ABDOMINAL

INJURIES
Prof.Dr. Turgut İPEK
 Resuscitation and Evaluation
 Resuscitation
 Evaluation of the Patient with Blunt Trauma
 Evaluation of the Patient with Penetrating Trauma
 Treatment
 Abdominal wall injuries
 Liver injuries
 Splenic injuries
 Biliary tract injuries
 Pancreatic injuries
 Gastrointestinal tract injuries
 Genitourinary tract
 Injuries of to the male genitalia
 Uterine injuries
 Urethral injuries
 Bladder injuries
 Kidney injuries
Resuscitation and Evaluation 1
Resuscitation
1. Does the patient need an abdominal operation?
2. Will the patient tolerate the time required for
diagnostic maneuvers before surgery is
performed?
Resuscitation and Evaluation 2
 Airway maneuvers
 Endotracheal intubation
 Tube thoracostomy (pneumothorax, hemothorax)
 Circulation
 IV lines (upper extremity, neck, thoracic inlet)
(jugular, subclavian catheter)
 Nasogastric tubes (blood)
 Bladder catheterization
 Tetanus toxoid, antibiotics
Evaluation of the Patient with
Blunt Trauma 1
Difficult:
1. Multiple injuries (head, extremities, thorax)
2. Acute alcoholic + intoxication, drug abuse
3. Solid organs bleeds slowly
Evaluation of the Patient with
Blunt Trauma 2
Clinical Manifestations
 A careful history
 Physical examination
 Hypotension or peritonitis
 Inspection
Fractures in the lower six ribs?
Contusion over the lower chest?
Suspect: Liver or Spleen injury
 Palpation
Peritonitis (involuntary guarding, rigidity, rebound
tenderness)
Evaluation of the Patient with
Blunt Trauma 3
Diagnostic Procedures
Radiologic Findings
 Plain X-ray (Free air bubbles in the ruq)
 Chest X-ray
 Gross hematuria : IVP
 Retrograde cystography (blood at the meatus)
Examination and Observation
False + (% 43)
False – (% 21)
Evaluation of the Patient with
Blunt Trauma 4
 DIAGNOSTIC PERITONEAL TAP/LAVAGE
(DPL)
Indications
 Altered sensorium from a head injury, drug ingestion, or
alcohol intoxication
 Altered sensation from a spinal cord injury
 Rib or vertebrae fractures
 Equivocal findings on physical examination
Relative Contrindications
 Abdominal scars
 Latter stages of pregnancy
 Morbid obesity
 Coagulopathy
Evaluation of the Patient with
Blunt Trauma 5
Diagnostic Peritoneal Tap/Lavage (DPL)
 Local anesthesia, 2-3 cm vertical midline incision,
3-4 cm below the umblicus
 20 ml gross blood, feces, bile, food, intestinal fluid
(+)
 1000 ml normal saline (10+15 ml/kg child)
 RBC > 100.000 /mm3
WBC> 500 / mm3 + DPL
Gram stain
 24 h observation and repeated examinations
Evaluation of the Patient with
Blunt Trauma 6
Ultrasound
 Liver, spleen, pancreas and kidney injuries
CT
1. Stable patients with closed head injury
2. Stable patients with an equivocal abd. exa.
3. Patients with hematuria
4. Pelvic fractures
 Retroperitoneal structures (pancreas, kidney)
Arteriography
Laparoscopy
Evaluation of the Patient with
Penetrating Trauma
Clinical Manifestations
 How did it happen? (the tract)
 Physical examination
 Hypotension, distension, peritonitis hematemesis, proctorrhagia,
hematuria
Diagnostic Procedures
Radiologic Findings
Plain X-ray (free air, missile)
IVP
Observation
DPL (anterior abdomen, lower chest or flanks)
tangential gunshot wounds
Stab Wounds
 Local wound exploration and DPL and examinations
 Back wounds (colon?, observation)

contranst-enhanced CT enema
Gunshot Wound
Automatic laparotomy
Tangential (observation or DPL)
Shotgun Wound
Peritoneal penetration by pellets? Observation
Lateral X-ray
Frequency of Organ Injury in
Blunt ABD Trauma
Frequency % Frequency %
Organ injured Admission Celiotomy
Spleen 57.2 57.7
Liver 46.6 44.6
Colon 12.8 14
Small Bowel 12.2 14
Kidney 9.5 8.4
Pancreas 6 6.2
Duodenum 5.4 6
Bladder 4.3 3.8
Frequency of Organ Injury in
Stab Wounds of the ABD
Organ injured Frequency (%)
Liver 39.3
Small bowel 31.6
Diaphragm 19.6
Colon 15.3
Stomach 12.6
Major vascular 10.3
Kidney 9
Spleen 7
Pancreas 6
Gallbladder 2.3
Duodenum 1.6
Frequency of Organ Injury in
Gunshot Wounds of the ABD
Organ injured Frequency (%)
Small bowel 49.3
Colon 41.6
Liver 29.3
Vascular 24.6
Stomach 17.3
Kidney 17
Duodenum 11
Diaphragm 10
Spleen 7.6
Bladder 7.3
Gallbladder 7
Pancreas 6
Rectum 3.3
Other 4
Liver Injuries 1
 Themost commonly injured organ
Mechanism of Injury
 Direct blows, comression or shearing
Clinical Manifestations
 Profound hypotension
 Marked abdominal distension
DPL, CT
 Liver Injuries 2
Treatment
Nonoperative Approach
3. Simple hepatic parenchymal laceration or intrahepatic
hematoma
4. No evidence of active bleeding
5. Intraperitoneal blood loss < 250 ml
6. Absence of other intraperitoneal injuries requiring
operation
Subcapsular or Intrahepatic Hematoma
Nonoperative management (bed rest, nbm, antibiotics)
Liver Injuries 3
General Principles of operation
Pringle Maneuver (Clamping of porta hepatis 10-15 minute is
recommended but 30 mn. is acceptable)
Mobilization of Lobe
Compression, Topical Agents (Surgical, Spongostan)
Fibrin Glue
Suture Hepatorrhaphy
Hepatotomy with Selective Vascular Ligation
Omental Pack
Resectional Debridement with Selctive Vascular Ligation
Resection
Selective Hepatic Artery Ligation
Perihepatic Packing
Liver Injuries 4
Complications
Hemorrhage/Hemobilia
Intraabdominal Abscess
Hyperpyrexia
Biliary Fistulae
Spleen 1
Incidence
 The most commonly injured organ in blunt
abdominal trauma
Mechanism of Injury
 Deceleration-type trauma causes capsular
tears
Spleen 2
Diagnosis
Clinical Manifestations
 Hypotension (1/3)

 Kehr’s Sign: pain at the tip of the left shoulder

in the head down position (% 50)
 Leukocytosis (> 15.000)
Spleen 3
Radiologic Findings
2. Elevation of the left hemidiaphragm

3. Enlargement of the splenic shadow

4. Medial displacement of the gastric bubble

5. Widening of the space between splenic

flexure and the preperitoneal fat pad
Spleen 4
CT
 Extremely useful both in detection and fallowing the
healing
Treatment
Importance of the Spleen
 Immunologic importance. The risk of septicemias
from encapsulated microorganisms (pneumococcus,
meningococcus, and hemoplhilus) in the first 2 years
after splenectomy.
OPSI (Overwhelming postsplenectomy infection)
mortality 30 %
Spleen 5
Nonoperative Approach
1. No hemodynamic instability

2. No peritoneal findings

3. No need more than 2 units of blood

Splenectomy
Splenorrhpy
Partial splenectomy
 Resuscitation and Evaluation
 Resuscitation
 Evaluation of the Patient with Blunt Trauma
 Evaluation of the Patient with Penetrating Trauma
 Treatment
 Abdominal wall injuries
 Liver injuries
 Splenic injuries
 Biliary tract injuries
 Pancreatic injuries
 Gastrointestinal tract injuries
 Genitourinary tract
 Injuries of to the male genitalia
 Uterine injuries
 Urethral injuries
 Bladder injuries
 Kidney injuries