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Blunt abdominal injuries

Adam J Brooks and Brian J Rowlands


Section of Surgery, Queen's Medical Centre, University Hospital, Nottingham, UK

In 1988, the Report of The Royal College of Surgeons of England on The


Management of Patients with Major Injuries* identified intra-abdominal
injury as a significant cause of preventable deaths. Since then new
concepts and techniques have been introduced in the surgical management
of blunt abdominal injury (BAI). Some have been widely accepted by
those dealing with trauma on a frequent basis, whilst other approaches
and technical 'advances' remain contentious. This chapter will review
those main developments diat have found approval including: (i) damage
control; (ii) non-operative management of solid organ injury; (iii)
interventional radiology; and (iv) organ injury scales.
In addition, a balanced account will be given of some of the other
areas and procedures which remain open for debate: (1) investigation of
BAI; and (ii) therapeutic laparoscopy.

Correspondence to
Prof. Brian J Rowlands,
Section of Surgery,
Queen's Medical Centre,
University Hospital,
Nottingham
NG7 2UH, UK

Damage control
The acceptance by trauma surgeons of the 'abbreviated' or 'damage
control' laparotomy has been a significant development in surgery for
abdominal injury. It is not a new concept to terminate operative
procedures for a deteriorating patient to allow further resuscitation and

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The management of blunt abdominal injury (BAI) has undergone quite


significant changes over recent years. The emphasis is now on the recognition
and limitation of the underlying metabolic insult associated with severe
abdominal injury. The concepts of damage control and non-operative management while seeming diametrically opposed have both found favour in selected
patient groups. The interventional radiologist has opened a new dimension in
the control of inaccessible bleeding and is able to contribute to non-operative
approaches. The complimentary use of the methods of investigation available
for BAI will also improve the accuracy and specificity of diagnosis allowing more
appropriate management. Embracing these new concepts of management by all
institutions dealing with trauma victims will hopefully reduce the morbidity and
mortality of BAI.

Blunt abdominal injuries

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restoration of physiological reserve. Its origins can be traced back to


Halsted's original description of the control of bleeding by packing in
the management of liver injuries in 1908. In the 1980s, Stone et ah
repopularised this approach by advocating abdominal packing and
closure in the approach to major intra-operative coagulopathy.
Subsequently, this technique has become referred to as either 'damage
control'3 or the 'abbreviated laparotomy'4. Rotondo et aP refined the
technique and published a prospective study of 46 severely injured
patients comparing definitive laparotomy with damage control. They
showed a survival advantage m the damage control group amongst these
patients with major vascular and multiple visceral injuries.
The principles of resuscitation and the objectives of surgery in the
trauma patient remam unchanged. The aim of resuscitation is to correct
and maintain oxygenation and tissue perfusion. The surgical approach
involves control of haemorrhage, limitation of contamination and
restoration of continuity. The concept of damage control is based on the
realisation that patients with hypothermia, acidosis and coagulopathy
are in metabolic exhaustion and have a high risk of death. The final
objective of surgical intervention remains unaltered, but the emphasis on
timing has changed in damage control. Surgical techniques must be
performed to minimise the metabolic insult rather than merely restoring
anatomical continuity.
There are three key factors that interact to produce the downward
metabolic spiral5. They are: (i) hypothermia despite warming; (ii) clinically
detectable coagulopathy (non-surgical bleeding); and (iii) persistent severe
acidosis. Trauma patients are at high risk of hypothermia during the
prehospital phase and during resuscitation and operative procedures
where heat loss sometimes occurs at rates of 8cC/h6. Hypothermia inhibits
blood clotting, induces vasoconstriction, impairs myocardial performance
and increases myocardial irritability. The effect of hypothermia on
mortality is marked in severe injury. Jurkovich7 reported a significant
difference in mortality in hypothermic patients from a cohort of 71
injured patients. There were no survivors amongst the patients who
developed a core body temperature less than 32C. The trauma team must
be aware constantly of the risks of heat loss and take measures to
minimise it. Rewarming using rapid blood warming infusion devices,
warm air convection blankets or thermal reflective sheets should be
started early in resuscitation and assessment.
Coagulopathy may develop despite aggressive blood and component
replacement because of dilution of clotting factors from resuscitation
fluids and hypothermia. Cosgriff8 showed that hypothermia and
metabolic acidosis were predictors for life-threatening coagulopathy in a
study of 58 severely injured patients. Likewise, persistent acidosis
increases cardiac instability and decreases the response to catecholamines.

Trauma

Abdominal compartment syndrome and techniques of


wound closure
Damage control, like any procedure, has its complications. It may result
in the abdominal compartment syndrome (ACS) and complex wound
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The recognition of patients who have metabolic decompensation or


dysfunction is the first stage in the damage control approach. No controlled trials exist to determine the optimum timing of damage control or the
recognition of the interdependence of the key factors. It has been
suggested that the procedure should be terminated rapidly when hypothermia is progressive or a temperature of 34C is reached; acidosis with
a pH of < 7.2 develops despite adequate volume replacement and of
peroperative coagulopathy is recognised as non-surgical bleeding9.
Prehospital stability, resuscitation requirements, pre-existing medical
conditions and injury pattern recognition all impact on the decision to
institute damage control.
Once recognised, the procedure is rapidly terminated using standard
surgical techniques, packing and closure. This is followed by secondary
resuscitation in the critical care unit to correct physiological exhaustion
and restore reserve. Definitive laparotomy follows within 48 h on restoration of normal physiology3. In the patient with continuing instability, this
technique may have to be employed a number of times to deal with all the
injuries.
The components of the damage control laparotomy are control of
haemorrhage and contamination. Haemorrhage may be controlled initially
by four-quadrant packing, followed by ligation, repair or temporary shunt
of vessels. Development of non-surgical bleeding will require packing of
the abdomen to produce tamponade. Care must be taken to avoid further
injury during this process and some institutions recommend covering packs
with Op Site to prevent adherence to tissues. Initially, enteric
contamination can be temporarily controlled with Babcock clamps or soft
bowel clamps. This may be followed by ligation, suturing or stapling of
bowel injuries leaving definitive anastomosis to re-establish bowel
continuity until subsequent laparotomy.
In the intensive care unit, fluid therapy and monitoring continue the
resuscitation that began in the emergency room. The core principles are
invasive monitoring and cardiopulmonary support, aggressive rewarming,
and replacement of blood and clotting factors to correct coagulopathy
and the correction of the acid-base imbalance. The decision to return to
theatre for definitive surgery can usually be made within 24 h, but must
be made at a time when there is correction of key factors, restoration of
reserve and cardiovascular stability.

Blunt abdominal injuries

Table I Adverse effects of raised intra-abdommal pressure


Abdominal pressure

Adverse effects

>15 mmHg

Fall in cardiac output


Increase in airway pressures
Decreased pulmonary compliance
Decreased blood flow t o intra-abdominal organs
Ohguna
Fatal organ failure

> 30 mmHg

Non-operative management of blunt abdominal injury


The vogue for the non-operative management of solid organ injury has
increased and found wide acceptance. The use of computerised tomography (CT) and other modalities of diagnosis (ultrasound, laparoscopy,
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closure. ACS is defined as adverse physiological consequences caused by


an acute increase in intra-abdominal pressure10.
Following crystalloid resuscitation and prolonged laparotomy, there
may be progressive and sustained oedema and distension of the bowel.
This increase in volume coupled with slow haemorrhage from on-going
coagulopathy and the insertion of abdominal packs, may lead to an
increase in the intra-abdominal pressure following closure of the fascia
- the abdominal compartment syndrome. The increased intraabdominal pressure (IAP) leads to adverse effects on the cardiac output,
respiratory function and renal function (see Table I) 11 .
The indication for abdominal decompression depends on the response
to raised IAP. IAP can be reliably measured using bladder pressure
measurements, but the development of oliguria/anuria, high airway
pressures or inadequate oxygenation are indications for decompression
of the abdomen.
Numerous techniques of closure of the abdominal wall following
trauma laparotomy or damage control procedure are described in an
effort to avoid high intra-abdominal pressures and ACS.
Temporary closure can be obtained by either direct suture fascial
closure or simple towel clip closure of the skin with application of a
Steri-drape to prevent excessive seepage. Both have the disadvantage
that they do not totally eliminate the possibility of raised intraabdominal pressure. The use of a temporary silo for closure of the cavity
has been recommended in those patients at risk of raised LAP12. This has
been performed successfully using Steri-drape or silastic sheeting or by
suturing a large intravenous or urological irrigation bag to the wound
edges - the 'Bogata Bag'. This system alleviates the rise in intraabdominal pressure, preventing the development of ACS.

Trauma

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magnetic resonance imaging) in conjunction13, has allowed the


assessment of the grade or extent of organ injury and the accurate
follow-up of its resolution. When the latest therapeutic techniques in
interventional radiology14 are also used, an increasing number of
patients with isolated abdominal solid organ injury can be managed
without surgical intervention.
Haemodynamic stability is of paramount importance when patients
are considered for non-operative management. Mucha et aP5 suggested
that adults with splenic injury should only be treated non-operatively
when they had minimal physical signs, cardiovascular stability and
required less than 2 units of transfused blood. Two retrospective studies
of the use of CT scan to determine the need for surgery in splenic trauma
have recently been published. They looked at the scans from 45
patients16 and 70 patients17, respectively, and concluded that, despite
accurate determination of injury grade by CT scan, clinical criteria
should be used to make the decision about appropriate need for surgical
intervention. 'Non operative management' should not be considered
'conservative' management as these injured patients still have great
potential for rapid deterioration. They should be closely monitored for
haemodynamic instability, fluid and transfusion requirements in a high
dependency or intensive care unit.
Accurate assessment of the extent, severity of primary injury and
associated injuries is vital to successful management. Smith18 showed, in
a prospective series of 112 patients with blunt splenic trauma, that
younger patients with less severe injuries (American Association of
Surgeons for Trauma Organ Injury Scale I, II or III), haemodynamic
stability and the absence of other abdominal injuries could be managed
non surgically with success in 93% of cases. Carillo's19 recent review of
blunt hepatic injury concluded that non-operative management could be
considered in up to 50% of blunt liver injuries in adults with a 50-80%
success rate. Patient selection and accurate CT grading of injury severity
was essential, although the latter could not predict failure. The majority
of renal injuries in the stable patient can be managed non-operatively
unless there is injury to the renal pedicle as determined by CT scan,
intravenous urogram or selective arteriogram.
Paediatric surgeons have more readily embraced the concept of nonoperative management although there is no definite evidence that
children tolerate this approach better than adults. Thaemert20 showed
no difference between adults and children in the non-operative
management of splenic injury. Smith18 showed a greater success for this
approach in patients less than 55 years old. In children, non-operative
management is recommended in lower grades of splenic and liver21
injuries. A recent retrospective study showed a 79% success rate for this
approach in 123 patients with grade 1 or 2 pancreatic injury22.

Blunt abdominal injuries

Interventional radiology

Assessment of organ injury severity


In 1987, the Organ Injury Scaling Committee of the American
Association for the Surgery of Trauma (AAST) was established. It was
charged with devising injury severity scores for individual organs and
body structures to facilitate clinical research and quality improvement.
The classification scheme is a systematic, graded anatomic description
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The interventional radiologist has become an integral member of the


trauma team. Their technical expertise has allowed the diagnosis of
inaccessible and unrevealed haemorrhage and brought new therapeutic
strategies into play. Angiography is an important diagnostic adjunct in
trauma13'14 especially when used in conjunction with CT. This allows
accurate diagnosis of bleeding and provides therapeutic options in both
surgical and non-operative management. Sclafani14 reported 60 patients
with splenic injury who underwent coil embolisation of the proximal
splenic artery following angiography showing contrast extravasation.
This technique was successful in stopping bleeding in 93% of patients
allowing non-operative management. Interventional radiology has
added a new dimension to the treatment of severe liver injuries. The
technique is complimentary to traditional surgical techniques and
perihepatic packing. Denton23 reported the successful use of a
combination of arterial embolisation and transhepatic venous stenting in
a multidisciplinary approach to grade V liver injury involving the
retrohepatic vena cava. A similar surgical and radiological approach
involving the placement of a stent in a damaged hepatic vein with
successful outcome has also been reported by Burch10. It opens a new
avenue for the management of these complex problems, which have a
high morbidity and mortality.
In abdominal trauma, interventional radiological techniques have found
most acceptance in the diagnosis and management of haemorrhage from
complex pelvic fractures. Different fractures have been shown to be
associated with injuries to specific arteries24 and arteriography and
embolisation allows accurate diagnosis and control of bleeding.
Interventional radiological techniques including selective arterial
embolisation, temporary balloon occlusion for vascular control and stent
placement have all been successfully reported in the management of head
and neck vascular injuries25126. There is potential for applying these
techniques to BAI both in the acute phase and in the treatment of complications, e.g. percutaneous drainage of post injury intra-abdominal
abscess and haematoma.

Trauma

Table 2 Spleen injury scale (1994 revision)


Grade

'Grade

Injury description

Haematoma
Laceration

Subcapsular, < 10% surface area


Capsular tear, < 1 cm parenchymal depth

II

Haematoma
Laceration

Subcapsular, 10-15% surface area, intraparenchymal, < 5 cm in diameter


Capsular tear, 1-3 cm parenchymal depth which does not involve a
trabecular vessel

III

Haematoma

Subcapsular, > 50% surface area or expanding, ruptured subcapsular or


parenchymal haematoma, intraparenchymal haematoma > 5 cm or
expanding
> 3 cm parenchymal depth or involving trabecular vessels

Laceration
Laceration

Lacerationinvolving segmental or hilar vessels producing major


devasculansation (> 25% of spleen)

Laceration
Vascular

Completely shattered spleen


Hilar vascular injury which devasculanses spleen

'Advance one grade for multiple injuries up to grade III


After Moore et aP

scaled from I to VI that differs from the Injury Severity Score as it is not
intended to correlate with anticipated patient outcome. The grades
represent increasingly complex injuries and grade VI is reserved for
injuries that are beyond repair and are incompatible with survival. The
majority of institutions dealing with trauma on a regular basis have
uniformly accepted this scheme. The organ injury scales provides a
common descriptive language for the comparison of technique and results
between organisations. The organ injury scales for splenic and duodenal
injuries are reproduced in Tables 2 and 3 27 .
Table 3 Duodenum injury scale
Grade

'Grade

Injury description

Haematoma
Laceration

Involving single portion of duodenum


Partial thickness no perforation

II

Haematoma
Laceration

Involving more than one portion


Disruption < 50% of circumference

III

Laceration

Disruption 50-75% circumference of D2


Disruption of 50-100% circumference of D1, D3, D4

IV

Laceration

Disruption > 75% circumference of D2


Involving ampulla or distal common bile duct

Laceration
Vascular

Massive disruption of duodenopancreatic complex


Devasculansation of duodenum

'Advance one grade for multiple injuries up to grade III


After Moore et aP

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IV

Blunt abdominal injuries

Current debate
Abdominal assessment and investigation

Patients with suspected abdominal injuries from blunt trauma could be


categorised in to three groups:
1 Those requiring immediate surgery on clinical examination alone.
2 Those requiring further investigation using appropriate diagnostic test to
determine intra-abdominal injury and assess the most appropriate
management.

The proportion in each group at any institution depends on the


mechanisms of trauma most commonly seen and the severity.
There is continuing debate over the most appropriate diagnostic
investigation for patients who fall into the second group where diagnosis
of injury is required. The most commonly used modalities for this
assessment are: (i) diagnostic peritoneal lavage; (ii) ultrasound; (iii) computerised tomography; (iv) diagnostic laparoscopy; and (v) magnetic
resonance imaging.
Diagnostic peritoneal lavage

Original described in 1965 by Root et aP3, diagnostic peritoneal lavage


(DPL) has been the gold standard investigation for BAI against which
others have been compared. Despite the advent of ultrasound and CT,
DPL has remained the investigation of choice in many institutions
because it is reproducible29, inexpensive and accurate. Powell et al30
found an accuracy of 97.3% in a review of collected series with false
positive and false negative rates of 1.4% and 1.3% only. In blunt
trauma, lavage counts of 100,000 red cells/mm3 (RCC) and 500 white
cells/mm3 have been accepted as providing the most appropriate balance
between false negative and false positive investigations. With equivocal
results (RCC 50,000100,000) the use of a second diagnostic test
improves accuracy. The most recent studies comparing open techniques
with closed percutaneous techniques have reported equal sensitivity and
specificity between these methods and found the closed technique to be
faster and associated with fewer complications31'32.
Ultrasound

In Europe and the US, ultrasound has become the main investigation for
blunt abdominal trauma and is most useful in detecting injury to solid
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3 Those with no abdominal injury on clinical examination and where there is


a low index of suspicion require only observation and re-examination.

Trauma

Computerised tomography

In the stable patient with blunt abdominal injury, CT is the investigation


of choice in many institutions. A standard trauma scan with a modern
spiral scanner can be acquired in 3-5 min and should include
intravenous contrast. The use of oral contrast is unnecessary in trauma
patients38, and many institutions no longer use it. The scans should
image from the top of the diaphragm, to visualise intrathoracic haemoand pneumothoraces, to the pubic symphysis and into the pelvis to aid
orthopaedic assessment of suspected pelvic fracture.
The advantages of CT are the capacity to visualise retroperitoneal in
addition to peritoneal structures. The severity of injury and its suitability
for non operative treatment17 can also be judged although the correlation
between CT assessment and operative grading of organ injury has been
reported to be 20 %39. A review of prospective studies from the 1990s using
modern CT scanners gives a sensitivity of 88% and a negative predictive
value of 97%40, but has significantly reduced accuracy in the diagnosis of
hollow organ41 and pancreatic injuries42.
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intraperitoneal and retroperitoneal organs and the presence of free


intrapentoneal fluid or blood. It is common for the surgical residents or
trauma fellows to perform the examination. Accuracy improves with the
experience of the investigator33. Rozycki's34 study evaluated 476 patients
and showed 79% sensitivity and 96% specificity with surgeons performing the examination. For the detection of free intraperitoneal fluid,
the sensitivity has been reported to be 81 %35 to 88%36 with an accuracy
of detecting injury of 99% in McKenny's36 report of 1000 consecutive
ultrasounds for BAI.
The focused abdominal sonogram for trauma (FAST) is the technique of
choice for surgeons using ultrasound to assess the abdomen34. This
involves a limited number of ultrasound windows to detect fluid: right
upper quadrant (Morrison's pouch); left upper quadrant (splenorenal
recess and subdiaphragmatic space); the pouch of Douglas and a pericardial window to assess for pericardial effusion. Rozycki37 showed m a
collective review of 4941 patients that surgeons using FAST for the
investigation of BAI had a sensitivity of 93.4%, specificity of 98.7% and
accuracy of 97.5% in detecting both haemopentoneum and visceral injury.
Ultrasound is a fast, non-invasive and portable modality for investigations, but is dependent on operator experience. It may be limited by
obesity and is poor for evaluation of injuries to the diaphragm and some
retroperitoneal structures (e.g. pancreas). Reliability and accuracy is
improved by repeating the procedure over a period of time34. A single
normal ultrasound examination cannot be taken as a guarantee that
there is no intra-abdominal injury.

Blunt abdominal injuries

Diagnostic laparoscopy

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) is unlikely to be used in the


assessment of the acute patient. However, this technique may develop a
role in patients where presentation is delayed. Specifically, the value of
MR cholangiography in assessing the biliary and pancreatic system
following trauma has yet to be assessed.
No single diagnostic modality is ideal in the investigation of every patient
with BAI. The sensitivity and specificity of the tests vary with DPL being
the most sensitive but not as specific as CT or ultrasound47. Catre40 and
Liu47 have suggested that the methods are complementary and theu: use in
combination would improve the overall accuracy and organ specificity.
Therapeutic laparoscopy
The extension of laparoscopic procedures to abdominal trauma in a
therapeutic capacity remains largely in the hands of a few enthusiasts.
The largest series published to date reports on 28 therapeutic procedures
including the repair of diaphragm injuries and a closure of gastrostomy48. The mean stay in the absence of other injuries was only 2.7
days, however the mean time taken for the surgical procedures was 111.8
min (range 75-265 min). As a technique in abdominal trauma surgery, it
is unlikely to have a major role due to the constraints of theatre time, the
instability of trauma patients and the technical difficulties encountered
with performing laparoscopic procedures.
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There is little work to support the use of diagnostic laparoscopy (DL) in


blunt abdominal injury. Leppaniemi43 published a collective analysis of 11
reports with 355 blunt abdominal injury patients. He found DL to be
97% accurate but concluded that it was limited by time and cost when
compared to less invasive bedside investigations. At present it cannot be
recommended as a primary investigation in blunt abdominal injury.
Salvino44 compared DPL to diagnostic laparoscopy in a prospective study
of 59 patients with BAI. He concluded that alterations in management
and improvement in outcome would occur in only 3 % of cases assessed
by DL and, therefore, its routine use could not be justified.
Technically, DL is hampered by the presence of blood and it is difficult
to thoroughly assess the spleen and retroperitoneal structures. The role
for DL in the assessment of BAI is two fold - as an adjunct to other
diagnostic tests in selected patients, e.g. the assessment of diaphragmatic
rupture, and to determine those patients with minor injuries suitable for
non-operative management45'46.

Trauma

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