January 4,

ABDOMINAL INJURIES
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:
 Haemodynamically ‘normal’ – investigation can be completed before
treatment is planned;
 Haemodynamically ‘stable’ – investigation is more limited.

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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.
 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.

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• 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
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.

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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:
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

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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 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.

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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.

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.

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 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.
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.

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 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.

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.

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 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.
 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

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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.
 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

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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 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.

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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.
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

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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

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

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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%.

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.

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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.
 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.

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 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.
 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.

Sequences:

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ABDOMINAL INJURIES

 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.
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

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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
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

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ABDOMINAL INJURIES

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 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.

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ABDOMINAL 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.
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

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ABDOMINAL INJURIES

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.

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

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ABDOMINAL INJURIES

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
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

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ABDOMINAL INJURIES

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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