Abdominal Trauma Revisited

DAVID V. FELICIANO, M.D.

Clinical Professor of Surgery, University of Maryland School of Medicine/Shock Trauma Center,

Baltimore, Maryland; Battersby Professor of Surgery, Indianapolis, Indiana; and
Chief Emeritus, Division of General Surgery, Department of Surgery, Indiana University
School of Medicine, Indianapolis, Indiana

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma
were not performed until the 1800s. Even with the introduction of general anesthesia in the United
States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed
during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States
was finally performed in New York City in 1884. An aggressive operative approach to all forms of
abdominal trauma till the establishment of formal trauma centers (where data were analyzed)
resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s.
More selective operative approaches to patients with abdominal stab wounds (1960s), blunt
trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the di-
agnosis of abdominal trauma when serial physical examinations are unreliable include the fol-
lowing: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination;
3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative
techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined consid-
erably since World War II. These need to be emphasized repeatedly in an era when fewer patients
undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valu-
able operative approach in patients with physiologic exhaustion and multiple injuries.

Epidemiology of Trauma History of Abdominal Trauma

T HERE ARE APPROXIMATELY 5.1 million deaths from

injuries around the world each year. More than 2/3
of these occur in males, and more than 50 per cent
occur in males 10 to 24 years of age. Norton and
Kobusingye have noted that data from the World
Health Organization document that trauma causes 6
per cent of all deaths in high-income countries.1 By
contrast, deaths from injuries account for 11 to 12 per
cent of all deaths in low-income countries in Southeast
Asia and “in the Americas.”
In the United States, there are 150,000 deaths
from injuries each year or 54.4 injury deaths for 100,000
population. There are 400 injury deaths per day, and
trauma continues to be the most common cause of death
for Americans aged 1 to 44 years.2 Of interest, firearms
continue to be the second leading cause of trauma
deaths in the United States after motor vehicle crashes
with an average of 32,300 deaths per year.3–5
Presidential Address 85th Meeting, Southeastern Surgical
Congress Nashville, Tennessee February 25–28, 2017.
Address correspondence and reprint requests to David V.
Feliciano, M.D., 640 S. River Landing Road, Edgewater, Maryland
21037. E-mail: davidfelicianomd@gmail.com.
The Edwin Smith Papyrus, the oldest surgical trea-
tise in world history, describes 48 patients and is
thought to date from 3000 to 2500 BC or 1600 BC.6
The patients were mainly victims of trauma, and some
of the surgical techniques described included stitching,
cauterization, nasal packing, application of splints,
reduction of fractures, etc. There is, however, no
mention of abdominal trauma in the treatise.
Early comments on the management of patients
with abdominal trauma were made by some of
the most prominent individuals in the history of
medicine—namely, Hippocrates, Celsus, and Galen.
Hippocrates (460–370 BC) noted that eviscerated
omentum through an abdominal wound “mortifies
imperatively” in the Corpus Hippocraticum.7 Celsus
(25 BC–50 AD), a nobleman in Rome, recommended
repairing wounds of the eviscerated colon (but not the
small intestine). He then described returning the bowel
to the abdomen and closing the wound in the abdom-
inal wall in layers.7, 8 Both Galen of Pergamum (129
AD–199 AD) and Albucasis (936–1013) of Spain de-
scribed the importance of enlarging abdominal wounds
when eviscerated bowel could not be easily returned to
the peritoneal cavity before repair of the abdominal

1193
1194 THE AMERICAN SURGEON
wall. Guy de Chauliac (1300–1369) of Avignon, France,
repeated the principles described previously in Inven-
torium Seu Collectorium Cyrugie written in 1363 and
printed as a text in 1478.9 He, too, recommended suture
repair of the eviscerated perforated colon and empha-
sized that “nothing is more dangerous for the intestine
than the contact with air.”7
Approximately 50 years later, Jerome of Bruynswyke
(England) repeated this advice in old English, as follows:
“If that the wounde of the belly is not grete inowgh, then
shall ye make it greater…than shall you take out proply
the guttes, and sow it thereafter as it is needful with
a skinner’s nedyll.”10, 11
Jean Baudens (1804–1857), a French military sur-
geon, is credited with the diagnostic maneuver of
introducing a finger or a small sponge through an ab-
dominal wound during the Crimean War. When no
blood, feces, or bubble of gas was present, he advised
against laparotomy.12 Also, Baudens was reported to
have performed laparotomies with enterorrhaphies in
two victims of abdominal gunshot wounds during the
French Algerian War in 1830, and one survived.13
In the United States during the first half of the 19th
century, laparotomy was not performed for victims of
abdominal trauma except for isolated cases.14 And, it
is surprising how little impact the introduction of
general anesthesia had on this conservative approach.
In particular, the contributions of Crawford W. Long,
MD, Jefferson, Georgia, Horace Wells, DDS, Hartford,
CT., and William T.G. Morton, DDS, Boston, MA,
from 1842 to 1846 did not lead to a more aggressive
approach to abdominal wounds during the Civil War.
Although there had been one report of a successful
laparotomy for a blunt rupture of the bladder in 1849,
Shaftan has reminded all about the Civil War data re-
ported by George Alexander Otis.15, 16 He documented
an 82 per cent mortality in 3690 soldiers with pene-
trating abdominal wounds presumably treated conser-
vatively during this conflict.15, 16
Conservative (nonoperative) management of pene-
trating abdominal gunshot wounds was challenged in
the United States after the death of James A. Garfield,
the 20th president. Garfield was wounded in the right
lower posterior thorax in an assassination attempt by
Charles J. Guiteau in Washington, DC, on July 2,
1881.17 After 79 days of finger probing of the wound
by a number of renowned surgeons and failure of the
president to improve, Garfield died on September 19,
1881. At autopsy, Garfield was noted to have a fracture
of the first lumbar vertebra, a possible missed pan-
creatic injury, a ruptured splenic artery aneurysm,
and an intraabdominal abscess.17 J. Marion Sims
(1813–1883), described by eminent surgical historian
Ira M. Rutkow as “perhaps the first great American
gynecologist,” was one of the strongest critics of the
November 2017 Vol. 83
nonoperative management of President Garfield.18, 19
A later article continued to advocate an operative ap-
proach to penetrating abdominal wounds.13
It was William T. Bull (1849–1909), a prominent
surgeon in New York, who is credited with performing
the first formal laparotomy on a patient with a gunshot
wound of the abdomen in the United States.15, 20 The
patient was a 22-year-old man with a 0.32-caliber
gunshot wound approximately 1.5 inches left lateral
and inferior to the navel. The patient was brought to
the Chambers Street Hospital in New York City on
November 2, 1884, and underwent a laparotomy 17
hours later on November 3, 1884. Bull performed four
repairs of five perforations of small bowel, including
operative techniques such as transverse closure and
converting two adjacent perforations into one oblique
repair. In addition, he repaired a perforation of the
sigmoid colon, removed all free intestinal content, and
swabbed the pelvis with a 2.5 per cent solution of
carbolic acid. The patient then developed a subfascial
abscess on the sixth postoperative day. The midline
“heavy silk sutures” were removed except superiorly,
and the open incision was “stuffed with carbolized
compresses.” After the open incision slowly granu-
lated, “a large number of skin-grafts were applied on
two occasions.” The patient was discharged on the 58th
postoperative day.
The oral report of this case by Bull at the New York
Surgical Society on January 27, 1885, and the publi-
cation 18 days later in the New York Medical Journal
evidently stimulated great interest in treating future
victims of penetrating abdominal wounds in the United
States with exploratory laparotomy.
Excellent reviews of this new approach were then
published by two other surgeons in New York City—
Stephen Smith, MD, one of the founders of the Bellevue
Hospital Medical College, on January 2, 1886, and by
Frederic S. Dennis, later to be President of the American
Surgical Association in 1895, on March 6, 1886.18, 21, 22
William T. Bull reported his second successful lap-
arotomy for a patient with a gunshot wound to the
abdomen at the New York Surgical Society on October
11, 1886.23 A through-and-through wound of the small
bowel, a second wound of the sigmoid colon, and two
wounds of the sigmoid mesentery were repaired. On
the sixth postoperative day, the patient had a partial
dehiscence of the superior aspect of the midline in-
cision. This area was allowed to granulate, and skin
grafts were eventually used to cover the defect.
Loria has noted that these case reports helped to
convince American surgeons of the benefits of lapa-
rotomy for patients with penetrating abdominal
wounds.11 In addition, he described the symposium on
penetrating abdominal gunshot wounds held at the
meeting of the American Surgical Association in May
No. 11 ABDOMINAL TRAUMA REVISITED ? David V. Feliciano 1195

1887. This “concluded with the consensus of opinion
in favor of the operative treatment, even in those cases
in which the diagnosis of injury to important intraperi-
toneal structures was in doubt.” Further review articles
over the ensuing 30 years emphasized the benefits of an
aggressive operative approach and documented contin-
ued refinements in operative technique.24, 25
An aggressive operative approach to victims of ab-
dominal trauma persisted to the 1960s for those with
stab wounds, to the 1970s for those with blunt trauma,
and to the 1990s for those with gunshot wounds. The
reason for a change in philosophy was related to the
development of trauma centers in the United States
where large amounts of data on trauma victims were
collected and analyzed during the decades listed. Over
time, it became obvious that an aggressive (manda-
tory) operative approach to all victims of penetrating
(through the peritoneum) anterior abdominal stab
wounds resulted in a 25 to 40 per cent nontherapeutic
laparotomy rate.26–28 The figures for victims of blunt
abdominal trauma were similar,29–31 whereas those for
victims of penetrating wounds of the flank or back
were 70 to 85 per cent32–37 and for gunshot wounds of
the abdomen were 15 to 27 per cent.38–42
Classical Indications for Laparotomy
The classical indications for laparotomy after ab-
dominal trauma are listed in Table 1.43–47
Diagnosis of Abdominal Trauma
A diagnosis of peritonitis on physical examination
is compromised when one of the following is pres-
ent: 1) patient is intoxicated48; 2) patient has taken
illicit drugs; or 3) patient has associated injuries to the
brain, spinal cord, thoracolumbar spine, lower ribs,
or pelvis.
In such patients, when serial physical examinations
will not be useful, the currently available diagnostic
options are as follows: 1) diagnostic peritoneal tap/
lavage, 2) surgeon-performed ultrasound examination
(FAST), 3) contrast-enhanced CT of the abdomen and
pelvis, and 4) diagnostic laparoscopy.
Multisystem Blunt Trauma/Hemodynamically Unstable
In such a patient with a compromised abdominal
examination, a surgeon-performed FAST will rule out
pericardial tamponade and determine whether intra-
abdominal fluid (blood) is present.49–51 In the older
series by Rozycki et al.,52 there was a 100 per cent
sensitivity and 100 per cent specificity of surgeon-
performed ultrasound in determining whether intra-
peritoneal bleeding was the cause of hypotension in
patients with multisystem blunt injuries.
When no ultrasound machine is available or the re-
sults of the surgeon-performed ultrasound examination
are equivocal, a diagnostic peritoneal tap/lavage is
performed.
Multisystem Blunt Trauma/Hemodynamically Stable
A stable patient with a compromised abdominal ex-
amination and a positive FAST, negative FAST, and/or
hematuria should undergo contrast-enhanced abdomi-
nopelvic CT to determine the presence and magnitude
of any injuries.
Penetrating Abdominal Trauma/Hemodynamically
Unstable/Multiple Truncal and Extremity Wounds
It is usually true that patients with multiple wounds
have hypotension related to one of the wounds. In the
absence of external bleeding from an extremity, an
expanded surgeon-performed ultrasound will confirm
whether the hypotension is caused by pericardial
tamponade, intrapleural hemorrhage, or intraperitoneal
hemorrhage.
As in patients with possible blunt abdominal trauma,
a diagnostic peritoneal tap/ lavage is performed when
the FAST cannot be performed or the results are
equivocal.
Possible Penetrating Thoracoabdominal Trauma/
Hemodynamically Stable
A stab or gunshot wound in the thoracoabdomen
(nipple to costal margin from midline to anterior ax-
illary line) will penetrate the diaphragm and abdomen
15 per cent and >45 per cent of the time, respectively.53

TABLE 1. Classical Indications for Laparotomy after Abdominal Trauma43, 44

d Penetrating or blunt abdominal trauma with hypotension (and positive FAST or diagnostic peritoneal lavage with blunt
trauma)
d Peritonitis on initial or subsequent physical examination
d Evisceration of bowel and in some centers, omentum (controversial45–47)
d Bleeding from stomach, rectum, or genitourinary tract after penetrating trauma
d X-ray or CT demonstrates free air, retroperitoneal air, or rupture of the hemidiaphragm after blunt trauma
d Contrast-enhanced CT demonstrates rupture of gastrointestinal tract, rupture of intraperitoneal bladder, or severe (AAST
OIS Grade V) visceral parenchymal injury after blunt or penetrating trauma
1196 THE AMERICAN SURGEON
In the absence of peritonitis or evisceration, a surgeon-
performed ultrasound demonstrating intraperitoneal
fluid (blood) documents that the hemidiaphragm and,
possibly, intraabdominal viscera have been injured. A
“negative” surgeon-performed ultrasound will not be
helpful, however, as little intraperitoneal blood can be
expected from the usual stab or gunshot wound of
the hemidiaphragm. Certain centers will perform
a contrast-enhanced CT of the abdomen as the next
study after a negative surgeon-performed ultrasound.
This would be useful with a possible right thor-
acoabdominal wound because intravenous contrast
would be expected to demonstrate an injury to the
liver. On the left side, a triple-contrast CT would be
necessary to demonstrate any injury to the stomach,
transverse colon, or splenic flexure. There is, however,
an aversion of some radiology departments to the labor
and timing-intensive nature of triple-contrast CT stud-
ies. So, some trauma centers will perform diagnostic
laparoscopy with a 30° laparoscope under general an-
esthesia in the operating room instead. On the left side,
an even simpler diagnostic approach is to review the
patient’s serial chest X-rays after insertion of a thor-
acostomy tube for a lower left thoracic penetrating
wound. Before discharge of the patient, these X-rays
always show a persistent abnormal appearance of the
left hemidiaphragm if an injury has been missed.54 This
is presumably due to the early herniation of a portion of
the omentum from negative intrapleural pressure.
Penetrating Anterior Stab Wound/Hemodynamically Stable
A stab wound to the anterior abdomen (costal mar-
gins to inguinal ligaments between anterior axillary
lines) penetrates the peritoneal cavity 25 to 33 per cent
of the time. Many patients with documented (passage
of Q-tip, positive local wound exploration, or positive
surgeon-performed ultrasound) or presumed perito-
neal penetration do not have peritonitis or eviscera-
tion. Serial physical examinations over 24 hours
rather than other diagnostic tests have continued to
be the most popular approach as patients with con-
tinuing hemorrhage or gastrointestinal contamina-
tion are almost always symptomatic within 6 to 12
hours. Diagnostic peritoneal lavage has an accuracy
of 88 to 92 per cent in the early diagnosis of patients
with injuries requiring repair, with the compromised
accuracy mainly because of false-positive studies.55
There is, however, little enthusiasm for this tech-
nique in modern trauma centers. Surgeon-performed
ultrasound can only document penetration of the
peritoneal cavity as noted previously, but not visceral
injury. In addition, in busy urban trauma centers around
the world, it is impractical and not cost effective to
perform diagnostic laparoscopy in so many patients.
November 2017 Vol. 83
Penetrating Flank or Back Trauma/Hemodynamically
Stable
A stab or gunshot wound to the flank (sixth in-
tercostal space to iliac crest between anterior and
posterior axillary lines) or back (tips of scapulae to
iliac crests posterior to posterior axillary lines) may
penetrate the visceral-vascular area of the retro-
peritoneum or the peritoneal cavity. Most patients with
such wounds do not have peritonitis or evisceration.
Serial physical examinations continue to be a popular
diagnostic approach, and patients with visceral injuries
will almost always develop symptoms or signs within
18 hours.56 Double (intravenous and upper gastroin-
testinal) or triple (add rectal) contrast CT remains the
most commonly used diagnostic test in patients with
penetrating wounds to the flank or back. With an
accuracy >95 per cent when performed properly, this
study rapidly answers the question of whether opera-
tive intervention is indicated.34, 57
Operative Management
Resuscitation
There are multiple guidelines for predicting which
operative patients will likely require massive transfusion
and, possibly, a “damage control” operation.58–61 Mea-
surement of the initial base deficit is predictive of
outcome in patients with blunt or penetrating abdom-
inal trauma as well.62, 63 “Damage control resuscitation”
with fixed ratios of red blood cells, plasma, and
platelets has been confirmed to have a beneficial im-
pact on survival and on achieving hemostasis in the
The PRospective Observational Multicenter Major
Trauma Transfusion and Pragmatic Randomized Op-
timal Platelet and Plasma Ratios studies, respectively,
in recent years.64, 65 Yet, there has been an even more re-
cent evolution to “goal-directed hemostatic resuscitation”
based on thromboelastography (Haemonetics Corp.,
Niles, IN) or rotational thromboelastometry (TEM
International, GM6H, Munich, Germany).66, 67
General Principles
Once the surgeon has been updated on the patient’s
hemodynamic status and status of resuscitation before
operation, a second- or third-generation cephalosporin
antibiotic is administered intravenously.
The surgeon must then decide on the positioning of
the patient. It has always been the author’s preference
to position the patient’s upper extremities at the pa-
tient’s sides for the following reasons: 1) easy applica-
tion of self-retaining retractors to the operating table;
2) space for any team members holding retractors in
the right or left upper quadrants; and 3) ready access
No. 11 ABDOMINAL TRAUMA REVISITED
to perform an anterolateral thoracotomy or median
sternotomy during the emergency laparotomy. The one
other consideration in positioning is whether to place
the pelvis and lower extremities in the lithotomy po-
sition should an injury to the rectum be known or
suspected.
Preparation and draping of the patient should extend
from the chin to the bilateral knees and encompass all
of the anterolateral trunk and thighs. This allows for
extension of the midline exploratory laparotomy into
a median sternotomy if needed. In addition, it allows
for access to the groins for distal/proximal vascular
control of an injury to the external iliac artery/vein or
for retrieval of an autogenous saphenous vein graft.
Finally, all of the standard maneuvers to prevent,
decrease, or reverse hypothermia are instituted before
the incision and maintained throughout the emergency
operation.68
Hepatic Trauma
With a blood supply of 1500 mL/min, control of
hemorrhage is the obvious priority when operating on
a patient with an American Association for the Surgery
of Trauma (AAST) Organ Injury Scale (OIS) Grade
III, IV, or V hepatic injury. And, as befits the largest
organ in the body, there are at least 11 different op-
erative techniques that can be used to attain hepatic
hemostasis—compression, topical agent, suture hep-
atorrhaphy (minor or extensive), hepatotomy with se-
lective vascular ligation, resectional debridement with
selective vascular ligation, absorbable mesh com-
pression, formal resection, selective hepatic artery li-
gation, intrahepatic balloon tamponade, and perihepatic
packing.
Any AAST Hepatic OIS Grade III (<3 cm depth)
hepatic injury mandates application of a Pringle ma-
neuver and mobilization of the ipsilateral lobe unless it
is on the anterior surface of the liver. Lobar mobili-
zation includes division of the ipsilateral triangular
ligament and the anterior coronary ligament and ele-
vation on folded laparotomy pads.
Techniques for the modern operative management of
hepatic trauma are summarized in Table 2.69–73
TABLE 2. Modern Operative Management of Hepatic Trauma69–73
Injury
AAST OIS Grade III
AAST OIS Grade IV or V or long peripheral bullet tract
Long deep bullet tract
Partial avulsion Couinaud segments II/III or VI/VII
Large subcapsular hematoma, capsular avulsion, or
unruptured retrohepatic hematoma
? David V. Feliciano 1197
Splenic Trauma
With a blood supply of 200 mL/min, it is not sur-
prising that patients with splenic injuries continue to
bleed to death. Unfortunately, this has been true even
for patients under observation in Level I trauma cen-
ters.74 But, nonoperative management (failure rate
6–10%) for hemodynamically stable patients and
angiographic embolization for patients with extrava-
sation and pseudoaneurysms on CT are now the
mainstays of care other than splenectomy. This reflects
the long-delayed recognition and acceptance of splenic
immunity in adults.75–79
One of the effects of large numbers of patients with
splenic injuries being managed nonoperatively is
a lack of interest in and knowledge about techniques of
splenorrhaphy.80 This is unfortunate because splenic
injuries continue to occur during general surgery op-
erations in the left upper abdomen on a regular basis
as well.
Any AAST OIS Grade I-V splenic injury that is
bleeding mandates mobilization of the spleen out of
the left upper quadrant. This includes division of the
lienorenal ligament posteriorly, of the three most su-
perior short gastric vessels, and of the splenocolic
ligament inferomedially.
Techniques for the modern operative management of
splenic trauma are summarized in Table 3.73, 80–82
Guidelines for vaccinations preelective splenectomy or
postoperative splenectomy or postembolization of the
main splenic artery are available at https://www.cdc.gov/
vaccines/adults/rec-vac/health-conditions/asplenia.html
Duodenal Trauma
The incidence of injuries to the duodenum at lapa-
rotomies is <2 per cent with stab wounds, 5 to 6 per
cent with blunt trauma, and 10 to 11 per cent with
gunshot wounds. In patients with blunt abdominal
trauma, delays in diagnosis and operative treatment of
duodenal injuries were historically due to its retro-
peritoneal location combined with a neutral pH and
low bacterial count in extravasated contents.
The major factors in operative repair of duodenal
injuries have always been the presence or absence of
Technique
Hepatorrhaphy with 0 chromic suture
Hepatotomy, selective vascular and biliary ligation,
viable omental pedicle
Transtract balloon catheter tamponade
Resectional debridement through uninjured liver
Perihepatic packs (over topical
hemostatic agent if liver only)
1198 THE AMERICAN SURGEON
one of the following: 1) a delay in diagnosis; 2) hy-
potension secondary to associated upper abdominal
vascular injuries; 3) loss of tissue from the wall of the
duodenum; and 4) associated injury to the pancreas.
Injuries to the duodenum are detected at operation
by the presence of palpable retroperitoneal air and
visible bile staining of the upper right retroperitoneum.
An extended Kocher maneuver will allow for adequate
visualization of D1, D2, and proximal D3; however,
complete visualization of D3 and D4 mandates exten-
sive mobilization of the ligament of Treitz or a Cattell-
Braasch maneuver.83
Techniques for the modern operative management of
duodenal trauma are summarized in Table 4.84–87 In
general, duodenal repairs are divided into closure,
closure with the addition of a diversion procedure, or
resection. Pyloric exclusion with gastrojejunostomy,
the one diversion procedure mentioned, was first de-
scribed in 1907 by Albert Berg, MD in New York
City.88 The technique was reintroduced by Vaughan
et al.89 at the Ben Taub General Hospital in Houston
and used in over 150 patients in two subsequent se-
ries.90, 91 These series had some of the lowest duodenal
fistula rates and mortalities ever reported in the Amer-
ican trauma literature. Therefore, readers are urged to
carefully interpret the small retrospective series con-
demning pyloric exclusion with gastrojejunostomy that
have been published in the past 10 years.92, 93
TABLE 3. Modern Operative Management of Splenic Trauma73, 80–82
Injury
Isolated AAST OIS Grade I Injury
Isolated AAST OIS Grade II-III injuries
Isolated AAST OIS Grade IV injury/surgeon
experienced in splenorrhaphy
Ruptured subcapsular hematoma
* Covidien-Medtronic, Minneapolis, MN.
y Ligation of segmental vessels to injured area, division of parenchyma, closure of remaining raw end with chromic vertical
mattress sutures over absorbable mesh.
TABLE 4. Modern Operative Management of Duodenal Trauma84–87
Injury
AAST OIS Grade II-III injuries
AAST OIS Grade II-III injuries with loss of tissue
AAST OIS Grade IV (with ampulla) – V injuries
Narrowed or discolored duodenal repair or
combined head of pancreas and duodenal
injuries (Whipple not justified)
* Exclusion performed with #1 polypropylene suture. Patient screened for Helicobacter pylori and undergoes upper gastro-
intestinal X-ray series before discharge.
November 2017 Vol. 83
Pancreatic Trauma
The incidence of injuries to the pancreas at lapa-
rotomies is approximately 6 per cent for patients
with blunt, stab or gunshot wounds. In patients with
blunt abdominal trauma, delays in diagnosis and
operative treatment of pancreatic injuries in the pre-
CT era were, much as with the duodenum, because
of its retroperitoneal location, lack of bacteria in
drainage, and inconsistent elevation of serum amylase
when injured.
The major factors in operative repair of pancreatic
injuries have always been the presence or absence of
one of the following: 1) injury to the main pancreatic
duct; 2) a delay in diagnosis; 3) hypotension secondary
to associated upper abdominal vascular injuries; and
4) associated injury to the duodenum. One other com-
plicating factor in patients with severe blunt injuries is
that blunt transections that occur at the neck are much
closer to the C-loop of the duodenum than is commonly
depicted in textbooks. In patients with gunshot wounds,
there are inevitably perforations of the stomach, duo-
denum, and/or transverse colon, which increase the in-
cidence of postoperative sepsis.
Techniques for the modern operative management of
pancreatic trauma are summarized in Table 5.87, 94–97 In
general, pancreatic repairs are managed with drainage,
resection, or Roux-en-Y drainage.
Technique
Compression over topical hemostatic agent
Continuous 2–0 chronic suture over piece of omentum
or Argon Beam Coagulator*
Partial splenectomyy
Topical hemostatic agent under absorbable mesh
replacement for capsule
Technique
Primary transverse or oblique 2-layer repair
Retrocolic Roux-en-Y side-to-end or end-to-end
duodenojejunostomy
Whipple procedure with delayed reconstruction if necessary
Duodenal repair, closed suction of pancreas, consider pyloric
exclusion with gastrojejunostomy*
No. 11 ABDOMINAL TRAUMA REVISITED
TABLE 5. Modern Operative Management of Pancreatic Trauma87, 94–97
Injury
AAST OIS Grade I-II injury
AAST OIS Grade III injury
AAST OIS Grade IV injury (hemodynamically stable)
AAST OIS Grade V injury
Combined head of pancreas
and duodenal injuries (Whipple not justified)
Abdominal Damage Control
The concept of an abbreviated laparotomy combined
with intraabdominal pack tamponade in injured patients
with an intraoperative coagulopathy was first described
by Stone et al.98 at Grady Memorial Hospital in Atlanta,
Georgia, in 1983. The U.S. Navy term “damage control”
(the capacity of a ship to absorb damage and maintain
mission integrity) was subsequently applied to the ab-
breviated trauma laparotomy concept by Rotondo et al.99
at the University of Pennsylvania in 1993.
The historical development of “damage control” in
injured patients over the past 115 years has been
reviewed recently by Roberts et al.100 A comprehen-
sive review of “trauma damage control” is now avail-
able as well.68
Dedications
This Presidential Address is dedicated to Jon A. van
Heerden, MD, former Mayo Clinic surgeon, for all that
he taught me about General and Endocrine Surgery and
for his endless support of my academic career. Gary L.
Dunnington, MD, Grosfeld Professor and Chair, De-
partment of Surgery, Indiana University School of
Medicine, for restoring my faith in Academic Surgery
and for his extraordinary support over the past four
years.
Acknowledgments
This Presidential Address was completed with the in-
valuable assistance of Ira M. Rutkow, MD, MPH, Dr. PH,
surgical historian extraordinaire, who provided the refer-
ence material on early laparotomies for penetrating wounds
in the United States. Gerald W. Shaftan, MD, one of the
founding fathers of modern trauma care, whose ACS
Scudder Oration on Trauma on October 25, 1988, was the
inspiration for this address.
REFERENCES
1. Norton R, Kobusingye O. Injuries. N Engl J Med 2013;368:
1723–30.
? David V. Feliciano 1199
Technique
Closed, suction drainage, consider
viable omental plug to defect
Distal pancreatectomy with closure using
4.8 mm staples or sutures
Oversew proximal stump, Roux-en-Y distal
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Whipple procedure with delayed reconstruction
if necessary
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