ABDOMINAL INJURY Shanghai Jiaotong University Medical School Renji Hospital Cao Hui

Abdominal Injury-Epidemology 0.4-1.8% of various injury Open injury: integrity of abdominal wall Penetrating non- penetrating Closed injury Organ injured?

Abdominal Injury- Etiology Open injury: Sharps, missile, etc Liver, small intestine, stomach, colon, big vessels Closed injury Fall, crush, blows, etc Spleen, kidney, small intestine, liver, mesentery Severity depends on Foreign force and anatomy or co-exist illness

Abdominal Injury- Etiology Severity Foreign force and anatomy or co-exist illness Foreign force Power, velocity, location, direction Anatomy or co-exist illness liver, spleen: fragile, blood supply, fixed Antrum, duodenum and pancreas Full stomach or bladder

Abdominal Injury- Clinical Manifestations ANATOMIC CONSIDERATIONS

Abdominal Injury- Clinical Manifestations Pathological changes Intra-or retro-peritoneal bleeding Peritonitis Solid organ or big vessels Hollow viscera

Abdominal Injury- Clinical Manifestations Solid organ or big vessels: Liver, pancreas, spleen, kidney *Symptoms & signs of hypo-volemic shock Intra-or retro-peritoneal bleeding *Peritonitis Not prominent but could be in rupture of liver and pancreas injury *Intra-peritoneal mass or moveable dullness

Abdominal Injury- Clinical Manifestations Hollow viscera: GI tract, billiary tract and bladder etc *Diffusive peritonitis Stimuli: gastric, bile, pancreas, bowel, blood Gas abdomen Inflammatory shock Perineum radiation pain retro-peritoneal rupture of duodenum * GI tract symptoms nausea, vomit, hematochezia * Systematic infection * Massive bleeding if combined big vessels injury

Abdominal Injury- Diagnosis History and physical examination How, what, and when it happened Evaluation of the patient and injury Careful and thorough examination

Abdominal Injury- Diagnosis Viscera injured? Which one injured? More than one? What to do if you can not make diagnosis?

Abdominal Injury- Diagnosis Viscera injured? Fully understanding of history Observation Pulse, breath, BT , BP and any sign of shock Thorough examination with emphasis Tenderness, muscle rigidity and rebound tenderness Change of liver dullness or movable dullness Bowel movement PR

Abdominal Injury- Diagnosis Viscera injured? Necessary lab test Hb Hct Serum and urine amylase Urinary tests Stomach contents examination Blood gas analysis Serum glucose and serum creatinine level

Abdominal Injury- Diagnosis You should consider viscera injured if: Shock at early stage, esp. hypovolemic shock Constant or progressive abdominal pain with nausea, vomits Abdomen irritation Gas abdomen Movable dullness Hematouria, hematochezia or vomit blood Positive finding in PR: pain, fluctuation or blood-stain

Abdominal Injury- Diagnosis Which one injured? Decide which system first then which organ GI tract: nausea, vomit, gas abdomen or blood in stool Urinary tract: dysuria, hematuria Upper abdominal viscera: diaphragmalgia Liver or spleen rupture: lower rib fracture Rectum, bladder or urinary tract: pelvic fracture

Abdominal Injury- Diagnosis More than one? Multiple injury in single organ More than one organ injured Intro-and extra-abdominal

Abdominal Injury- Diagnosis What to do if you can not make diagnosis? Lab examination Intensive observation Laparotomy

Abdominal Injury- Diagnosis Lab examination Abdominal puncture and peritoneal lavage X-ray B type ultrasound CT scan Angio-gram

Abdominal Injury- Diagnosis Abdominal puncture and peritoneal lavage Contraindications Previous abdominal procedures Presence of dilated bowel Late pregnancy Positive needle para-centesis.

Abdominal Injury- Diagnosis Abdominal puncture and peritoneal lavage Method Selects a point Inserts a plastic catheter Aspirates the peritoneal cavity Infuses a liter of saline rapidly into the peritoneal cavity Siphones the fluid out of the peritoneal cavity Analysis the fluid sample

Abdominal Injury- Diagnosis Used when need for abdominal exploration is not clear. Also useful when physical assessment is not productive eg. When patient is unconscious or neurologically impaired. Bladder empyted (catheter) Nasogastric tube Peritoneal dialysis catheter is inserted through a small incision. Abdominal puncture and peritoneal lavage

Abdominal Injury- Diagnosis Positive results Greater than 100*109/L RBC, or 0.5*109/L WBC Detection of bile, food fibers, or urine Serum amylase level is greater than 100 Somogyi unit Detection of bacteria

Abdominal Injury- Diagnosis X-ray Gas abdomen, retro-peritoneal gas, hiatus hernia, obliteration of psoas outline B type ultrasound Liver, spleen, pancreas and kidneys injury CT scan Arteriography MRI Diagnostic key-hole surgery

Abdominal Injury- Diagnosis Intensive observation Pulse, breath and BP every 15-30 min Abdomen signs every 30min RBC, Hb and Hct every 30-60min Repeat paracentesis or lavage if necessary

Abdominal Injury- Diagnosis Importance during intensive observation No unnecessary move to avoid secondary injury Careful using analgesics Nil by mouth Maintain blood volume Broad-spectrum antibiotics Naso-gastric intubation

Abdominal Injury- Diagnosis Laparotomy Indications Worsened abdominal pain or signs Bowel sound weakened or disappeared or distention Worsened systemic condition Gas abdomen Progressive decline of RBC count Unstable BP Positive finding in para-centesis or lavage GI Bleeding

Abdominal Injury- Treatment Prolapsed visceral covering Priority setting Airway, breath and circulation are of greatest importance Open airway Hemostasis Tension pneumothrax Open pneumothrax

Abdominal Injury- Diagnosis Procedure General anesthesia A long midline incision is made Blood is rapidly evacuated Spleen and liver are assessed as possible sources of bleeding Bleeding from spleen is definitively controlled first Bleeding from the liver is addressed next All the abdominal viscera are carefully examined from the diaphragm to the pelvic floor, Special attention to the retro-peritoneum

Abdominal Injury- Splenic Rupture Most vulnerable organ 20%-40% in close injury, 10% in open Parenchyma rupture, tear beneath capsule and tear of capsule Intra-peritoneal bleeding Delayed rupture Subcapsular hematoma 36-48 hrs after injury, within 2 wks

Abdominal Injury- Splenic Rupture Pain, tenderness and guarding in left upper quadrant Pain in the left should-tip Signs of blood loss or shock Associated fractures of lower left ribs in 20% Can be confirmed by ultrasound Arteriography when hematoma or delayed rupture suspected

Abdominal Injury- Splenic Rupture Splenectomy Spleen-conserving procedure Partial splenectomy Repair Mesh wrapping Auto-transplantation OPSI Overwhelming postsplenectomy infection

Abdominal Injury- Splenic Rupture CT of splenic rupture Preservation of traumatic spleen

Abdominal Injury- Splenic Rupture Preservation of traumatic spleen

Abdominal Injury- Liver Rupture 15%-20% in abdomen trauma Right lobe>Left Symptoms similar to splenic rupture but with abdominal pain and peritoneal irritation Mortality: 9% Liver only 50% Multiple injury Hematochezia or vomit blood

Abdominal Injury- Liver Rupture Non-surgical for stable patient 30% Surgical Adequate exposure Control bleeding temporally with gauze or press on hepatoduodenum ligament 30 or 15 min Debridement with removal of devitalized tissue Suture-ligation of torn vessels and bile ducts Hepatic lobectomy for extensive damage Multiple drainage

Abdominal Injury- Liver Rupture An extensive med-line incision Hemostasis of liver fracture

Abdominal Injury- Liver Rupture Pringle maneuver compression of Intracaval shunt for retrohepatic portal triad structure venous injury

Abdominal Injury- Liver Rupture Approach to liver fracture Scalpel-handle resection

Abdominal Injury- Pancreatic Injury 1-2% in abdominal trauma Easily to be ignored, with mortality of 20% Mechanism of injury Pseudocyst Hemorrhage is cause of death Peritonitis Diagnosis Palpable retro-peritoneal swelling A rise serum amylase B type ultrasound or CT

Abdominal Injury- Pancreatic Injury Treatment Control hemorrhage Debridement and inhibit exocrine No duct injury Adequate drainage Duct injured Body and tail Pancreatectomy or repair Head and neck Suture close and Roux-en-Y anastomosis Head with duodenum Roux-en-Y anastomosis or Pancreatico-duodenectomy

Abdominal Injury- Pancreatic Injury Drainage of a pancreatic wound Removal of the distal pancreas

Abdominal Injury- Pancreatic Injury Left retroperitoneal exposure Internal drainage of a pancreatic injury

Abdominal Injury- Pancreatic Injury Pancreatico-duodenal trauma The completed pancreaticoduodenectomy

Abdominal Injury- Gastric Injury Rare Usually penetrating trauma Peritoneal irritation Excision or suture

Abdominal Injury- Gastric Injury Posterior stomach exposure

Abdominal Injury- Liver Rupture Simple repair partial gastrectomy

Abdominal Injury- Duodenal Injury 3.7%-5% in abdominal trauma 2nd ,3rd part of duodenum Cause of death Combined lesion or massive bleeding Infection, hemorrhage and MOF Intra-peritoneal rupture severe peritonitis Retro-peritoneal rupture Progressive pain, radiation to right should, mild signs but worse systematic reaction, retro-peritoneal gas formation and obliteration of psoas outline on X-ray

Abdominal Injury- Duodenal Injury Treatment Anti-shock and surgery Excised and repair in 70-80% Occluded with a loop of jejunum Duodenectomy and partial pancreatectomy for 2nd part of duodenum injury

Abdominal Injury- Duodenal Injury Duodenal mobilization Right retroperitoneal exposure

Abdominal Injury- Duodenal Injury A jejunoileal patch used to reinforce repair of the duodenum Pyloric exclusion for complex duodenum injury

Abdominal Injury- Rupture of small intestine Peritonitis Gas abdomen Simple repair

Abdominal Injury- Rupture of colon Rarer than that of small intestine Peritonitis Repair or resection Small wound, mild contamination, optimal condition Exteriorization and restore later

Abdominal Injury- Rupture of colon Exteriorization

Abdominal Injury- Retroperitoneal Hematoma Controversy for years Central hematomas (zone 1) are associated with pancreaticoduodenal injuries or major abdominal vascular injury. Flank or perinephric hematomas (zone 2) :injuries to the genitourinary tract or, in the case of penetrating trauma, with injuries to the colon. Zone 3 injuries, which are confined to or originate from the pelvis, are most often associated with pelvic fractures.

Abdominal Injury- Retroperitoneal Hematoma Retroperitoneal hematomas in zone 1, regardless of cause or size, are formally explored with inspection of each of the relevant structures. This is required because of the high incidence of associated major vascular, pancreatic, or duodenal injuries and the high morbidity and mortality if these are overlooked.

Abdominal Injury- Retroperitoneal Hematoma Zone 2 hematomas caused by penetrating injuries should routinely be explored. Whether proximal control of the renal pedicle should be obtained before exploration of a perinephric hematoma is controversial. If there is severe ongoing hemorrhage, time should not be taken to obtain proximal control, and the kidney should be mobilized directly. If time and the degree of hemorrhage permit probably safest to obtain vascular control before mobilization of the kidney. Zone 2 hematomas caused by blunt trauma can be left alone if they are not expanding and the intravenous urogram is normal.

Abdominal Injury- Retroperitoneal Hematoma Zone 3 retroperitoneal hematomas in patients with penetrating injuries are usually explored to exclude major vascular injuries. Patients with zone 3 hematomas secondary to blunt trauma usually have associated pelvic fractures. Exploration of the hematoma can be hazardous and is usually avoided. There is often extensive injury to the rich presacral venous and arterial circulation. Incision of the peritoneum releases the tamponade, and dissection within the hematoma can produce catastrophic bleeding. Discrete bleeding points can rarely be identified.

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