & PAWP (false), decrease cardiac output

76. Abdominal compartment syndrome
Indirect measure through Foley catheter
Normal < 5mmHg
<25mmHg – fluid resuscitation
>25mmHg + oliguria with adequate blood volume => consider decompression
Bogota bag, sandwich-vacuum closure, other commercial packs

81. Thank you