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. Abdomen and Abdominal Injuries
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
Emergency Abdominal
Surgery in Trauma =
48%
J Trauma 2005;58:657–662

6. Mechanism of Injury
PENETRATING
BLUNT

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

8. West J Med 1974; 120:

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

10. ACUTE CARE SURGICAL CASE PRIORITY

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

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

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

16. Summary of Clinical Action
ATLS
Summary of Clinical Action
Haemodynamic
Abdominal Sign
Action
Unstable +
Laparotomy
Uncertain
FAST or DPL
Stable
+ / Uncertain CT
Emergency in Trauma. Oxford, 2010.

17. Clinical abdominal scoring system (CASS)
Score
Action
< 9
Clinical Observations
9 - 11
Auxiliary investigations*
> 11
Immediate Laparotomy
*Auxiliary investigations include US, CT, DPL
STABILITY
“… is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality …”
LOCAL STATUS
International Journal of Surgery 2008; 6: 91e95

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

19. Hollow Viscus ??? 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
Hollow Viscus ???
BMJ 2008;336:938-42

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. SOP FKUI RSCM

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, 7th ed. 2009

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

26. (Thorough) Exploration (Adequate) Exposure (Hemorrhage) Control
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. “Trauma surgery is just general surgery,
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