3. Introduction
• Abdominal trauma is regularly
encountered in the emergency department
• One of the leading cause of death and
disability
• Identification of serious intra-abdominal
injuries is often challenging
• Many injuries may not manifest during
the initial assessment and
treatment period
4. Epidemiology
• Peak incidence Abdominal Trauma
15 - 30yr
• More than 1.5 Lac people die every year
as a result of injuries by motor vehicle
accident , fall, suicide and homicide
• Injury accounts for 10% of all deaths
• Estimates indicate that by 2020, 8.4
million people will die yearly.
• Prevalence: 13%
5. ■ In Cameroon,in a study conducted in 2021,Abdominal trauma
mainly affected adults between age 20 and 39 years old . The
male sex was most affected, with sex ration of 3.3. Road
accidents occupy the first place with 34.9% (15 cases). Wounds
in our series represented 27.9% (12 cases) and contusions
72.1% (31 cases). In fact, Abdomen without preparation was
performed in 7.0% (3 cases) of cases, abdominal ultrasound in
48.8% (21 cases) and abdominal CT scan in 25.6% of patients
(11 cases). The organs affected in order were the spleen, small
intestine, colon, stomach and liver. We recorded postoperative
complications with a morbidity of 11.6% with a single case of
parietal suppuration and no death.
6. Regions to consider in abdominal Trauma
Anterior Abdomen:
Between the anterior axillary lines; bound by the costal margin superiorly and the groin crease
distally.
Thoracoabdominal Area:
The area superiorly delimited by the fourth intercostal space (anterior), sixth
intercostal space (lateral), and eighth intercostal space (posterior), and
inferiorly delimited by the costal margin (definitions vary — a pragmatic
approach is to use the nipple line as the upper boundary… in non-obese men
at least!). Injuries in the region increase the likelihood of chest, mediastinal,
and diaphragmatic injuries.
7. Flanks:
From the inferior costal margin superiorly to the iliac crests; bound anteriorly by the
anterior axillary line and posteriorly by the posterior axillary line.
Back:
Between the posterior axillary lines extending from the costal margin to the iliac
crests.
8.
9.
10.
11. Blunt Abdominal Trauma
■ “A force to the abdomen that doesn't leave an open
wound.”
• Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple
organs/systems.
• Solid organ injury >> Hollow viscus injury
• Solid Organs: Spleen > Liver, Intestine is the most likely
hollow viscus.
• MVA (50 - 75% of cases) > blows to abdomen (15%) > falls
(6 - 9%).
12. Pathophysiology Of Blunt Trauma
• Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal
pressures.
• Crushing Injury(Solid Organs more Vulnerable )
• Acceleration and deceleration forces → shear injury(liver And Spleen
Laceration at the site of Supporting Ligaments)
• Seat belt injuries
“Seat belt sign” = highly correlated with intraperitoneal injury.
15. Penetrating Trauma
“A force to the abdomen that leave an open wound.”
• A stabbing wound 3x more common than firearm wounds.
• Gun shot wound cause 90% of the deaths.
• Small intestine > colon > liver
16. Pathophysiology Of Penetrating Trauma
Stab Wounds
🠶 Knives, ice picks, pens, coat hangers, broken bottles
🠶 Liver, small bowel, spleen
Gunshot wounds
🠶 Small bowel, colon and liver
🠶 Often multiple organ injuries,
🠶 Bowel perforations
18. Primary Survey –ATLS approach
🠶 ABCDE pattern: Airway, Breathing, Circulation, Disability
(neurologic status), and Exposure.
🠶 A - intubation may be required if patient is shocked, hypotensive or
unconscious or
in need for ventilation. *with cervical precaution.
🠶 B - watch for hemothorax in both blunt and penetrating
thoracoabdominal injuries.
🠶 C - start with 2 L crystalloid (If active bleeding you must find
source and stop the
bleeding)
🠶 D – May seen associated with
thoracolumbar Fracture.
🠶 E -Watch for other injury
21. Secondary Survey History
🠶 History for all trauma patients:
🠶 It doesn't necessarily making an accurate diagnosis
S.A.M.P.L.E
🠶 S: Symptoms: pain, vomiting, hematuria,
hematochezia,dyspnea,respiratory distress…
🠶 A: Allergies
🠶 M : Medications
🠶 L : Last meals
🠶 E : Events (mechanism of injury)
22. Physical Examination
🠶Inspection: abrasions, contusions, lacerations, deformity,
entrance and exit wounds to determine path of injury(Grey-
Turner, Kehr, Balance, Cullen, seat belt sign….)
🠶Palpation: elicit superficial, deep, or rebound tenderness;
involuntary muscle guarding
🠶 Percussion: subtle signs of peritonitis; tympany in gastric
dilatation or free air; dullness with hemoperitoneum.
🠶Auscultation: bowel sounds may be decreased(late finding).
23. • Grey-Turner sign: Bluish discoloration of lower flanks, lower
back; associated with retroperitoneal bleeding of pancreas,
kidney, or pelvic fracture.
• Cullen sign: Bluish discoloration around umbilicus, indicates
peritoneal
bleeding, often pancreatic hemorrhage.
• Kehr sign: shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abdominal bleeding)
•Balance sign: Dull percussion in LUQ. Sign of splenic injury;
blood accumulating in subcapsular or extracapsular spleen.
27. FAST
Rapid, accurate, non invasive, inexpensive study and Operator
dependent.
It Views
1. Pericardium (subxiphoid)
2. Perihepatic &hepatorenal space (morrison’s pouch)
3. Perisplenic
4. Pelvis (pouch of Douglas /rectovesical pouch)
Suprapubic view (Transverse; before inserting folleys)Sensitivity 60 to 95% for
detecting 100 mL - 500 mL of fluid. The larger the hemoperitoneum, the higher
the sensitivity. So sensitivity increases for clinically significant
hemoperitoneum.
FAST has a low sensitivity (29–35%) for organ injury without
haemoperitoneum. FAST is also unreliable for excluding injury in
penetrating trauma. If there is doubt, the FAST examination can be repeated.
28.
29. Diagnostic peritoneal Lavage/Tap
DPA- The recovery of 10 cc of frank blood (or more) from the peritoneum is a
strong predictor (90% PPV in blunt trauma) of intraperitoneal injury, and the
procedure is then terminated.
DPL - If aspiration findings are negative, lavage is conducted in
which the peritoneal cavity is washed with saline. RBC count
exceeding 100,000/cc
is considered positive and generally specific for injury. Sensitivity 90%.
Method:
A cannula is inserted below the umbilicus, directed caudally and posteriorly.
The cannula is aspirated for blood (>10 mL is deemed as positive) and,
following this, 1000 mL of warmed Ringer’s lactate solution is allowed to run
into the abdomen and is then drained out via the same route.
30.
31.
32. Is there still a role for DPA?
FAST has largely replaced DPA, likely due to
ease of use. However, 2 areas where still is
warranted:
◦Hemodynamically unstable and an equivocal FAST
◦No FAST available
“DPL is safe, sensitive, and reduces the use of CT” (Journal of
Trauma 2007)
DPLisespeciallyusefulinthehypotensive,unstablepatientwithmultiple
injuriesas
ameansofexcludingintra-abdominalbleeding.
33. Local Wound Exploration
• To determine the depth of penetration in stab wounds
• If peritoneum is violated, must do more diagnostics
• Prep, extend wound, carefully examine (No blind probing)
• Indicated for anterior abdominal stab wounds, less clear for
other areas
34. CT Scan
• CT has become the ‘gold standard’ for the intra-abdominal diagnosis of
injury in the stable patient. The scan can be performed using intravenous
contrast. CT is sensitive for blood and individual organ injury, as well as
for retroperitoneal injury.An entirely normal abdominal CT is usually
sufficient to exclude intraperitoneal injury.
Indications:
• Blunt trauma
• Hemodynamically stable patient
• Normal or unreliable physical examination
Contraindications
• Clear indication for exploratory laparotomy
• Hemodynamically unstable patient
• Contrast allergic patient
35.
36. Most useful to evaluate penetrating wounds to
thoracoabdominal region in stable patient
especially for diaphragm injury: Sensitivity 87.5%, specificity
100%.
Can repair organs via the laparoscope.
• diaphragm, solid viscera, stomach, small bowel.
Disadvantage:
• Poor sensitivity for hollow visceral injury, retroperitoneum
When used in this role laparoscopy reduces the non-
therapeutic laparotomy rate. There is no place for laparoscopy
in the unstable patient.
Laparoscopy
37. Which patients need Laparotomy ?
• Blunt abdominal trauma with hypotension with a positive FAST or clinical
evidence of intraperitoneal bleeding.
• Blunt or penetrating abdominal trauma with a positive DPL.
• Hypotension with a penetrating abdominal wound.
• Gunshot wounds traversing the peritoneal cavity or
visceral/vascular retroperitoneum.
• Bleeding from the stomach, rectum, or genitourinary tract from penetrating
trauma
• Peritonitis
• Free air, retroperitoneal air, or rupture of the hemidiaphragm
• CECT findings of ruptured GIT, intraperitoneal bladder injury, renal
pedicle injury, or severe visceral parenchymal injury after blunt or
penetrating trauma
40. 1. Incision. Generous midline incision is preferred. Self retaining retractor systems and headlights
are invaluable.
2. Bleeding control. Scoop-free blood and rapidly pack all quadrants
3. If packing does not control a bleeding site, this source must be controlled as the first priority.
4. Contamination control. Quickly control bowel content contamination.
5. Systematic exploration. Systematically explore the entire abdomen, giving priority to areas of
ongoing hemorrhage
A. Liver B. Spleen C. Stomach
D. Right colon, transverse colon, descending colon, sigmoid
colon, rectum, and small bowel, from ligament of Treitz to terminal ileum, looking at the entire
bowel wall and the mesentery.
E. Pancreas, by opening lesser sac (visualize and palpate).
F. Kocher maneuver to visualize the duodenum, with evidence of possible injury
G. Left and right hemidiaphragms and retroperitoneum.
H. Pelvic structures, including the bladder.
I.With penetrating injuries, exploration should focus on following the track of the weapon or
missile.
6. Injury repair.
7. Closure.
Exploratory Laparotomy
41. 1.Peritoneal
2.Retroperitoneal
3.Diaphragm
Treatment of an organ injury is similar whether the injury mechanism is penetrating or
blunt
•An exception to the rule is a retroperitoneal hematoma. Explore all retroperitoneal
hematomas caused by penetrating injury.
SPECIFIC ORGAN INJURY
42. Until the 1970s, splenectomy was considered mandatory for all splenic injuries.
Recognition of the immune function of the spleen refocused efforts on operative splenic
salvage in the 1980s.
Management options
• Observation
• Angiographic Embolization (Gd I-III; age < 55y)
• Surgery (Splenectomy/ partial splenectomy/ splenorrhaphy)
Depending upon
• Hemodynamic status of patient.
• Grade of injury.
• Presence of other injuries.
• Medical co-morbidities.
Upto 20% patients require early splenectomy.
Delayed hemorrhage/ rupture can occur weeks after injury
SPLEEN
44. • Hemodynamic stability
• Negative abdominal examination
• Absence of contrast extravasation on CT
• Absence of other clear indication for exploratory laparatomy or
associated injuries requiring a surgical intervention
• Absence of associated health condition that carry an increased risk of
bleeding(coagulopathy, hepatic failure, use of anti coagulant, specific
coagulation factor deficiency)
• Grade 1-3 injury
> 70 % patients still undergo splenectomy after NOM.
Higher failure rates of NOM with increasing grades of
Severity.
Criteria forNon Operative Management
45. • Absolute bed rest & NPO
• 6 hourly Hb check in first 24h
• Allowed orally if Hb stable & no surgical intervention likely
• Follow-up CT: Falling Hb, abdominal pain, fever, Lt shoulder pain
• Duration based on
1. Grade of splenic injury
2. Nature & severity of other injuries
3.Clinical Status (Incl peritoneal signs – missed hollow viscus injury
& Hb levels)
• Embolization – 73-97% success rate
Management
46. Splenectomy (with auto-transplantation)
• Hilar injuries
• Pulverized splenic parenchyma
• GD III and above + coagulopathy/ multiple injuries
In patients undergoing splenectomy, prophylaxis against Meningococcus, Pneumococcus, HIb
bacteria is provided via vaccines administered optimally at 14 days.
Partial splenectomy – isolated polar injuries
Splenorrhaphy
Cautery, argon beam coagulator, gelfoam, fibrin glue, collagen, envelopment in absorbable
mesh, pledgeted suture repair
Bleeding edges – Horizontal mattress sutures + parenchymal compression
Operative Management
49. Its possible in injuries to the thoracoabdominal region.
Can be due to blunt(>85%) or penetrating injury and is larger in the blunt
Possible cardiac injury if the penetrating wound is more
central The weakest point of diaphragm is the left
posteriorlateral(80%) Often missed in polytrauma
In isolated injury it may go unnoticed and there is often a delay between the
injury and the diagnosis
Patients present with non specific symptoms and may complain of chest pain,
abdominal pain, dyspnea, tachypnea and cough.
Rupture with herniation is diagnosed by CXR or CT but without herniation is
difficult to diagnose.
Thoracoscopy or laparascopy is diagnostic.
Diaphragmatic
injury
50. Once identified must be repaired because it will not close spontaneously
regardless the size.
Early diagnosis needs abdominal approach using the interrupted
nonabsorbable
suture and the large defect(>25cm2) may need nonabsorbable mesh.
In the event of a gross contamination, endogenous tissue can be
utilized for a definitive repair as latissimus dorsi flap, tensor fascia lata
or omentum.
There are some who advocate using biologic tissue grafts, such as
AlloDerm(human
acellular tissue matrix).The durability of such a repair is questionable.
Place chest tube on the surgery side at the time of repair
Treatment
51. Most stomach injuries are caused by penetrating trauma while The small bowel is
frequently injured as a result of blunt trauma.
Surgical repair is required but great care must be taken to examine the stomach fully, as an
injury to the front of the stomach can be expected to have an ‘exit’ wound elsewhere on the
organ.
Gastric Wounds – running single layer suture (full
thickness bites)/ stapler
Partial gastrectomy – for destructive injuries
Small intestine injury < 1/3rd of bowel circumference transverse running 3-0
PDS
Multiple injuries/ mesenteric injuries – segmental
resection and anastomosis/ stoma
• Post-op ileus is obligatory
• No enteral feeds for atleast 48 hrs if managing conservatively.
Stomach and small Intestines
53. Duodenal hematoma – NG aspiration & parenteral
nutrition
Small duodenal perforation/ laceration – primary single layer
repair
1st part injuries – debridement & end-to end anastomosis with gastric
antrum/ pylorus
2nd part injuries – patch with vascularized jejunal graft.
Injuries b/w Ampulla of vater and SMA- Roux-en-Y
Duodenojujonostomy
Distal 3rd & 4th part injuries – resection and anastomosis(
Duodenojuonostomy) on Lt side of Superior mesenteric vessels.
Pyloric exclusion – high risk, complex duodenal repairs
Duodenum
54.
55. Most pancreatic injury occurs as a result of blunt trauma. The major problem is that of diagnosis,
because the pancreas is a retroperitoneal organ. CT remains the mainstay of accurate diagnosis.
Amylase or lipase estimation is insensitive. In penetrating trauma, injury may only be detected during
laparotomy.
Management depends on location of injury to
1. Parenchyma
2. Intrapancreatic CBD
3. MPD
Contusion (ductal system intact)/ proximal pancreatic injuries (to Rt of SM
vessels)--Non operative/ closed suction drain.
Distal duct disruption (body & tail) to left of SMA – distal pancreatectomy with
splenic preservation.
Injury to Head with duct injury – distal duct ligation with Roux-en-Y
choledochojejunostomy.
Pancreas
56.
57. Primary aim is to arrest bleeding.
Perihepatic packing is effective most of the times, if not
then perform Pringle maneuver
Difficult to perform perihepatic packing in Lt lobe Mobilize it and
compress between surgeon’s hands
Pringle maneuver
• Bleeding stopped => from HA / PV.
• Doesn’t stop => HVs and retrohepatic IVC is the source>Packing
done>Failed>direct vascular repair ± hepatic vascular Isolation.
Repair the Hepatic artery proper.
Cholecystectomy if Rt hepatic artery is ligated.
Liver trauma
60. • Manual compression
Minor lacerations
• Topical hemostats (cautery, argon beam coagulator, gelfoam, fibrin glue,
collagen)
Shallow lacerations >>> Running PDS suture
Deep lacerations
• Interrupted Horizontal mattress parallel to edge of laceration
• Omentum to fill large defects (obliterates dead space; source of
macrophages)
• Deep recalcitrant hemorrhage>>hepatic lobar arterial ligation.
61. • Repeat laparotomy within 24 hrs for pack removal
• Ongoing hemorrhage – early exploration (<24h h)
• Complex injuries – angioembolization
• Complex injuries – typical ‘liver fever’ upto 5 days post injury.
• Non-anatomical resection – stable without coagulopathy
• GB injury--cholecystectomy
• EHBD Transaction with significant tissue loss>>Roux-en-Y
choledochojejunostomy
• Till then intubate the duct for external drainage
Complications:
Hemorrhage, hepatic necrosis, bilomas, arterial
pseudoaneurysms and biliary fistulas.
62. • 50-80% of liver bleed stops spontaneously
• Better results of NOM in children
• Significant development of CT scan in liver imaging
Initially introduced for minor injuries (1972)
Presently being used for grades III – V also.
Selection criteria
• Hemodynamic stability after initial resuscitation
• No other visceral/ retroperitoneal injuries needing surgery
• Multidisciplinary team – Experienced surgeon, Intensivist, CT scan, 24x7 OT facilities
Failure rate significantly higher in Grade IV & V than Grade I to III.
Most common reason for intervention – co-existing abdominal injury (e.g. bleed form spleen
or kidney).
Non Operative Management Basis
63. Predictors of NOM failure
• Advanced age
• Anaemia & HTN
• Active extravasation on CT
• Massive blood transfusion
CT follow up for Gd I & II not necessary
Others need clinical and CT follow up
64. 3 methods for colonic injuries
1. Primary repair
2. End colostomy
3. Primary repair with diverting colostomy
Weigh the risk of primary repair Vs colostomy
Lt colon injuries - Temporary colostomy
Other high risk pts - Diverting ileostomy with colocolostomy
Rectal injuries – loop ileostomy/ sigmoid loop colostomy
Accessible rectal injury – attempt primary repair with diversion
Extensive rectal injury – End colostomy (Hartmann’s)
Complications:
Intra-abdominal abscess, fecal fistula, infection,stomal complications
Colon & Rectum
65. Injury to the retroperitoneum is often difficult to diagnose, especially in the presence of other
injury, when the signs may be masked. Diagnostic tests (such as ultrasound and DPL) may be
negative. The best diagnostic modality is CT, but this requires a physiologically stable patient. The
retroperitoneum is divided into three zones for the purposes of intraoperative management:
In BluntTrauma
Zone 1 (central): central haematomas should always be explored, once proximal and distal
vascular control has been obtained.
Zone 2 (lateral): lateral haematomas should only be explored if they are expanding or pulsatile.
They are usually renal in origin and can be managed non-operatively, though they may sometimes
require angioembolisation.
Zone 3 (pelvic): as with zone 2, these should only be explored if they are expanding or pulsatile.
Pelvic haematomas are exceptionally difficult to control and, whenever possible, should not be
opened; they are best controlled with compression or extraperitoneal packing, and if the bleeding is
arterial in origin, with angioembolisation.
In penetrating trauma, every injury should be explored for damage to structures along the wound
track (e.g. ureter), unless preoperative investigation allows non-surgical management of the injury.
Retroperitonial Hematomas
67. 90 % Renal injuries managed conservatively
• Hematuria resolves in few days with absolute rest
Operative intervention – Hypotension due to
• Renovascular injuries
• Destructive parenchymal injuries
Persistent gross hematuria – embolization
Urinoma – Percutaneous drainage
Renal artery repair
• Success rates very low
• Image guided endostent placement can be attempted.
Renorrhaphy
• Take vascular control for proper visualization
• Preserve renal capsule
• Collecting system is closed separately with absorbable sutures.
• Preserved capsule is closed over collecting system repair
Genitourinary Tract
68. Ureter injuries:
• Primary repair with renal mobilization for tension relief.
• Reimplantation (with psoas hitch) for distal ureter injuries.
• Damage control – B/L ligation + Nephrostomy.
69. Bladder injuries
Intraperitoneal injuries
• Running, single layer 3-0 absorbable monofilament
suture
• Lap repair – if other injuries not needing repair
Extraperitoneal injuries
• NOM with bladder decompression for 2 weeks
Urethral injuries
• Bridge the defect with Foley’s
• Elective repair for strictures later
