abdominal injury shanghai jiaotong university medical school renji hospital cao hui

ABDOMINAL INJURYABDOMINAL INJURY

Shanghai Jiaotong University Medical School Renji Hospital

Cao Hui

Abdominal Injury-Abdominal Injury-EpidemologyEpidemology

0.4-1.8% of various injury0.4-1.8% of various injury Open injury:Open injury: integrity of abdominal wallintegrity of abdominal wall

– Penetrating Penetrating – non- penetratingnon- penetrating

Closed injuryClosed injury– Organ injured?Organ injured?

Abdominal Injury-Abdominal Injury- EtiologyEtiology

Open injury:Open injury:– Sharps, missile, etc Sharps, missile, etc – LiverLiver, small intestine, stomach, colon, big vessels, small intestine, stomach, colon, big vessels

Closed injuryClosed injury– Fall, crush, blows, etcFall, crush, blows, etc– SpleenSpleen, kidney, small intestine, liver, mesentery, kidney, small intestine, liver, mesentery

Severity Severity depends ondepends on

Foreign force and anatomy or co-exist illnessForeign force and anatomy or co-exist illness

Abdominal Injury-Abdominal Injury- EtiologyEtiology

SeveritySeverity

Foreign force and anatomy or co-exist illnessForeign force and anatomy or co-exist illness

Foreign forceForeign force

Power, velocity, location, directionPower, velocity, location, direction

Anatomy or co-exist illnessAnatomy or co-exist illness

liver, spleen: fragile, blood supply, fixedliver, spleen: fragile, blood supply, fixed

Antrum, duodenum and pancreasAntrum, duodenum and pancreas

Full stomach or bladderFull stomach or bladder

Abdominal Injury-Abdominal Injury- Clinical ManifestationsClinical Manifestations

ANATOMIC ANATOMIC

CONSIDERATIONSCONSIDERATIONS


Pathological changesPathological changes

Intra-or retro-peritoneal bleeding Intra-or retro-peritoneal bleeding PeritonitisPeritonitis

Solid organ or big vesselsSolid organ or big vessels

Hollow visceraHollow viscera


Solid organ or big vessels:Solid organ or big vessels:

Liver, pancreas, spleen, kidneyLiver, pancreas, spleen, kidney

*Symptoms & signs of hypo-volemic shockSymptoms & signs of hypo-volemic shock

Intra-or retro-peritoneal bleeding Intra-or retro-peritoneal bleeding **PeritonitisPeritonitis

Not prominent but could be in rupture of liver and Not prominent but could be in rupture of liver and pancreas injurypancreas injury

**Intra-peritoneal mass or moveable dullnessIntra-peritoneal mass or moveable dullness

Hollow viscera:Hollow viscera:

GI tract, billiary tract and bladder etcGI tract, billiary tract and bladder etc

**Diffusive peritonitisDiffusive peritonitis

Stimuli: gastric, bile, pancreas, bowel, bloodStimuli: gastric, bile, pancreas, bowel, blood

Gas abdomenGas abdomen

Inflammatory shock Inflammatory shock

Perineum radiation pain Perineum radiation pain retro-peritoneal rupture of retro-peritoneal rupture of duodenumduodenum

* GI tract symptoms GI tract symptoms nausea, vomit, hematochezianausea, vomit, hematochezia

* Systematic infectionSystematic infection

* MassiveMassive bleeding bleeding if combined big vessels injuryif combined big vessels injury


Abdominal Injury-Abdominal Injury- DiagnosisDiagnosis

History and physical examinationHistory and physical examination

How, what, and when it happened How, what, and when it happened

Evaluation of the patient and injuryEvaluation of the patient and injury

Careful and thorough examinationCareful and thorough examination

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



Viscera injured?Viscera injured?Fully understanding of historyFully understanding of historyObservationObservation

Pulse, breath, BT , BP and any sign of shockPulse, breath, BT , BP and any sign of shock

Thorough examination with emphasisThorough examination with emphasisTenderness, muscle rigidity and rebound tenderness Tenderness, muscle rigidity and rebound tenderness

Change of liver dullness or movable dullnessChange of liver dullness or movable dullnessBowel movement Bowel movement PRPR

Viscera injured?Viscera injured?

Necessary lab testNecessary lab test

Hb Hb

HctHct

Serum and urine amylaseSerum and urine amylase

Urinary testsUrinary tests

Stomach contents examinationStomach contents examination

Blood gas analysis Blood gas analysis

Serum glucose and serum creatinine levelSerum glucose and serum creatinine level


You should consider You should consider viscera injuredviscera injured if: if: Shock at early stage, esp. hypovolemic shockShock at early stage, esp. hypovolemic shock Constant or progressive abdominal pain with nausea, vomitsConstant or progressive abdominal pain with nausea, vomits Abdomen irritationAbdomen irritation Gas abdomenGas abdomen Movable dullnessMovable dullness Hematouria, hematochezia or vomit bloodHematouria, hematochezia or vomit blood Positive finding in PR: pain, fluctuation or blood-stainPositive finding in PR: pain, fluctuation or blood-stain


Which one injured?Which one injured?

Decide which system first then which organDecide which system first then which organ GI tract: nausea, vomit, gas abdomen or blood in stoolGI tract: nausea, vomit, gas abdomen or blood in stool Urinary tract: dysuria, hematuriaUrinary tract: dysuria, hematuria Upper abdominal viscera: diaphragmalgiaUpper abdominal viscera: diaphragmalgia Liver or spleen rupture: lower rib fractureLiver or spleen rupture: lower rib fracture Rectum, bladder or urinary tract: pelvic fracture Rectum, bladder or urinary tract: pelvic fracture


More than one?More than one? Multiple injury in single organMultiple injury in single organ More than one organ injuredMore than one organ injured Intro-and extra-abdominal Intro-and extra-abdominal


What to do if you can not make diagnosis?What to do if you can not make diagnosis? Lab examinationLab examination Intensive observationIntensive observation LaparotomyLaparotomy


Lab examinationLab examination Abdominal puncture and peritoneal lavageAbdominal puncture and peritoneal lavage X-rayX-ray B type ultrasoundB type ultrasound CT scanCT scan Angio-gramAngio-gram


Abdominal puncture and peritoneal lavageAbdominal puncture and peritoneal lavage Contraindications Previous abdominal proceduresPrevious abdominal procedures Presence of dilated bowelPresence of dilated bowel Late pregnancyLate pregnancy Positive needle para-centesisPositive needle para-centesis..


Abdominal puncture and peritoneal lavageAbdominal puncture and peritoneal lavage MethodMethod

Selects a point Selects a point Inserts a plastic catheter Inserts a plastic catheter Aspirates the peritoneal cavityAspirates the peritoneal cavity Infuses a liter of saline rapidly into the peritoneal cavityInfuses a liter of saline rapidly into the peritoneal cavity Siphones the fluid out of the peritoneal cavitySiphones the fluid out of the peritoneal cavity Analysis the fluid sample Analysis the fluid sample



Abdominal puncture and peritoneal lavageAbdominal puncture and peritoneal lavage

Positive resultsPositive results Greater than 100*10Greater than 100*1099/L RBC, or 0.5*10/L RBC, or 0.5*1099/L WBC/L WBC Detection of bile, food fibers, or urineDetection of bile, food fibers, or urine Serum amylase level is greater than 100 Somogyi unitSerum amylase level is greater than 100 Somogyi unit Detection of bacteriaDetection of bacteria


X-rayX-rayGas abdomen, retro-peritoneal gas, hiatus hernia, Gas abdomen, retro-peritoneal gas, hiatus hernia, obliteration of psoas outlineobliteration of psoas outline

B type ultrasoundB type ultrasoundLiver, spleen, pancreas and kidneys injuryLiver, spleen, pancreas and kidneys injury

CT scanCT scan ArteriographyArteriography MRIMRI Diagnostic key-hole surgeryDiagnostic key-hole surgery


Intensive observationIntensive observation Pulse, breath and BP every 15-30 minPulse, breath and BP every 15-30 min Abdomen signs every 30minAbdomen signs every 30min RBC, Hb and Hct every 30-60minRBC, Hb and Hct every 30-60min Repeat paracentesis or lavage if necessaryRepeat paracentesis or lavage if necessary


Importance during intensive observationImportance during intensive observation No unnecessary move to avoid secondary injuryNo unnecessary move to avoid secondary injury Careful using analgesicsCareful using analgesics Nil by mouthNil by mouth Maintain blood volumeMaintain blood volume Broad-spectrum antibioticsBroad-spectrum antibiotics Naso-gastric intubationNaso-gastric intubation


Laparotomy Laparotomy IndicationsIndications

Worsened abdominal pain or signsWorsened abdominal pain or signs Bowel sound weakened or disappeared or distentionBowel sound weakened or disappeared or distention Worsened systemic conditionWorsened systemic condition Gas abdomenGas abdomen Progressive decline of RBC countProgressive decline of RBC count Unstable BPUnstable BP Positive finding in para-centesis or lavagePositive finding in para-centesis or lavage GI BleedingGI Bleeding


Abdominal Injury-Abdominal Injury- TreatmentTreatment

Prolapsed visceral coveringProlapsed visceral covering Priority settingPriority setting

Airway, breath and circulation are of Airway, breath and circulation are of greatest importancegreatest importance

Open airwayOpen airwayHemostasisHemostasisTension pneumothraxTension pneumothraxOpen pneumothraxOpen pneumothrax

ProcedureProcedure General anesthesiaGeneral anesthesia A long midline incision is madeA long midline incision is made Blood is rapidly evacuatedBlood is rapidly evacuated Spleen and liver are assessed as possible sources of Spleen and liver are assessed as possible sources of

bleedingbleeding Bleeding from spleen is definitively controlled firstBleeding from spleen is definitively controlled first Bleeding from the liver is addressed nextBleeding from the liver is addressed next All the abdominal viscera are carefully examined from the All the abdominal viscera are carefully examined from the

diaphragm to the pelvic floor, diaphragm to the pelvic floor, Special attention to the retro-peritoneumSpecial attention to the retro-peritoneum


Abdominal Injury-Abdominal Injury- Splenic RuptureSplenic Rupture

Most vulnerable organMost vulnerable organ20%-40% in close injury, 10% in open20%-40% in close injury, 10% in open

Parenchyma rupture, tear beneath Parenchyma rupture, tear beneath capsule and tear of capsulecapsule and tear of capsule

Intra-peritoneal bleedingIntra-peritoneal bleeding Delayed ruptureDelayed rupture

– Subcapsular hematomaSubcapsular hematoma– 36-48 hrs after injury, within 2 wks36-48 hrs after injury, within 2 wks


Pain, tenderness and guarding in left upper Pain, tenderness and guarding in left upper quadrantquadrant

Pain in the left should-tipPain in the left should-tip Signs of blood loss or shockSigns of blood loss or shock Associated fractures of lower left ribs in 20%Associated fractures of lower left ribs in 20% Can be confirmed by ultrasoundCan be confirmed by ultrasound Arteriography when hematoma or delayed Arteriography when hematoma or delayed

rupture suspectedrupture suspected


SplenectomySplenectomy Spleen-conserving procedureSpleen-conserving procedure

– Partial splenectomyPartial splenectomy– RepairRepair– Mesh wrappingMesh wrapping– Auto-transplantationAuto-transplantation

OPSI OPSI Overwhelming postsplenectomy infectionOverwhelming postsplenectomy infection


Preservation of traumatic spleen Preservation of traumatic spleen CT of splenic rupture CT of splenic rupture


Preservation of traumatic spleen Preservation of traumatic spleen

Abdominal Injury-Abdominal Injury- Liver RuptureLiver Rupture

15%-20% in abdomen trauma15%-20% in abdomen trauma Right lobe>LeftRight lobe>Left Symptoms similar to splenic rupture but with Symptoms similar to splenic rupture but with

abdominal pain and peritoneal irritationabdominal pain and peritoneal irritation Mortality:Mortality:

– 9%9% Liver onlyLiver only– 50% Multiple injury50% Multiple injury

Hematochezia or vomit bloodHematochezia or vomit blood

Non-surgical for stable patient Non-surgical for stable patient 30%30%

SurgicalSurgical Adequate exposureAdequate exposure Control bleeding temporally with gauze or press Control bleeding temporally with gauze or press

on hepatoduodenum ligament 30 or 15 minon hepatoduodenum ligament 30 or 15 min Debridement with removal of devitalized tissueDebridement with removal of devitalized tissue Suture-ligation of torn vessels and bile ductsSuture-ligation of torn vessels and bile ducts Hepatic lobectomy for extensive damage Hepatic lobectomy for extensive damage Multiple drainageMultiple drainage



An extensive med-line incision Hemostasis of liver fractureAn extensive med-line incision Hemostasis of liver fracture


Pringle maneuver compression of Pringle maneuver compression of Intracaval shunt for retrohepatic Intracaval shunt for retrohepaticportal triad structure portal triad structure venous injuryvenous injury


Approach to liver fracture Scalpel-handle resection Approach to liver fracture Scalpel-handle resection

Abdominal Injury-Abdominal Injury- Pancreatic InjuryPancreatic Injury

1-2% in abdominal trauma1-2% in abdominal traumaEasily to be ignored, with mortality of 20%Easily to be ignored, with mortality of 20%

Mechanism of injury Mechanism of injury PseudocystPseudocyst Hemorrhage is cause of deathHemorrhage is cause of death PeritonitisPeritonitis DiagnosisDiagnosis

– Palpable retro-peritoneal swellingPalpable retro-peritoneal swelling– A rise serum amylaseA rise serum amylase– B type ultrasound or CTB type ultrasound or CT


TreatmentTreatmentControl hemorrhageControl hemorrhage

Debridement and inhibit exocrine Debridement and inhibit exocrine No duct injury Adequate drainageNo duct injury Adequate drainageDuct injuredDuct injured Body and tail Pancreatectomy or repair Body and tail Pancreatectomy or repair Head and neck Suture close and Roux-en-Y anastomosis Head and neck Suture close and Roux-en-Y anastomosis

Head with duodenum Roux-en-Y anastomosis or Head with duodenum Roux-en-Y anastomosis or Pancreatico-duodenectomyPancreatico-duodenectomy


Drainage of a pancreatic wound Removal of the distal pancreas Drainage of a pancreatic wound Removal of the distal pancreas


Left retroperitoneal exposureLeft retroperitoneal exposure Internal drainage of a pancreatic injury Internal drainage of a pancreatic injury


Pancreatico-duodenal trauma The completed pancreaticoduodenectomy Pancreatico-duodenal trauma The completed pancreaticoduodenectomy

Abdominal Injury-Abdominal Injury- Gastric InjuryGastric Injury

RareRare Usually penetrating traumaUsually penetrating trauma Peritoneal irritationPeritoneal irritation Excision or sutureExcision or suture

Abdominal Injury-Abdominal Injury- Gastric InjuryGastric Injury

Posterior stomach Posterior stomach exposureexposure


Simple repair partial gastrectomySimple repair partial gastrectomy

Abdominal Injury-Abdominal Injury- Duodenal InjuryDuodenal Injury

3.7%-5% in abdominal trauma3.7%-5% in abdominal trauma 22ndnd ,3 ,3rdrd part of duodenum part of duodenum Cause of deathCause of death

– Combined lesion or massive bleedingCombined lesion or massive bleeding– Infection, hemorrhage and MOFInfection, hemorrhage and MOF

Intra-peritoneal rupture Intra-peritoneal rupture severe peritonitissevere peritonitis Retro-peritoneal ruptureRetro-peritoneal rupture

– Progressive pain, radiation to right should, mild signs Progressive pain, radiation to right should, mild signs but worse systematic reaction, retro-peritoneal gas but worse systematic reaction, retro-peritoneal gas formation and obliteration of psoas outline on X-rayformation and obliteration of psoas outline on X-ray


TreatmentTreatment Anti-shock and surgeryAnti-shock and surgery Excised and repairExcised and repair in 70-80%in 70-80% Occluded with a loop of jejunumOccluded with a loop of jejunum Duodenectomy and partial pancreatectomy for 2Duodenectomy and partial pancreatectomy for 2ndnd

part of duodenum injury part of duodenum injury


Duodenal mobilizationDuodenal mobilization Right retroperitoneal exposure Right retroperitoneal exposure


A jejunoileal patch used to reinforce A jejunoileal patch used to reinforce repair of the duodenumrepair of the duodenum

Pyloric exclusion for complex Pyloric exclusion for complex duodenum injury duodenum injury

Abdominal Injury-Abdominal Injury- Rupture of small intestineRupture of small intestine

PeritonitisPeritonitis Gas abdomenGas abdomen Simple repairSimple repair

Abdominal Injury-Abdominal Injury- Rupture of colonRupture of colon

Rarer than that of small intestineRarer than that of small intestine PeritonitisPeritonitis Repair or resectionRepair or resection

– Small wound, mild contamination, optimal conditionSmall wound, mild contamination, optimal condition

Exteriorization and restore laterExteriorization and restore later

Abdominal Injury-Abdominal Injury- Rupture of colonRupture of colon

ExteriorizationExteriorization

Abdominal Injury-Abdominal Injury- Retroperitoneal HematomaRetroperitoneal Hematoma

Controversy for years Controversy for years Central hematomas (zone 1) are Central hematomas (zone 1) are

associated with associated with pancreaticoduodenal injuries or pancreaticoduodenal injuries or major abdominal vascular injury. major abdominal vascular injury.

Flank or perinephric hematomas Flank or perinephric hematomas (zone 2) :injuries to the (zone 2) :injuries to the genitourinary tract or, in the case of genitourinary tract or, in the case of penetrating trauma, with injuries to penetrating trauma, with injuries to the colon. the colon.

Zone 3 injuries, which are confined Zone 3 injuries, which are confined to or originate from the pelvis, are to or originate from the pelvis, are most often associated with pelvic most often associated with pelvic fractures. fractures.

Abdominal Injury-Abdominal Injury- Retroperitoneal HematomaRetroperitoneal Hematoma

Retroperitoneal hematomas in Retroperitoneal hematomas in zone 1, regardless of cause or size, zone 1, regardless of cause or size, are formally explored with are formally explored with inspection of each of the relevant inspection of each of the relevant structures. structures.

This is required because of the This is required because of the high incidence of associated major high incidence of associated major vascular, pancreatic, or duodenal vascular, pancreatic, or duodenal injuries and the high morbidity injuries and the high morbidity and mortality if these are and mortality if these are overlooked. overlooked.

Abdominal Injury-Abdominal Injury- Retroperitoneal HematomaRetroperitoneal Hematoma Zone 2 hematomas caused by penetrating Zone 2 hematomas caused by penetrating

injuries should routinely be explored. injuries should routinely be explored. – Whether proximal control of the renal pedicle Whether proximal control of the renal pedicle

should be obtained before exploration of a should be obtained before exploration of a perinephric hematoma is controversial.perinephric hematoma is controversial.

– If there is severe ongoing hemorrhage, time If there is severe ongoing hemorrhage, time should not be taken to obtain proximal control, should not be taken to obtain proximal control, and the kidney should be mobilized directly.and the kidney should be mobilized directly.

– If time and the degree of hemorrhage permit If time and the degree of hemorrhage permit probably safest to obtain vascular control probably safest to obtain vascular control before mobilization of the kidney. before mobilization of the kidney.

Zone 2 hematomas caused by blunt Zone 2 hematomas caused by blunt trauma can be left alone if they are not trauma can be left alone if they are not expanding and the intravenous urogram is expanding and the intravenous urogram is normal. normal.

Abdominal Injury-Abdominal Injury- Retroperitoneal HematomaRetroperitoneal Hematoma Zone 3 retroperitoneal hematomas in Zone 3 retroperitoneal hematomas in

patients with penetrating injuries are patients with penetrating injuries are usually explored to exclude major usually explored to exclude major vascular injuries. vascular injuries.

Patients with zone 3 hematomas Patients with zone 3 hematomas secondary to blunt trauma usually have secondary to blunt trauma usually have associated pelvic fractures. Exploration associated pelvic fractures. Exploration of the hematoma can be of the hematoma can be hazardous hazardous and is and is usually avoidedusually avoided. . – There is often extensive injury to the rich There is often extensive injury to the rich

presacral venous and arterial circulation. presacral venous and arterial circulation. – Incision of the peritoneum releases the Incision of the peritoneum releases the

tamponade, and dissection within the tamponade, and dissection within the hematoma can produce catastrophic bleeding. hematoma can produce catastrophic bleeding.

– Discrete bleeding points can rarely be Discrete bleeding points can rarely be identified. identified.

Thank you very much!

abdominal injury shanghai jiaotong university medical school renji hospital cao hui

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