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ABDOMINAL TRAUMA

By Dr. Saleh M.Al-Salamah



B.Sc, MBBS, FRCS
Associate
Professor of Surgery
General &
Laparoscopic Surgeon
College
of Medicine
King Saud
ni!ersity
Riyad"

K.S.A
By Dr. Saleh M.Al-Salamah

B.Sc, MBBS, FRCS
Associate
Professor of Surgery
General &
Laparoscopic Surgeon
College
of Medicine
King Saud
ni!ersity
Riyad"

K.S.A


Objectives
Types of abdominal
Trauma
Anatomical regions of the abdomen
Hospital Care and
diagnosis (Evaluation of patient
with blunt / enetarating Trauma!

"pecific organs trauma

'B()C*+,)S&

1
-escri%e t"e anato#ical
regions of t"e a%do#en.
1
-iscuss t"e difference in
in.ury pattern %et$een %lunt
and penetrating trau#a.

1
+dentify t"e signs suggesting
retroperitoneal, intraperitoneal
or pel!ic in.uries.
1
'utline t"e diagnostic &
t"erapeutic procedures
specific to a%do#inal trau#a.

1
*"e #a.ority of a%do#inal
in.uries are due to %lunt
a%do#inal trau#a secondary to
"ig" speed auto#o%ile
accidents. *"e failure to
#anage t"e a%do#inal in.uries
accounts for #a.ority of
pre!enta%le deat" follo$ing
#ultiple in.uries.

1 *"e pri#ary #anage#ent of
a%do#inal trau#a is
deter#ination t"at an intra
a%do#inal in.ury )/+S*S and
operati!e inter!ention is
re0uired.

1
Types of the abdominal trauma.
1a2 Blunt a%do#inal trau#a.
1%2 Penetrating a%do#inal
trau#a.

*"e recognition of t"e
#ec"anis# of t"e in.ury
$eat"er is penetrating or non3
penetrating trau#a is a greatest
i#portance for treat#ent and
diagnosis and $or4up t"erapy.
*"e li!er, spleen and 4idneys
co##only in!ol!ed in t"e %lunt
a%do#inal in.uries.

1
Anato#ical regions of t"e
a%do#en&
1a2 Peritoneu#.
1 +ntrat"oracic a%do#en
1 *rue
a%do#en
1%2 Retroperitoneu#
a%do#en 1c2
Pel!ic a%do#en.

1
5ospital Care and -iagnosis


1 +nitial
Manage#ent&


+ *"e resuscitation &
Manage#ent priorities of
patient $it" #a.or a%do#inal
trau#a are. *"e 1ABC-)2 of
)M)RG)7C8 resuscitations
air$ay, %reat"ing and
circulation $it" "e#orr"age
control s"ould %e initiated.
+ 7G* & Folly9s
Cat"eter.

1
5+S*'R8&
1a2 Blunt
a%do#inal trau#a
1%2 Penetrating a%do#inal
trau#a.
1
P58S+CAL )/AM+7A*+'7&
+
General p"ysical ):a#ination
+ ):a#ination of t"e
a%do#en.

1 +nspection
1
Palpation
1
Percussion
1
Auscultation
1 Rectal
):a#ination
1 ,aginal
):a#ination

1
-+AG7'S*+C PR'C)-R)S
1+n!estigations2

1A2 Blood *ests
1B2
Radiological Studies
1Plain
a%do#inal /3ray,
C/R2 1C2
Peritoneal la!age 1-PL2
1-2 SS
a%do#en
1)2 C* a%do#en

1F2 Peritoneoscopy
1-iagnostic laproscopy2


1
)S*ABL+S5+7G PR+'R+*+)S
A7- +7-+CA*+'7S F'R
SRG)R8&
1*"e indications for
laparoto#y2
1A2 Signs
of peritoneal in.ury
1B2
ne:plained s"oc4

1C2 )!isceration of !iscus
1-2
Positi!e diagnostic 1-PL2
1)2
-eter#ination of finding
during routine follo$ up


1
Speifi Or!ans Trauma"

1 Li!er
1
Spleen



IN#ID$N#$ IN#ID$N#$
*"e li!er is t"e largest organ
in t"e a%do#inal ca!ity and
continues to %e t"e #ost
co##only in.ured organs in all
patients $it" a%do#inal
*rau#a 1Blunt6Penetrating2 1;<3
=<>2 in %lunt a%do#inal
*rau#a =?> in sta% $ound
;?> in guns"ot $ounds to
a%do#en.

M$#%ANISM O& IN'UR( M$#%ANISM O& IN'UR(
5epatic in.uries result fro# direct
%lo$s, co#pression %et$een t"e
lo$er ri%s on rig"t side and t"e
spine or s"earing at fi:ed points
secondary to deceleration. Any
penetrating guns"ot, sta% or
s"otgun $ound %elo$ t"e rig"t
nipple on rig"t upper 0uadrant of
t"e a%do#en is also li4ely to cause
a "epatic in.ury.

DIA)NOSIS *LI+$R TRAUMA, DIA)NOSIS *LI+$R TRAUMA,

-iagnosis of "epatic in.ury is


often #ade at laparoto#y in
patients presenting $it"
penetrating in.uries re0uiring
i##ediate Surgery

'r t"ose sustaining %lunt


*rau#a $"o re#ain in s"oc4 or
present $it" a%do#inal rigidity.

Ad.u!ant diagnostic tests are
necessary in t"e decision
#a4ing process to deter#ine
$"et"er or not laparoto#y is
necessary&

1a2 -iagnostic peritoneal
la!age 1-PL2 "as %een
e:tre#ely relia%le @A> in
deter#ining t"e presence of
%lood in t"e peritoneal ca!ity
once 1positi!e2 patient s"ould
%e ta4en to t"e 'perating
Roo# $it"out delay.

1%2 C*.Scan a%do#en
used for diagnosing
intraperitoneal in.uries in
sta%le patients after %lunt
trau#a.


Patients sustaining significant
Rig"t lo$er t"oracic, Rig"t
upper 0uadrant and )pigastric
%lunt trau#a, s"ould %e
suspected of "a!ing suffered a
"epatic in.ury, clinical
assess#ent and a%do#inal
paracentesis
SUMMAR( SUMMAR(
Cont .

& -PL are #ost i#portant
factors in deter#ining operati!e
inter!ention. C* Scanning #ay
%e useful ad.u!ant in t"e
"ae#odyna#ically sta%le %lunt
trau#a patient.

B"en patient arri!ed to


)R t"e initial #anage#ent of
t"e patient s"ould %e unifor#
regardless of organs syste#
in.uries. Resuscitation is
perfor#ed 1ABC-)2 in t"e
standard fas"ion.

Non operati-e approah"


*"e "epatic in.ury diagnosed
%y C* in sta%le patient is no$
non operati!e approac"
practiced in #any centers.
C*. Criteria for nonoperati!e
#anage#ent include t"e
follo$ing&

C Si#ple "epatic laceration 'r
intra"epatic "e#ato#a
C 7o e!idence of acti!e %leeding
C +ntra peritoneal %lood loss CD<? #l
C A%sence of ot"er +ntraperitoneal
in.uries re0uired surgery

'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(

Si#ple tec"ni0ues includes


drainage only of non3%leeding
in.uries, application of fi%rin glue,
and sutures "epatorr"ap"y and ,
Application of Surgical 1+ & ++2.

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 -,*

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