PRINCIPLES OF

HEPATOBILIARY AND
PANCREATICODUODENAL
TRAUMA
MODERATOR: PROF SHIB SHANKAR RAY CHOWDHURY
PRESENTOR: SUMAN BISWAS
ABDOMINAL INJURY
 CAN BE CLASSIFIED INTO 3 CATEGORIES
1. hemodynamically NORMAL :investigation completed before treatment
2. Hemodynamically STABLE: investigation limited , ot required or not
3. Hemodynamically UNSTABLE: immediate surgery

Laparotomy is the final step to delineate injury.

Safest option in multiple injury patient.
Patients physiology must be assessed at regular interval.
Blood is not an irritant.
Drop of blood pressure may be a late sign.
INVESTIGATION
 BEST AND MOST SENSITIVE : CT SCAN WITH IV CONTRAST
 NOT POSSIBLE IN UNSTABLE PATIENT
 METAL MARKERS PLACED ON EXTERNAL WOUNDS IN PENETRATING
INJURIES.
 FAST : RAPID,REPRODUCABLE ,PORTABLE AND NON INVASIVE BEDSIDE TEST.
 E FAST
DRAWBACK: LESS THAN 100 ML
PENETRATING WOUND
RETROPERITONEUM
HOLLOW VISCUS
OBESE PATIENT
DIAGNOSTIC PERITONEAL LAVAGE:

 PRESENCE OF BLOOD OR CONTAMINATION

 GASTRIC TUBE AND CATHETER INSERTED
 CANNULA BELOW UMBILICUS
 MORE THAN 10 ML IS POSITIVE
 1LT RL GIVEN AND ASPIRATED
 ONE TENTH IN CASE OF PENETRATING TRAUMA
 DPL LARGELY REPLACED BY EFAST
 STANDARD IN INSTITUTIONS WHERE EFAST NOT AVAILABLE.
CT SCAN

 GOLD STANDARD FOR STABLE PATIENTS

 SENSITIVE FOR BLOOD AND INTRA ABDOMINAL AS WELL AS
RETROPERITONEAL INJURY
 INAPPROPRIATE FOR UNSTABLE PATIENTS
 ORAL CONTRAST HELPFUL FOR DUODENAL INJURY
 RECTAL CONTRAST HELPFUL FOR RECTAL AND COLONIUC INJURY
LAPAROSCOPY

 SCREENING: PENETRATING INJURY

 DIAGNOSTIC: VISCERAL INJURUY
 THERAPEUTIC
 PENETRATING INJURY IN MOST CASES REQUIRE LAPAROTOMY
LIVER INJURY

 BLUNT LIVER INJURY OCCURS AS A RESULT OF DIRECT TRAUMA

 LIVER IS A SOLID ORGAN AND EASILY INJURED
 USUALLY COMPRESSED BETWEEN THE OBJECT AND RIBCAGE OR
VERTEBRAL COLUMN
 PENETRATING TRAUMA ALSO COMMON.
 INVESTIGATION OF CHOICE: CT SCAN
 INJURY WITH SUGGESTION OF VASCULAR COMPONENT SHOULD BE
REIMAGED: RISK OF ISCHAEMIA,ARTERIO VENOUS FISTULA OR
HAEMOBILIARY FISTULA
LIVER INJURY
MANAGEMENT
 OPERATIVE MANAGEMENT CAN BE SUMMARISED AS
 PUSH
 PRINGLE
 PLUG
 PACK
 BLEEDING POINTS SHOULD BE CONTROLLED LOCALLY AND IF REQUIRED
SUBSEQUENT ANGIOEMBOLISATION DONE
 NOT NECESSARY TO SUTURE PENETRATING INJURIES UNLESS HEMOSTASIS CAN NOT
BE CONTROLLED
 HEPATIC ARTERY CAN BE TIED OFF
 DAMAGE TO PORTAL VEIN MUST BE REPAIRED
 TYING OFF PORTAL VEIN HAS 50% MORTALITY
 IF REPAIR NOT POSSIBLE THEN SHUNTED
BILIARY INJURY

 ISOLATED TRAUMATIC BILIARY INJURIES ARE RARE AND OCCUR

MAINLY FROM PENETRATING TRAUMA
 OFTEN ASSOCIATED WITH CLOSE STRUCTURE INJURY
 CBD CAN BE REPAIRED OVER T TUBE OR DRAINED OR EVEN
LIGATED
PANCREATIC INJURY

 MOSTLY BLUNT TRAUMA

 DIAGNOSIS IS PROBLEMATIC BECAUSE RETROPERITONEAL
 CT REMAINS MAINSTAY
 AMYLASE OR LIPASE ESTIMATION IS INSENSITIVE
 IN PENETRATING TRAUMA DETECTED DURING LAPAROTROMY
 CLASSICALLY TREATED WITH CONSERVATIVE SURGERY AND CLOSED
SUCTION DRAINAGE
 INJURY TO BODY LEFT OF SM VESSELS AND TO THE TAIL
 DISTAL PANCREATECTOMY IF DUCT IS INVOLVED
 PROXIMAL INJURIES TREATED CONSERVATIVELY ALSO PARTIAL
RESECTION MAY BE NECESSARY
 ADDITIONAL PYLORUS EXCLUSION AND GASTRIC DRAINAGE
 WHIPPLE RARELY DONE
DUODENAL INJURY
THANK YOU