TRAUMA

GINJAL
 TRAUMA GINJAL
Trauma Tumpul Abdomen / Pinggang
Multi Trauma

Keadaan Umum, Kesadaran Tensi, Nadi, Respirasi, Temperatur

Status Lokalis : Jejas, Massa, Nyeri tekan
Laboratorium : Hb, Kreatinin Serum, Sedimen Urin
Pasang Infus

Pielografi Infusion (USG)

KLASIFIKASI KERUSAKAN GINJAL

KONTUSIO RUPTUR GINJAL RUPTUR GINJAL PRAGMENTED/ NON

 KU baik  KU labil VISUALIZED
RENIS SHATTERED
 Ekstravasasi minimal  Ekstravasasi luas KONTUR BAIK

OBSERVASI OBSERVASI EKSPLORASI EKSPLORASI SEGERA

LAPAROTOMI LAPAROTOMI ARTERIOGRAFI
 PENDAHULUAN
• 10% trauma abdomen  trauma
traktus urogenitalis.
• trauma urogenitalis  trauma ginjal
>>>  5% trauma abdomen.
• dewasa muda sekitar 74%, usia tua
15%, dan anak-anak 9%.
• sering bersama trauma organ lain
(multiorgan trauma).
• AS : trauma ginjal bersama hepar
(40%), lien (5-7%), pankreas (13%),
kolon (7%) dan usus halus / gaster
(3%)
 ETIOLOGI
• Trauma tumpul (Blunt Injury)  80-85%
Mekanisme trauma tumpul ginjal:
1. Trauma langsung pinggang kosta 11 & 12 fraktur 
melukai ginjal.
2. Trauma tumpul bagian depan abdomen.
3. Jatuh terduduk dari ketinggian.
AAST Renal Injury Grading Scale
Grade* Description of Injury
1 Contusion or non-expanding subcapsular haematoma
No laceration
2 Non-expanding peri-renal haematoma
Cortical laceration < 1 cm deep without extravasation
3 Cortical laceration < 1 cm without urinary extravasation
4 Laceration: through corticomedullary junction into collecting system
Or
Vasculary: segmental renal artery or vein injury with contained
haematoma, or partial vassel laceration, or vessel thrombosis
5 Laceration: shattered kidney
Or
Vascular: renal pedicle or avulsion
ETIOLOGI
• trauma tembus (penetrating injury)
1. luka tusuk (stab wound)
2. luka tembak (gun shot)
 80% luka tembus ginjal  trauma
visera intraabdomen
 intervensi operatif
KLASIFIKASI
DIAGNOSIS
1. Riwayat trauma
2. hematuria (95%)
3. hematoma di regio flank
4. fraktur costa bawah
5. Hemodinamik tidak stabil
(hipotensi)
History and Physical Examination
Recommendations GR
Haemodynamic stability should be decided upon admission B
History should be taken from conscious patient, witnesses and rescue team
C
personnel with regard to the time and setting of the incident
Past renal surgery, and known pre-existing renal abnormalities (ureteropelvic
B
junction obstruction, large cysts, lithiasis) should be recorded
A though examination should be made of the thorax, abdomen, flanks and back
B
for penetrating wounds
Findings on physical examination such as haematuria, flank pain, flank
absasions and ecchymoses, fractured ribs, abdominal tenderness, distension or B
mass, could indicate possible renal involvement
Laboratory Evaluation
Recommendations GR
Urine from a patient with suspected renal injury should be inspected grossly
B
and then by dipstick analysis
Serial haematocrit measurement indicates blood loss. However, until
evaluation is complete. It not be clean whether it is due to renal trauma and B
or associated injuries.
Creatinine measurement could highlight patient who had impaired renal
C
function prior to injury
PEMERIKSAAN IMEJING GINJAL
• Dahulu: IVP  skg: CT Scan kontras
• Jk fasilitas CT Scan (-)  pakai IVP
• Indikasi:
1. Trauma tembus regio flank / abdomen tdk
lihat derajat hematuria
2. Trauma tumpul dewasa dg gross hematuria /
mikrohematuria + shock (sistolik < 90
mmHg)
3. Trauma deselerasi
4. Trauma mayor berhubungan trauma intra-
abdominal & mikrohematuria
5. Trauma abdomen / flank penderita anak
dengan hematuria
Imaging
Recommendation GR
Blunt trauma patients with macroscopic or microscopic haematurial (at least 5rbc/hpf) with
B
hypotention (systolic blood preassure <90mmHg) should undergo radiographic evaluation
Radiographic evaluation is also recommended for all patients with a history of rapid declaration
B
injury and/or significant associated injuries.
All patients with any degree of haematuria after penetrating abdominal or thoracic injury
B
require urgent renal imaging
Ultrasonograpy can be informative during the primary evaluation o polytrauma patients and for
the follow-up of recuperating patients, although more data is required to suggest this modality C
university
A CT scan with enchancement of intravenous contrast material is the best imaging study for
B
the diagnosis and staging of renal injuries in haemodynamically stable patients
Unstable patients who require emergency surgical exploration should undergo a one-shot IVP
C
with bolus intravenous unjection of 2mL/kg contrast
Formal IVP/, MRI and radiographic scintigraphy are acceptable second-line alternative for
C
imaging renal trauma when CT is not availabel
Angiography can be used for diagnosis and simultaneous selective embolisation of bleeding
B
vessels
PENGELOLAAN NON OPERATIF

• 98% trauma tumpul renal

• Penderita hemodinamik stabil & staging (+) &
CT Scan (+)
• Trauma tembus luka tembak / tusuk  staging
hati-hati dg CT Scan  monitor ketat
• 55% trauma tusuk & 24% trauma luka tembak
 nonoperatif
• Trauma derajat III & IV  monitor ketat (serial
hematokrit & CT Scan)
• perdarahan persisten  angiografi  embolisasi
Non-operative Management of
Renal Injuries
Recommendations GR
Following grade 1-4 blunt renal trauma, stable patients should be manage
conservatively with bed-rest, prophylactics antibiotic and continuous of vital B
signs until haematurial resolves
Following grade 1-3 stab and low-velocity gunshot wounds, stable patients, after
B
complete staging, should be selected expectant management
Indicated for surgical management include
Haemodynamic instability
Exploration for associated injuries
Expanding or pulsatile peri-renal haematoma identified during laparotomy
Grade 5 injury
Incidental finding of pre-existing renal pathology requiring surgical therapy B
Renal reconstructing should be attempted in cases with where the primary goal of
controlling haemorrhage is achieved and sufficient amount of renal parenchyma B
is viable
EKSPLORASI GINJAL
• INDIKASI ABSOLUT
1. perdarahan ginjal yang persisten 
hematoma meluas, denyut, hematom
retroperitoneal
2. trauma renal derajat V
 EKSPLORASI GINJAL
• INDIKASI RELATIF
1. Trauma tumpul & tembus ginjal 
komplikasi: ekstravasasi urin persisten, abses
perinefrik, urinoma terinfeksi, & perdarahan
2. trauma derajat III & IV dg jar non-vital luas
& trauma organ intraperitoneal
3. trauma grade IV dg laserasi pelvis renalis,
parenkim ginjal & sistem kolektivus & avulsi
UPJ
4. trauma tumpul dg hematom retroperitoneal &
kelainan pd ’single shot’ IVP
Algoritma pengelolaan trauma ginjal
(a) IVP pada trauma tumpul ginjal dengan trauma pada pelvis renalis yang
ditunjukkan ekstravasasi kontras. (b) Tomogram yang menunjukkan trauma
ginjal mengenai kaliks pole bawah.
 TRAUMA VASKULAR
• trauma vaskular renal (50%)  syok (+) 
mortalitas 10-50%.
• Trauma arteri renalis sulit utk diselamatkan
& rekonstruksi.
• Pembedahan rekonstruksi < 12 jam  >>>
diselamatkan  keberhasilan revaskularisasi
10-30%,  ↓ fs ginjal

CT Scan ginjal menunjukkan absen komplit

kontras pada ginjal kiri oleh karena adanya
avulsi komplit pedikel renal
 TROMBOSIS ARTERI RENALIS
 NEFREKTOMI

CT Scan ginjal kiri dengan trombosis arteri renalis, menunjukkan kurangnya perfusi
kontras ke ginjal (kiri); Arteriografi menunjukkan oklusi komplit arteri renalis kiri
sekunder akibat trombus

Pergerakan ginjal ok deselerasi 

peregangan arteri renalis  ruptur
intima  trombus
 EKSPLORASI & REKONSTRUKSI
GINJAL
• Insisi midline transabdominal dr proc xiphoideus - simfisis pubis
• Kolon transversum  rongga dada (bungkus kasa lembab)
• Identifikasi cab a. mesenterika pd usus halus
• angkat usus keatas dan ke kanan  retroperitoneum tampak
• Insisi vertikal di atas aorta superior dr a. mesenterika superior
smp retroperitoneum perluas keatas dr lig Treitz
• V. mesenterika inf  petunjuk insisi  diseksi hingga ant perm
aorta
• diseksi smp sup hingga v. renalis sin  tanda identifikasi pd
renalis  tegel dipasang
• kontrol perdrhan dg kompresi manual parenkim ginjal  jk
perdarahan (+)  klem vena  waktu iskemik < 30’
 EKSPLORASI & REKONSTRUKSI
GINJAL
• kontrol PD (+)  evakuasi hematom retroperitoneal
• Insisi fasia Gerota di lateral  ginjal terpapar 
evaluasi pelvis renalis, parenkim & pd
• rekonstruksi  debridement adekuat: jar mati dibuang
 preservasi kapsula renalis utk penutupan ginjal
• Ligasi PD parenkim kromik 4/0
• Laserasi sistem kolektivus dijahit scr kedap air
(watertight fashion) kromik 4/0.
• Inj metilen blue ke pelvis renalis  identifikasi trauma
lain & penutupan sistem kolektivus
• tutup kapsula renalis reaproksimasi tepi parenkim 
jahitan interrupted Vicryl 3/0
• Jk defek ginjal luas  packing dg agen hemostasis
(Avitene, Tissel, lemak perinefrik)
EKSPLORASI & REKONSTRUKSI
GINJAL
• segmen pole ginjal tidak vital (+)  parsial
nefrektomi (amputasi & penutupan sistem
kolektivus)  pakai omentum utk tutup
defek pole ginjal jk kapsula renalis (-)
• pasang Penrose drain (drainase
retroperitoneum) Suction drain tidak boleh
EKSPLORASI & REKONSTRUKSI
GINJAL
EKSPLORASI & REKONSTRUKSI
GINJAL
EKSPLORASI & REKONSTRUKSI
GINJAL
EKSPLORASI & REKONSTRUKSI
GINJAL
EKSPLORASI & REKONSTRUKSI
GINJAL
DAMAGE CONTROL
• Coburn (2002): keuntungan  ↑
penyelamatan ginjal
 packing dg laparotomy pads  kontrol
perdrhn & dibuka kembali dalam 24 jam
 eksplorasi & evaluasi luas trauma
• mencegah nefrektomi total
 NEFREKTOMI
Indikasi :
• trauma ginjal ekstensif, hemodinamik
tidak stabil, suhu tubuh rendah, &
koagulasi buruk  renal repair tdk
mgkn (fs ginjal kontralateral N)
• Nash dkk (1995)  77% nefrektomi (+)
ok perdrhn parenkim luas, vaskular &
kombinasi, 23% ok hemodinamik tdk
stabil dg ginjal dpt direkonstruksi.
Complication
Recommendations GR
Complication following renal trauma require a thorough radiographic
B
evaluation
Medical management and minimally invasive technique should be the first
C
choice for the management of complications
Renal salvage should be the surgeon’s aim for patients in whom surgical
C
intervention is necessary
 KOMPLIKASI
• Ekstravasasi urin persisten  urinoma,
infeksi perinefrik & kehilangan ginjal
 Obs ketat & AB tepat
• Perdarahan ginjal tertunda (21 hari)
 bedrest, hidrasi, angiografi &
embolisasi
• hipertensi arterial
Post Operative Care and Follow-
Up
Recommendations GR
Repeat imaging is recommended for all hospitalized patients within 2-4 days of
significant renal trauma (although no specific data exists). Repeat imaging is B
always recommended in cases of fever, flank pain, or falling haematrocrit
Nuclear scintigraphy before discharge from the hospital is useful for
C
documenting functional recovery
Within 3 month of major renal injury, patients follow-up should involve:
1.Physical examination
2.Urinalysis
C
3.Individualized radiological investigation
4.Serial blood pressure measurement
5.Serum determination of renal function
Long-term follow-up should be dedicated on a case-by-case basis but should at
C
the very last involve monitoring for renovascular hypertension
Paediatric Renal Trauma
Recommendations GR
Indications for radiography evaluation of children suspect of renal trauma
include:
1.Blund and penetrating trauma patients with any level of haematuria
2.Patient with associated abdominal injury regardless of the findings of B
urinalysis
3.Patient with normal urinaluses who sustained a rapid deceleration event,
direct flank trauma, or all a fall from a height
Ultrasonography is the considered a reliable method of screening and
monitoring blunt renal injuries by some researchers, but is not universally B
accepted
CT scanning is the imaging study of choice for staging renal injuries B
Haemodynamic instability and a diagnoses grade 5 injury are absolute
B
indications for surgical exploration
Renal Injury in The Polytrauma Patient
Recommendations GR
Polytrauma patients with associated renal injuries should be evaluated on the
C
basic of the most threatening injury
In case where surgical intervention is chosen, all associated injuries be
C
evaluated simultaneously
The decision for conservative management should consider all injuries
C
independently
Percutaneous Renal Procedures
Recommendations GR
Latrogenic rupture of the main renal artery should be treated with balloon
C
tamponade, and, in case of failure, with a stent graft
Surgical venous injuries should be managed with venorrhaphy or patch
C
agioplasty
The transoanted kidney should be evaluated on the basis of renal function, type
C
of injury and the patients’ conditions
Hyperselective embolisation may control arterial bleeding during percutaneous
C
procedures
 Algorithm for The Management of Paediatric Renal Trauma

Paediatric renal trauma

Blunt Penetrating

UA UA
UA

>50 rbc/hpf <50 rbc/hpf or

>5 rbc/hpf
or haemodynamicall
deceleration y stable
Stable Unstable
Stable Unstable
CT Scan Abdominal
exploration
Abdominal
CT Scan
exploration

Observes Renal IVP

exploration
Observes Renal IVP
exploration
NL ABNL

NL ABNL

Renal Observes Renal

Observes
exploration exploration
 Evaluation of Bunt Renal Trauma in Adults
Suspected adult blunt Renal trauma

Determine haemodynamic stability

Stable
Unstable

Microscopic
Gross haematueria
haematueria

Emergency
Rapid deceleraton laparotomy One-
Renal Imaging Injury or Major shot IVP
associated injuries

Grade 1-2 Observation Normal IVP

Grade 3-4

Grade 5
Retroperitoneal
Stable
haematoma

Observation, Associated Renal Pulsatile or

bed rest. Serial injuries requiring exploration expanding
Ht, antibiotics laparotomy
Abnormal IVP
 Evaluation of Penetrating Renal Trauma in Adults
Suspected adult blunt Renal trauma

Determine haemodynamic stability

Stable Unstable

Emergency
Renal Imaging laparotomy One-
shot IVP

Grade 3 Grade 4-5 Grade 1-2 Observation Normal IVP

Retroperitoneal
Stable
haematoma

Pulsatile or
expanding
Observation, Associated
Renal Abnormal IVP
bed rest. Serial injuries requiring
Ht, antibiotics laparotomy exploration