Abdominal Trauma

1. Abdominal Trauma Ramon Garza III M.D.

2. Boundaries of Abdomen • Superior- Diaphragm • Inferior- Infragluteal fold • Medial/Lateral- Entire circumference of torso

3. Abdominal Divisions • Intrathoracic Abdomen • True Abdomen* • Pelvic Abdomen • Retroperitoneal abdomen

4. Intrathoracic Abdomen

5. Pelvic Abdomen

6. Retroperitoneum

7. Blunt Abdominal Injuries • 60% of abdominal injuries • Liver, Spleen, and retroperitoneal hematomas are most common injuries • Liver > Spleen • Spleen more clinically significant

8. Penetrating Abdominal Injuries • Handguns 80% • Stab Wounds 20% • Handguns = High Kinetic Energy = Higher Injury Potential

9. 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

10. 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

11. 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

12. 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?

13. F.A.S.T of Morrison’s Pouch LIVER Kidney

14. F.A.S.T. • Good for blunt abdominal trauma • Not reliable for penetrating injuries except…. • to evaluate pericardial space

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Specific Abdominal Injuries

22. 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

23. 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

24. 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

25. Pringle Maneuver

26. 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

27. 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

28. Kocher Maneuver Right Kidney

29. 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)

30. 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

31. Retroperitoneal Hematomas Always Explore Explore Penetrating Explore Penetrating