ABDOMINAL INJURIES January 4, 2023

ABDOMINAL INJURIES

Etiology and mechanism of Injury:

1. Closed injuries: Contusions and crush injuries of the abdomen by
blows, kicks, falls or run-over accidents often damage the intra-
peritoneal viscera without rupturing the muscles of the abdominal
wall. Motor car accidents due to sudden deceleration which causes
stress to areas of junction between freely mobile intra-peritoneal
organs and those with a fixed retroperitoneal position. Common sites
of injury include the renal pedicle, the duodeno-jejunal flexure, the
ileo-caecal area or the neck of the pancreas. Sudden compression of
the abdomen may also cause laceration of the liver or spleen.
2. Open injuries (penetrating injuries): These are caused by
penetration of a pointed object as a knife or gunshots not only to the
abdomen but also by similar injuries to the chest, loin, buttock or
perineum. These wounds are deeper than long. Accordingly, there is
risk of injury to deep important structures. The external opening is
small and drainage is poor, thus encouraging infection. These wounds
are deceiving and an unwary surgeon may suture a stab wound in the
abdominal wall and miss an injured viscus inside. While missile
wounds are very serious as the bullet transmits its high kinetic energy
to the tissues. The damage to the soft tissue caused by bullet injury
results in direct damage to the soft tissue through its track and in
addition extensive damage to the surrounding tissue and even to areas
far from the primary tract caused by shock waves which spread out of
the missile tract.
3. Blast injuries: The blast waves cause shear waves which may lead to
submucosal haemorrhages, mesenteric tears or perforation near the
ileocaecal area. Solid organs as the liver may be severely lacerated. In
addition to the blast wave, the produced missiles after the explosion
can cause different blunt or penetrating abdominal injuries.

Possible intra-abdominal injuries

• Injury to solid organs e.g. the liver, the spleen or the mesentery
leading to internal haemorrhage.
• Injury to hollow organs e.g. the stomach, duodenum, the small bowel
or the colon leading to peritonitis.
• Retroperitoneal injuries e.g. the pancreas, the kidneys or the major
blood vessels.

Clinical features
Patients can generally be classified into the following categories based on
their physiological condition after initial resuscitation:

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 Haemodynamically ‘normal’ – investigation can be completed before

treatment is planned;
 Haemodynamically ‘stable’ – investigation is more limited.
It is aimed at establishing whether the patient can be managed non-
operatively, whether angioembolisation can be used or whether
surgery is required;
 Haemodynamically ‘unstable’ – investigations need to be suspended
as immediate surgical correction of the bleeding is required.

Shock and signs of external trauma to the abdominal wall are present, but
their absence soon after injury does not rule out the possibility of intra-
peritoneal damage which will soon manifest itself in one of 2 ways:
1. Internal hemorrhage
 May arise from injury to the solid viscera, mesenteries or main blood
vessels.
 It is characterized by progressive pallor, tachycardia and hypotension
with thirst, air hunger and subnormal temperature.
 Locally, there may be tenderness and slight rigidity over the injured
organ, and shifting dullness may be elicited.
2. Peritonitis
 Follows rupture of a hollow viscus. It manifests itself by pain,
tenderness, rigidity, fever and tachycardia. In late cases, there is:
a) Obliteration of liver dullness due to the escape of gas.
b) Shifting dullness in the flanks.
c) Dead silence on auscultation.

Diagnosis
1. Observation: Every patient with a history of abdominal injury should
be kept under close observation for at least 24 hours.
2. Exploratory laparotomy: is indicated whenever suspicious signs are
present, and should never be delayed until frank signs appear.

N.B.
 Blood loss into the abdomen can be subtle and there may be no clear
clinical signs.
 Blood is not an irritant and does not initially cause any abdominal
pain.
 Distension is subjective, and a drop in the blood pressure may be a
very late sign in a young fit patient.

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 Examination in unstable patients should take place either in the ED or

in the operating theatre if the patient is deteriorating rapidly.

Investigations
Laboratory investigations
• Blood picture and haematocrit value ↓↓ denote bleeding.
• Leucocytic count A high or rising count points to peritonitis.
• Serum amylase A high level suggests pancreatic injury.

Radiological investigations
 Plain chest and abdominal X-rays (only in haemo-dynamically stable
patient).
o May reveal fracture of the lower ribs or pelvis or the presence of a
foreign body.
o Free air under the right copula of the diaphragm denotes injury of a
hollow organ.

 Abdominal ultrasound; Focused abdominal sonography of trauma

(FAST)
o It is non-invasive, quick, inexpensive and performed at the bedside.
o It has a sensitivity of 85-95% for the detection of intra-abdominal fluid
or blood e.g. perisplenic or perihepatic haematoma.
o The disadvantages are that it is operator dependent and it is not
sensitive for the diagnosis of bowel perforation or acute pancreatic
injuries.

 CT abdominal scan;
o It should be only performed in a stable patient as it entails transfer of
the patient and it takes some time to be performed.
o It is very accurate in detecting injury to solid organs and in the grading
and follow-up of these injuries.
o It is also sensitive in the diagnosis of retroperitoneal and
diaphragmatic injuries.
o It is not sensitive in the detection of bowel injuries or acute pancreatic
injuries at an early stage.

 Diagnostic peritoneal lavage (DPL; )

Indications
Blunt abdominal trauma in an adult, associated with:
1. Suspicion of organ injury with equivocal signs.
2. Unreliable abdominal examination because the patient is unconscious,
e.g., head trauma, or drug or alcohol intoxication.
3. Unexplained hypotension that may be caused by blood loss.
Contraindications

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1. Evident intra-abdominal organ injury that requires laparotomy.

2. Pregnancy.
3. Liver cirrhosis.
4. Severe obesity.
5. Prior abdominal surgery.

Procedure
1. Abdomen is prepared with an antiseptic solution and is draped with
sterile towels.
2. Local infiltration of local anesthetic, e.g. lidocaine in the midline
below the umbilicus.
3. 2-3 cm skin incision followed by a 1 cm incision in the linea alba.
4. Peritoneum is entered with a dialysis catheter.
5. The tube is directed posteriorly and inferiorly into the pelvis.
6. Aspiration with a syringe. Gross blood, or gross enteric contents are
indications for immediate laparotomy.
7. If neither blood nor enteric content is aspirated, I L of warm saline is
instilled into the peritoneum by intravenous tubing.
8. After waiting for 5 minutes the empty saline bottle is placed down in a
dependent position to siphon the lavage fluid out of the abdomen.
9. A sample of the fluid is sent to the laboratory. Positive findings that
diagnose an intra-abdominal surgery, and thus require laparotorny are:
a. Red blood cell count >1000000/ml.
b. White blood cell count> 500/rnl.
c. Elevated amylase.
10. The catheter is removed, and the linea alba and skin are closed with
sutures.

 Diagnostic laparoscopy in haemo-dynamically stable patients.

Treatment of abdominal injury

• Follow the general measures for trauma patients.
• The surgeon should decide whether the patient needs an urgent
Laparotomy or the patient's condition is stable so that he can do the
necessary investigations and follow the patient's condition.
• Urgent laparotomy is indicated for:
1. General and local clinical manifestations of intra-abdominal
bleeding,.
2. General and local clinical manifestations of peritonitis.
3. Stab wounds with a protruding viscus.
4. All missile injuries of the abdomen.

Incision:

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1. The abdomen is usually opened through a right paraumbilical

paramedian incision
2. On opening the abdomen, any escaping gas, turbid fluid or fecal
matter indicates injury to the hollow viscera while a large effusion of
blood suggests damage to the solid viscera, omentum or mesentery
3. However, a clean peritoneal cavity does not exclude injury to the
bowel since small perforations are readily sealed by prolapsed mucous
membrane

Exploration:
1. The solid viscera and mesentery are examined first so that any
source of bleeding can be located and dealt with.
2. The small intestine is systematically examined throughout its entire
length, commencing usually at the cecum. If a perforation is
discovered, the affected loop is held in a non-crushing clamp and
retained at the surface until the rest of the gut is examined since the
discovery of further injuries may influence the treatment to be adopted
3. The stomach and duodenum are inspected and palpated
4. The transverse colon is brought out for examination, and by suitable
retraction the other parts of the colon are examined in turn
Procedure:
The injured viscera are dealt with as follows:
1. Ruptured spleen is best treated by splenectomy !.
2. Liver: The tear is repaired with deeply placed mattress sutures of thick
catgut supported by a patch of falciform ligament or rectus sheath so
that they do not cut out. If the tear is inaccessible, the abdominal
incision is extended into the chest along the right eighth intercostal
space to allow proper exposure and debridement.

3. Mesentery: Small or radial tears are treated by simple suture, but large
or transverse tears interfering with the blood supply of the related
segment of bowel are treated by resection-anastomosis.
4. Small intestines: Small perforations can be closed by a single purse-
string suture, but large wounds are repaired transversely by 2 layers to
avoid narrowing of the lumen. Resection-anastomosis is indicated for
multiple injuries confined to one segment, for extensive laceration and

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bruising, and for infarction of the gut due to laceration of the

mesentery.
5. Colon: Perforations are best treated by exteriorization, the affected
loop being mobilized and brought to the surface as in the Paul-
Mikulicz's operation for carcinoma.
6. Stomach and duodenum: The tear is repaired transversely in two
layers to avoid narrowing of the lumen.
7. Pancreas: The tear is repaired accurately by silk sutures, and the
lesser sac should always be drained through the flank.
8. Gall-bladder and bile ducts: Injuries of the gall-bladder are treated by
cholecystectomy. A torn common bile duct may be repaired by suture
over a T-tube, or by anastomosis to the jejunum.
9. Urinary bladder: The tear is repaired in two layers, and an indwelling
catheter is inserted for several days to keep the bladder empty.
Closure: All free fluid in the peritoneal cavity is removed by suction and
mopping with gauze. The peritoneal cavity should always be drained by a
strip of corrugated rubber inserted at the site of the lesion and brought out
through the flank. If frank peritonitis is present, a drain is inserted into the
rectovesical pouch through a suprapubic stab.

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INDIVIDUAL ORGAN INJURY

Liver
 The liver is the second most common organ injured in abdominal
trauma after the spleen.
 Liver injuries are commonly associated with affection of other intra or
extraabdominal organs. The ribs, pleura, lungs, colon and spleen are
common associations.
 The prognosis after treatment of liver injury largely depends on these
associated injuries.
 The mortality of liver injury averages 15-20%. It gets worse if other
major organs are injured.

Aetiology
Liver trauma can be divided into those inflicted by accidents which may be
blunt and penetrating injuries;
• Blunt trauma occurs as a result of direct injury. The liver is a solid
organ and compressive forces can easily burst the liver substance. The
liver is usually compressed between the impacting object and the rib
cage or vertebral column. Most injuries are relatively minor and can be
managed non-operatively. Blunt injury produces contusion, laceration
and avulsion injuries to the liver, often in association with splenic,
mesenteric or renal injury. Blunt injuries are more common and have a
higher mortality than penetrating injuries.
• Penetrating trauma is relatively common. Penetrating injuries, such as
stab and gunshot wounds, are often associated with chest or pericardial
involvement. Not all penetrating wounds require operative
management and may stop bleeding spontaneously.
• Iatrogenic injury is increasing with the rising popularity of invasive
investigations as percutaneous liver biopsy, and percutaneous
transhepatic cholangiography (PTC).
• Spontaneous rupture of the liver is an extreme rarity that may happen
with eclampsia or hepatic tumours.

Pathology
Type of injury In increasing seriousness the following types can be seen
1. Small subcapsular haematoma.

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2. Small superficial tear or tears.

3. Large subcapsular or intrahepatic haematoma.
4. Large deep tear or tears.
5. Shattered liver parenchyma which may include a whole lobe.
6. Vascular injury, the most difficult to control is that of the main hepatic
veins because of the difficult access.

Clinical features and diagnosis of liver injury

 Presence of intraperitoneal haemorrhage with history of trauma
except in spontaneous cases.
 All lower chest and upper abdominal stab wounds should be
suspect, especially if considerable blood volume replacement
has been required.
 Severe crushing injuries to the lower chest or upper abdomen
often combine rib fractures, haemothorax and damage to the
spleen and/or liver.
 Abdominal pain, tenderness and rigidity due to parietal
peritoneal irritation, by blood.
 Massive bleeding presents with the picture of haemorrhagic
shock and minor bleeding is discovered by diagnostic peritoneal
lavage (DPL), ultrasound or by CT scan, which are done in
suspected cases. These tests are particularly useful in the
unconscious patient as it is difficult to assess the abdomen.
 The injury may also be discovered with systematic exploration
during laparotomy for penetrating abdominal trauma.
 FAST can diagnose free intraperitoneal fluid. Patients with free
intraperitoneal fluid on FAST and haemodynamic instability,
and patients with a penetrating wound, will require a
laparotomy and/or thoracotomy once resuscitation is under way.
 Owing to the opportunity for massive ongoing blood loss and
the rapid development of a coagulopathy, the patient should be
directly transferred to the operating theatre while blood
products are obtained and volume replacement is taking place.
Patients who are haemodynamically stable should have a
contrast enhanced CT scan of the chest and abdomen as the next
step. This scan will demonstrate evidence of parenchymal
damage to the liver or spleen, as well as associated traumatic
injuries to their feeding vessels. Free fluid can also be clearly
established.

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Initial management of liver injuries

Penetrating
 The initial management is maintenance of airway patency,
breathing and circulation (ABC) following the principles of
advanced trauma life support (ATLS). Peripheral venous access
is gained with two large-bore cannulae and blood sent for cross-
match of 10 units of blood, full blood count, urea and
electrolytes, liver function tests, clotting screen, glucose and
amylase. Initial volume replacement should be with blood.
 Arterial blood gases should be obtained and the patient
intubated and ventilated if the gas exchange is inadequate.
 Intercostal chest drains should be inserted if associated
pneumothorax or haemothorax is suspected. Once initial
resuscitation has commenced, the patient should be transferred
to the operating theatre, with further resuscitation performed on
the operating table. The necessity for fresh frozen plasma and
cryoprecipitate should be discussed with the blood transfusion
service immediately the patient arrives in the hospital (often by
activation of a major transfusion protocol), as these patients
rapidly develop irreversible coagulopathies due to a lack of
fibrinogen and clotting factors. Standard coagulation profiles
are inadequate to evaluate this acute loss of clotting factors, and
factors should be given empirically, aided by the results of
thromboelastography (TEG), if available. A contrast CT prior to
laparotomy should be considered if the patient is
haemodynamically stable.

Blunt trauma
 Patients who are haemodynamically unstable will require an
immediate laparotomy.
 For the patient who is haemodynamically stable, imaging by CT
should be performed to further evaluate the nature of the injury.
It provides information on the liver injury itself, as well as on
injuries to the adjoining major vascular and biliary structures.
 Injury in which there is a suggestion of a vascular component
should be reimaged, as there is a significant risk of the
development of subsequent ischaemia, false aneurysms,
arteriovenous fistulae or haemobiliary fistula. It is advised that
all patients should be rescanned prior to discharge.

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 Most patients with blunt liver injury who are

haemodynamically stable can be managed conservatively. A
subcapsular or intrahepatic haematoma requires no specific
intervention and should be allowed to resolve spontaneously.
 The indication for discontinuing conservative treatment is the
development of haemodynamic instability, evidence of ongoing
blood loss despite correction of any underlying coagulopathy
and the development of signs of generalised peritonitis.
 Interventional radiology has an important role in management
of liver trauma and embolization to control hepatic artery
bleeding is safe and effective in a stable patient with no
evidence of hollow viscus perforation.

The surgical approach to liver trauma

Treatment for both liver and spleen
1. Patients who are haemodynamically stable with no evidence of
peritonitis, are treated conservatively by repeated examination and CT.
2. Patients who are haemodynamically unstable, have peritonitis or
deteriorate under conservative treatment will need laparotomy.
 Good access is vital. A ‘rooftop’ incision with midline
extension to the xiphisternum and retraction of the costal
margins gives excellent access to the liver and spleen.
Compression of the liver with packs and correction of
coagulopathy, if present, will control most of the active
bleeding. If bleeding persists, further control by Pringle
maneuver.

 A stab incision in the liver can be sutured with a fine absorbable

monofilament suture. Lacerations to the hepatic artery should
be identified and repaired with 6/0 Prolene suture. If
unavoidable, the hepatic artery may be ligated, although
parenchymal necrosis and abscess formation will result in some
individuals.
 Bleeding points should be controlled locally when possible, and
such patients if required, subsequently undergo subsequent
angioembolisation.
 If there has been direct damage to the hepatic artery, it can be
tied off. Damage to the portal vein must be repaired, as tying
off the portal vein carries a greater than 50% mortality rate.

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 If it is not technically feasible to repair the vein at the time of

surgery, it should be shunted by veno-venous bypass using
cannulae in the femoral vein via a long saphenous cut-down,
with the blood returned using a roller pump to the superior vena
cava (SVC) via an internal jugular line and the patient referred
to a specialist centre. Venous return is provided by the
venovenous bypass. Warm ischaemia of the liver is tolerated for
up to 45 minutes, allowing sufficient time in a blood-free field
for repair of injuries to the IVC or hepatic veins. A closed
suction drainage system must be left in situ following hepatic
surgery.
 Finally, the liver can be definitively packed, restoring the
anatomy as closely as possible. Placing omentum into cracks in
the liver is not recommended.
 Portal vein injuries should be repaired with 5/0 Prolene. Inflow
occlusion facilitates suturing of lacerations and vessels. If
bleeding persists despite inflow occlusion, consider major
hepatic vein or IVC injuries, and also look for abberant arteries
to the liver. Deceleration injuries often produce lacerations of
the liver parenchyma adjacent to the anchoring ligaments of the
liver. These may be amenable to suture with an absorbable
monofilament suture. Again, inflow occlusion may facilitate
this suturing and, if necessary, the sutures can be buttressed to
prevent them cutting through the liver parenchyma. With more
severe deceleration injuries, a portion of the liver may be
avulsed. These injuries are more complex as they are associated
with a devitalised portion of the liver and, often, major injuries
to the hepatic veins and IVC. Diffuse parenchymal injuries
should be treated by packing the liver to achieve haemostasis.
 Care should be taken to avoid overzealous packing, as this may
produce pressure necrosis of the liver parenchyma or abdominal
compartment syndrome.
 Crush injuries to the liver often result in large parenchymal
haematomas and diffuse capsular lacerations. Suturing is
usually ineffective, and perihepatic packing, is the most useful
method of providing haemostasis, to be removed after 48 hours,
antibiotic cover is advisable.
 Translobar penetrating injuries are particularly challenging
because the extent of the injury cannot be fully visualized.
Options include intraparenchymal tamponade with a Foley

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catheter or balloon occlusion. If tamponade is successful with

either modality, the balloon is left inflated for 24 to 48 hours
followed by sequential deflation and removal at a second
laparotomy.
 Hepatotomy with ligation of individual bleeders occasionally
may be required; however, division of the overlying viable
hepatic tissue may cause considerable blood loss in the
coagulopathic patient. Finally, angioembolization is an effective
adjunct in any of these scenarios and should be considered early
in the course of treatment.
 Several centers have reported patients with devastating hepatic
injuries or necrosis of the entire liver who have undergone
successful hepatic transplantation. Clearly this is dramatic
therapy, and the patient must have all other injuries delineated,
particularly those of the central nervous system, and have an
excellent chance of survival excluding the hepatic injury.

Principles of surgical management in short:

1. Adequate exposure by a longitudinal incision that can be extended to
the chest in case of need.
2. Thorough systematic exploration of the abdomen is required to assess
the liver affection and to detect other intra-abdominal injuries.
3. Priority is for arrest of bleeding. As mentioned before, most small
liver tears are found to have stopped bleeding by the time the abdomen
is explored, and these tears deserve no treatment Preliminary control
of brisk liver haemorrhage can be attained by a combination of
temporarily packing the bleeding area, and the application of Pringle's
manoeuvre to occlude the hepatic artery and the portal vein for a
period up to 20 minutes. The lessened rate of bleeding allows the
surgeon to visualize and ligate the injured vessels.
4. Whenever possible suturing liver tears should be avoided because it is
likely to leave a space for accumulation of haematoma that may infect
or communicate with intrahepatic bile ducts. It is, however, resorted to
if control of bleeding vessels is not possible in deep tears. Tying
sutures over pedicled omentum helps haemostasis. Deep transverse
mattress sutures using special liver needles is recommended.
5. A haematoma is explored to ligate the damaged vessels and ducts, and
to excise the dead tissues. It is then left open for drainage.
6. A lobe that is shattered beyond salvage is treated by excision of this
lobe.

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7. Firm packing of inaccessible and difficult bleeding areas, e.g., the

hepatic veins, may be the only method for temporary arrest of
bleeding. The patient is transferred to a specialized centre where the
pack is removed in the operating theatre, and the injury is dealt with.
8. Multiple intraperitoneal drains are always placed to guard against
collections of blood and bile. Prophylactic antibiotics are prescribed.

Consequences
1. The main danger of such injuries is bleeding, and this should be the
main concern of the surgeon. Most liver injuries stop bleeding by the
time they are explored, but some of them cause death from blood loss.
2. A liver haematoma sometimes communicates with a torn bile duct
allowing blood to trickle down the biliary passages to gastrointestinal
tract producing what is known 'haematobilia',

Other complications of liver trauma

 Abscesses especially after penetrating trauma. Treatment is
with systemic antibiotics and aspiration under ultrasound
guidance once the necrotic tissue has liquefied.
 Bile collections require aspiration under ultrasound guidance or
percutaneous insertion of a pigtail drain. The site of origin of a
biliary fistula should be determined by endoscopic or
percutaneous cholangiography, and biliary decompression
achieved by nasobiliary or percutaneous transhepatic drainage
or stent insertion. If this fails to control the fistula, the affected
portion of the liver may require resection.
 Late vascular complications include hepatic artery aneurysm
and arteriovenous (precipitating acute heart failure if between
the hepatic artery and hepatic vein and acute portal
hypertension if arterioportal) or arteriobiliary fistulae (resulting
in often painful haemobilia). These are best treated non-
surgically by a specialist hepatobiliary interventional
radiologist. The feeding vessel can be embolised transarterially.

 Hepatic failure may occur following extensive liver trauma.

This will usually reverse with conservative supportive treatment
if the blood supply and biliary drainage of the liver are intact.

Long-term outcome of liver trauma

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The capacity of the liver to recover from extensive trauma is

remarkable, and parenchymal regeneration occurs rapidly.
 Late complications are rare, but the development of biliary
strictures many years after recovery from liver trauma has been
reported. The treatment depends on the mode of presentation
and the extent and site of stricturing. A segmental or lobar
stricture, associated with atrophy of the corresponding area of
liver parenchyma and compensatory hypertrophy of the other
liver lobe, may be treated expectantly. A dominant extrahepatic
bile duct stricture associated with obstructive jaundice may be
treated initially with endobiliary balloon dilatation or stenting,
but will usually require surgical correction using a Roux-en-Y
hepatodochojejunostomy.

Important points to remember regarding liver injuries

 Suspect liver injuries in patients with fractures of the right
lower ribs.
 Minor liver injuries can be treated conservatively.
 Pringle's maneuver is useful for temporary control of hepatic
bleeding during the operation.
 Perithepatic packing is very useful as a last resort to stop
bleeding in serious hepatic injuries.

Biliary injuries
Aetiology
Injuries to the gallbladder and extrahepatic biliary tree are rare.
They occur as a result of blunt or penetrating abdominal trauma
and occur mainly from penetrating trauma, often in association
with injuries to other structures that lie in close proximity. The
common bile duct can be repaired over a T-tube or drained and
referred to appropriate care as part of damage control, or even
ligated.

Pathology
Types of bile duct injuries include leaks, transection, occlusion
(ligation or stricture), or a combination. The majority of bile
duct injuries are iatrogenic, most commonly following
laparoscopic cholecystectomy, with an incidence of 0.3–2%.

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Clinical Findings
Iatrogenic injury is perhaps more frequent than external trauma.
The physical signs are those of an acute abdomen. Patients
usually present with abdominal pain that may be diffused or
localized. Nausea, anorexia, and abdominal distention due to
ileus may also be seen. Clinically apparent ascites and bile
peritonitis are less common. Fever is often absent.

Investigations
Laboratory evaluation typically reveals leukocytosis and
nonspecific liver function test abnormalities. Initial imaging
studies should involve abdominal ultrasound to assess for fluid
collections or abnormalities in the biliary tree such as focal
dilation, and radionuclide biliary scintigraphy to assess for
ongoing leakage. Technetium-99m–labeled hepatoiminodiacetic
acid derivative (HIDA) scanning is most accurate, approaching
100%.

Treatment

Management depends on the location and extent of the biliary

and associated injury. In the stable patient a transected bile duct
is best repaired by a Roux-en-Y choledochojejunostomy.

Spleen
The spleen is one of the most frequently injured organ in the abdomen. Its
injury is particularly important because it causes severe blood loss. The
spleen is normally small, hidden by ribs and protected by the thick abdominal
muscles.
Aetiology
Predisposing factors
 Splenic enlargement, which makes it more liable to trauma.
 Diseases of the spleen like malaria which make it friable.

Types of trauma
 Blunt abdominal trauma or trauma to lower thoracic cage. This
is usually a result of road traffic accidents and falling from a
height.

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 Penetrating trauma of gunshots or stabbing.

 Operative trauma occurs during an operation on adjacent
viscera, e.g., during gastric or colonic surgery.
 Spontaneous rupture of the spleen is rare.

Pathology
Splenic injury occurs from direct blunt trauma. Most isolated splenic
injuries, especially in children, can be managed non-operatively.
However, in adults, especially in the presence of other injury or
physiological instability, laparotomy should be considered. The spleen
can be packed, repaired or placed in a mesh bag. Splenectomy may be
a safer option, especially in the unstable patient with multiple potential
sites of bleeding. In certain situations, selective angioembolisation of
the spleen can play a role.
Types of splenic injury
 Subcapsular haematoma.
 Small superficial tears, single or multiple.
 Deep tear, single or multiple.
 Avulsion of a pole of the spleen.
 Complete pulping of the spleen.
 Injury of the vascular pedicle, i.e., avulsion or thrombosis of the
vessel.

Clinical picture
There are 3 clinical presentations of rupture of the spleen.
Fatal type
The tear is deep or the pedicle is ruptured and haemorrhage is so massive that
rapid death occurs. Small vessels in the spleen and sinusoidal, i.e., they lack
muscle coats and hence do not constrict to stop bleeding.
Classical rupture
This is the commonest presentation.
 The general manifestations of internal haemorrhage are present
with dyspnoea, increasing pallor, weak and rapid pulse and low
blood pressure.
 Abdominal examination shows tenderness and rigidity in the
left hypochondrium which spreads into the rest of the
abdomen. Shifting dullness might be elicited.

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 Special signs may be present, but they are not essential for the
diagnosis.
 Ballance's sign. Shifting dullness on the right side and fixed
dullness on the left.
 This is due to free fluid blood in the peritoneal cavity in the
right flank, but on the left side fixed dullness is due to the
presence of intraperitoneal clotted blood and to retroperitoneal
haematoma.
 Kehr's sign. The patient has pain in the left shoulder. This is
referred pain due to irritation of the diaphragm. Pain
particularly occurs if the patient is put in the Trendelenburg
position.
 Cullen's sign. Brownish or bluish discolouration around the
umbilicus may occur in about 20% of people who have thin
linea alba around the umbilicus through which blood can shine.

Delayed rupture
 The initial shock is followed by a long lucid interval, which
may extend to a few days or weeks, after which the patient
presents with the picture of internal haemorrhage.
 This delay of clinical presentation may be due to
 A subcapsular haematoma or a perisplenic one that is enclosed
in omentum enlarges gradually and ruptures.
 A clot stops bleeding but is later dislodged when the blood
pressure rises, or is digested by enzymes from an injured
pancreas.

Investigations
 Repeated blood picture. Declining haemoglobin and
haematocrit denote
 haemorrhage.
 Ultrasound or CT scan of the abdomen have diagnostic
accuracy of more than 90%. Serial examinations monitor the
haematoma size.
 Plain x-ray of the abdomen is a poor diagnostic substitute but
may reveal fracture of one or more of lower ribs.
 Peritoneal lavage reveals blood.

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 If the patient is in severe shock, there is no need for

investigations. The surgeon depends on clinical findings and
proceeds for immediate laparotomy to stop bleeding.

Treatment
 Until the 1970s, splenectomy was considered mandatory for all
splenic injuries. Recognition of the immune function of the
spleen refocused efforts on operative splenic salvage in the
1980s.
 After demonstrated success in pediatric patients, nonoperative
management has become the preferred means of splenic salvage
for all patients. The identification of contrast extravasation as a
risk factor for failure of nonoperative management led to liberal
use of angioembolization.
 The role of selective angioembolization (SAE) continues to be
defined, but appears warranted in high grade injuries,
particularly those with contrast blush.
 It is clear, however, that up to 15% to 20% of patients with
splenic trauma warrant early splenectomy and that failure of
nonoperative management often represents inappropriate patient
selection.

Indications for early intervention in adults include initiation of blood transfusion

within the first 12 hours and hemodynamic instability. Unlike hepatic injuries,
which usually rebleed within 48 hours, delayed hemorrhage or rupture of the
spleen can occur up to weeks after injury.
 Splenic injuries are managed operatively by splenectomy, partial
splenectomy, or splenic repair (splenorrhaphy), based on the extent of
the injury and the physiologic condition of the patient. Splenectomy is
indicated for significant hilar injuries, pulverized splenic parenchyma,
or any >grade II injury in a patient with coagulopathy or multiple life-
threatening injuries.
 Autotransplantation of splenic implants to achieve partial
immunocompetence in younger patients who do not have an
associated enteric injury. Partial splenectomy can be employed in
patients in whom only the superior or inferior pole has been injured.
During splenorrhaphy hemostasis is achieved by topical methods
(electrocautery; argon beam coagulation; application of thrombin-
soaked gelatin foam sponges, fibrin glue, or BioGlue), envelopment of
the injured spleen in absorbable mesh, and pledgeted suture repair.

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 ABDOMINAL INJURIES

Sequences:
 After splenectomy or splenorrhaphy, postoperative hemorrhage may
be due to an improperly ligated or unrecognized short gastric artery, or
recurrent bleeding from the splenic parenchyma if splenic repair was
used.
 An immediate postsplenectomy increase in platelets and WBCs is
normal; however, beyond postoperative day 5, a WBC count above
15,000/mm3 and a platelet/WBC ratio of <20 are associated with
sepsis and should prompt a thorough search for underlying infection.
A common infectious complication after splenectomy is a subphrenic
abscess, which should be managed with percutaneous drainage.
 Additional sources of morbidity include a concurrent or unrecognized
iatrogenic injury to the pancreatic tail during rapid splenectomy
resulting in pancreatic ascites or fistula, or gastric perforation during
short gastric vessel ligation. Enthusiasm for splenic salvage was driven
by the rare, but often fatal, complication of overwhelming
postsplenectomy sepsis. Overwhelming postsplenectomy sepsis is
caused by encapsulated bacteria, Streptococcus pneumoniae,
Haemophilus influenzae, and Neisseria meningitidis, which are
resistant to antimicrobial treatment.
 In patients undergoing splenectomy, prophylaxis against these bacteria
is provided via vaccines administered optimally at >14 days
postinjury. In children, they are repeated every five years until the age
of 18. For adults, antibody titres every five years determine the need
for revaccination.
 Splenic cyst may follow a perisplenic haematoma after conservative
management.

INJURIES TO THE PANCREAS

The pancreas, thanks to its protected location in the retroperitoneum, is
not frequently damaged in blunt abdominal trauma. The reported
incidence of pancreatic injury is relatively low, ranging from 0.2% to
6% following abdominal trauma.
If there is damage to the pancreas, it is often concomitant with injuries
to other viscera, especially the liver, the spleen and the duodenum.
Occasionally, a forceful blow to the epigastrium (such as a kick from a
human or a horse, or pressure from the steering wheel in a car
accident) may crush the body of the pancreas against the vertebral
column.

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 ABDOMINAL INJURIES

Pathology
Penetrating trauma to the upper abdomen or the back carries a higher
chance of pancreatic injury. Pancreatic injuries may range from a
contusion or laceration of the parenchyma without duct disruption to
major parenchymal destruction with duct disruption (sometimes
complete transection) and, rarely, massive destruction of the
pancreatic head.
Although several organ injury grading systems exist, the most
important factor in predicting clinical course and guiding therapy is
the integrity of the main pancreatic duct. This is a key element of the
diagnostic and management strategy.
Clinical features and diagnosis of pancreatic injury
Blunt pancreatic trauma presents with epigastric pain, which may be
minor at first, followed by escalation over the subsequent 6–8 hours
due to the sequelae of leakage of pancreatic fluid into the surrounding
tissues.
Notably, pancreatic trauma may frequently be overlooked or not
readily appreciated on initial clinical examination and investigation. A
delayed presentation or clinical deterioration of the patient may in
some instances be the first clue of an underlying occult or undetected
injury.
The clinical presentation can be quite deceptive; careful serial
assessments and a high index of suspicion are required. A rise in
serum amylase occurs in most cases.
Physical examination is neither sensitive nor specific, and even
profound pancreatic injury may not be detected on initial examination.
If pain is present, it is often out of proportion to tenderness, and
guarding is unusual.
The major problem is that of diagnosis, because the pancreas is a
retroperitoneal organ. In penetrating trauma, injury may only be
detected during laparotomy.
In penetrating injuries, especially if other organs are injured and the
patient’s condition is unstable, there is a greater need to perform an
urgent surgical exploration.
Early mortality is typically due to associated injuries, with less than
10% due to pancreatic injury.
Laboratory Findings

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No single laboratory test is adequate for early detection. Serum

amylase at time of admission is unreliable. Elevation of serum
amylase may be seen due to causes other than pancreatic trauma,
including bowel injury, head trauma, alcohol ingestion, profound
hypotension, and salivary gland damage. But serial amylase levels
been found to be useful in identifying pancreatic injury and guiding
management. Nevertheless, additional diagnostic modalities are
typically needed.
Imaging Studies
Plain film radiographs and ultrasound are of limited value. Loss of a
distinct psoas margin or a halo of air surrounding the kidney or psoas
may suggest a retroperitoneal process, however, this is nonspecific.
Abdominal CT scan is useful and may have findings specific to the
diagnosis, including pancreatic transaction, local hematoma, fluid
separating the pancreas and splenic vein, pancreatic enlargement, and
increased attenuation of the peripancreatic fat. In lieu of these, the
admission CT scan may hold signs suggestive of pancreatic injury,
including fluid in the lesser sac, thickening of the anterior renal fascia,
and associated injuries to local structures. CT rarely shows ductal
disruption. Sensitivity for detecting pancreatic injury by initial CT
scan alone ranges from 60% to 80%, and repeat imaging may be
helpful. Specificity is high, ranging from 80% to 100%, although CT
tends to underestimate degree of injury.
MRCP is particularly good at identifying pancreatic injury and at
characterizing type and degree of damage. MRCP is excellent at
clarifying ductal status and at detailing parenchymal injury. ERCP is
no longer considered a first-line diagnostic option, due to its invasive
nature.
Support with intravenous fluids and a ‘nil by mouth’ regimen should
be instituted while these investigations are performed. There is no
need to rush to a laparotomy if the patient is haemodynamically stable,
without peritonitis.
Principles of management
It is preferable to manage conservatively at first, investigate and, once
the extent of the damage has been ascertained, undertake appropriate
action.
ERCP with pancreatic stent placement is a less invasive alternative
that should be considered when emergent surgery is not required and
when disruption is suggested on imaging. Outcomes appear to vary

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depending on the degree and location of disruption. Partial disruptions

in the body and head appear to have the highest response rates.
Additionally, placement of a stent that bridges the disruption is
associated with better outcomes. Patients with complete duct
disruptions do not fare as well with endoscopic treatment; however,
data are limited.
Operation is indicated if there is disruption of the main pancreatic
duct; in almost all other cases, the patient will recover with
conservative management.
Assessment of pancreatic damage and duct disruption at the time of
surgery can be difficult, because the bruising associated with the
retroperitoneal damage prevents clear visualization of the pancreas. A
patient and thorough examination of the gland should be carried out.
Haemostasis and closed drainage is adequate for minor parenchymal
injuries.
If the gland is transected in the body or tail, a distal pancreatectomy
should be performed, with or without splenectomy.
If damage is purely confined to the head of the pancreas, haemostasis
and external drainage is normally effective. In the emergency setting,
in an unstable patient with concomitant injuries, a surgeon
unaccustomed to pancreatic surgery should refrain from trying to
ascertain whether the duct in the pancreatic head is intact or
embarking on a major resection.
However, if there is severe injury to the pancreatic head and
duodenum, then a pancreatoduodenectomy may be necessary. A
Whipple’s procedure (pancreaticoduodenectomy) should not be
performed in the emergency situation because of the very high
associated mortality rate.
Classically the pancreas should be treated with conservative surgery
and closed suction drainage.
Injuries to the pancreatic body to the left of the superior mesenteric
vessels and to the tail are treated by closed suction drainage alone,
with distal pancreatectomy if the duct is involved.
Proximal injuries (to the right of the superior mesenteric artery) are
treated as conservatively as possible, although partial pancreatectomy
may be necessary.

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The pylorus can be temporarily closed (pyloric exclusion) in

association with a gastric drainage procedure, to minimise pancreatic
enzyme stimulation by gastric juice or distension.
A damage control procedure with packing and drainage should be
performed and the patient referred for definitive surgery once
stabilised.

Sequences and Prognosis

Persistent drain output occurs in up to a third of patients (see the
section on pancreatic fistulae below). Sometimes, in the aftermath of
trauma that has been treated conservatively, duct stricturing develops,
leading to recurrent episodes of pancreatitis. The appropriate treatment
in such cases is resection of the tail of the pancreas distal to the site of
duct disruption.
Pancreatic pseudocyst may develop. If the main duct is intact, the cyst
can be aspirated percutaneously.
The majority of patients managed nonoperatively will develop a
complication related to the pancreatic injury. Pseudocysts occur in up
to 75% of patients who survive beyond 48 hours. Pancreatic fistula,
pancreatitis, and peripancreatic abscess are also seen in roughly 30%.
Iatrogenic injury
This can occur in several ways:
 Injury to the tail of the pancreas during splenectomy, resulting
in a pancreatic fistula.
 Injury to the pancreatic head and the accessory pancreatic duct
(Santorini), which is the main duct in 7% of patients, during
Billroth II gastrectomy. A pancreatogram performed by
cannulating the duct at the time of discovery of such an injury
will demonstrate whether it is safe to ligate and divide the duct.
If no alternative drainage duct can be demonstrated, then the
duct should be reanastomosed to the duodenum or alternatively
resection of the pancreatic head should be considered.
 Enucleation of islet cell tumours of the pancreas can result in
fistulae.
 Duodenal or ampullary bleeding following sphincterotomy.
This injury may require duodenotomy to control the bleeding.

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 ABDOMINAL INJURIES

Stomach
Most stomach injuries are caused by penetrating trauma.
Blood presence is diagnostic if found in the nasogastric tube, in the
absence of bleeding from other sources.
Surgical repair is required but great care must be taken to examine the
stomach fully, as an injury to the front of the stomach can be expected
to have an ‘exit’ wound elsewhere on the organ.

Duodenum
Duodenal injury is frequently associated with injuries to the adjoining
pancreas. Like the pancreas, the duodenum lies retroperitoneally and
so injuries are hidden, discovered late or at laparotomy performed for
other reasons. CT is the diagnostic modality of choice. The only sign
may be gas or a fluid collection in the periduodenal tissue, and leakage
of oral contrast, administration of which may improve accuracy of
diagnosis.
Smaller injuries can be repaired primarily. The first, third and fourth
parts of the duodenum behave like small bowel, and can be repaired in
the same fashion. The second part of the duodenum is fixed to the
head of the pancreas with a common blood supply, and may have a
poorer blood supply compared to the remainder. Major trauma,
especially if the head of the pancreas is simultaneously injured, should
be treated as part of a damage control procedure and be referred for
definitive care.

Small bowel
The small bowel is frequently injured as a result of blunt trauma. The
individual loops may be trapped, causing high-pressure rupture of a
loop or tearing of the mesentery.
Penetrating trauma is also a common cause of injury.
Small bowel injuries need urgent repair. Haemorrhage control takes
priority and these wounds can be temporarily controlled with simple
sutures. In blunt trauma with mesenteric vessel damage, the bowel
ischaemia that results will dictate the extent of a resection. Resections
should be carefully planned to limit the loss of viable small bowel, but
should be weighed against an excessive number of repairs or
anastomoses. Haematomas in the small bowel mesenteric border need
to be explored to rule out perforation. With lowenergy wounds,
primary repair can be performed, whereas more destructive wounds

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associated with military type weapons require resection and

anastomosis. Damage control ‘clip and drop’ of damaged or resected
bowel may be necessary.

Colon
Injuries to the colon from blunt injury are relatively infrequent, and are
more frequently a penetrating injury. If relatively little contamination
is present and the viability is satisfactory, such wounds can be repaired
primarily. If, however, there is extensive contamination, the patient is
physiologically unstable or the bowel is of doubtful viability, then the
bowel can be closed off (‘clip and drop’). A defunctioning colostomy
can be formed later or the bowel reanastomosed once the patient is
stable.

Rectum
Only 5% of colon injuries involve the rectum. These are generally
from a penetrating injury, although occasionally the rectum may be
damaged following fracture of the pelvis.
Digital rectal examination will reveal the presence of blood, which is
evidence of intestinal or rectal injury. These injuries are often
associated with bladder and proximal urethral injury.
With intraperitoneal injuries, the rectum is managed as for colonic
injuries. Full-thickness extraperitoneal rectal injuries should be
managed with either a diverting end-colostomy and closure of the
distal end (Hartmann’s procedure) or a loop colostomy. Presacral
drainage is no longer used.

Mesenteric injury
A wound of the mesentery can follow severe abdominal contusion and
is a cause of haemoperitoneum. More commonly, it is injured by a
torsional force, so-called seatbelt syndrome.
This occurs during a vehicular collision when a seatbelt is being worn
with sudden deceleration resulting in a torn mesentery.
This possibility should be borne in mind, particularly as multiple
injuries may distract attention from this injury. Aside from control of
any ongoing haemorrhage, associated ischaemic or ruptured gut will
require resection.

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