SURGERY

Basic Emergency Skills in Trauma (Part 3)

Penetrating Abdominal Injury
Oliver I. Belarma, MD | June 5, 2021

OUTLINE: ● X-Ray = pneumoperitoneum or foreign body

I. Objectives ● Blood in orifices (NGT, Foley catheter); Blood for NGT or
II. Penetrating Abdominal Injury IGT can be iatrogenic
III. Clinical Vignette
IV. Management of Colonic Injuries
If with indications in doing surgery: DECIDE
● Is the wound penetrating the peritoneum?
OBJECTIVES: ● Is there intraperitoneal injury?
● Interpret abdominal physical findings in penetrating
abdominal injury Q1: IF THE PATIENT CANNOT TELL IF THE TENDERNESS
● Understand and apply the different diagnostic modalities used IS COMING FROM THE WOUND OR INSIDE THE ABDOMEN,
in penetrating injury to the abdomen WHAT TO DO NEXT?
• Management will depend on the availability and skills of the
PENETRATING ABDOMINAL INJURY surgeons in the area.
● Penetrating Abdominal Injury
o penetrating injury entering the peritoneal space to a. Serial PE of the abdomen
retroperitoneum inflicting damage to the abdominal i. Doing the abdomen PE every 30mins for 2-3x
cnotents done by one examiner only.
● Entry wounds of abdominal injury extends in the 5th ii. Patient develops tenderness away from the entry
intercostal space up to the respective lobe causing wound or diffusely tender; do exploratory
penetrating abdominal injury laparotomy
● Most patients with penetrating abdominal injury require
laparotomy with difference in management between b. Perform wound exploration of the epigastric wound
projectile (gunshot) and non-projectile (stab). i. Single anterior abdominal wound
● Any wound in the area between the nipple line, (T4) and ii. PERFORM via the GUIDELINES, if wound
groin anteriorly and from T4 to the 3rd iliac crest the exploration is positive (penetration of fascia)
posteriorly = potential abdominal injury iii. If negative, admit for 24 hrs and do PE every 3 hrs
● If the wound is projectile, the penetrating injury could result iv. DISADVANTAGE: No practical use for multiple
to wounds present in any part of the body. abdominal wounds
● 4 important parts: v. For upper abdominal wounds, inadvertently enter
o Between the ant abdomen between the anterior the chest
axillary line bound by costal margin superiorly and vi. Low utility in stab wounds
the groin distally
o The thoracoabdominal area superiorly delimited by c. Diagnostic peritoneal lavage
the 4th intercostal space anteriorly, 6th intercostal i. For single and multiple anterior abdominal wounds
space laterally, 8th intercostal space posteriorly and ii. Do exploratory laparotomy if positive (with feces
inferiorly delimited by costalmargins. and bile on your DPL; if RBC > 100,000; WBC
o Back >500 on fluid; food particles)
o Flank iii. Negative: discharge the patient if no associated
injury
iv. Advantage: High false positive result, increase
CLINICAL VIGNETTE: non-therapeutic laparotomy
● 30/M came in 8 hours post-injury after sustaining multiple
abdominal stab wounds d. Perform laparoscopy
● BP: 100/70 mmHg; HR: 98/min; RR: 18/min i. Diagnostic laparoscopy
● Pink palpebral conjunctiva, clear breath sounds, distinct ii. Open laparotomy: if positive (with penetration of
heart sounds abdominal wall, presence of bowel or vascular
● PHYSICAL EXAMINATION: injuries, isolated diaphragmatic injury cannot be
o ABDOMEN: (+) multiple stab wounds, repaired laparoscopically)
▪ 1 Epigastric area iii. Negative: admit for 24 hours
▪ 2 Left lower quadrant iv. Disadvantages: surgical expertise exhausted,
▪ 3 Right lumbar area laborious preparation
▪ (+) direct tenderness on the epigastric
area e. UTZ
▪ (-) rebound (-) guarding i. Focused abdominal sonography on trauma
o RECTAL EXAM: (-) blood, (-) gross hematuria
ii. POSITIVE: free intraperitoneal fluid or presence of
any solid organ injury
Cite signs and symptoms to determine if it warrants iii. NEGATIVE: patient discharge in absence of other
immediate surgery injury
● Signs of hemodynamic stability associated with abdominal iv. DISADVANTAGE: operator-dependent; hollow
injury injuries can be missed; needs 50cc of
● Early Abdominal contents intraperitoneal fluid to be sonographically visible;
● Peritoneal signs conclusive of a hemoperitoneum (+) with 5mL of fluid
● Gunshot wound or Intraperitoneal penetration
● Lower extremity ischemia (vascular injury)

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 SURGERY
Penetrating Abdominal Injury

v. CT Scan to assess the inferior and lateral posterior

abdominal wounds
vi. POSITIVE: (+) free intraabdominal and/or
peritoneal fluid or presence of any solid organ
injury, hollow viscous injury
vii. NEGATIVE: patient discharge
viii. DISADVANTAGE: edxpensive and needs 50 cc to
become positive

f. Do outright exploratory laparotomy

i. If A-E cannot be done, proceed to ex-lap
Colostomy
Q2: WHILE DOING ONE OF THE ABOVE PROCEDURES,
THE PATIENT BP WENT DOWN TO 80/60 MMHG, HOW WILL
YOU RESUSCITATE THE PATIENT?
• Hemorrhage: MOST COMMON CAUSE OF SHOCK IN
TRAUMA PATIENTS
• Patient’s Case: Class III (31-40% blood loss) before
hypotensive, hypovolemic

YOU WOULD RESUSCITATE BY:

a. Giving boluses of crystalloid (1L only)
b. Transfusing with fresh whole blood (< 24hrs)
c. Transfusing PRBC (if FWB no available within 24hrs)
d. Giving colloids while awating for blood
o Should be minimal in hypovolemic patients with
shock (up to 1L)

Q3: AFTER RESUSCITATION, BP ROSE TO 100/80 MMHG,

HR=115/MIN. ONE SHOULD:
a. Proceed with exploratory laparotomy (since patient is
normotensive already) Steps:
b. Continue resuscitation and wait for blood a. Exteriorization of the injured chronic segment.
c. Continue further observation b. Primary repair of the injured colon by creation of toximostoma
d. Proceed with further diagnostic work-up c. Do repair and divert
d. Do resection of colonic segment with end-colostomy or the
hartmann’s procedure
PENETRATING COLONIC INJURIES
PERITONITIS
Things to initially check:
• inflammation of the peritoneum or serosal surfaces as
1. Hypotension
evidenced by congestion and edema
2. Fecal contamination
• presence of fibrinous, purulent, or fibrino-purulent exudates,
3. Associated injuries and/or frank abscesses
4. Blood transfusion
5. Location of injury Guidelines
1. Primary repair for all non-destructive colon wounds
Colon – segment of bowel from the ileocecal valve up to the sacral
EXCEPT: PERITONITIS
promontory
2. Primary repair for DESTRUCTIVE EXCEPT: PERITONITIS,
>3 ORGANS ASSOCIATED INJURIES, SIGNIFICANT
MANAGEMENT OF COLONIC INJURY
UNDERLYING INJURIES
Primary Repair
1. Debridement with simple closure of perforation/s

2. Resection of a segment of large bowel containing the

perforation/s followed by resection and anastomosis

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Penetrating Abdominal Injury

• segmental resection and primary anastomosis: for

perforation > 50% of the bowel circumference, multiple
injuries in close proximity

MANAGEMENT OF INJURY TO THE PANCREAS

• SIMPLE REPAIR AND DRAINAGE: minor pancreatic
lacerations or contusions
• PYLORIC EXCLUSION OR DIVERTICULARIZATION:
repair of the duodenum, drainage and closure of the pylorus
with diversion of gastriccontents through a
gastrojejunolstomy
• PANCREATICODUODENAL RESECTION: indicated only
for severe injuries to the head of the pancreas and the
duodenum (rarely)
• DISTAL PANCREATECTOMY: for pancreatic injuries with
major ductal involvement
• DAMAGE CONTROL SURGERY AND POST-OPERATIVE
ERCP: for highly unstable patients

The following are done:

MANAGEMENT OF ARTERIAL INJURY
ZONES REGIONS
ZONE 1 Aortic hiatus to sacral
promontory divided into
supra promontory and
infra promontory zones
ZONE 2 Renal hilum to pericolic
gutters (involve kidney)
ZONE 3 Pelvicoperitonium
Sacral promontory and
encompasses the pelvis
Common injuries: Major arteries
• Triple shot open of the pancreas: makes the glands more
MANAGEMENT firm
All organs require
exploration
REFERENCE:
Explore all penetrating
trauma but avoid Penetrating Abdominal Injuries
exploration of blunt Oliver I. Belarma, MD, FPCS
abdominal trauma June 5, 2021
Explore all penetrating
trauma or all expanding
hematoma in penetrating
trauma

MANAGEMENT OF SPLEEN INJURY

• 2nd MOST COMMONLY INJURED ORGAN FOLLOWING
BLUNT ABDOMINAL TRAUMA: SPLEEN
• Do Splenectomy: patients who are unstable and with higher
rates of injury (Grade 4 or 5)
• Splenic Digital pressure while spleen is being mobilized
• Mass tracting the hilum for hypertensive patients

MANAGEMENT OF HOLLOW VISCUS INJURY

• involves initial hemostasis and subsequent repair or
resection
• assume even number of wounds (with each entry wound
having an associated exit wound)
• Mesenteric border of the bowel, the retroperitoneal
duodenum and colon, the cardia, posterior wall, and the
greater and lesser curvatures of the stomach are areas that
might be missed.

Stomach
• primary repair for small perforations
• proximal or distal gastrectomy for extensive injuries

Small Intestines
• Primary Repair: for perforations <50% bowel circumference

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