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'P)RA*+,) APPR'AC5
q
Persistent "ypotension, despite
ade0uate !olu#e replace#ent,
suggests ongoing %lood loss and
#andates i##ediate operati!e
inter!ention.
q
+n.ury classification& *"is
classification %ased on operati!e
findings and #anage#ent. So
"epatic in.ury classified as follo$s&
E Grade +&
Si#ple in.uries E non %leeding
E Grade ++&
Si#ple in.uries
#anaged %y
superficial suture alone
E Grade +++&
Ma.or intraparenc"y#al in.ury
$it" acti!e %leeding %ut
not re0uiring inflo$
occlusion
1Pringle #aneu!er2 to control
"ae#orr"age
E Grade +,&
):tensi!e intraparenc"y#al
in.ury $it" #a.or acti!e %leeding
re0uiring inflo$ occlusion for
"e#ostatic control
E Grade ,&
(u:ta"epatic
!enous in.ury 1in.uries to
retro"epatic ca!a or #ain
"epatic !eins2
All patients undergoing
laparoto#y for trau#a s"ould
%e e:plored t"roug" #idline
incision.
O.$RATI+$ MANA)$M$NT" O.$RATI+$ MANA)$M$NT"
1Grade3+&++& Si#ple in.uries can
%e #anage#ent %y any one of
!ariety of #et"ods 1si#ple
suture, electrocautery or
*ropical 5e#ostatic Agents2 *"is
type of in.ury li4e Li!er B:. does
not re0uire drainage.
1
Grade +++& Ma.or intraparenc"y#al
in.uries $it" acti!e %leeding can
%est %e #anaged %y Finger
Fracturing t"e "epatic parenc"y#a
and ligating or repairing lacerated
%lood !essels & %ile ducts under
direct !ision.
1
Grade+,&
):tensi!e intraparenc"ynal in.uries
$it" #a.or rapid %lood loss re0uire
occlusion of portal trial to control
"ae#orr"age.
SUMMAR( SUMMAR(
Ad!anced *ec"ni0ues of
Repair 1+++ & +,2 all perfor#ed
$it" Pringle Maneu!er in place.
1a2 ):tensi!e "epatorr"aply
1%2 5epatoto#y $it"
selecti!e !ascular ligation
1c2
'#ertal Pac4
1d2 Resectional de%ride#ent
$it" selecti!e !ascular ligation
1e2 Resection
1f2 Selecti!e 5epatic
Artery Ligation
1g2 Peri"epatic pac4ing
#OM.LI#ATIONS / MORTALIT(" #OM.LI#ATIONS / MORTALIT("
O Recurrent %leeding
O 5e#ato%ilia
O
Peri"epatic a%scess
O Billiary Fistula
O +ntra"epatic
5ae#ato#a O
Pul#onary Co#plications
O Coagulopat"y
O 5ypoglyce#ia
IN#ID$N#$ IN#ID$N#$
*"e spleen re#ains t"e #ost
co##only in.ured organ in
patients $"o "a!e suffered %lunt
a%do#inal trau#a and is
in!ol!ed fre0uently in
penetrating $ounds of t"e left
lo$er c"est and upper a%do#en.
Manage#ent of t"e in.ured
spleen "as c"anged radically
o!er t"e pastdecade.
7o$ recogniFed as an i#portant
i##unologic factory as $ell as
reticuloenlot"elial filter.
Alt"oug" t"e ris4 of o!er
$"el#ing postsplencto#y sepsis
1'PSS2 is greatest in c"ild less
t"an D yrs recognition of 'PSS
"as sti#ulated efforts to
1Conser!e spleen2 %y
splenorr"ap"y.
M$#%ANISM O& IN'UR( M$#%ANISM O& IN'UR(
1
*"e spleen is co##only in.ured in
patients $it" %lunt a%do#inal
trau#a %ecause of its #o%ility.
1
Most ci!ilian sta% $ounds and
guns"ot $ounds cause si#ple
lacerations or t"roug" and t"roug"
in.uries.
1
+t is of interest D> of patient $"o
are undergoing surgery LG of t"e
a%do#en can in.ured t"e spleen
.AT%O.%(SIOLO)( / #LASSI&I#ATION .AT%O.%(SIOLO)( / #LASSI&I#ATION
*"e Magnitude of spleanic
disruption depend on patient
age, in.ury #ec"anis# and
presence of underlying
disease spleanic in.ury "a!e
%een classified according to
t"eir pat"ologic anato#y as
suc"&
E Grade +& Su%capsular "e#ato#a
E Grade ++& Su% seg#ental
parenc"g#al in.ury
E Grade +++& Seg#ental
de!italiFation
E Grade +,&
Polar disruption
E Grade ,& S"attered or
de!asculariFed
organ
DIA)NOSIS *$+ALUATION, DIA)NOSIS *$+ALUATION,
Patient 5istory
P"ysical ):a#ination
Radiological )!aluation
1 C/R
1 Plain
a%do#inal /3Ray
1 C* Scan
1 Angiograp"y
TR$ATM$NT" TR$ATM$NT"
+nitial Manage#ent
1Resuscitation2 ABC-)
7on operati!e approac"&
4 Bidely
practiced in pediatric trau#a t"e
criteria for nonoperati!e approac" 1
5ae#odyna#ically sta%le
c"ildren 6 adult
1 *"ose patient
$it"out peritoneal finding at
anyti#e 1 *"ose $"o
did not re0uire greater t"an t$o
unit of %lood
C *"e patient "as protracted
"ypotension
C ndue delay is anticipated in
atte#pting repair t"e spleen
C *"e patient "as ot"er se!ere
in.ury
'perati!e approac"&
1 -ecision to perfor#
splencto#y or splenorrap"y is
usually #ade after
assess#ent & grading t"e
splenic in.ury
Postsplecto#y and
splenorrap"y co#plications&
1 )arly
E Bleeding
E Acute gastric
distention E
Gastric necrosis
E Recurrent splenic %ed
%leeding
E Pancreatits
E Su%p"erinic
a%scess
1
Late Co#plications&
E *"ro#%ocytosis
E
'PSS 1H E I Bee42
E -,*