Download - Abdominal injuries
Abdominal injuries
Yoram Klein MD
Introduction
Suture repair of bowel - the 15th century. Routine exploration not employed until
WW I. – mortality 70-75%. WW II – mortality 50%.
Introduction
Diagnostic challenge. Importance of prompt management (?!). Evolution in surgical management:
Damage control. Staged repair.
Colo-rectal repair. Duodenal repair.
Decisions
What is the systemic condition? Is there an abdominal injury? Can the systemic condition be related to
the abdominal injury?
What is the systemic condition?
Oxygenation. Hemodynamic stability. Neurological status.
Is there an abdominal injury?
Mechanism of injury. Physical examination. FAST. Plain X-ray. CT. DPL.
Physical examination
Blunt Hemodynamic
status. Abdominal wall
hematoma. Seat-belt sign. Peritoneal irritation. GI bleeding. Confounding factors.
Penetrating Hemodynamic
status. Location of the
wound. Evisceration. Peritoneal irritation. GI bleeding. Confounding factors.
FASTFocused Assessment Sonography for
Trauma Advantages
Free fluid in the peritoneal or pericardial cavity?
Quick. Bedside. Repeatable.
Disadvantages False sense of
security. Retoperitoneum. Hollow viscous injury Penetrating trauma. User dependant.
Plain X-ray
Blunt CXR. Pelvic.
Penetrating CXR. KUB in GSW.
CT
Blunt The gold standard. Hemodynamic
stability. Normal FAST?
Penetrating RUQ low-energy
missiles. Triple-contrast for
flank and back wounds.
DPL
Blunt Free fluid with no
organ injury in the CT. Patient’s examination unreliable.
Discrepancy between FAST and physical finding.
Penetrating Violation of the
anterior abdominal fascia --- stab wounds.
Emergency laparotomy
Hemodynamic instability and abdominal injury. Hemodynamic instability and positive FAST. Diffuse peritoneal irritation. Significant evisceration. Imaging study suggesting hollow viscous
injury. GI bleeding.
Management of penetrating injuryGSW
85% need surgical repair. Low energy RUQ. Tangential wounds.
Management of penetrating injurystab wounds
Anterior abdomen local wound exploration. Violation of anterior fascia – DPL.Flank and back Triple contrast CT.Left thoraco-abdominal Surgical evaluation of the diaphragm.Right thoraco-abdominal CT.
Management of blunt injury
CT. Free fluid with no organ injury in the CT.
Patient’s examination unreliable --- DPL. If signs of arterial bleeding - angiogram?
Hollow viscous injuries
Diagnostic challenge. Importance of prompt management (?!). Evolution in surgical management:
Damage control. Staged repair.
Colo-rectal repair. Duodenal repair.
Evolution in surgical management
Non-operative management. Damage control. Staged repair. Colo-rectal repair. Duodenal repair.
Non-operative treatment
No indication for emergency surgery.
Spleen – OPSI in pediatric surgery.
Liver – non bleeding CT diagnosed injuries.
Penetrating injuries – good outcome with stable patients and unavailable OR.
Damage control
Physiological failure
On-going coagulopathy
acidosis hypothermia
Damage control
Bleeding control. Contamination
control. Temporary
abdominal closure.
Damage control
Bleeding control. Contamination
control. Temporary
abdominal closure.
Damage control
Bleeding control. Contamination
control. Temporary
abdominal closure.
Surgical approach
Hemorrhage control. Primary exploration and temporary control of
spillage. Thorough exploration and definitive spillage
control. Irrigation.------------------------------------------ Reconstitute continuity. Definitive abdominal closure.
???