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

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

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

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

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

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

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

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)

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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)

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

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

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)

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

Aim of urgent operation Haemorrhage control Contamination control Anatomical repair

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

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

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)

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

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

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

Interventional radiologist

Specific organs injury

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

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

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

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)

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)

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

Pancreatic injury

Pancreatic injury

Pancreatic injury

Pancreatic injury

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

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

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

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

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

Thank you