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

13. 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

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

19. 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)

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

21. 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

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

27. 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

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

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

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

35. 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

36. 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

38. 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)

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

42. 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

45. 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)

46. 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

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

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