ABDOMINAL

TRAUMA

DR.R.SRIVATHSAN
PG-II
OUTLINE
Anatomic definition of abdomen
Mechanism of injury
Typical injury patterns
Assessment of abdominal trauma
Diagnostic algorithms

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Abdominal trauma
Common site of injury for both blunt and
penetrating injuries
29% of polytraumapatient requires abdominal
exploration
Rapid, life-threatening bleeding can be hidden
in the abdomen
Unrecognized abdominal injuries in the multi-
system trauma patient

3
Abdomen – anatomic
boundaries
External:

Anterior abdomen: transnipple line superiorly,

inguinal ligaments and symphasis pubis
inferiorly, anterior axillary lines laterally.
Flank: between anterior and posterior axillary
lines from 6th intercostals space to iliac crest.
Back: Posterior to posterior axillary lines, from tip
of scapulae to iliac crests.

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Internal:

Upper peritoneal cavity: covered by lower aspect

of bony thorax. Includes diaphragm, liver,
spleen, stomach, transverse colon.
Lower peritoneal cavity: small bowel, ascending
and descending colon, sigmoid colon, and (in
women) internal reproductive organs.
Pelvic cavity: contains rectum, bladder, iliac
vessels, and (in women) internal reproductive
organs.
Retroperitoneal space: posterior to peritoneal
lining of abdomen. Abdominal aorta, IVC, most
of duodenum, pancreas kidneys, ureters, and
posterior aspects of ascending and descending
colon.

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6
Intraperitoneal and
retroperitoneal cavities

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Mechanisms and
Pathology
Blunt vs Penetrating
Often both occur simultaneously
Blunt injury is the most common mechanism

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Direct impact

Acceleration-deceleration:
differential movements of fixed and nonfixed
structures (e.g. liver and spleen lacerations
at sites of supporting ligaments)

Compression, crush, or sheer injury

abdominal viscera deformation of solid or hollow
organs, rupture (e.g. small bowel, bladder,gravid
uterus)

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Key points
No correlation between size of contact area
and resultant injuries
Abdomen = Pandora’s box
A potential site of major blood loss with little
evident signs/symptoms.

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Assessment: History
Mechanism
Symptoms, Medications, drugs
MVC:
Speed
Type of collision (frontal, lateral, sideswipe, rear,
rollover)
Vehicle intrusion into passenger compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle

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Assessment: Physical
Exam
Inspection, auscultation, percussion,
palpation
Inspection: abrasions, contusions, lacerations,
deformity

Percussion: subtle signs of peritonitis; tympany

in gastric dilatation or free air; dullness with
hemoperitoneum

Palpation: superficial, deep, or rebound

tenderness; involuntary muscle guarding
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Physical Exam: Eponyms
Grey-Turner sign:
 Bluish discoloration of lower flanks, lower back; associated
with retroperitoneal bleeding of pancreas, kidney, or pelvic
fracture.
Cullen sign:
 Bluish discoloration around umbilicus, indicates peritoneal
bleeding, often pancreatic hemorrhage.
Kehr sign:
 Left shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abd bleeding)
Ballance sign:
 Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.

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Diagnostic modalities
Labs:
- Complete Blood profile
- Coagulation profile
- Serum Amylase/Lipase
- Urine analysis
- Toxicology screen

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Radiological profile
Plain films:
- Chest XRay,
- Pelvic XRay
- Abdomen XRay

FAST
CT

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DPL - Procedure
18
DPL
Standard criteria
10cc gross blood
RBC > 100,000/mm2
WBC > 500/mm2
Amylase > 175 IU/dL
Bile, bacteria, fiber or food.

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Indications:
- Equivocal physical examination
- Unexplained shock or hypotension   
- Altered sensorium (closed head injury, drugs,
etc.)   
- General anesthesia for extra-abdominal
procedures   
- Cord injury

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Contraindications :
Clear indication for exploratory laparotomy   
Relative contraindications:   
- Previous exploratory laparotomy   
- Pregnancy   
- Obesity

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DPL
Highly sensitive to intraperitoneal blood,
but low specificity 



Diaphragm
Retroperitoneal hematomas
Renal, pancreatic, duodenal
Minor intestinal
Extraperitoneal bladder injuries
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Focused Assessment with
Sonography for Trauma (FAST)

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 FAST: Strengths and
Strengths Limitations Limitations
 Does not typically identify
Rapid (~2 mins)
source of bleeding, or detect
Portable injuries that do not cause
Inexpensive hemoperitoneum
 Requires extensive training
Technically simple, easy to assess parenchyma
to train (studies show reliably
competence can be  Limited in detecting <250 cc
achieved after ~30 intraperitoneal fluid
studies)  Particularly poor at detecting
Can be performed bowel and mesentery
damage (44% sensitivity)
serially
 Difficult to assess
Useful for guiding triage retroperitoneum
decisions in trauma  Limited by habitus in obese
patients patients

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 FAST: Accuracy
For identifying hemoperitoneum in blunt abdominal
trauma:
 Sensitivity 76 - 90%
 Specificity 95 - 100%
The larger the hemoperitoneum, the higher the
sensitivity. So sensitivity increases for clinically
significant hemoperitoneum.

How much fluid can FAST detect?

 250 cc total
 100 cc in Morison’s pouch

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 CT Scan
Hemodynamically stable patient

The patient should be in a transportable

condition

Triple contrast CT is the preferred mode

IV + ORAL + RECTAL

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 Indications and Contraindications
for Abdominal Computed
Tomography
Indications
 
Blunt trauma   
Hemodynamic stability  
Normal or unreliable physical examination
Mechanism: Duodenal and pancreatic trauma

Contraindications
Clear indication for exploratory laparotomy
Hemodynamic instability
Agitation 27
Advantages
Adequate assessment of the retroperitoneum
Nonoperative management of solid organ injuries
Assessment of renal perfusion
Noninvasive
High specificity

Disadvantages
Specialized personnel
Hardware
Duration: Helical versus conventional
Hollow viscus injuries
Cost

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29
 Laparoscopy
Role still being defined
Good for diaphragm injury evaluation
Cons
Invasive
Expensive
Missed small bowel, splenic, retroperitoneal
injuries

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 ROLE OF DIAGNOSTIC
LAPAROSCOPY

Hemodynamically stable patients

Inadequate/equivocal FAST or borderline
DPL (80 * 103 - 120 * 103 RBC/HPF)
Intermittent mild hypotension or
persistent tachycardia
Persistent abdominal signs/symptoms
Potential to decrease incidence of
nontherapeutic laparotomies

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 Diagnosis
Test of choice dependent on hemodynamic
stability and severity of associated injuries.
Stable blunt trauma FAST or CT
Unstable blunt trauma  FAST or DPL
Stab wounds without peritoneal signs,
evisceration, or hypotension  wound
exploration or DPL.
Gun shot wounds  surgical exploration.

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EAST Algorithm:
Unstable

Eastern Association for the Surgery of Trauma, 2001

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EAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001

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LIVER INJURY

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38
 Initial hemostasis
Rapid mobilisation of injured lobe with
bimanual compression
Perihepatic packing
Pringle maneuver
Failure of pringle maneuver – major hepatic
venous involvement

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In the event of continued bleeding a vascular
clamp can be placed around porta hepatis-
hepatoduodenal lig.
Pringle Maneuver
If bleeding continues…
B. It is coming from the portal vein or hepatic
artery
OR
E. It is coming from the retrohepatic vena
cava or hepatic veins
Schrock shunt: atrial-caval shunt can be life
saving.
Total hepatic isolation: vascular clamps at
hepatoduodenal ligament, descending
aorta at infra diaphragmatic region and
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42
 Definitive
hemostasis
Surface ooze: cautery;argon beam laser;
parenchymal sutures; topical hemostatics
Deeper wounds: hepatotomy – finger fracture
tech

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Packing
Used when other
techniques fail in
controlling hemorrhage
Use in patients that are
hypothermic, acidotic,
coagulopathic
ICU for rewarming
Re-explore 48-72 hours
Intra-abd abscesses
<15%
Arteriography/embolizati
on useful adjunct

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 Splenic injury
Most frequently injured intra-abdominal organ
in blunt trauma.
Suspected in all c/o LUQ injury; L lower ribs
fracture
Splenic preservation when possible
 OPSI (0.6% in children, 0.3% in adults)
More than 70% can be treated non-operatively

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Criteria for conservative
mng
Hemodynamic stability
Negative abdominal exam
Absence of extravasation of contrast on CT
Absence of bleeding diasthesis
Absence of other indications of laprotomy
Grade I - III

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Monitoring in the ICU setup
NG tube
Strict bed rest
Serial abdominal examinations
Serial hematocrit

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Extravasation / Blush on CECT:
Stable: angiography and selective embolisation
Unstable: surgery
SURGERY : splenectomy / splenic salvage
surgery
Deep lacerations: horizontal absorbable mattress
sutures
Major laceration < 50% parenchyma :
segmental/partial splenic resection
Extensive injury of hilum/ central portion of
spleen : spleenectomy + autotransplantation
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Predictive factors for nonop success:

Localized trauma to flank/abdomen

Age<60
No associated trauma
Transfusion <4 units
Grade I-III

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56
 Pancreatic Injury
Rare 10-12% of abdominal injuries, but
mortality 10-25%, mostly from associated
intra-abd injury
Most caused by penetrating trauma - 75%
associated with major vascular injury
Blunt trauma 





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Pancreatic Injury

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GSW to Pancreatic Head

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PANCREAS INJURY SCALE

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61
 Pancreatic Injury



Distal duct injury (Grade III) 







62
Complications after
Pancreatic Trauma
High complication rate 35-40%
Most common are pancreatic fistulas &
abscesses
Most fistulas close spontaneously if well
drained
Somatostatin / Octreotide to expedite
healing
Abscesses - surgical debridement &
drainage
Incidence of pancreatitis 8-18%
Pseudocysts are infrequent
63
 Gastric Injury
Mostly penetrating trauma.
<1% from blunt trauma
Including iatrogenic injury from CPR/ ET in
esophagus
NGT + aspirate for blood
Intraop evaluation includes good
visualisation of EG junction; ant gastric wall;
opening of gastrocolic ligament and
complete visualization of posterior wall
Most penetrating wounds treated by
debridement and primary closure in layers.
Evacuation of hematomas.
Major tissue loss may necessitate gastric
resection. 64
Gastric Injury
Post-op
complications
Bleeding, abscesses,
gastric fistula with
peritonitis,empyema
Recent meal 
neutralization of
gastric acidity 




65
 Duodenal Injury
Incidence: 3 – 5%
Majority due to penetrating trauma.
Blunt injury usually secondary to steering
wheel blow to the epigastrium (difficult to
diagnose)
Retroperitoneal location is protective, but also
prevents early diagnosis.
Isolated injury to the duodenum is rare
Hyperamylasemia in 50% with blunt injury.

66
67
Plain films of the abdomen
§ mild scoliosis
§ obliteration of the right psoas shadow
§ absence of air in the duodenal bulb
§ air in the retroperitoneum outlining the kidney

68
Duodenal Injury
Gastrograffin UGI
or CT with contrast
Extravasation of
contrast 
If CT eqivocal –
dilute barium UGI
May see retro-
peritoneal air on CT
DPL unreliable but
may be positive
from an associated
injury 69
 Duodenal
Hematoma
The radiographic
finding of a duodenal
hematoma (coiled
spring or stacked coin
sign) is not an
indication for surgical
exploration
NGT until peristalsis
resumes.
Slow introduction of
food.
OR if obstruction
persists > 10 –15
days.
70
Stacked coin sign

71
 Duodenal Injury
Appropriate repair depends
on injury severity and
elapsed time
80-85% can be primarily
repaired.
Duodenal decompression
advisable if injury >6 hours
old (transpyloric nasogastric
tube, tube jejunostomy, or
tube duodenostomy)

72
Grade III injuries(major disruption of the
duodenal circumference ) : primary repair,
pyloric exclusion, and drainage or by Roux-en-
Y duodenojejunostomy.
Grade IV injuries (involving the ampulla or
distal common bile duct) : primary repair of the
duodenum, repair of the common bile duct and
placement of a T-tube with a long
transpapillary limb or a choledochoenteric
anastomosis
If repair of the CBD is impossible, ligation and a
second intervention for a biliary enterostomy
Pancreaticoduodenectomy - grade V injuries
(massive disruption of the duodenum and
pancreatic head or massive devascularization 73
 Duodenal injury
severity

74
 COMPLICATIONS
Duodenal fistulas (5 – 15%) – conservative
mng
Abscess (10 – 20%) – percutaneous / open
drainage

75






 

 
 




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


77

13% perforated
small bowel have a
normal CT scan
Suggestive findings
include free air, free
fluid without solid
organ injury,
thickening of small
bowel wall or
mesentery

78
 
 


 Penetrating injuries by
firearms should be
debrided.
 Small tears closed
primarily.
 Adjacent holes
connected and closed
transversely.
 Extensive lacerations
and devascularization
require resection and
reanasatomosis.
 Explore all mesenteric 79
 Colon Injury
Second most frequent injured organ,
usually from penetrating trauma
Repair within 2 hours dramatically reduces
infectious complications.
Pre-operative antibiotics important adjunct.
PE blood per rectum, stab to flanks or back
CT with rectal contrast, XR-
pneumoperitoneum
WWI primary repair led to 60% mortality.
WWII colostomy led to 35% mortality.
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 Colon Injury
Primary repair criteria
Early diagnosis (within 4-6 hours)
Absence of prolonged shock/hypotension
Absence of gross contamination
Absence of associated colonic vascular injury
Less than 6 units blood transfusion
No requirement for use of mesh for closure
Extensive wounds
Right colon 


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 Rectal Injury
Most from GSW
Other causes - foreign body, impalement,
pelvic fractures, and iatrogenic
Lower abdomen/buttock penetrating injury
should raise suspicion.
May be intra- or extraperitoneal
Rectal exam may reveal blood or laceration
Work-up includes anoscopy and rigid
sigmoidoscopy.

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 Rectal Injury
Extraperitoneal
injury
Primary closure
Diverting colostomy
Washout of rectal
stump
Wide presacral
drainage
Intraperitoneal
injury
Primary closure
Diverting colostomy

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Complications
Sepsis
Pelvic abscess
Urinary/rectal fistulas
Rectal incontinence / stricture
Loss of sexual function
Urinary incontinence

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 Renal trauma
 Classified as major and minor injuries (85%)
 MC injured part of urinary tract

American association for surgery of trauma classification:

 GRADE I: contusion or contained subcapsular hematoma,

without parenchymal laceration.
 GRADE II: non expanding, confined perirenal hematoma or
cortical laceration less than 1 cm deep, without urinary
extravasation.
 GRADE III: parenchymal laceration extending less than 1 cm
into the cortex without urinary extravasation.
 GRADE IV: parenchymal laceration extending through the
corticomedullary junction and into the collecting system.
There can be also thrombosis of a segmental renal artery
without a parenchymal laceration.
 GRADE V: three situations are possible:
- thrombosis of the main renal artery;
- multiple major lacerations; 85
86
Renal contusion is the most common type and
is managed conservatively.
Major renal trauma includes deep cortical
medullary lacerations, large perinephric
hematomas and pedicle injury.
All perinephric hematomas by penetrating
injuries must be explored

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Surgical techniques

Nephrectomy - Shattered kidney, multiple

concurrent injuries,uncontrolled hemorrhage and
hilum injury.

Partial nephrectomy - Avulsed fragments, polar

penetrating mechanism, and collecting system
repair

Adjuncts - Absorbable mesh wrap, topical

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Complications of renal injuries :
- secondary hemorrhage, usually due to infection
(10 to 14 days after trauma)
-paralytic ileus (4 to 5 days) d/t retroperitoneal
hematoma
-hypertension as a result of the constricting effect
of reorganizing perirenal hematoma
-arterio-venous fistula;
-renal failure;
-renal atrophy;
-hydronephrosis;
-chronic pyelonephritis;
-renal calculi;
-renal artery stenosis.
89
 Bladder injury
The majority of bladder injuries occur as a result of
blunt trauma, and the association of bladder
rupture and pelvic fractures is extremely high(75%)
Hematuria is the most frequent sign
Bladder rupture may be extraperitoneal or
intraperitoneal.
Extraperitoneal rupture usually results from
perforation by adjacent bony fragments.
Intraperitoneal rupture of the bladder results from
injuries located in the dome- full bladder sustains a
direct blow.
The diagnosis is made by cystography - a postvoid
film is necessary to identify lateral or posterior
90
Intraperitoneal injuries are repaired
primarily by three-layer closure +/-
Suprapubic cystostomy
Extraperitoneal rupture of the bladder:
primarily nonoperative –Foley’s catheter for
10 to 14 days
Severe pelvic fractures and massive
retroperitoneal bleeding : initially managed
nonoperatively. delayed repair of the
extraperitoneal rupture is performed

91
Complications of bladder rupture
Hemorrhage
Urinoma
Abscess formation
Sepsis.

92
Retroperitoneal
hematoma
Zone 1
Explore regardless of
mechanism.
Zone 2
Explore penetrating
trauma.
Observe blunt
trauma
(nonexpanding,
nonpulsatile, no
urologic indications)
Zone 3
Explore penetrating.
Observe blunt.
93
 Damage Control
Abbreviated laparotomy and temporary
packing
Effort to blunt physiologic response to shock
and hemorrhage
Severe metabolic acidosis, coagulopathy, and
hypothermia
ICU resuscitation
Return to OR in 48-72 hours

94
Damage Control Surgery
Phase I
 Rapid termination of operative procedure
 Arrest of bleeding
 Removal of contamination

Phase II
Correction of physiologic abnormalities
Acidosis, hypothermia, coagulopathy
Phase III
Definitive surgery

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96
Abdominal compartment
syndrome
End organ dysfunction secondary to
intraabdominal hypertension
Tense abdomen,
Elevated peak airway pressure
Inadequate ventilation
Inadequate oxygenation
Oliguria
Reversed with decompression
Bladder pressure >16mmHg
Full blown syndrome >35 mmHg
Worse with fascial closure

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THANK
YOU

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