Abdominal Trauma

 LD Britt MD, MPH, D.Sc (Hon), FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS
(Hon), FRCSI (Hon), FCS(SA) (Hon)

Current Surgical Therapy, 1010-1021

Initial Management
Before focusing on the specific anatomic region of an obvious traumatic injury, an
initial assessment of the entire patient is imperative.

The concept of initial assessment includes the following components: (1) rapid
primary survey; (2) resuscitation; and (3) detailed secondary survey (evaluation)
and reevaluation. Such an assessment is the cornerstone of the Advanced Trauma
Life Support (ATLS) program. Integrated into primary and secondary surveys are
specific adjuncts. Such adjuncts include the application of electrocardiographic
monitoring and other monitoring modalities, such as arterial blood gas
determination, pulse oximetry, measurement of ventilatory rate and blood
pressure, and insertion of urinary or gastric catheters, and the incorporation of
necessary x-rays and other diagnostic studies, when applicable, such as focused
assessment with sonography for trauma (FAST) and plain radiography of the
spine/chest/pelvis and computed tomographic (CT) scan.

The focus of the primary survey is both identification and expeditious address of
immediate life-threatening injuries. Only after the primary survey is completed
(including the initiation of resuscitation) and hemodynamic stability is addressed
should the secondary survey be conducted; this survey entails a head-to-toe (and
back-to-front) physical examination, along with a more detailed history.

Only the emergency care disciplines of medicine have this two-tier approach to
their initial assessment of the patient, with primary and secondary surveys as
integral components. As highlighted previously, the primary survey is designed to
quickly detect life-threatening injuries. Therefore, a universal approach has been
established with the following prioritization:

 ▪

Airway maintenance (with protection of the cervical spine);

 ▪

Breathing (ventilation);

 ▪

Circulation (including hemorrhage control);

 ▪

Disability (neurologic status);

 ▪

And exposure and environmental control.

Such a systematic and methodical approach (better known as the ABCDEs of the
initial assessment) greatly assists the surgical or medical team in the timely
management of those injuries that could result in a poor outcome.


o A.

Airway assessment management (along with cervical spine protection).

Because loss of a secure airway can be lethal within 4 minutes, airway assessment
and management always has the highest priority during the primary survey of the
initial assessment of any injured patient, irrespective of the mechanism of injury or
the anatomic wound. The chin-lift and jaw-thrust maneuvers are occasionally
helpful in attempting to secure a patent airway. However, in the trauma setting, the
airway management of choice is often a translaryngeal, endotracheal intubation. If
this cannot be achieved because of upper airway obstruction or some technical
difficulty, a surgical airway (needle or surgical cricothyroidotomy) should be the
alternative approach. No other management can take precedence over obtaining
appropriate airway control. Until adequate and sustained oxygenation can be
documented, administration of 100% oxygen is required.

o B.

Breathing (ventilation assessment).

 An airway can be adequately established and optimal ventilation still not be
achieved: for example, in the case of an associated tension pneumothorax (other
examples include a tension hemothorax, open pneumothorax, or a large flail chest
wall segment). Worsening oxygenation and an adverse outcome ensue unless such
problems are expeditiously addressed. Therefore, assessment of breathing is
imperative, even with an established and secure airway. A patent airway but poor
gas exchange still results in a poor outcome. Tachypnea, absent breath sounds,
percussion hyperresonance, distended neck veins, and tracheal deviation are all
consistent with inadequate gas exchange. Decompression of the pleural space with
a needle or chest tube insertion should be the initial intervention for a
pneumothorax or hemothorax. A large flail chest, with underlying pulmonary
contusion, likely requires endotracheal intubation and the administration of
positive-pressure ventilation.

o C.

Circulation assessment (adequacy of perfusion management).

The most important initial step in determination of adequacy of circulatory

perfusion is quick identification and control of any active source of bleeding, along
with restoration of the patient's blood volume with crystalloid fluid resuscitation
and blood products, if necessary. Decreased levels of consciousness, pale skin color,
slow (or nonexistent) capillary refill, cool body temperature, tachycardia, and
diminished urinary output are all suggestive of inadequate tissue perfusion.
Optimal resuscitation requires the insertion of two large-bore intravenous lines
and infusion of crystalloid fluids (warmed). Adult patients with severely
compromised conditions need a fluid bolus (2 L of Ringer's lactate or saline
solution). Children should receive a 20-mL/kg fluid bolus. Blood and blood
products are administered as needed. Along with the initiation of fluid
resuscitation, emphasis needs to remain on identifying the source of active
bleeding and stopping the hemorrhage. For a patient in hemorrhagic shock, the
source of blood loss is an open wound with profuse bleeding, or within the thoracic
or abdominal cavity, or an associated pelvic fracture with venous or arterial
injuries. Disposition (operating room, angiography suite, etc.) of the patient
depends on the site of bleeding. For example, a FAST assessment that documents
substantial blood loss in the abdominal cavity in a patient with a hemodynamically
labile condition dictates an emergency celiotomy. However, if the quick diagnostic
 workup of a patient with a hemodynamically unstable condition who has sustained
blunt trauma shows no blood loss in the abdomen or chest, then the source of
hemorrhage could be from a pelvic injury that would likely necessitate angiography
or embolization if external stabilization (e.g., a commercial wrap or binder) of the
pelvic fracture fails to stop the bleeding. Profuse bleeding from open wounds can
usually be addressed with application of direct pressure or occasionally with
ligation of torn arterial vessels that can easily be identified and isolated.

o D.

Disability assessment and management.

Only a baseline neurologic examination is required when performing the primary

survey to determine neurologic function deterioration that might necessitate
surgical intervention. A detailed neurologic examination is inappropriate to
attempt initially. Such a comprehensive examination should be done during the
secondary survey or evaluation. This baseline neurologic assessment could be the
determination of the Glasgow Coma Scale (GCS), with an emphasis on the best
motor or verbal response and eye opening. An alternative approach for a rapid
neurologic evaluation is the assessment of the pupillary size and reaction, along
with establishing the patient's level of consciousness (alert, responds to visual
stimuli, responds only to painful stimuli, or unresponsive to all stimuli). The caveat
that must be highlighted is the fact that neurologic deterioration can occur rapidly
and that a patient with a devastating injury can have a lucid interval (e.g., epidural
hematoma). Because the leading causes of secondary brain injury are hypoxia and
hypotension, adequate cerebral oxygenation and perfusion are essential in the
management of a patient with neurologic injury.

o E.

Exposure and environmental control.

For a thorough examination, the patient must be completely undressed. This often
requires cutting off the garments to safely expedite such exposure. However, care
must be taken to keep the patient from becoming hypothermic. Adjusting the room
temperature and infusing warmed intravenous fluids can help establish an optimal
environment for the patient.
 The secondary survey should not be done until the primary survey has been
completed and resuscitation initiated, with some evidence of normalization of vital
signs. This head-to-toe evaluation must be performed in a detailed manner to
detect less obvious or occult injuries. This is particularly important in the
unevaluable patient (e.g., with head injury or severely intoxicated). The physical
examination should include a detailed assessment of every anatomic region,
including the following:

 ▪

Head

 ▪

Maxillofacial region

 ▪

Neck (including cervical spine)

 ▪

Chest

 ▪

Abdomen

 ▪

Perineum (including the rectum and genital organs)

 ▪

Back (including the remaining spinal column)

 ▪

Extremities (musculoskeletal)
A full neurologic examination needs to be performed, along with an estimate of the
GCS score if one was not done during the primary survey. The secondary survey
and the utilization (when applicable) of the armamentarium of diagnostic adjuncts
previously mentioned allow detection of more occult or subtle injuries that could, if
not found, account for significant morbidity and mortality. When possible, the
secondary survey should include a history of the mechanism of injury, along with
vital information regarding allergies, medications, past illnesses, recent food
intake, and pertinent events related to the injury.

It cannot be overemphasized that frequent reevaluation of the injured patient is

necessary to detect any deterioration in the patient status. This sometimes requires
repeating both the primary and the secondary surveys.

Topography and Clinical Anatomy

The abdomen is often defined as a component of the torso that has for its superior
boundary the left and right hemidiaphragm, which can ascend to the level of the
nipples (fourth intercostal space) on the frontal aspect and to the tip of the scapula
in the back. The inferior boundary of the abdomen is the pelvic floor. For clinical
purposes, further division of the abdomen into four areas is helpful: (1) anterior
abdomen (below the anterior costal margins to above the inguinal ligaments and
anterior to the anterior axillary lines); (2) intrathoracic abdomen (from the nipple
or the tips of the scapula to the inferior costal margins); (3) flank (inferior scapular
tip to the iliac crest and between the posterior and anterior axillary lines); and (4)
back (below the tips of the scapula to the iliac crest and between the posterior
axillary lines). Most of the digestive system and urinary tract, along with a
substantial network of vasculature and nerves, are contained within the abdominal
cavity. A viscera-rich region, the abdomen can often be the harbinger for occult
injuries as a result of penetrating wounds, particularly in the unevaluable abdomen
as the result of a patient's compromised sensorium.

Physical Examination
A complete and thorough physical examination of the entire body is essential in the
management of abdominal injury. Some findings ( Box 1 ) on physical examination
are absolute indications for operative intervention. The components of the physical
examination should include careful inspection, palpation, and auscultation.
 BOX 1:
Absolute indications for exploratory laparotomy in abdominal injuries
 A.

Peritonitis

 B.

Evisceration

 C.

Impaled object

 D.

Hemodynamic instability (documented or suspected intra-abdominal source)

 E.

Associated bleeding from natural orifice

With respect to penetrating abdominal trauma, inspection can sometimes

determine the trajectory of the missile or other wounding agents and,
consequently, guide management decisions. Often this can be determined by the
location, extent, and number of wounds. For example, a patient with a
documented, superficial tangential gunshot wound (low-velocity) with no other
remarkable physical findings is likely to be managed expectantly (observation).
However, if a penetrating abdominal injury results in a patient presenting with an
evisceration, exploratory laparotomy is the management option of choice.
Palpation enables the examiner to elicit abdominal tenderness or frank peritoneal
signs and to detect abdominal distention and rigidity. On occasion, missiles can be
palpated lodged in the soft tissue. Unless the setting is controlled and sterile, such
as the operative theater, probing of a wound should be avoided. Auscultation is also
an important component of the physical examination. It can help determine
diminished or absent bowel sounds that could be suggestive of evolving peritonitis.
Also, auscultation could detect a trauma-induced bruit, suggestive of a vascular
injury.
The examiner has to be keenly aware of situations in which the abdominal
examination is unreliable because of possible spinal cord injury or a patient's
altered mental state.

Diagnostic Studies
The abdomen is notorious for hiding its secrets: occult injuries. Access to an
extensive diagnostic armamentarium is imperative in the optimal management of
these injuries. The mainstay diagnostic modality for evaluation of blunt abdominal
trauma is CT scan. Although CT scan is beginning to have a more pivotal role in the
assessment of penetrating abdominal injuries, there are diagnostic options strongly
advocated by some for abdominal stab wounds. Local wound exploration, for
example, has the advantage of allowing the patient to be discharged from the
trauma bay or emergency department if surgical exploration of the wound fails to
show penetration of the posterior fascia and peritoneum. However, if the patient
has to go to the operating room for other injuries, the local wound exploration
should be done in the surgical suite that has better lighting and a more sterile
environment. A positive finding during local wound exploration dictates a formal
laparotomy or laparoscopy. However, even with local wound exploration as a guide,
the nontherapeutic laparotomy rate can be high, given that only a third of the
patients with stab wounds to the anterior abdomen need therapeutic laparotomy.
In the patient who has an evaluable abdomen, serial abdominal examinations are
an acceptable alternative to local wound exploration, to determine the need for
operative intervention. Local would exploration should only be done for stab
wounds to the anterior abdomen. Such an approach is potentially too hazardous for
thoracoabdominal penetrating injuries and back or flank wounds. Plain
radiography (abdomen/pelvis/chest) can be pivotal in documenting the presence of
missiles and other foreign bodies and determining the trajectory of the injury tract,
particularly for wounds from firearms. Also, the presence of free air might be
confirmed with plain radiography. Unless concern exists about a retained broken
blade or some other object, plain radiography has little utility for stab injuries. The
diagnostic peritoneal lavage (DPL) developed by David Root in 1965 was a major
advance in the care of the hemodynamically labile case of blunt trauma. With the
advent of FAST and rapid CT scan, DPL has very limited utility. Diagnostic
peritoneal lavage has never had a broad appeal in the diagnostic evaluation of
penetrating abdominal wounds. Although some have advocated its use with
tangential wounds of the abdominal wall, the technique has failed to receive
widespread support. Its reliability in detection of clinically significant injuries
sustained as a result of penetrating abdominal injuries has been a prevailing
concern. The reported sensitivity and specificity of DPL for abdominal stab wounds
are 59% to 96% and 78% to 98%, respectively. Also, DPL is a poor diagnostic
modality for detection of diaphragmatic and retroperitoneal injuries.

Diagnostic imaging has had the greatest impact in changing the face of trauma
management, with CT scan taking the lead in this area. Its ubiquitous presence in
the management of blunt abdominal trauma is well established. As underscored
previously, it is becoming an important diagnostic study in the evaluation of
penetrating abdominal injuries. In addition to its excellent sensitivity in detection
of pneumoperitoneum, free fluid, and abdominal wall/peritoneal penetration, CT
scan is helpful in identification of the tract of the penetrating agent. Hauser and
colleagues recommended the use of triple-contrast CT scan in the assessment of
penetrating back and flank injuries. CT scan evaluation is an essential diagnostic
tool in the increasing advocacy for selective management of abdominal gunshot
wounds, obviating the need for mandatory surgical exploration. However, two
major limitations of CT scan still remain: detection of an intestinal perforation and
finding of a diaphragmatic injury.

Unless the injury is confined to the solid organ of the abdomen, such as the liver or
spleen, the matrix of intestinal gas patterns makes detection of penetrating injuries
difficult. Kristensen, Buemann, and Kuhl were one of the first teams to introduce
the role of ultrasound scan as part of the diagnostic armamentarium in trauma
management. Kimura and Otsuka endorsed use of ultrasound scan in the
emergency room for evaluation of hemoperitoneum. FAST does not have the same
broad application in the evaluation of penetrating trauma as it does in blunt
trauma assessment. Rozycki, Ochsner, Schmidt, and associates reported on the
expanded role of ultrasound scan as the “primary adjuvant modality” for the
injured patient assessment. Rozychi also reported that FAST examination was the
most accurate for detection of fluid within the pericardial sac. Such a finding is
confirmatory for a cardiac injury and possible cardiac tamponade, given a
mechanism of injury that could result in an injury to the heart.

As a diagnostic modality, laparoscopy is not a new innovation. Other specialists

have used this operative intervention for several decades. However, it was formally
introduced as a possible diagnostic procedure of choice for specific torso wounds
when Ivatury and colleagues did a critical evaluation of laparoscopy on penetrating
abdominal trauma. Fabian and associates also reported on the efficacy of
diagnostic laparoscopy in a prospective analysis.

No conventional diagnostic tool can conclusively rule out a diaphragmatic

laceration or rent, so diagnostic laparoscopy becomes the study of choice for
penetrating thoracoabdominal injuries, particularly left thoracoabdominal wounds.
Laparoscopy can also be used to determine peritoneal entry from a tangential
penetrating injury.

Penetrating Abdominal Injuries and the Hemodynamically

Stable and Unstable Condition
The management principles in patients with penetrating abdominal injuries whose
conditions remain hemodynamically stable depend on the mechanism and location
of injury, along with the hemodynamic status of the patient. Irrespective of the
patient's hemodynamic parameter, the ATLS protocol should be strictly followed
on arrival of the patient to the trauma bay.

Exploratory Laparotomy in Trauma

The operative theater should be large enough to accommodate more than one
surgical team, in the event the patient might need simultaneous procedures. In
addition, the room should have the capability of maintaining room temperature as
high as the lower 80°F-plus range to avoid hypothermia in the patient. Also, a
rapid transfusion device should be in the room to facilitate the delivery of large
fluid volume and ensure that the fluid administration is appropriately warm.

Abdominal exploration for trauma has basically four imperatives: (1) hemorrhage
control; (2) contamination control; (3) identification of the specific injury; and (4)
repair or reconstruction. The abdomen is prepared with a topical antimicrobial
from sternal notch to bilateral mid thighs and extended laterally to the side of the
operating room table followed by wide draping of the patient. Such preparation
allows for expeditious entry into the thorax if needed and possible vascular access
or harvesting. Exploration is initiated with a midline vertical incision that should
extend from the xiphoid to the symphysis pubis for optimal exposure.

The first priority on entering the abdomen is control of exsanguinating

hemorrhage. Such control can usually be achieved with direct control of the
lacerated site or with proximal vascular control. After major hemorrhage is
controlled, blood and blood clots are removed. Abdominal packs (radiologically
labeled) are used to tamponade any bleeding and allow for identification of any
injury bleeding. The preferred approach to packing is to divide the falciform
ligament and retract the anterior abdominal wall. This allows manual placement of
the packs above the liver. Abdominal packs should also be placed below the liver.
This arrangement of the packs on the liver creates a compressive tamponade effect.
After manual evisceration of the small bowel out of the cavity, packs should be
placed on the remaining three quadrants, with care taken to avoid an iatrogenic
injury to the spleen. During the packing phase, after ongoing hemorrhage has been
controlled, the surgeon should communicate with the anesthesia team that major
hemorrhage has been controlled and that this is an optimal time to establish a
resuscitative advantage with fluid, blood, or blood product administration.

The next priority should be control or containment of gross contamination. This

begins with the removal of the packs from each quadrant, one quadrant at a time.
Packs should be removed from the quadrants that are least suspected as the source
for blood loss, followed by removal of the packs from the final quadrant, the one
that is believed to be the area of concern.

After control of major hemorrhage has been achieved, any evidence of gross
contamination must be addressed immediately. Obvious leakage from intestinal
injury can be initially controlled with clamps (e.g., Babcock clamp), staples, or
sutures. The entire abdominal gastrointestinal tract needs to be inspected,
including the mesenteric and antimesenteric border of the small and large bowel,
along with the entire mesentery. Rents in the diaphragm should also be closed to
prevent contamination of the thoracic cavity.

Further identification of any and all intra-abdominal injuries should be initiated.

Depending on the mechanism of injury and the estimated trajectory of wounding
agent, a thorough and meticulous abdominal exploration should be performed,
including entering the lesser sac to better inspect the pancreas and the associated
vasculature. In addition, mobilization of the C-loop of the duodenum (Kocher's
maneuver) might be necessary, along with medial rotation of the left or right colon
for exposure of vital retroperitoneal structures.
The final component of a trauma laparotomy is definitive repair, if possible, of
specific injuries. As highlighted subsequently in this chapter, the status of the
patient dictates whether each of the components of a trauma laparotomy can be
achieved at the index operation. A staged celiotomy (“damage control” laparotomy)
might be necessary if the patient becomes acidotic, hypothermic, coagulopathic, or
hemodynamically compromised.

Diaphragm
The diaphragm, a dome-shaped muscular structure with an aponeurotic sheath
(“central tendon”), effectively separates the thoracic and abdominal cavities. It
attaches to the first three lumbar vertebrae, the ribs, and the posterior aspect of the
lower sternum. Because of the decussation of its crura and hiatal architecture, the
diaphragm provides an avenue for many vital structures, including the aorta,
esophagus, thoracic duct, vagi, azygos vein, and inferior vena cava. Physiologically,
the wide excursion of the diaphragm during inspiration and expiration contributes
to both respiratory function and venous return.

Blunt trauma accounts for up to 30% of traumatic diaphragmatic ruptures in the

United States. Motor vehicle collisions and falls from heights are the most common
mechanisms of injury. Diaphragmatic rupture occurs as a result of an acute
increase in the intra-abdominal pressure. Probably because of the buttressing effect
of the liver, right-sided diaphragmatic ruptures occur less frequently than those on
the left.

In addition to ruling out a possible cardiac injury if the penetrating wound is more
central, the paramount reason that the thoracoabdominal region ( Figure 1 )
presents such a diagnostic challenge to the acute care surgeon is the possibility of
an occult diaphragmatic injury. Patients who are hemodynamically labile or have
peritoneal signs need mandatory exploration. Patients with clinically stable
conditions should undergo a more selective approach. Although the imaging
armamentarium is quite vast, no conventional diagnostic modalities can
consistently and conclusively make the definitive diagnosis of a diaphragmatic
injury. The diagnosis of a diaphragmatic injury is important for two basic reasons.
First, the presence of an acute injury to the diaphragm mandates abdominal
exploration because of the potential of risk for an associated intra-abdominal
injury. Second, both acute and long-term risks exist for diaphragmatic herniation
and possible incarceration or strangulation. Even with chest x-ray (CXR), CT scan,
FAST, DPL, magnetic resonance imaging (MRI), and fluoroscopy, this dilemma
persists, because none of these diagnostic modalities reliably detect a
diaphragmatic rent. Because of this diagnostic challenge, the thoracoabdominal
region was correctly underscored as “the ultimate blind spot” in penetrating
trauma. This ongoing challenge was attributed to the presence of the diaphragm in
this region. Documentation of a diaphragmatic injury has been a difficult task since
it was first described by Sennertus in 1541. Patients who present with indications
for exploration ( Box 2 ) need no essential diagnostic studies. Without any definitive
way of determining diaphragmatic injury, even with no absolute indication for
operative intervention, a celiotomy was often the management approach of choice
for such injuries, particularly left penetrating thoracoabdominal injuries. An
expectant approach (observation only) does not address potential for the presence
of an injury to the diaphragm and its sequela, such as the increased risk for the
development of a herniation of abdominal viscera. This potential complication is
thought to be secondary to nonhealing of the injury site. Factors proposed that may
contribute to hernia formation include: (1) relative thinness of the diaphragm; (2)
constant motion; and (3) pressure difference across the diaphragm that favors
movement of abdominal contents from the abdomen into the thoracic cavity.
Although the injury occurs acutely, clinical signs of a hernia are usually lacking and
a high index of suspicion is imperative to prompt optimum investigation. The time
from injury to presentation of a symptomatic diaphragmatic hernia may vary from
days to many years after injury. This has led to the development of a classification
system for diaphragmatic hernias based on time of presentation. The acute phase
occurs during or shortly after the time of injury. The next phase is the interval, or
latent, phase. During this phase, the patient may have abdominal pain that greatly
resembles that of common etiologies for upper abdominal pain. The final phase is
the obstructive, or strangulation phase; the patient may present with signs and
symptoms of bowel obstruction or even peritoneal signs as a result of necrosis of
the incarcerated bowel. Patients who present in the obstructive phase with necrotic
viscera are common and have a documented mortality rate of greater than 40%.
This further emphasizes the importance of diagnosis and repair of these injuries in
the acute setting, to avoid such complications.

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FIGURE 1
 Areas of concern for thoracoabdominal injuries.
BOX 2:
Absolute indication for celiotomy
 1.

Hemodynamic lability

 2.

Peritoneal signs

 3.

Free air

 4.

Bleeding from an orifice

 5.

Massive hemothorax

o CT scan, >1500-mL initial output

o CT scan, >200 mL/h for more than 4 h

 6.

Impaled object

CT, Computed tomographic.

Several diagnostic modalities have been used in the evaluation of

thoracoabdominal trauma in both the blunt and the penetrating settings. Chest x-
ray is the usual screening diagnostic modality. However, the diagnostic accuracy
for diaphragmatic injuries ranges from as low as 13% to as high as 94% in the
literature. Shah and associates looked at a collective series where CXR was
diagnostic in 40.7% of cases reviewed. This approaches the 50% accuracy rate.
They also found that the accuracy was increased when the study was repeated after
the placement of a radiopaque nasogastric tube. However, the sensitivity of CT scan
has been less than optimal. Shanmuganathan and colleagues looked retrospectively
at CT scan as a diagnostic modality in thoracoabdominal injuries. Forty-one
patients with both blunt and penetrating injuries were included. CT scan had a
sensitivity of 63% and a specificity of 100% for diaphragmatic “rupture” in the
blunt cases. CT scan failed to diagnose diaphragmatic injuries without associated
visceral herniation. Patients with penetrating injuries are less likely to have visceral
herniation; therefore, their injuries can easily be missed if CT scan is used as a
mode of diagnosis. In the McQuay/Britt study, five patients would have fallen into
this category. These and other radiologic studies are usually not accurate in the
acute phase of penetrating injuries. This was the rationale for establishing a
practice of mandatory exploration to evaluate better the integrity of the diaphragm
and associated injuries.

The incidence rate of diaphragm injuries as a result of penetrating trauma ranges

from 0.8% to 15%. Mandatory exploration of all penetrating thoracoabdominal
injuries has been advocated for many years on the premise that it is the only way to
assess definitively the diaphragm. The importance of adequate visualization cannot
be underestimated, considering the increased morbidity and mortality as a result of
a missed diaphragmatic injury.

Mandatory celiotomy for an injury with such a low incidence resulted in a high
number of nontherapeutic explorations, prompting the need for an alternative
approach. In 1992, Rao Ivatury and associates introduced for this cohort of patients
diagnostic laparoscopy as the definitive modality for identification of
diaphragmatic injuries in penetrating thoracoabdominal trauma. In the acute
setting of penetrating thoracoabdominal injuries, few (if any) indications exists for
performing diagnostic thoracoscopy to determine the integrity of the diaphragm.
Such an intervention likely requires a double-lumen endotracheal tube insertion
and lateral decubitus positioning of the patient. If a diaphragmatic through-and-
through injury is actually confirmed (especially on the left side), the patient needs
to be repositioned in the supine position and prepared and draped for a celiotomy.
Therefore, a diagnostic laparoscopy is more appropriate and efficient management
for these injuries.

Laparoscopy was introduced as a possible alternative for the evaluation of

penetrating thoracoabdominal trauma. Fabian and colleagues studied 182 patients
over a 19-month period. Laparoscopy revealed no peritoneal penetration in 55% of
the patients reviewed. Of the remaining patients, 66% had therapeutic laparotomy,
17% had nontherapeutic laparotomy, and 17% had negative laparotomy. Ortega and
colleagues studied 24 patients with penetrating thoracoabdominal injuries and
reviewed their experience with diagnostic laparoscopy (DL). Their specificity and
positive predictive values were 100% for lesions of the diaphragm, liver, spleen,
and hollow viscus. Others have attempted to use DL not only to document
peritoneal penetration but also to determine the extent and operative management
of intra-abdominal injury. Zantut and associates looked at laparoscopy as both a
diagnostic and a therapeutic modality. Retrospective data of 510 patients from 3
institutions were included. Laparotomy was avoided in 303 patients (59.4%) in
whom laparoscopy was negative for peritoneal penetration. Livingston and
colleagues prospectively evaluated 39 patients with hemodynamically normal
conditions with penetrating thoracoabdominal injuries with DL. Laparoscopy
correctly identified the presence of intra-abdominal injuries in 26 patients. The
McQuay/Britt study revealed 22 unsuspected injuries, 17 of them with intra-
abdominal organ injuries that necessitated operative repair.

The ability to adequately evaluate the diaphragm with the laparoscope provides an
attractive diagnostic modality that benefits those patients with diaphragmatic
injury and avoids an unnecessary celiotomy. As the technology and the
laparoscopic skills of surgeons develop, diagnostic laparoscopy will become more of
a therapeutic option.

In the acute setting, diaphragmatic injuries are preferentially repaired primarily in

a two-layer fashion, with a heavy nonabsorbable suture. Although the implications
are infrequent, a nonabsorbable mesh can be incorporated in the diaphragmatic
closure where there is significant tissue destruction, which usually occurs in blunt
trauma. In the unlikely event of a gross contamination, endogenous tissue can be
used for a definitive repair. Such tissue includes a latissimus dorsi flap, tensor
fascia lata, or omentum. Some practitioners advocate use of biologic tissue grafts,
such as AlloDerm (human acellular tissue matrix; Life Cell Corporation). The
durability of such a repair is questionable. Figure 2 is a treatment algorithm for
generating thoracoabdominal injuries, the most common mechanism for
diaphragmatic injuries.

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FIGURE 2
Treatment algorithm.
Overall, the expected outcomes for diaphragmatic injuries are good ( Table 1 ).
Mortality and significant morbidity are related to associated organ injuries.

TABLE 1:
Diaphragmatic injuries
Organ Incidence rate Diagnosis Specific Outcome
management

Diaphragm 6% of all intra- Physical Preoperative Associated
abdominal examination antibiotics injuries
injuries that Primary closure is dictate
result from o • the preferred morbidity
penetrating definitive and mortality
trauma Chest pain and management
shortness of With
breath documentation of a
diaphragmatic rent
o • (laceration),
exploratory
Scaphoid
laparotomy is
abdomen
necessary
o •

Bowel sounds on
auscultation of
the hemithorax

 Plain
radiography

o •

Hollow viscus
noted in the left
hemithorax
Nasogastric tube
in the left
hemithorax

 FAST
examination

o •
Organ Incidence rate Diagnosis Specific Outcome
management
Unreliable

 DPL

o •

Inconclusive;
high false-
negative

 CT scan

o •

Inconclusive

 Laparoscopy, the
diagnostic
modality of
choice

CT, Computed tomographic; DPL, diagnostic peritoneal lavage; FAST, focused assessment
with sonography for trauma.

Stomach, Small Bowel, Colon, and Rectum

Stomach
The stomach is the second most common intraperitoneal hollow viscus injured. Its
size and intraperitoneal location make this organ a vulnerable target, with size
being affected by the intraluminal volume. Gastric injury from blunt trauma is
quite infrequent. When it does occur, it is often the result of increased intraluminal
pressure and distension. Seatbelt injuries and direct blows to the epigastrium are
common causes of gastric injuries. With respect to penetrating wound of the
stomach, a more frequent mechanism of injury, the anterior and posterior aspects
of the stomach need to be meticulously inspected for accompanying through-in-
through injuries. Penetrating injuries of the stomach should be repaired primarily
after débridement of nonviable edges. The primary repair can be performed in
either a single layer with nonabsorbable suture or as a double-layer closure with an
absorbable suture (e.g., Vicryl, Ethicon, Inc., Somerville, NJ), with the first layer
and the second layer closed with unabsorbable sutures (e.g., silk). This approach
compromises the gastric lumen in only a very few penetrating injuries of the
stomach. Fortunately, major resective procedures are not commonly necessary in
gastric injuries. Because gross contamination is usually associated with stomach
wounds, copious irrigation of the abdominal cavity is an essential component of the
operative strategy.

Small Intestine
Small bowel is the most common intraperitoneal hollow viscus injured. As with
other hollow viscus injuries, nonoperative management has no place in a small
bowel perforation or rupture. CT scan evaluation is usually not necessary with
penetrating injuries, but it can be helpful in detection of a possible bowel injury.
The two basic types of findings of bowel injury on CT scan are direct and indirect
( Table 2 ). The management of injuries to the small intestine is well established,
with control of bleeding and gross spillage being strategic mainstays. If bowel
viability is questioned secondary to blunt or penetrating trauma, a segmental
resection should be performed. Isolated small bowel enterotomies can be closed
primarily with nonabsorbable sutures for a one-layer closure. If the edges of the
enterotomy appear nonviable, they should be gently débrided before primary
closure. However, multiple contiguous small bowel holes or an intestinal injury on
the mesenteric border with associate mesenteric hematoma likely necessitate
segmental resection and anastomosis of the remaining viable segments of the small
bowel. The operative goal is always the reestablishment of intestinal continuity
without substantial narrowing of the intestinal lumen, along with closure of any
associated mesenteric defects. Application of noncrushing bowel clamps can
contain ongoing contamination while the repair is being performed. Although a
hand-sewn or stapler-assisted anastomosis is operator dependent, trauma
laparotomies are time-sensitive interventions and expeditious management is
imperative. In the immediate postoperative period, bowel decompression for 12 to
24 hours is prudent. As in most trauma laparotomies, antibiotics should be
routinely given in only the perioperative period, unless an ensuing infectious
complication occurs in the postoperative period.

TABLE 2:
Computed tomographic scan findings of blunt bowel injury
Direct Indirect
Oral contrast extravasation Mesenteric hematoma
Direct Indirect
Free air Mesenteric blush
Bowel wall edema
Unexplained ascites
Fat streaking
Unopacified (vascular contrast media) bowel loops
Colon/Rectum
Penetrating trauma accounts for most of the colon and rectal injuries that occur in
the civilian setting. Even today, a debate remains regarding the optimal treatment
of colon injuries, with the preponderance of evidence supporting primary closure of
the colonic wounds and segmental resection (with primary anastomosis) in most
traumatic settings. Most colonic injuries are quickly diagnosed during the initial
exploration and mobilization of the colon. With two thirds of the rectum being
extraperitoneal and bordered by the bony pelvis, detection and direct management
of a localized rectal injury is a challenge. Rectal injuries are usually a result of
pelvic fractures and penetrating trauma. Oftentimes, rectal injuries are managed
with proximal diversion. The segment of injured bowel should be thoroughly
inspected for potential through-in-through enterotomies and associated mesenteric
injuries. This requires adequate mobilization of the colon for visualization of the
entire circumference of the bowel wall. As highlighted previously, initially
controversial, an enterotomy (right-sided or left-sided injuries) of the colon can be
closed primarily, irrespective of contamination or transient shock state. If the colon
injury is so extensive that primary repair is not possible or would severely
compromise the lumen, a segmental resection should be performed. Depending on
the environmental setting, the remaining proximal segment can be anastomosed to
the distal segment or a proximal ostomy and Hartmann's procedure can be
performed. If the distal segment is long enough, a mucous fistula should be
established. Documented rectal injuries below the peritoneal reflection should
necessitate a diverting colostomy and presacral drainage (exiting from the
perineum). Such drainage is, however, not universally endorsed.

A capsule summary of the incidence, diagnosis, management options, and related

outcomes for injuries of the stomach, small intestine, colon, and rectum is depicted
in Table 3 .
TABLE 3:
Injuries of the stomach, small intestine, colon, and rectum: incidence, diagnosis, management
options, and outcomes
Organs Incidence Diagnosis Specific Outcome
management
Stomac More common  Physical Preoperative Associated
h injury in examination antibiotics injuries
penetrating Débridement dictate
trauma than in o • when necessary morbidity and
blunt Primary closure mortality
10% of Epigastric (two layers)
penetrating tenderness
injuries of the
abdomen o •

Peritoneal signs

o •

Bloody gastric
aspirate

 Plain radiography

o •

Free air under the

diaphragm

 FAST examination

o •

Unreliable

 DPL

o •

Lavage

 RBCs

 WBCs
Organs Incidence Diagnosis Specific Outcome
management
 Gross
contamination

 CT scan

o •

Pneumoperitoneum

 Laparoscopy

o •

Operator dependent

Small Highest  Physical Preoperative Outcome is

bowel incidence rate examination antibiotics good
of injury of the Primary closure of Negligible
intra- o • simple lacerations leak rate
abdominal Segmented even in
organ Cannot rely on resection of contaminated
tenderness or complex injuries field
peritoneal signs in with functional
the early stage of end-to-end
injury tensionless
anastomosis
 Plain radiography One-layer (or
double-layer)
 FAST examination:
closure/anastomo
free fluid with CT
sis or stapled
scan shows no solid
anastomosis
organ injury

 CT scan

o •

High false-negative
rate

o •

Pneumoperitoneum
Organs Incidence Diagnosis Specific Outcome
management
o •

Free fluid

Colon Majority  Physical Preoperative Overall,

Stab wounds examination antibiotics favorable
Gunshot Primary closure of outcome
wounds o • simple injuries Complication
Instrumentatio (avoid narrowing s
n Tenderness/periton the lumen)
Blunt trauma, eal signs Segmental  •
infrequent resection and
o • fecal diversion of Low leak rate
complex colonic
Gross blood on  •
wounds
rectal examination
Wound
infection

 •

Intraperitone
al abscess

CT, Computed tomographic; DPL, diagnostic peritoneal lavage; FAST, focused assessment
with sonography for trauma; RBCs, red blood cell counts; WBCs, white blood cell counts.

Retroperitoneal Injury
The retroperitoneum is an anatomic bonanza because several of the most vital
structures reside in this area, including portions of the duodenum, the pancreas,
the kidneys and adrenals, and major vessels (aorta, inferior vena cava, and other
vasculature), along with other organs. The specific retroperitoneal injury is usually
easily detected with advanced diagnostic imaging, such as CT scan. However, on
occasion, such injuries are found during an abdominal exploration for blunt or
penetrating trauma. In this setting, the only suggestion of an injury to a structure
in this region might be discovery of a retroperitoneal hematoma.

Retroperitoneal Hematomas
The retroperitoneum, an organ-rich region, has several key structures that can be
injured when its boundaries are penetrated. The retroperitoneal hematoma can be
a major potential site for hemorrhage in patients with either penetrating or blunt
trauma because of the substantial vascularity, along with bleeding, that can occur
from an associated solid organ wound (e.g., kidney). In the central region (zone I)
of the retroperitoneum resides the abdominal aorta, celiac axis, and the superior
mesenteric artery, vena cava, and proximal renal vasculature. The lateral
retroperitoneum (zone II) encompasses the proximal genitourinary system and its
vasculature. The pelvic retroperitoneum (zone III) contains the iliac arteries, veins,
and their tributaries. In addition to the vasculature and the kidneys (plus ureters)
highlighted previously, the retroperitoneum contains the second, third, and fourth
portion of the duodenum, along with the pancreas, the adrenals, and the intrapelvic
portion of the colon and rectum. Table 4 underscores the management principles of
traumatic retroperitoneal hematomas. Ideally, proximal (and when applicable,
distal) control needs to be achieved before exploration of any retroperitoneal
hematoma. For retroperitoneal hematomas in zone I, irrespective of a penetrating
or blunt mechanism, mandatory exploration is required. Also, a retroperitoneal
hematoma in any of the three zones requires exploration for all penetrating
injuries. For zone II retroperitoneal hematomas that result from blunt trauma, all
pulsatile or expanding hematomas should undergo exploration. Gross
extravasation of urine also necessitates exploration. Zone III (pelvic
retroperitoneum) hematomas should be explored only for penetrating injuries to
determine whether there is a specific intrapelvic colorectal, ureteral, or vascular
injury. However, such an approach should not be taken for blunt trauma because
the injury is likely venous and application of an external compression device is the
preferred intervention. An arterial injury could be addressed with arteriography or
embolization.

TABLE 4:
The “Zones” of penetrating cervical injuries
Zone Blunt Penetrating
I (Central) Explore Explore
II (Perinephric) Observe Explore
III (Pelvic) Observe Explore
Specific Injuries
Table 5 provides an overview of specific injuries.
TABLE 5:
Retroperitoneal
Organs Incidence Diagnosis Specific management Outcome
s
Duodenum/pancr Isolated  Physical  Preoperative Highly
eas injuries are examination antibiotics lethal as
uncommon a result
High o •  Duodenal injury: of
percentage operative associat
of Abdominal armamentarium ed
associated tenderness injuries
injuries o • Increase
o • d
Primary repair with mortality
Peritoneal gastrostomy with
signs retrograde delayed
 diagnosi
Plain o •
radiography s of
Jejunostomy: feeding duodenal
o • injury
o •
Free air
Jejunostomy
o •
o •
Retroperiton
eal air Pyloric exclusive

 FAST  Pancreatic injury:

operative
 DPL armamentarium

 CT scan o •

Drainage

o •

Débridement

o •

Partial resection

o •
Organs Incidence Diagnosis Specific management Outcome
s
Pancreaticoduodenect
omy

Kidney 20% of  Physical  Preoperative Mortality

renal examination antibiotics related
injuries to the
result from Penetrating Operative associat
penetrating wound or armamentarium ed
trauma trajectory in injuries
close  Primary repair with
proximity to viable tissue buttress
the kidney
o •
o •
Partial nephrectomy
Hematuria
o •
 Plain
radiography Nephrectomy

o •

Nonspecific

 FAST

 DPL

 CT scan (if
peritoneal
penetration
not
suspected in
a gunshot
wound)

o •

Perinephric
hematoma

o •
Organs Incidence Diagnosis Specific management Outcome
s
Extravasatio
n

Bladder Usually an Physical  Preoperative Excellent

occult examination antibiotics outcome
injury found s
during o •  Multilayer closure with Morbidity
intraoperati absorbable sutures and
ve Penetrating with indwelling bladder mortality
abdominal wound or catheter relate to
exploration trajectory in associat
close ed
proximity to injuries
the bladder

o •

Hematuria

 Plain
radiography

o •

Nonspecific

 FAST

 DPL

 CT scan (if
peritoneal
penetration
not
suspected)

 Perinephric
hematoma

o •

Extravasatio
n of contrast
agent
Organs Incidence Diagnosis Specific management Outcome
s
Ureter Infrequent Usually an  Preoperative Good
injury in intraoperativ antibiotics outcome
penetrating e diagnosis if no
trauma  Management major
armamentarium associat
ed
 Primary repair/stenting injuries

 Delayed repair and

suprapubic cystostomy

 Diverting
nephrostomies

CT, Computed tomographic; DPL, diagnostic peritoneal lavage; FAST, focused assessment
with sonography for trauma.
Duodenum and Pancreas
The most frequent retroperitoneal hollow viscus injury, particularly in blunt
trauma, is the duodenum. Full-thickness duodenal wounds demand operative
management.

Duodenal injuries can be repaired primarily in a one-layered or two-layered

fashion if the penetration is less than half the circumference of the duodenum.
However, for more complex duodenal injuries, an operative procedure is needed to
divert gastric contents away from the site (where closure of the wound has been
attempted). A pyloric exclusion with the establishment of a gastrojejunostomy is
such a procedure.

Superficial or tangential penetrating wounds of the pancreas, in which there is no

injury to the main pancreatic duct, can be externally drained. However, a
penetrating injury that transects the pancreas, including the main pancreatic duct,
requires extirpation of the distal pancreas (distal pancreatectomy), particularly if
the transection site is to the left of the superior mesenteric vessels. A more
proximal penetrating injury that involves the main pancreatic duct, with associated
complex duodenal injury (e.g., injury to the ampulla) likely necessitates a
pancreatoduodenectomy. Unfortunately, because of the rich vascular network that
surrounds the pancreas, penetrating pancreatic wounds can be lethal injuries.
In blunt abdominal trauma, assessment of pancreatic injuries to determine
whether surgery is required can be extremely challenging. Clinical symptoms,
physical examination, and diagnostic imaging (e.g., CT scan) are all important
parameters in making the correct decision regarding operative intervention. If a
patient presents with abdominal pain and examination has associated abdominal
tenderness, along with CT confirmation of pancreatic injury, then that patient
needs to proceed to the operative theater for exploration. If the patient is relatively
asymptomatic and CT scan findings are consistent with a likely pancreatic injury,
endoscopic retrograde cholangiopancreatography (ERCP) can assist in determining
whether there is a major ductal injury. Such a finding necessitates exploration for
definitive management.

Genitourinary System
Less than 10% of patients with penetrating abdominal wounds sustain
genitourinary tract injuries, with most of the injuries being renal. Penetrating
injuries that result in a grade IV (cortical/calyceal injury and associated vascular
injury with contained hemorrhage) or grade V (shattered kidney and vascular
avulsion) invariably necessitate a nephrectomy, particularly if there is a viable
contralateral kidney. Lacerations or more superficial wounds of the kidney might
require renorrhaphy, with approximation of the disrupted capsule with pledgeted
sutures or a prosthetic (mesh) wrap. Absorbable interrupted suture should be used,
and all repairs should be drained. On occasion, the injury pattern dictates the need
for a partial nephrectomy. Ureteral injuries can be extremely difficult to identify in
penetrating wounds with an accompanying retroperitoneal hematoma. When
possible, the ureter should be repaired primarily with interrupted absorbable
suture over a double J stent. A complete transection of the ureter requires
débridement of the nonviable edges, spatulation of the ends, and primary repair
over a stent. All repair sites should be adequately drained. If the anastomosis
cannot be performed in a tension-free fashion, a bladder flap (Buari's) could be
surgically constructed, with implantation of the proximal segment of the transected
ureter into the flap. A psoas “hitch” might be necessary if there is any tension on
the flap and the tunneled ureter.

Penetrating injury to the intraperitoneal bladder requires surgical repair. After

confirmation of no involvement of the trigone, the bladder should be closed with a
two-layer closure with absorbable suture (the second layer incorporates Lembert
sutures to imbricate the first layer). Suprapubic drainage should only be done
selectively; however, a Foley catheter should be left in place.

Abdominal Vascular Injury

With no suggestion of an abdominal visceral injury, a patient who is
hemodynamically labile with increasing abdominal distension has a vascular
injury, either secondary to a mesenteric rent or specific vessel wound. Several
major intra-abdominal vessels can, if injured, result in substantial bleeding. In the
central area (zone I), these include the abdominal aorta, the celiac axis vessels, the
superior mesenteric artery or vein, the portal vein, and the inferior vena cava. The
perinephric region (zone II) encompasses the renal artery and vein, bilaterally.
Zone III represents the pelvic region where the iliac arteries and veins and their
tributaries lie. Although blunt trauma can result in mesenteric avulsions with
associated bleeding, most vascular injuries occur from penetrating abdominal and
transpelvic trauma.

The role of aggressive crystalloid resuscitation in the initial management of

patients who are in shock from intra-abdominal hemorrhage is still being debated.
However, less aggressive fluid resuscitation has been reported to have some
benefit, particularly in situations in which the time between the prehospital setting
and the definitive hospital management is relatively short. Also, some investigators
advocate for performing an emergency thoracotomy, with cross clamping of the
descending aorta, to sustain intracranial and coronary flow while decreasing
arterial inflow into the abdomen to temporarily address ongoing intra-abdominal
hemorrhage in a patient who is in profound shock. In the trauma bay, the quickest
method of confirming intra-abdominal hemorrhage is by performing the FAST
examination. Such an assessment can be done while the patient is undergoing
expeditious ATLS protocol, with the establishment of an optimal airway and the
insertion of large-bore intravenous catheters.

On entering the abdomen, free blood and clots should be removed followed with
gauze (laparotomy pads) packing of each of the four quadrants. Areas of concern
should be manually compressed as the pads are carefully removed from the other
quadrants. Also, operative prioritization of intra-abdominal hemorrhage should be
done, expeditiously, with identification and control of aortic and inferior vena caval
injuries, followed by management of bleeding solid organs. Afterwards, contained
retroperitoneal hematomas should be addressed. When appropriate, the
fundamental principle of obtaining proximal and distal control of an injured vessel
before repair remains the same. Definitive management of specific arterial and
venous injuries is elucidated in Tables 6 and 7 . Two fundamental maneuvers in
gaining access to the central vasculature are medial mobilization of right-sided and
left-sighted intra-abdominal viscera ( Figures 3 and 4 ). In addition to having a
prepared blood bank, a trauma surgeon encountering a major abdominal vascular
injury should have certain adjuncts (e.g., conduits for establishment of temporary
shunts and material for silo development in the open abdomen) to assist in the
management of the injured patient.

TABLE 6:
Abdominal arterial injuries: exposure and management options
Site of Principle route of operative Preferred management
abdominal exposure options
vascular injury
Infrarenal Midline inframesocolic Lateral suture, patch repair,
aorta retroperitoneum or interposition graft (rare)
Ligation requires
extraanatomic bypass
reconstruction
Suprarenal Left-to-right medial visceral Lateral suture or patch
aorta rotation (spleen, pancreas, and left repair
colon) Interposition graft requires
bypass to celiac, superior
mesenteric, or renal arteries
(rare)
No ligation
Celiac axis Left-to-right medial visceral Lateral suture if feasible;
rotation (spleen, pancreas, and left ligation otherwise preferred;
colon) interposition graft if
collaterals disrupted (rare)
Hepatic artery Hepatoduodenal ligament Lateral suture, interposition
graft, or ligation (may require
bypass graft)
Splenic artery Through lesser sac Ligation preferred
Superior Left-to-right medial visceral Lateral suture, patch repair,
mesenteric rotation (spleen, pancreas, and left or ligation and distal bypass
artery colon); base of mesentery
Site of Principle route of operative Preferred management
abdominal exposure options
vascular injury
Inferior Midline inframesocolic Ligation preferred
mesenteric retroperitoneum
artery
Proximal renal Midline inframesocolic Lateral suture, patch repair,
arteries retroperitoneum, right-to-left litigation and bypass, or
medial visceral rotation (right colon nephrectomy
and left duodenum), or left-to-right
medial visceral rotation
Distal renal Right-to-left medial visceral Lateral suture, patch repair,
arteries rotation (right colon and interposition graft or
duodenum) on right; left-to-right nephrectomy
medial visceral rotation on left
Common and Midline pelvic retroperitoneum; Lateral suture, patch repair,
external iliac medical reflection of sigmoid colon interposition graft, or ligation
arteries on left with bypass to external iliac
artery (may be
extraanatomic)
Internal iliac Midline pelvic retroperitoneum Ligation preferred
arteries
Adapted from Kokino, PG, Thompson RW: Abdominal vascular trauma. In Soper NJ,
Thompson EC, editors:Problems in general surgery: abdominal trauma, vol 15, Philadelphia,
1998, Lippincott-Raven, p. 84.
TABLE 7:
Abdominal venous injuries: exposure and management options
Site of Principal route of operative Preferred management
abdominal exposure options
vascular injury
Infrarenal Midline inframesocolic Lateral suture, patch repair,
inferior vena retroperitoneum or right-to-left or ligation
cava medial visceral rotation (right
colon)
Renal veins Right-to-left medial visceral Lateral suture or patch
rotation (right colon and repair, ligation if collaterals
duodenum) on right; midline intact on left; interposition
inframesocolic retroperitoneum on vein graft on right or on left if
left no collaterals; nephrectomy
Site of Principal route of operative Preferred management
abdominal exposure options
vascular injury
Juxtarenal Right-to-left medial visceral Lateral suture or patch repair
inferior vena rotation (right colon and
cava duodenum)
Retrohepatic Right-to-left medial visceral Lateral suture or patch repair
inferior vena rotation (right colon, duodenum
cava and right liver) with vascular
exclusion of the liver (Pringle's
maneuver and atriocaval shunt)
Portal vein Hepaduodenal ligament; right-to- Lateral suture, patch repair
left medial visceral rotation (right (vein), splenic vein bypass to
colon and duodenum); lesser sac superior mesenteric vein, or
and transpancreatic ligation
Iliac veins Midline pelvic retroperitoneum; Lateral suture, patch repair,
medial reflection of sigmoid colon or ligation
on left; divide iliac artery (rare)
Adapted from Kokino, PG, Thompson RW: Abdominal vascular trauma in problems in general
surgery. In Soper NJ, Thompson EC, editors: Problems in general surgery: abdominal
trauma, vol 15, Philadelphia, 1998, Lippincott-Raven, p. 85.
Abrir imagen a tamaño completo
FIGURE 3
Medial rotation of the right-sided intraabdominal viscera.
(Adapted from Kokinos PG, Thompson RW: Abdominal vascular trauma. In Soper NJ,
Thompson EC, editors:Problems in general surgery: abdominal trauma, vol 15, Philadelphia,
1998, Lippincott-Raven, p. 85.)
Abrir imagen a tamaño completo
FIGURE 4
Medial rotation of the left-sided intraabdominal viscera.
(Adapted from Kokinos PG, Thompson RW: Abdominal vascular trauma. In Soper NJ,
Thompson EC, editors:Problems in general surgery: abdominal trauma, vol 15, Philadelphia,
1998, Lippincott-Raven, p. 86.)
Approximately 25% of patients with major abdominal injuries have significant
vascular trauma. No other intra-abdominal presentation defines time-sensitive
management like this cohort of injuries.

Summary
Although the concept of standard-of-care management is broadly accepted and
adamantly advocated, such care is at times institution dependent. Unfortunately,
resource-rich trauma facilities and systems are not uniform throughout the country
and regionalization has not been perfected nationwide.

However, the overarching mission remains the same: optimal management for
everyone, irrespective of where the patient receives trauma care