Abdominal TraumaAbdominal Trauma

Ramon Garza III M.D.

Boundaries of Abdomen

• Superior- Diaphragm

• Inferior- Infragluteal fold

• Medial/Lateral- Entire circumference of torso

Abdominal Divisions

• Intrathoracic Abdomen

• True Abdomen*

• Pelvic Abdomen

• Retroperitoneal abdomen

Intrathoracic Abdomen

Pelvic Abdomen

Retroperitoneum

Blunt Abdominal Injuries

• 60% of abdominal injuries

• Liver, Spleen, and retroperitoneal hematomas are most common injuries

• Liver > Spleen

• Spleen more clinically significant

Penetrating Abdominal Injuries

• Handguns 80%

• Stab Wounds 20%

• Handguns = High Kinetic Energy = Higher Injury Potential

Initial Management

• ABC’s• 2 Large Bore Peripheral IV’s

– Above Diaphragm

• Resuscitate w/ LR/NSS– Especially important in TBI– Should not delay operative intervention

• Don’t forget CXR and Pelvic films as other sources of hemorrhage

Diagnostic Penetrating

• If HD unstable-> OR• If HD stable:

• Obvious peritonitis -> OR• Gun: KUB w/ markers, if tangential ? CT, no FAST• Knife: check fascial integrity, CT, laparoscopy, DPL

*CT should be…

contrast x 3

** If laparoscopy…

careful w/ diaphragmatic injury ->

tension pneumothorax

Diagnostic Blunt

• HD unstable -> FAST, Pelvic Film, DPL, vs OR

• HD Stable -> CT A/P, serial abd exam– CT can miss hollow viscous injury– Can trend amylase and lipase

F.A.S.T.

• Look at 4 sites– Right Subhepatic Space “Morrison’s

Pouch”– Left Upper Quadrant– Pericystic Area (better to have no Foley)– Pericardial Space

• What to look for?

F.A.S.T of Morrison’s Pouch

LIVER

Kidney

F.A.S.T.

• Good for blunt abdominal trauma

• Not reliable for penetrating injuries except….– to evaluate pericardial space

Diagnostic Peritoneal Lavage

• Positive findings in Blunt Trauma:– 10cc blood on initial draw back– Greater than 100,000 RBC/mL– Enteric Contents

• Positive findings in Stab Wounds– 10cc blood on initial draw back– Greater than 10,000 RBC/mL– Enteric Contents

How to perform DPL

• Pelvic X-ray- if fx incision cephalad to umbilicus

• Foley Catheter• Prep/Drape• 3cm vertical infraumbilical incision down

to linea alba• PD catheter directed into pelvis

How to perform a DPL

• Aspirate initially

• 1L warm NSS (10mL/Kg for children)

• Drop IV bag back to floor and let fluid siphon back into bag

• Analyze fluid

Decision for OR

• Foley

• Start broad spectrum Abx– D/c’d 24hrs post surgery even if hollow

viscous injury (except colon)

• Tetanus prophylaxis: booster vs IG

• Prep from sternal notch to middle thighs

OR

• Vertical Midline Incision• Evacuate obvious clots/blood• Pack all 4 quadrants• Can clamp aorta at diaphragmatic

hiatus• Obvious hollow viscous injuries->

rapidly controlled w/ staple vs running suture vs Babcocks

OR cont

• Allow anesthesia to catch up once bleeding controlled

• Stop and think about case and what to do next

• Avoid hypothermia from resuscitation• Methodically Explore Abdomen• If damage control-> minimize OR time

and take to ICU to resuscitate

Specific Abdominal Injuries

Diaphragmatic

• Repair all injuries to avoid intraabdominal herniation

• Repair primarily w/ permanent suture or w/ prosthetic material if too large

• Early repair through abdomen

• Late repair can be transthoracic

Spleen

• Kehr’s sign: pain in L shoulder• CT w/ blush-> Angio embolization• If or have to mobilize tail of pancreas w/

spleen • Try to use topical hemostatic agents to

control bleeding• No need to anticoagulate w/ post

splenectomy thrombocytosis

Liver

• CT is best tool to evaluate liver injury• Angio for liver injury w/ blush• No strenuous activity x 3months• Use Pringle maneuver to control bleeding

– If does not work-> ? Bleed from hepatic vein vs replaced R hepatic artery

• Post operatively give D10 fluids and Factor VII may be needed for coagulopathic pts

Pringle Maneuver

Stomach

• Take down gastrocolic ligament from left side to medial

• Evaluate posterior portion of stomach

• Low threshold for VATs if diaphragmatic injury is also present to washout chest

• Rarely injured in blunt trauma

Duodenum

• Dx by imaging w/ GI contrast• Kocher to evaluate • Repair in two layers

– Vicryl for inner layer– Silk for Lembert– Close transversely

• Drain periduodenal area• Duodenum does not require drainage• Can use jejunal patch, RY D-J, Trauma

Whipple

Kocher Maneuver

RightKidney

Small Intestine

• Definitive repair should not be performed until all of the bowel is evaluated– Use Babcocks to control contamination

• Resect segments w/ >50% injured• Débride devitalized portions of SI• If shotgun injury w/ multiple enterotomies plan

for repeat Ex-Lap• Chance fx in lumbar spine-> check for SB

injury (repeat CT w/ GI contrast)

Colon/Rectum

• If colon injury-> Abx 2-3 days• Can perform primary repair if no

hypotension, other significant organ injury, < 6hrs since injury, and EBL < 1L

• DRE to check for blood, sign of rectal injury

• Proctoscopy/Sigmoidoscopy to evaluate rectum

Retroperitoneal HematomasAlways Explore

ExplorePenetrating

ExplorePenetrating