Additional Notes for Abdominal Trauma II

Group 1- Ninja Stones

Please refer to the Notes for Abdominal Trauma II
Definitions
Exploratory Laparotomy
By definition, is a laparotomy performed with
objective of obtaining information that is not
available via clinical diagnostic methods
Indications:
1. Acute onset abdominal pain and clinical
findings suggestive of intra-abdominal
pathology requiring emergency surgery
2. Abdominal trauma with hemiperitoneum and
hemodynamic stability
3. Chronic abdominal pain
4. Staging of ovarian malignancy and Hodgkin
disease
5. Obscure gastrointestinal bleeding
In patients with penetrating abdominal trauma
(PAT), it is conventionally carried out : to rule out
intra-abdominal injury
Laparoscopy has been found to be useful in
identifying diaphragmatic injury
less sensitive: for detecting hollow visceral
injuries
very good: for identifying the need for
exploratory laparotomy
Surgical Options for Hepatic Injuries
Pringle Maneuver
In 1908, is first described by Pringle as a technique
to minimize blood loss during hepatic surgery by
clamping the vascular pedicle
The surgeons must be able to isolate the sources of
blood flow (hepatic artery and portal vein) to liver
to control bleeding during:
1. Traumatic liver injuries
2. Elective liver resections
The portal triad may be accessed through the
Foramen of Winslow by placing a finger directly on
the caudate lobe and sweeping it to the right ,
thereby encircling the hepatoduodenal ligament or
porta hepatis.
Often used as an adjunct to packing for the
temporary control of haemorrhage
Only control bleeding coming from hepatic artery
and portal vein
Cannot control bleeding coming from retrohepatic
vena cava or hepatic veins

Placement of Omental Pedicle

Omentum can be used to fill large defects in the
liver
The tongue of omentum not only obliterates the
potential dead space with viable tissue but
provides an excellent source of macrophage
The omentum can provide buttressing support for
parenchymal sutures
Perihepatic packing
Is effective in controlling most major hepatic
injuries
Used to control bleeding from retrohepatic vena
cava and hepatic veins
The right costal margin is elevated and the pads are
strategically placed over and around the bleeding
site
Additional pads should be placed between the
liver, diaphragm and anterior chest wall until the
bleeding has been controlled
10-15 pads maybe needed to control haemorrhage
from an extensive right lobe injury
Packing of injuries in the left lobe is not as effective
because there is insufficient abdominal and
thoracic wall anterior to left lobe to provide
adequate compression with the abdomen open.
If bleeding continues despite perihepatic packing,
direct repair with or without hepatic vascular
isolation should be attempted:
3 techniques to achieve vascular occlusion:
1. Isolation with clamps in the abdominal aorta, the
suprarenal cava and suprahepatic cava
2. Atriocaval shunt
3. Moore-Pilcher balloon shunt
Two complications may be encountered with the
packing of hepatic injuries.
1. Tight packing compresses the inferior vena
cava, decreases venous return, and reduces
left ventricular filling- hypovolemic patients
may not tolerate the resultant decrease in
cardiac output.
2. It forces the right diaphragm superiorly and
impairs its motion- this may lead to increased
airway pressures and decreased tidal volume.

Atriocaval Shunt
Designed to achieve hepatic vascular isolation
while still permitting some venous blood from
below the diaphragm to flow through the shunt
into the right atrium.
After a few early successes, the initial enthusiasm
for the atriocaval shunt declined as high mortalities
associated with its use began to be reported.
Surgeons' lack of familiarity with the technique;
the manipulation of a cold, acidotic heart; and poor
patient selection have all contributed to the poor
overall results.
Liver balloon tamponade
One method of fashioning such a device is to tie a
2.5 cm Penrose drain to a hollow catheter
The balloon is then inserted into the bleeding
wound and inflated with a soluble contrast agent.
If the hemorrhage is controlled, a stopcock or
clamp is used to occlude the catheter and maintain
the inflation.
The balloon is left in the abdomen and removed at
a subsequent operation after 24 to 48 hours.
The hemorrhage may recur when the balloon is
deflated.

Finger Fracture
used to extend the length and depth of a laceration
or a missile tract until the bleeding vessels can be
identified and controlled
It should be remembered that considerable blood
loss may be incurred with the division of viable
hepatic tissue in the pursuit of bleeding from deep
penetrating wounds.
Liver suturing
Suturing of liver parenchyma is an effective
hemostatic technique
Do not use blunt 0 chromic suture as it can tear
liver capsule and is associated with necrosis
Manual Compression
Done to control massive bleeding of the left lobe of
liver
Mobilizing the lobe and compressing it between
surgeons hands
Also for minor lacerations in liver parenchyma

Selective Ligation
For injuries in the portal triad
The right or left hepatic artery or in urgent
situations, the portal vein maybe selectively ligated
If right hepatic artery is ligated, cholecystectomy
should be performed
If vascular injury is a stab wound, with clean
transection of the vessels, primary end-end repair
is done
Its primary role is in the management of deep
injuries when application of the Pringle maneuver
results in the cessation of arterial hemorrhage.

Surgical Options for Extrabiliary Tree Injuries

T-tube Stenting
Insertion of T tube through the wound to treat
small lacerations with no accompanying loss or
devitalization of adjacent tissue
Lateral Repair
Lateral suturing using 6-0 monofilament
absorbable suture also to treat small lacerations
with no accompanying loss or devitalization of
adjacent tissue
Roux-en-Y choledojejunostomy
Is required to treat all transections and any injury
associated with significant tissue loss
Anastomosis is performed using a single layer
interrupted technique with 4-0 or 5-0
monofilament absorbable suture
Intubation and external drainage
An approach to reduce anastomotic tension in
Roux-en-Y-choledojejunostomy
Surgical Options for Splenic Injuries
Splenectomy
Indicated for hilar injuries, pulverized splenic
parenchyma or any injury of grade 2 or higher in
patient with coagulopathy or multiple injuries

Partial Splenectomy
Employed in patients whom only the superior or
inferior pole of spleen in injured
Splenorraphy
Splenic repair
Achieved by topical methods such as
electrocautery, argon beam coagulation application
of thrombin soaked gelatin from sponges , fibrin
glue or Bio Glue
Surgical Options for Duodenal Injuries
Simple repair
For small duodenal lacerations
Use of single layer suture of 3-0 monofilament
The wound should be closed in a direction that
results in largest residual lumen
Debridement and End-end anastomosis
For extensive injuries in 1st portion of duodenum
because of the mobility and rich blood supply of
the dusta gastric atrium and pylorus
For 2nd portion of duodenum, often results in
unacceptably narrow lumen
Serosal patching
For defects in 2nd portion of duodenum
Patching with a vascularized jejunal graft
Roux-en Y- duodenojejunostomy
For duodenal injuries with tissue loss distal to
ampulla of Vater and proximal to mesenteric
vessels
For defects in 3rd and 4th portion of duodenum
Pyloric Exclusion
Often used to divert GI
stream after high risk
complex
duodenal
repairs
To perform, 1st
a
gastrostomy is made in
the greater curvature
near the pylorus
Pylorus is then grasped
with a Babcock clamp
via gastrostomy and
oversewn with an O polypropylene suture
Duodenal diverticulization
In cases of severe injury to the duodenum, it may
be advisable to divert gastric contents away from

the duodenal repair.

One technique for accomplishing this diversion is
duodenal diverticularization, which employs
primary closure of the duodenal wound,
antrectomy, vagotomy, end-to-side
gastrojejunostomy, drainage of the CBD with a T
tube, and lateral tube duodenostomy

Diagnosing Pancreatic Duct Injuries

Operative Pancreatography
Performed through duodenotomy by cannulating
the duct using 5F pediatric feeding tube
Under fluoroscopy, full strength constrast material
is slowly injected while observing for obstruction or
extravasation
Ductal cannulation
Passing a 1.5 to 2.0 mm coronary dilator into the
main duct via the papilla and observe the depth of
the pancreatic wound
If the dilator is seen in the wound, a ductal injury is
confirmed
Endoscopic Retrograde pancreatography
Technique that uses a combination of luminal
endoscopy and fluoroscopic image to diagnose and
treat conditions associated with pancreaticobiliary
system
Roux-en-Y pancreaticojejunostomy
To preserve both spleen and distal transected end
of the pancreas
Distal Pancreatomy with splenectomy
Also used to preserve both spleen and distal
transected end of pancreas but only to those who
are physiologically compromised

Surgical Repair of Rectal Injuries

Rectal injuries and management are classified according to
anatomic criteria:
1. The anterior and lateral sidewalls of the upper two
thirds of the rectum are serosalized
injuries in this region are classified as
intraperitoneal and are managed in the same
manner as colonic injuries

1. The upper two thirds of the rectum posteriorly and

the lower one third of the rectum circumferentially
are not serosalized
injuries in these regions are classified as
extraperitoneal.
Diverting Colostomy
Also performed as an adjunctive measure and may
be accomplished with either loop or end
colostomy.
In select cases in which the wound is primarily
intraperitoneal with minimal extraperitoneal
involvement: diversion may be omitted
Distal washout
Distal rectal washout was initially advocated on the
basis of experience gained during the Vietnam
War.
In the majority of civilian studies since then,
however, distal rectal washout has had no
significant effect on morbidity.
Useful in cases of : severe wound contamination or
fecal impaction
But in general, it does not seem to be an important
adjunct to the management of rectal injuries.
Typically, it involves lavage of the rectum distal to
the injury with 3 to 6 L of irrigant via an irrigation
tube placed into the distal limb of a loop
colostomy.
Presacral Drainage
For inaccessible extraperitoneal wounds, presacral
drainage is required to prevent retroperitoneal
abscess formation, which results from fecal
contamination of a relatively closed space and can
produce significant morbidity in the form of
retroperitoneal infection that may also track
downward into the thighs.

For accessible extraperitoneal wounds that are

explored and repaired become effectively
intraperitonealized, presacral drainage is not
required.
Is performed with the patient in the lithotomy
position
A curvilinear incision is made in the skin between
the coccyx and the anus, and blunt dissection is
employed to gain entry into the presacral space.
Generally, we place one or two Penrose drains into
this space and gradually withdraw them between
postoperative days 5 and 7.
Reference: Schwartz Principle of Surgery 9th Ed
ACS Surgery, Principles and Practice, 2007
Medscape : for Laparotomy and ERCP definition
Note: most lectures are taken from ACS Surgery and
Practice, 2007 edition

Table 1 AAST Organ Injury Scales for Liver, Biliary Tract, Diaphragm, and Spleen
Injured
Structure

AAST
Grade
I

II

III

IV

Liver*

VI
I

Extrahepatic
biliary tree*

II
III
IV

Characteristics of Injury
Hematoma: subcapsular, nonexpanding, < 10%
surface area
Laceration: capsular tear, nonbleeding, < 1 cm
parenchymal depth
Hematoma: subcapsular, nonexpanding, 10%50% surface area; intraparenchymal,
nonexpanding, < 10 cm in diameter
Laceration: capsular tear, active bleeding, 1-3
cm parenchymal depth, < 10 cm in length
Hematoma: subcapsular, > 50% surface area,
expanding; ruptured subcapsular hematoma
with active bleeding; intraparenchymal, > 10
cm or expanding
Laceration: > 3 cm parenchymal depth
Hematoma: ruptured intraparenchymal
hematoma with active bleeding
Laceration: parenchymal disruption involving
25%-75% of hepatic lobe or 1-3 Couinaud's
segments within a single lobe
Laceration: parenchymal disruption involving >
75% of hepatic lobe or > 3 Couinaud's
segments within a single lobe

Vascular: juxtahepatic venous injuries (i.e.,

injuries to retrohepatic vena cava or central
major hepatic veins)

Vascular: hepatic avulsion

Gallbladder contusion/hematoma
Portal triad contusion
Partial gallbladder avulsion from liver bed;
cystic duct intact
Laceration or perforation of gallbladder
Complete gallbladder avulsion from liver bed
Cystic duct laceration
Partial or complete right or left hepatic duct
laceration

Management

AIS-90 Score
2
2

1. Apply topical agents

2. Do not drain
3. Close abdomen

2
2

3
3
4
4

5
2
2
2
2
3
3
3

Bleeding is controlled by Pringle Maneuver

1. If bleeding is controlled close
abdomen without drains
2. If bleeding continues (mostly low
pressure before Pringle Maneuver)
a. suture bleeding vessels even
those deep in liver parenchyma
b. pack abdomen if necessary
c. drain as indicated, close
abdomen
3. If bleeding continues (mostly high
pressure before Pringle maneuver)
a. Suture bleeding vessels even
those deep in liver parenchyma
b. If necessary ligate right or left
hepatic artery
c. Drain as indicated and close
abdomen
Bleeding is not controlled by Pringle
Maneuver:
1. If bleeding is controlled
a. Close abdomen without drains
b. Remove packs in 1 to 2 days
2. If bleeding continues
a. Control bleeding with
intrahepatic balloon
tamponade, atriocaval shunt or
vascular isolation as necessary
b. Repair injury to hepatic vein or
vena cava
c. Drain as indicated and close
abdomen

If only one hepatic duct is injured:

- ligate it and deal with any infections
or atrophy of the hemiliver rather
than to attempt repair.
If both ducts are injured
- each should be intubated with a
small catheter brought through the
abdominal wall. Once the patient
has recovered sufficiently, delayed

Partial common hepatic duct or common bile

duct laceration (< 50%)
> 50% transection of common hepatic duct or
common bile duct
Combined right and left hepatic duct injuries

3
3-4
3-4

V
Intraduodenal or intrapancreatic bile duct
injuries

Diaphragm

3-4

Contusion

II
III
IV

Laceration < 2 cm
Laceration 2-10 cm
Laceration > 10 cm, with tissue loss < 25 cm2

3
3
3

Laceration with tissue loss > 25 cm2

Hematoma: subcapsular, nonexpanding, < 10%

surface area
I
Laceration: capsular tear, nonbleeding, < 1 cm
parenchymal depth
Hematoma: subcapsular, nonexpanding, 10%50% surface area; intraparenchymal,
nonexpanding, < 5 cm in diameter
II
Laceration; capsular tear, active bleeding, 1-3
cm parenchymal depth, not involving a
trabecular vessel
Hematoma: subcapsular, > 50% surface area or
expanding; ruptured subcapsular hematoma
Spleen*
with active bleeding; intraparenchymal, > 5 cm
III
or expanding
Laceration: > 3 cm parenchymal depth or
involving trabecular vessels
Hematoma: ruptured intraparenchymal
hematoma with active bleeding
IV
Laceration: laceration involving segmental or
hilar vessels producing major devascularization
(> 25% of spleen)
V
Laceration: completely shattered spleen
Vascular: hilar vascular injury that
devascularizes spleen
*Advance one grade for multiple injuries, up to grade III.

Advance one grade for bilateral injuries, up to grade III.

AAST (American Association for the Surgery of Trauma)

repair is performed under elective

conditions.
Injuries to the intrapancreatic portion of
the CBD :
- treat by dividing the duct at the
superior border of the pancreas,
ligating the distal portion, and
performing a Roux-en-Y
choledochojejunostomy.
Repair using a long Allis clamp to grasp
part of the injury and evert the
diaphragm
Lacerations are repaired with continuous
No. 1 monofilament nonabsorbable
sutures.
With large avulsions or gunshot wounds
accompanied by extensive tissue loss:
polypropylene mesh is required to bridge
the defect

2
2
2
Total Splenectomy /Partial Splenectomy
2

3
4
4
5
5

Table 2 AAST Organ Injury Scales for GI Tract and Pancreas

Injured
Structure
Stomach

AAST Grade*

Characteristics of Injury

AIS-90 Score

Intramural hematoma < 3 cm; partialthickness laceration

Partial thickness: treat with hemostasis and

seromuscular closure

II

Intramural hematoma <3 cm; small (< 3

Full thickness: treat with hemostasis and

cm) laceration
III

Large (> 3 cm) laceration

closure in two layers

3

IV

Large laceration involving vessels on

greater or lesser curvature

Extensive (> 50%) rupture; stomach

devascularized

Single-segment hematoma; partialthickness laceration

2; 3

II

Multiple-segment hematoma; small (<

50% of circumference) laceration

2; 4

Perform near total or total gastrectomy

with Roux-en Y reconstruction
Grade 1 or 2 hematoma
1. If hematoma is detected at
laparotomy, treat with evacuation
2. If hematoma is detected by nonoperative means, observe patient
and support with NGT suction and
TPN
Grade 1 or 2 laceration
3. Perform primary suture closure in 1
or 2 layers
4. Consider pyloric exclusion if theres
pancreatic injury
1st option: primary closure with
concomitant pyloric exclusion

Duodenum

III

IV
V
I
Pancreas

If no associated injuries to duodenum,

pancreas and esophagus
- treat with gastrectomy and
gastroduodenostomy
If with associated injuries to duodenum
and pancreas
- treat with distal gastrectomy and
gastrojejunostomy

II
III

Large laceration (50%-75% of

circumference of segment D2 or
50%100% of circumference of
segment D1, D3, or D4)

Very large (75%-100%) laceration of

segment D2; rupture of ampullary or
distal bile duct
Massive duodenopancreatic injury;
devascularisation
Small hematoma without duct injury;
superficial laceration without duct injury
Large hematoma without duct injury or
tissue loss; major laceration without duct
injury or tissue loss
Distal transection or parenchymal

If primary repair is not feasible:

- Injury proximal to ampulla:
perform antrectomy plus
gastrojejunostomy and stump
closure
- Injury distal to ampulla: Perform
Roux-en Y duodenojejunostomy to
proximal end of duodenal injury
with oversewing of distal
duodenum
Pancreaticoduodenectomy

5
5
2

Reimplantation of ampulla or distal CBD

into duodenum
Treat with unroofing , careful inspection to
confirm absence of duct injury and
drainage

2; 3
4

Perform distal pancreatectomy with or

laceration with duct injury

without splenic salvage (splenic salvage is

worth considering in children)

IV

Proximal transection or parenchymal

laceration involving ampulla

Massive disruption of pancreatic head

Contusion or hematoma without

devascularization; partial-thickness
laceration

Perform pancreaticoduodenotomy
(Whipples Procedure)
Partial thickness injury: treat with
hemostasis and seromuscular closure

II

Small (< 50% of circumference) laceration

Repair with limited debridement and

closure in one or two layers

Small bowel
III

Large (>50% of circumference) laceration

without transection

IV

Transection

V
I
II
III
IV

Transection with segmental tissue loss;

devascularized segment
Contusion or hematoma; partialthickness laceration
Small (< 50% of circumference) laceration
Large (>50% of circumference) laceration
Transection

Transection with tissue loss;

devascularized segment

II
III

Contusion or hematoma; partialthickness laceration

Small (< 50% of circumference) laceration
Large (>50% of circumference) laceration

IV

Full-thickness laceration with perineal

If primary closure will not narrow lumen:

- Repair with limited debridement
and closure in one or two layers
If Primary closure will narrow lumen:
- Repair with resection and primary
anastomosis
Repair with resection and primary
anastomosis

Partial Thickness: perform seromuscular

closure

3
3
4

Full thickness: repair with primary closure

If No risk factors are present

repair with resection and primary
anastomosis
If Risk factors are present:
- perform resection with end
colostomy or perform resection
and primary anastomosis with
proximal diversion

If Location of Wound is intraperitoneal

- Manage as colon injury

Colon

Rectosigmoid
and rectum

If Unstable patient:
- Treat with hemostasis and
drainage with post op ERCP to
define duct anatomy and allow
duct stenting if necessary
If Stable patient:
- Divide pancreas completely,
oversew proximal stump and
perform Roux-en Y anastomosis of
distal pancreatic remnant to
jejunal limb
- Consider adding pyloric exclusion

3
4
5

If Location of wound is extraperitoneal

extension

Devascularized segment

1. Upper 2/3 of rectum:

- Repair with primary closure or
resection and primary anastomosis
- Perform proximal diversion
2. Lower 1/3 of rectum:
- If wound is accessible:
Repair with primary
closure
Repair with proximal
diversion
- If wound is inaccessible:
Perform proximal
diversion and presacral
drainage

*Advance one grade for multiple injuries, up to grade III. AIS-90 (Abbreviated Injury Score, 1990 version AAST (American
Association for the Surgery of Trauma)
Source: ACS Surgery Principles and Practice 2007 edition