1. ABDOMINAL INJURY
Shanghai Jiaotong University Medical School Renji Hospital
Cao Hui

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

3. 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

4. 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

5. Abdominal Injury- Clinical Manifestations
ANATOMIC CONSIDERATIONS

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

7. 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

8. 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

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

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

11. 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

12. 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

13. 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

14. 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

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

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

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

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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

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

27. 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

28. 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

29. 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

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

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

32. Abdominal Injury- Splenic Rupture
Preservation of traumatic spleen

33. 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

34. 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

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

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

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

38. 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

39. 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

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

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

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

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

44. Abdominal Injury- Gastric Injury
Posterior stomach exposure

45. Abdominal Injury- Liver Rupture
Simple repair partial gastrectomy

46. 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

47. 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

48. Abdominal Injury- Duodenal Injury
Duodenal mobilization Right retroperitoneal exposure

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

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

51. 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

52. Abdominal Injury- Rupture of colon
Exteriorization

53. 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.

54. 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.

55. 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.

56. 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.

57. Thank you very much!