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Abdominal injury and Management

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  1. Abdominal injury and Management Dr Wong Wai Man Department of Surgery NTWC 29 Apr 2009

  2. Mechanism • Blunt abdominal trauma • Penetrating abdominal trauma • Overall about 20% require surgical operation

  3. Blunt abdominal trauma Motor vehicle crush MVC injury Seat belt injury Handle bar injury Fell from height Common in HK

  4. Penetrating abdominal injury • Stab wound – low energy transfer • Gun shot wound – high energy transfer • Not common in HK

  5. Anatomy • Between diaphragm and pelvic floor • Beware of diaphragmatic injury in penetrating chest injury below the nipples (5th ICS) • Mid-axillary line • Retro-peritoneal spaces – zone I, II & III

  6. Anatomy • Solid organs – liver, spleen, kidney (blood) • Hollow organs – blood, bile, urine, food, digestive juice, air • Remember the diaphragm which is neither solid nor hollow organ

  7. First step of Management • Resuscitation of patients with suspected abdominal injuries – same as other trauma patients • ATLS • Surgical plan

  8. Basic plan of Surgical Decision • Is there any abdominal injury? (PE, Ix) • Is intervention required? (conservative treatment + close monitoring +/- serial Ix) • Is surgery required? (interventional radiology) • Damage control or definitive surgery (correct physiology then anatomy)

  9. Assessment and diagnosis • Normal abdominal finding • Obvious injury to the abdomen eg gun shot wound • Equivocal findings requiring further investigation and re-assessment eg blunt abdominal trauma

  10. Investigations • Diagnostic peritoneal lavage DPL • FAST USG • CT scan • (Laparoscopy) • (DPA)

  11. DPL • Previously the standard investigation • Replaced FAST • Detect blood • Bowel content : bacteria, food particles, bile • Accuracy up to 98% • Miss diaphragmatic and retroperitoneal injury

  12. FAST • Detect fluid (blood) inside peritoneal cavity • Accuracy comparable to DPL • Non invasive and repeatable • Operator dependant • Miss specific injuries • Obesity • Replace DPL in many trauma centre

  13. CAT scan • Document specific organ injury • Retro-peritoneal organs • Accurate • Haemo-dynamically stable patients • Can still miss diaphragmatic injury and bowel injury

  14. Basic plan of Surgical Decision • Is there any abdominal injury? (PE, Ix) • Is intervention required? (conservative treatment + close monitoring +/- serial Ix) • Is surgery required? (interventional radiology) • Damage control or definitive surgery (correct physiology then anatomy)

  15. Surgical decision • Normal abdominal finding • Obvious injury to the abdomen • Equivocal abdominal findings

  16. Normal abdominal finding • Re-assessment and physical finding by same experienced surgeon in haemo-dynamically normal is usually sufficient • ? CAT scan before other extra-abdominal surgery in awake and alert patients • FAST or DPL in unstable patients

  17. Surgical decision • Normal abdominal finding • Obvious injury to the abdomen • Equivocal abdominal findings

  18. Obvious injury to the abdomen • Mostly applied to penetrating injury • Virtually all penetrating abdominal injury should be “explored” promptly, especially in the presence of hypotension • Local wound exploration • Laparoscopy / laparotomy • Gun shot wound - laparotomy • CAT scan

  19. Surgical decision • Normal abdominal finding • Obvious injury to the abdomen • Equivocal abdominal findings

  20. Equivocal abdominal findings • Further investigation very much depends on haemo-dynamic status of the patients • Haemodynamically normal: reassessment , CAT scan, other investigation

  21. Equivocal abdominal findings • Haemodynamically stable : CAT scan • Whether the patient has bled into the abdomen • Whether the bleeding has stopped. • Detect specific organ injury

  22. Equivocal abdominal findings • What if CT shows free fluid without solid organs injury in a stable patient? • Blood, bowel content, bile, urine • ? Mandatory laparotomy • But non-therapeutic laparotomy is up to 92% in one of the US multi-centre prospective study • Re-assessment

  23. Equivocal abdominal findings • Haemodynamically unstable : DPL or FAST • Positive finding : operation • A negative finding is also important : we have to focus on the other compartment (chest, pelvis, long bones) or external haemorrhage

  24. Basic plan of Surgical Decision • Is there any abdominal injury? (PE, Ix) • Is intervention required? (conservative treatment + close monitoring +/- serial Ix) • Is surgery required? (interventional radiology) • Damage control or definitive surgery (correct physiology then anatomy)

  25. Conservative management • NOM • Liver injury (esp grade I – III) • Splenic injury (esp grade I – III, paediatric group) • Renal injury • Interventional radiologist

  26. Conservative management • Beware of concomitant solid and hollow organ injury • ~7% • It is still safe to adopt non operative management to stable patients with solid organ injury patients but repeated assessment is required

  27. Basic plan of Surgical Decision • Is there any abdominal injury? (PE, Ix) • Is intervention required? (conservative treatment + close monitoring +/- serial Ix) • Is surgery required? (interventional radiology) • Damage control or definitive surgery (correct physiology then anatomy)

  28. Is urgent surgery required? • Radiological evidence of intraperitoneal gas • Radiological evidence of ruptured diaphragm • Gunshot wounds • Evisceration • Positive result on diagnostic peritoneal lavage • Rigid silent abdomen or unexplained shock

  29. Aim of urgent operation • Haemorrhage control • Contamination control • Anatomical repair

  30. Aim of urgent operation • Haemorrhage control • Contamination control • Anatomical repair • Haemorrhage control + contamination control – anatomical repair = damage control surgery