Penetrating abdominal Penetrating abdominal injuryinjury

Penetrating abdominal Penetrating abdominal injuryinjury

Chao-Wen Chen M.D. Hon-Man Chen M.D. Division of TraumatologyDivision of Traumatology

Department of Emergency MedicineDepartment of Emergency MedicineKaohsiung Medical University HospitalKaohsiung Medical University Hospital

Preface Preface

Penetrating abdominal injury is usually caused by gunshot wound or stab wound.More common in area of high level of poverty, low level of education and high alcohol consumption.

Penetrating abdominal injury is usually caused by gunshot wound or stab wound.More common in area of high level of poverty, low level of education and high alcohol consumption.

MechanismMechanism

Gunshot woundLow velocity: <2000ft/s (<609m/s)

Damage due to direct injury to vital structures

High velocity: >2000ft/s (>609 m/s)

Wide debridement necessaryOrgan injury generally requires more complex techniques

Stab woundKnives are most prevalent

Gunshot woundLow velocity: <2000ft/s (<609m/s)

Damage due to direct injury to vital structures

High velocity: >2000ft/s (>609 m/s)

Wide debridement necessaryOrgan injury generally requires more complex techniques

Stab woundKnives are most prevalent

Priorities Priorities

Hemodynamic statusArea of injurySpecific consideration based on injury area

Hemodynamic statusArea of injurySpecific consideration based on injury area

Gunshot woundGunshot wound

Stab woundStab wound

Immediate laparotomyImmediate laparotomy

ShockPeritonsimEvisceration

ShockPeritonsimEvisceration

EviscerationEvisceration

Categories of hemodynamicsCategories of hemodynamics

Dying patientsEmergent laparotomy is indicated

Unstable groupsEmergent laparotomy may be needed , if ABCs are well performed with poor response

Stable groupsDecision according to clinical presentation or trauma mechanism

Dying patientsEmergent laparotomy is indicated

Unstable groupsEmergent laparotomy may be needed , if ABCs are well performed with poor response

Stable groupsDecision according to clinical presentation or trauma mechanism

Initial Management of the HemoclyInitial Management of the Hemoclynamically Stable Patientnamically Stable PatientAssess ABC'sApply oxygenOxygen saturation/ECG MonitoringAt least two large-bore IV cathetersExpose patientAll patients: hematocrit, urinalysis, type and screenAs indicated: coagulation studies, platelet count, elec-trolytes, renal function studies, amylase, ethanol/toxicologyscreening, pregnancy screeningNasogastric tube/Foley catheter, as indicatedNotify trauma surgeon, anesthesiologist, operating room, asindicatedComplete physical exam with special attention to abdominalexam, rectal exam and neurovascular exam of the lowerextremitiesAntibiotics, tetanus prophylaxis

Assess ABC'sApply oxygenOxygen saturation/ECG MonitoringAt least two large-bore IV cathetersExpose patientAll patients: hematocrit, urinalysis, type and screenAs indicated: coagulation studies, platelet count, elec-trolytes, renal function studies, amylase, ethanol/toxicologyscreening, pregnancy screeningNasogastric tube/Foley catheter, as indicatedNotify trauma surgeon, anesthesiologist, operating room, asindicatedComplete physical exam with special attention to abdominalexam, rectal exam and neurovascular exam of the lowerextremitiesAntibiotics, tetanus prophylaxis

Pitfalls Pitfalls

Abdominal exam is frequently unreliablePhysical findings have been reported to be lacking in 23-36% of patients with intraperitoneal injuries*1

Whereas l4-28% of patients without intraperitoneal penetration will have false-positive physical findings*2

*1 Thai ER. Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 1977;17: 642-648

*2 Moore EE, Marx JA. Penetrating abdominal wounds: Rationale for exploratory laparotomy. JAMA 1985;252:2705-2708.

Abdominal exam is frequently unreliablePhysical findings have been reported to be lacking in 23-36% of patients with intraperitoneal injuries*1

Whereas l4-28% of patients without intraperitoneal penetration will have false-positive physical findings*2

*1 Thai ER. Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 1977;17: 642-648

*2 Moore EE, Marx JA. Penetrating abdominal wounds: Rationale for exploratory laparotomy. JAMA 1985;252:2705-2708.

Surgical managementSurgical management

Local wound explorationDamage control surgery

gradually accepted Definite surgery

based on area of abdomen injured

Consider the possible nontherapeutic laparotomies

Local wound explorationDamage control surgery

gradually accepted Definite surgery

based on area of abdomen injured

Consider the possible nontherapeutic laparotomies

Management based on area of Management based on area of abdomen injuredabdomen injuredUpper abdominal injuries

SpleenLiverStomachDuodenumPancreas

Middle abdominal injuriesSmall bowel and mesenteryColonRenal

Lower abdominal injuriesRectalPerinealBladder

Vascular injuries

Upper abdominal injuriesSpleenLiverStomachDuodenumPancreas

Middle abdominal injuriesSmall bowel and mesenteryColonRenal

Lower abdominal injuriesRectalPerinealBladder

Vascular injuries

Most Frequently Injured Organs Most Frequently Injured Organs from Anterior Abdominal Stab from Anterior Abdominal Stab

WoundsWounds

LiverLiverSmall bowel/mesenteSmall bowel/mesente

ryryStomachStomach

ColonColonSpleenSpleenKidneyKidney

PancreasPancreasDuodenumDuodenum

Biliary tract Biliary tract

Guidelines for management of Guidelines for management of anterior abdominal anterior abdominal injuriesinjuries(EMST)(EMST)

Laparotomy for all penetrating abdominal injuries with:

HypotensionPeritonitisEvisceration

GSW99% risk of significant injuryTherefore, explore ALL patients

Some evidence to contrary (after imaging) (Saadia R, Degiannis E. 2000)

If the injury is tangential, and the patient is stable, consider laparoscopy

Stab woundsLocal exploration of woundObserve if no signs on examination. Perform serial examinations or DPL

Laparotomy for all penetrating abdominal injuries with:

HypotensionPeritonitisEvisceration

GSW99% risk of significant injuryTherefore, explore ALL patients

Some evidence to contrary (after imaging) (Saadia R, Degiannis E. 2000)

If the injury is tangential, and the patient is stable, consider laparoscopy

Stab woundsLocal exploration of woundObserve if no signs on examination. Perform serial examinations or DPL

Flank and back injuriesFlank and back injuries

The thickness of the flank and back muscles is protective (skin to peritoneum: 10-20cm)Investigation of potential colon ,renal and ureteral injuriesWounds are more frequently tangential

Serial physical examinations are very accurate in detecting retroperitoneal or intraperitoneal

injuries to flanks or back Contrast CT scans are useful

The thickness of the flank and back muscles is protective (skin to peritoneum: 10-20cm)Investigation of potential colon ,renal and ureteral injuriesWounds are more frequently tangential

Serial physical examinations are very accurate in detecting retroperitoneal or intraperitoneal

injuries to flanks or back Contrast CT scans are useful

Specific management - spleenSpecific management - spleen

In recent years there has been an appreciable shift from operative management toward nonoperative management (Corson & Williamson, 2001)

In recent years there has been an appreciable shift from operative management toward nonoperative management (Corson & Williamson, 2001)

AAST Splenic injury grading AAST Splenic injury grading systemsystem

Grade Type Description of injuryI Haematoma Subcapsular, <10% surface area

Laceration Capsular tear, <1cm parenchymal depthII Haematoma Subcapsular, 10-50% surface area, intraparenchymal,

<5cm in diameterLaceration Capsular tear, 1-3cm parenchymal depth that does not

involve a trabecular vesselIII Haematoma Subcapsular, >50% suface area or expanding,

ruptured subcapsular or parencymal haematoma, intraparenchymal haematoma >5cm or expanding

Laceration >3cm parenchymal depth or involving trabecular vessels

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (>25% of spleen)

V Laceration Completely shattered spleenVascular Hilar vascular injury that devascularises spleen

Non-operative management - Non-operative management - spleenspleen

Can avoid post-splenectomy sepsisOnly applicable when operating theatre is available at short noticeFailure rates of conservative management:

Grades I,II,III 5%Grades IV,V 18% (Davis et al 1998)

Probably more dependent of amount of haemoperitoneum. Attempts have been made to classify this by CTNote delayed rupture occurs between 1 and 9 days (mean 3.5 days)Beware splenic artery false aneurysms (causing contrast blush) 62% failure rate

Can avoid post-splenectomy sepsisOnly applicable when operating theatre is available at short noticeFailure rates of conservative management:

Grades I,II,III 5%Grades IV,V 18% (Davis et al 1998)

Probably more dependent of amount of haemoperitoneum. Attempts have been made to classify this by CTNote delayed rupture occurs between 1 and 9 days (mean 3.5 days)Beware splenic artery false aneurysms (causing contrast blush) 62% failure rate

Operative management - Operative management - SpleenSpleen

SplenorrhaphyUncommon – if the patient needs a laparotomy, splenectomy is usually indicated

Use of superficial haemostatic agents (electrocautery, argon beam, topical thrombin, oxidised cellulose, absorbable gelatin sponge)Pledgeted repairResectional debridementMesh wrap

Splenectomy

SplenorrhaphyUncommon – if the patient needs a laparotomy, splenectomy is usually indicated

Use of superficial haemostatic agents (electrocautery, argon beam, topical thrombin, oxidised cellulose, absorbable gelatin sponge)Pledgeted repairResectional debridementMesh wrap

Splenectomy

Specific management - LiverSpecific management - Liver

Non-operative management is increasingSignificantly lower transfusion requirements (where injuries were matched for severity)(Croce MA et al 1995)

Most hepatic bleeding is venous, most splenic bleeding is arterialMaybe 80% of hepatic injury can be managed

conservatively

Unstable patients require emergency laparotomyDiscrete contrast blush or frank contrast extravasation probably mandates embolization or laparotomy

Non-operative management is increasingSignificantly lower transfusion requirements (where injuries were matched for severity)(Croce MA et al 1995)

Most hepatic bleeding is venous, most splenic bleeding is arterialMaybe 80% of hepatic injury can be managed

conservatively

Unstable patients require emergency laparotomyDiscrete contrast blush or frank contrast extravasation probably mandates embolization or laparotomy

Operative management - liverOperative management - liver

Gauze packingmay have infective complications (Ivatury RR et al 1986)

Omental packingResectional debridementMass liver sutureHepatic artery ligationTotal hepatic isolation - good for retrohepatic venous injuries

Atriocaval shunt

Gauze packingmay have infective complications (Ivatury RR et al 1986)

Omental packingResectional debridementMass liver sutureHepatic artery ligationTotal hepatic isolation - good for retrohepatic venous injuries

Atriocaval shunt

Specific management – Specific management – DuodenumDuodenum

Relatively uncommon 80% due to penetrating trauma (Corson & Williamson 1999)

Difficult diagnosis Mortality 5%-30%

Three times more likely to die if operation delayed > 24 hours (Lucas CE, Ledgerwood AM. 1985)Early death – exsanguination due to associated vascular injuryLate death – sepsis

Relatively uncommon 80% due to penetrating trauma (Corson & Williamson 1999)

Difficult diagnosis Mortality 5%-30%

Three times more likely to die if operation delayed > 24 hours (Lucas CE, Ledgerwood AM. 1985)Early death – exsanguination due to associated vascular injuryLate death – sepsis

Operative management – Operative management – DuodenumDuodenum

Most duodenal wounds can be closed primarily by duodenorrhaphyDebride devitalized tissueOne or two layer closurePyloric exclusion for more difficult injuries (Vauhgn GD et al 19987)

Primary repair, followed by Side-to-side gastrojejunostomy

Most duodenal wounds can be closed primarily by duodenorrhaphyDebride devitalized tissueOne or two layer closurePyloric exclusion for more difficult injuries (Vauhgn GD et al 19987)

Primary repair, followed by Side-to-side gastrojejunostomy

Specific management – Specific management – PancreasPancreas

Associated injuries in penetrating trauma

75% have injury to one of: (JurkovichGJ, Carrico CJ. 1990)

AortaPortal veinInferior vena cava

Mortality rate: 10% – 30%Manage haemorrhage and contamination first

Associated injuries in penetrating trauma

75% have injury to one of: (JurkovichGJ, Carrico CJ. 1990)

AortaPortal veinInferior vena cava

Mortality rate: 10% – 30%Manage haemorrhage and contamination first

AAST pancreatic injury gradeAAST pancreatic injury grade

Grade Description of injury

I Minor contusion / superficial laceration without duct injury

II Major contusion / major laceration without duct injury or tissue loss

III Distal transection or parenchymal injury with ductal injury

IV Proximal transection (to right of SMV) or parenchymal injury involving ampulla

V Massive disruption of pancreatic head

Operative management - Operative management - PancreasPancreas

Minor injuries (grades I and II)No ductal injuryExternal drainage alone

Closed systems superior to sump systems (Fabian TC et al 1990)

Grade IIIDistal pancreatectomy (up to 80% of gland is well tolerated)

Spleen can be preserved in 50%

Grade IVMost result in deathWide external drainage is becoming more commonDistal resection (up to 95% of gland)

Grade VMost die. Diversion procedures or pancreatoduodenectomy

Minor injuries (grades I and II)No ductal injuryExternal drainage alone

Closed systems superior to sump systems (Fabian TC et al 1990)

Grade IIIDistal pancreatectomy (up to 80% of gland is well tolerated)

Spleen can be preserved in 50%

Grade IVMost result in deathWide external drainage is becoming more commonDistal resection (up to 95% of gland)

Grade VMost die. Diversion procedures or pancreatoduodenectomy

Specific management – ColonSpecific management – Colon

Management recommendations depend on whether destruction is such that resection is requiredStrong evidence supporting primary repair of nondestructive wounds in the absence of peritonitisAnastomoses:

No difference between single/double layer, stapled/hand-sewn; absorbable/nonabsorble

Management recommendations depend on whether destruction is such that resection is requiredStrong evidence supporting primary repair of nondestructive wounds in the absence of peritonitisAnastomoses:

No difference between single/double layer, stapled/hand-sewn; absorbable/nonabsorble

Specific management – ColonSpecific management – Colon

Destructive wounds requiring resection, can undergo primary anastomosis if:

Hemodynamically stableNo severe underlying diseaseMinimal associated injuriesDo not have peritonitis

Destructive wounds requiring resection, can undergo primary anastomosis if:

Hemodynamically stableNo severe underlying diseaseMinimal associated injuriesDo not have peritonitis

Current trend : Why and Current trend : Why and How? How?

Emergent department discharge or not?FAST or not?Laparotomy or laparoscopy?Out of control? Damage control?Open or close?

Emergent department discharge or not?FAST or not?Laparotomy or laparoscopy?Out of control? Damage control?Open or close?

ED discharge or not?ED discharge or not?

236 patients were enrolled, 69 had selective ED work-up ED work-up including radiologic and invasive diagnostic procedures, ED disposition, complications and follow-up. Selective management include hospital admission for observation, triple contrast CT, and local wound exploration. Patients having a (-) selective ED work-up can be safely discharged…

*Selective Management Of Penetrating Truncal Injuries: Is Emergency Department Discharge A Reasonable Goal? J. H. Patton, Jr.M. F. Conrad et al. Am Surg 2001

236 patients were enrolled, 69 had selective ED work-up ED work-up including radiologic and invasive diagnostic procedures, ED disposition, complications and follow-up. Selective management include hospital admission for observation, triple contrast CT, and local wound exploration. Patients having a (-) selective ED work-up can be safely discharged…

*Selective Management Of Penetrating Truncal Injuries: Is Emergency Department Discharge A Reasonable Goal? J. H. Patton, Jr.M. F. Conrad et al. Am Surg 2001

ED discharge or not?ED discharge or not?

650 asymptomatic patients with abdominal stab wounds were admitted and underwent serial examination, over a 5 year period. 582 had no abdominal surgical intervention, while 68 patients had abdominal surgery.No patients were identified as requiring surgery, more than 12 hours after presentation…Asymptomatic patients with abdominal stab wounds can be safely discharged after 12 hours of observation.

*WHEN IS IT SAFE TO DISCHARGE ASYMPTOMATIC PATIENTS WITH ABDOMINAL STABWOUNDS? 2003 Annual Meeting Heythern Alzamel MD, Stephen Cohn MD

650 asymptomatic patients with abdominal stab wounds were admitted and underwent serial examination, over a 5 year period. 582 had no abdominal surgical intervention, while 68 patients had abdominal surgery.No patients were identified as requiring surgery, more than 12 hours after presentation…Asymptomatic patients with abdominal stab wounds can be safely discharged after 12 hours of observation.

*WHEN IS IT SAFE TO DISCHARGE ASYMPTOMATIC PATIENTS WITH ABDOMINAL STABWOUNDS? 2003 Annual Meeting Heythern Alzamel MD, Stephen Cohn MD

FAST or not?FAST or not?

100 victims of penetrating torso trauma assessed by our trauma teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound..The overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity of 96%. The positive predictive value was 86% and negative predictive value was 87%... The US examination lacks sensitivity to be used alone in determining operative intervention…Rarely does US information contribute to the management of patients with penetrating abdominal injuries

*A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003

100 victims of penetrating torso trauma assessed by our trauma teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound..The overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity of 96%. The positive predictive value was 86% and negative predictive value was 87%... The US examination lacks sensitivity to be used alone in determining operative intervention…Rarely does US information contribute to the management of patients with penetrating abdominal injuries

*A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003

FAST or not?FAST or not?

149 patients with suspicion for abdominal trauma were evaluated…leaving 134 patients for analysis. There were 111 true negative FAST exams, 5 true positives, 17 false negatives, and 2 false positives. Chi-square analysis showed significant discordance between FAST and CT (p<0.001).Utilization of FAST as a screening tool for BAI in hemodynamically stable trauma patients results in under-diagnosis of intraabdominal injury… Patients with suspected abdominal trauma should undergo routine CT scanning.

*Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002

149 patients with suspicion for abdominal trauma were evaluated…leaving 134 patients for analysis. There were 111 true negative FAST exams, 5 true positives, 17 false negatives, and 2 false positives. Chi-square analysis showed significant discordance between FAST and CT (p<0.001).Utilization of FAST as a screening tool for BAI in hemodynamically stable trauma patients results in under-diagnosis of intraabdominal injury… Patients with suspected abdominal trauma should undergo routine CT scanning.

*Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002

Laparotomy or laparoscopy?Laparotomy or laparoscopy?

Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoraco-abdominal injury.

Laparoscopy in the evaluation of penetrating thoracoabdominal trauma McQuay N Jr, Britt LD et al.Am Surg. 2003 Sep

Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoraco-abdominal injury.

Laparoscopy in the evaluation of penetrating thoracoabdominal trauma McQuay N Jr, Britt LD et al.Am Surg. 2003 Sep

Laparotomy or laparoscopy?Laparotomy or laparoscopy?

Forty-eight patients underwent LS (62 per cent male); average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8.58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation.LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury.

The value of laparoscopy in management of abdominal traumaChelly MR, Major K, Am Surg. 2003 Nov

Forty-eight patients underwent LS (62 per cent male); average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8.58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation.LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury.

The value of laparoscopy in management of abdominal traumaChelly MR, Major K, Am Surg. 2003 Nov

Laparoscopy vs. Laparoscopy vs. laparotomylaparotomy

Avoid nontherapeutic celiotomiesMissed injury

Difficulty to view all small bowel with laparoscopyDifficult to see right-sided diaphragmatic injury

May impair heart/lung functionMay cause tension pneumothorax

Avoid nontherapeutic celiotomiesMissed injury

Difficulty to view all small bowel with laparoscopyDifficult to see right-sided diaphragmatic injury

May impair heart/lung functionMay cause tension pneumothorax

Suggested m anagem ent of thoracoabdom inal injuries

L A PA RO T O M Y

Un stab le

L A PA RO T O M Y

Yes No

D iap h rag m atic in ju ry?

T HO RA C O S C O PY

Yes

L A PA RO T O M Y

Yes No

D iap h rag m atic in ju ry?

L A PA RO S C O PY

No

H aem oth orax o r p n eu m oth orax?

Stab le

H aem od yn am ics

Penetra ting thoracoabdom ina l traum a

(adapted from Ferrada R, Birolini D. 1999)

Control or not?Control or not?

Damage control surgery: an alternative approach for the management of critically injured patientsKouraklis G, Spirakos S, Glinavou A Surg Today. 2002;32(3):195-202

…These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery

Damage control surgery: an alternative approach for the management of critically injured patientsKouraklis G, Spirakos S, Glinavou A Surg Today. 2002;32(3):195-202

…These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery

Coagulopathy, hypothermia and acidosis in trauma patients: the rationale for damage control surgeryDe Waele JJ, Vermassen FE. Acta Chir Belg. 2002 Oct;102(5):313-6.

Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands…

Coagulopathy, hypothermia and acidosis in trauma patients: the rationale for damage control surgeryDe Waele JJ, Vermassen FE. Acta Chir Belg. 2002 Oct;102(5):313-6.

Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands…

Damage control Damage control

Definite surgery is time-consuming and may be not executedSurgical insult may waste functional reserveAims:

Damage control operationResuscitation in SICUPlanned reoperation in 24-48 hours

Definite surgery is time-consuming and may be not executedSurgical insult may waste functional reserveAims:

Damage control operationResuscitation in SICUPlanned reoperation in 24-48 hours

Timing for damage controlTiming for damage control

Bleeding caused by coagulopathySevere metabolic acidosis (pH <7.3) Hypothermia during operation (T° <34°)Inability to control the haemorrhage (hepatic, retroperitoneal, pelvic, thoracic or cervical)Inability to formally close the abdomen because of intestinal edema

Bleeding caused by coagulopathySevere metabolic acidosis (pH <7.3) Hypothermia during operation (T° <34°)Inability to control the haemorrhage (hepatic, retroperitoneal, pelvic, thoracic or cervical)Inability to formally close the abdomen because of intestinal edema

Technique for damage Technique for damage controlcontrol

Hemorrhage controlPacking ± angiographic embolisationLigation of vessels instead of repairBalloon catheter tamponade for deep or hepatic wounds

Contamination controlHollow viscus ligation instead of repairExternal tube drainage of biliary and pancreatic injury instead of pancreatoduodenectomyAvoidance of formal colostomy

Hemorrhage controlPacking ± angiographic embolisationLigation of vessels instead of repairBalloon catheter tamponade for deep or hepatic wounds

Contamination controlHollow viscus ligation instead of repairExternal tube drainage of biliary and pancreatic injury instead of pancreatoduodenectomyAvoidance of formal colostomy

Open or close?Open or close?

Recent studies demonstrate that ACS is an independent predictor of MOF and that the prevention of ACS decreases the incidence of MOF..

Abdominal Compartment Syndrome: The Cause or Effect of Postinjury Multiple Organ Failure. Balogh Z, McKinley BA et al. Shock. 2003 Dec

Recent studies demonstrate that ACS is an independent predictor of MOF and that the prevention of ACS decreases the incidence of MOF..

Abdominal Compartment Syndrome: The Cause or Effect of Postinjury Multiple Organ Failure. Balogh Z, McKinley BA et al. Shock. 2003 Dec

Open or close?Open or close?

Abdominal compartment syndromeIntraabdominal pressure rise to:

10 mmHg decreased venous return & CO25 mmHg increased airway pressures

How does it occur?Capillary leak gastrointestinal oedemaOngoing bleeding

Definite organ injury exacerbate general conditionDecompressive laparotomy

Abdominal compartment syndromeIntraabdominal pressure rise to:

10 mmHg decreased venous return & CO25 mmHg increased airway pressures

How does it occur?Capillary leak gastrointestinal oedemaOngoing bleeding

Definite organ injury exacerbate general conditionDecompressive laparotomy

ACS ACS (Abdominal compartment syndrome)(Abdominal compartment syndrome)

Pathophysiological effects include release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate. These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome.

Pathophysiology and management of abdominal compartment syndrome. Walker J, Criddle LM et al. Am J Crit Care. 2003 Jul

Pathophysiological effects include release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate. These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome.

Pathophysiology and management of abdominal compartment syndrome. Walker J, Criddle LM et al. Am J Crit Care. 2003 Jul

Decompressive laparotomyDecompressive laparotomy

Performe in the presence of Intraabdominal hypertension with definite organ failure Explore total abdomen, control bleeders, hemastasis, temporary abdominal closure or bridging wound gapTAC: Bogota bag or skin closure?

Performe in the presence of Intraabdominal hypertension with definite organ failure Explore total abdomen, control bleeders, hemastasis, temporary abdominal closure or bridging wound gapTAC: Bogota bag or skin closure?

Temporary Abdominal ClosureTemporary Abdominal Closure

In contrast to patients with skin closure, Bogota bag patients had no cases of ACS and less morbidity, while achieving similar rates of eventual fascial reapproximation.

the use of a Bogota bag is superior to skin closure in achieving TAC when primary fascial closure is deemed unwise.

In contrast to patients with skin closure, Bogota bag patients had no cases of ACS and less morbidity, while achieving similar rates of eventual fascial reapproximation.

the use of a Bogota bag is superior to skin closure in achieving TAC when primary fascial closure is deemed unwise.

Temporary Abdominal Closure (TAC): BogoTemporary Abdominal Closure (TAC): Bogota Bag Is Superior To Skin Closureta Bag Is Superior To Skin Closure

JJ Morken MD, SG Muehlstedt MD Hernia. 2002 DecJJ Morken MD, SG Muehlstedt MD Hernia. 2002 Dec

SummarySummary

Organ injury patterns and survival from penetrating abdominal injury have remained similar over the last decadeDeath from refractory hemorrhage in the first 24 hours remain the common cause of mortality.DCS and use of open abdomen are being used more frequently with imporved survival, but result in more morbidity.Evidence-based analysis will be the ultimate guideline to determine the optimal management.

Organ injury patterns and survival from penetrating abdominal injury have remained similar over the last decadeDeath from refractory hemorrhage in the first 24 hours remain the common cause of mortality.DCS and use of open abdomen are being used more frequently with imporved survival, but result in more morbidity.Evidence-based analysis will be the ultimate guideline to determine the optimal management.

Thank you for your Thank you for your attention!attention!