DR.R.

SRIVATHSAN PG-II

OUTLINE
y Anatomic definition of abdomen y Mechanism of injury y Typical injury patterns y Assessment of abdominal trauma y Diagnostic algorithms

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

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Abdomen anatomic boundaries
y External:
y Anterior abdomen: transnipple line superiorly, inguinal

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

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y Internal:
y Upper peritoneal cavity: covered by lower aspect of bony

thorax. Includes diaphragm, liver, spleen, stomach, transverse colon. y Lower peritoneal cavity: small bowel, ascending and descending colon, sigmoid colon, and (in women) internal reproductive organs. y Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women) internal reproductive organs. y 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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Intraperitoneal and retroperitoneal cavities

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

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y Direct impact y Acceleration-deceleration:

differential movements of fixed and nonfixed structures (e.g. liver and spleen lacerations at sites of supporting ligaments)
y 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
y No correlation between size of contact area and resultant injuries y Abdomen = Pandora s box y A potential site of major blood loss with little evident signs/symptoms.

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Assessment: History
y Mechanism y Symptoms, Medications, drugs y MVC:
y Speed y Type of collision (frontal, lateral, sideswipe, rear, y y y y

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
y Inspection, auscultation, percussion, palpation
y Inspection: abrasions, contusions, lacerations, deformity y Percussion: subtle signs of peritonitis; tympany in

gastric dilatation or free air; dullness with hemoperitoneum
y Palpation: superficial, deep, or rebound tenderness;

involuntary muscle guarding

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Physical Exam: Eponyms
y Grey-Turner sign:
y Bluish discoloration of lower flanks, lower back; associated with

retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.

y Cullen sign:
y Bluish discoloration around umbilicus, indicates peritoneal

bleeding, often pancreatic hemorrhage.

y Kehr sign:
y Left shoulder pain while supine; caused by diaphragmatic irritation

(splenic injury, free air, intra-abd bleeding)

y Ballance sign:
y Dull percussion in LUQ. Sign of splenic injury; blood accumulating

in subcapsular or extracapsular spleen.
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Diagnostic modalities
y Labs: - Complete Blood profile - Coagulation profile - Serum Amylase/Lipase - Urine analysis - Toxicology screen

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Radiological profile
y Plain films:

- Chest XRay, - Pelvic XRay - Abdomen XRay
y FAST y CT

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DPL - Procedure
Foleys & 2cm incision midway between umblicus and pubic bone under LA dialysis cat eter is passed t roug t e opening in t e peritoneal cavity and advanced towards t e ollow of t e pelvis.

Normal Saline is now connected to t e dialysis cat eter.

e wound is closed wit a stitc

fluid inside t e abdomen is now swis ed around by gentle agitation of t e abdomen so t at it is distributed all over t e peritoneal cavity

allowed to stay for up to 10 minutes

siphoned off by bringing the fluid bag or bottle down to the floor.

the returning fluid is clear then no gross internal injury to the abdomen and no major hemorrhage

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

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y 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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y Contraindications :

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

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DPL
y Highly sensitive to intraperitoneal blood, but low specificity p nontherapeutic explorations. y Supraumbilical if pelvic fracture present y Significant injuries may be missed
y Diaphragm y Retroperitoneal hematomas y Renal, pancreatic, duodenal y Minor intestinal y Extraperitoneal bladder injuries

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Focused Assessment with Sonography for Trauma (FAST)

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

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FAST: Accuracy
For identifying hemoperitoneum in blunt abdominal trauma: y Sensitivity 76 - 90% y Specificity 95 - 100% The larger the hemoperitoneum, the higher the sensitivity. So sensitivity increases for clinically significant hemoperitoneum. How much fluid can FAST detect? y 250 cc total y 100 cc in Morison s pouch

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CT Scan
y Hemodynamically stable patient y The patient should be in a transportable condition y Triple contrast CT is the preferred mode IV + ORAL + RECTAL

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Indications and Contraindications for Abdominal Computed Tomography
Indications
y y y y

Blunt trauma Hemodynamic stability Normal or unreliable physical examination Mechanism: Duodenal and pancreatic trauma

Contraindications
y y y y

Clear indication for exploratory laparotomy Hemodynamic instability Agitation Allergy to contrast media
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Advantages y Adequate assessment of the retroperitoneum y Nonoperative management of solid organ injuries y Assessment of renal perfusion y Noninvasive y High specificity Disadvantages y Specialized personnel y Hardware y Duration: Helical versus conventional y Hollow viscus injuries y Cost
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CT Accuracy Sensitivity Specificity Drawback 96% 97% 95% Stable pts only

FAST

DPL

95-99% 95% 90-92% 100% 88-90% 85% Cannot evaluate retroperitoneum. Cannot identify source of fluid. 0.5% miss intestinal perforation; cannot distinguish blood vs bowel contents

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

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ROLE OF DIAGNOSTIC LAPAROSCOPY
y Hemodynamically stable patients y Inadequate/equivocal FAST or borderline DPL (80 * 103 - 120 * 103 RBC/HPF) y Intermittent mild hypotension or persistent tachycardia y Persistent abdominal signs/symptoms y Potential to decrease incidence of nontherapeutic laparotomies

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Diagnosis
y Test of choice dependent on hemodynamic stability and severity of associated injuries. y Stable blunt trauma p FAST or CT y Unstable blunt trauma p FAST or DPL y Stab wounds without peritoneal signs, evisceration, or hypotension p wound exploration or DPL. y Gun shot wounds p 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 34

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LIVER INJURY

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Initial hemostasis
y Rapid mobilisation of injured lobe with bimanual compression y Perihepatic packing y Pringle maneuver y Failure of pringle maneuver involvement

major hepatic venous

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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 A. It is coming from the portal vein or hepatic artery OR B. 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 suprahepatic suprarenal vena cava.
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Definitive hemostasis
y Surface ooze: cautery;argon beam laser; parenchymal sutures; topical hemostatics

Deeper wounds: hepatotomy finger fracture tech

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Packing
y Used when other techniques y

y y y y

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/embolization useful adjunct

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Splenic injury
y Most frequently injured intra-abdominal organ in blunt trauma. y Suspected in all c/o LUQ injury; L lower ribs fracture y Splenic preservation when possible
y

OPSI (0.6% in children, 0.3% in adults)

y More than 70% can be treated non-operatively

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

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y Monitoring in the ICU setup y NG tube y Strict bed rest y Serial abdominal examinations y 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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y Predictive factors for nonop success:
y Localized trauma to flank/abdomen y Age<60 y No associated trauma y Transfusion <4 units y Grade I-III

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Transarterial embolisation

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Pancreatic Injury
y Rare 10-12% of abdominal injuries, but mortality 10-25%, mostly from associated intra-abd injury y Most caused by penetrating trauma - 75% associated with major vascular injury y Blunt trauma p compression of pancreas against vertebral column y Retroperitoneal location delays diagnosis. y Elevated amylase/lipase (serum and urine) y Role of CT improving y Pancreatic duct injury key factor in morbidity.
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Pancreatic Injury

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GSW to Pancreatic Head

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PANCREAS INJURY SCALE
GRADE[*] I TYPE OF INJURY He a Lacera a DESCRIPTION OF INJURY M rc u w h u duc jury Superf c a acera jury a Maj r c r ue u w h u duc

II

He a

w h u duc

jury

Lacera

Maj r acera r ue D a ra ec jury w h duc

w h u duc

jury

III

Lacera

r pare chy a jury

IV

Lacera

Pr x a ra ec r pare chy a jury v v g he a pu a[‚] Ma ve d rup head f he pa crea c

V

Lacera

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Pancreatic Injury
y Divided into proximal or distal according to location on the R or L of SMV y Contusions (Grade I-II) should be drained. y Distal duct injury (Grade III) p distal resection with splenic preservation y Proximal injury (Grade IV)
y Oversewing and distal resection or

pancreaticojejunostomy

y Extensive pancreatic head injuries (Grade V)
y 40% pancreatic fistula development y Simple external wide drainage
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Complications after Pancreatic Trauma
y High complication rate 35-40% y Most common are pancreatic fistulas abscesses y Most fistulas close spontaneously if well drained y Somatostatin / Octreotide to expedite healing y Abscesses - surgical debridement drainage y Incidence of pancreatitis 8-18% y Pseudocysts are infrequent
63

Gastric Injury
y Mostly penetrating trauma. y <1% from blunt trauma
y Including iatrogenic injury from CPR/ ET in esophagus

y NGT + aspirate for blood y Intraop evaluation includes good visualisation of EG junction; ant gastric wall; opening of gastrocolic ligament and complete visualization of posterior wall y Most penetrating wounds treated by debridement and primary closure in layers. y Evacuation of hematomas. y Major tissue loss may necessitate gastric resection.
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Gastric Injury
y Post-op complications
y Bleeding, abscesses,

gastric fistula with peritonitis,empyema

y Recent meal p neutralization of gastric acidity p increased lower GI tract bacteria (Bacteroides, E. coli, Strep faecalis) p increased infection

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Duodenal Injury
y Incidence: 3 y y y y y

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.

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GRADE[*] I

TYPE OF INJURY Hematoma Laceration

DESCRIPTION OF INJURY Involving a single portion of the duodenum Partial thickness, no perforation Involving more than one portion Disruption <50% of the circumference Disruption 50%-75% of the circumference of D2 Disruption 50%-100% of the circumference of D1, D3, D4

II

Hematoma Laceration

III

Laceration

IV

Laceration

Disruption >75% of the circumference of D2 and involving the ampulla or distal common bile duct Massive disruption of the duodenopancreatic complex Devascularization of the duodenum

V

Laceration Vascular

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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

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Duodenal Injury
y Gastrograffin UGI or CT with contrast y Extravasation of contrast p OT y If CT eqivocal dilute barium UGI y May see retroperitoneal air on CT y DPL unreliable but may be positive from an associated injury
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Duodenal Hematoma
y The radiographic finding

of a duodenal hematoma (coiled spring or stacked coin sign) is not an indication for surgical exploration y NGT until peristalsis resumes. y Slow introduction of food. y OR if obstruction persists > 10 15 days.
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Stacked coin sign

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

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y Grade III injuries (major disruption of the duodenal circumference ) : primary repair, pyloric exclusion, and drainage or by Roux-en-Y duodenojejunostomy. y 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 Ttube with a long transpapillary limb or a choledochoenteric anastomosis y If repair of the CBD is impossible, ligation and a second intervention for a biliary enterostomy y Pancreaticoduodenectomy - grade V injuries

(massive disruption of the duodenum and pancreatic head or massive devascularization of the duodenum)
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Duodenal injury severity
MILD AGENT SIZE LOCATION INJURY TO REPAIR INTERVAL ADJACENT INJURY OUTCOME MORTALITY DUODENAL MORTALITY DUODENAL MORBIDITY 6% 0% 6% 16% 6% 14%
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SEVERE Blunt/missile >75% wall involvement D1,D2 >24 hrs CBD +

Stab < 75% wall D3,D4 < 24 hrs CBD -

COMPLICATIONS
y Duodenal fistulas (5 y Abscess (10

20%)

15%) conservative mng percutaneous / open drainage

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Small Intestine Injury
y Most common organ

injured after penetrating trauma y Blunt trauma(5 20%)
y Crushing injury against

vertebral bodies y Shearing at fixed points y Closed loop rupture

y Seat-belt sign should

raise suspicion. y DPL/CT not reliable

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Small Intestine Injury

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Small Intestine Injury
y 13% perforated small bowel have a normal CT scan y Suggestive findings include free air, free fluid without solid organ injury, thickening of small bowel wall or mesentery
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Operative management
y y y y y

y

Bleeding initially controlled/leakage clamped 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 hematomas
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Colon Injury
y Second most frequent injured organ, usually from penetrating trauma y Repair within 2 hours dramatically reduces infectious complications. y Pre-operative antibiotics important adjunct. y PE blood per rectum, stab to flanks or back y CT with rectal contrast, XR- pneumoperitoneum y WWI primary repair led to 60% mortality. y WWII colostomy led to 35% mortality.
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Colon Injury
y Primary repair criteria
y Early diagnosis (within 4-6 hours) y Absence of prolonged shock/hypotension y Absence of gross contamination y Absence of associated colonic vascular injury y Less than 6 units blood transfusion y No requirement for use of mesh for closure

y Extensive wounds
y Right colon p hemicolectomy +/- ileostomy y Left colon p resection + colostomy
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Rectal Injury
y Most from GSW y Other causes - foreign body, impalement, pelvic fractures, and iatrogenic y Lower abdomen/buttock penetrating injury should raise suspicion. y May be intra- or extraperitoneal y Rectal exam may reveal blood or laceration y Work-up includes anoscopy and rigid sigmoidoscopy.
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Rectal Injury
y Extraperitoneal injury
y Primary closure y Diverting colostomy y Washout of rectal

stump y Wide presacral drainage

y Intraperitoneal injury
y Primary closure y Diverting colostomy

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

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

American association for surgery of trauma classification:
y GRADE I: contusion or contained subcapsular hematoma, without y y y

y

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; - avulsion of the main renal artery and/or vein.

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y Renal contusion is the most common type and is managed conservatively. y Major renal trauma includes deep cortical medullary lacerations, large perinephric hematomas and pedicle injury. y 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 thrombostatic agents, and omentum

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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.
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Bladder injury
y The majority of bladder injuries occur as a result of blunt

y y y y y

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 injuries.
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y Intraperitoneal injuries are repaired primarily by three-layer closure +/- Suprapubic cystostomy y Extraperitoneal rupture of the bladder: primarily nonoperative Foley s catheter for 10 to 14 days y Severe pelvic fractures and massive retroperitoneal bleeding : initially managed nonoperatively. delayed repair of the extraperitoneal rupture is performed

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Complications of bladder rupture y Hemorrhage y Urinoma y Abscess formation y Sepsis.

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Retroperitoneal hematoma
y Zone 1
y Explore regardless of

mechanism.

y Zone 2
y Explore penetrating

trauma. y Observe blunt trauma (nonexpanding, nonpulsatile, no urologic indications)

y Zone 3
y Explore penetrating. y Observe blunt.
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Damage Control
y Abbreviated laparotomy and temporary packing y Effort to blunt physiologic response to shock and hemorrhage y Severe metabolic acidosis, coagulopathy, and hypothermia y ICU resuscitation y Return to OR in 48-72 hours

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

y Phase II
y Correction of physiologic abnormalities y Acidosis, hypothermia, coagulopathy

y Phase III y Definitive surgery
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Abdominal compartment syndrome
y End organ dysfunction secondary to intraabdominal hypertension
y y y y y

Tense abdomen, Elevated peak airway pressure Inadequate ventilation Inadequate oxygenation Oliguria

y Reversed with decompression y Bladder pressure >16mmHg
y Full blown syndrome >35 mmHg

y Worse with fascial closure
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