Professional Documents
Culture Documents
Epidemiologa
Presente en el 12% del Trauma en General
En el 20% de los Traumatismos que requieren Ciruga El abdomen esta involucrado hasta e el 30% de las lesiones fatales
Lmites Anatmicos
Superior x cara anterior: 4 Espacio Intercostal
En el flanco:
5 Intercostal
Cara posterior :
7 Espacio intercostal
Inferior:
Pelvis y Peron
Compartimentos Anatmicos
1.- Cavidad Peritoneal
Abdomen superior :
Abdomen inferior:
Abdomen superior
Contiene: Higado Bazo Estmago Pncreas Grandes vasos Ramas arteriales viscerales
Abdomen medio
Entre margen costal y EIAS Intestino delgado y colon Riones Aorta VCI
Abdomen bajo
Pelvis falsa Pelvis verdadera Intestino delgado Colon rectosigmoide Recto Sistema genitourinario Vasculatura iliaca
Compartimentos Anatmicos
2.- Espacio Retroperitoneal :
(Aorta, Vena cava, Pncreas, Riones, Ureteros, Duodeno y algunas porciones del colon)
3.- Pelvis:
( Recto Vejiga, Prstata, Organos reproductores femeninos, Vasos Ilacos )
Trauma Penetrante
Ms frecuente en reas:
Altos niveles de pobreza Bajo nivel educativo Consumo elevado de alcohol Grandes ciudades
Armas de fuego
Baja velocidad:<609m/s Alta velocidad:>609 m/s La Mayoria de las armas de mano son de baja velocidad
Trauma Penetrante
Arma Blanca
Arma de Fuego Esquirlas de Granadas
Explosivos o bombas
Arma blanca
Lesiones adyacentes 40% Hgado 30% Intestino delgado 20% Diafragma 15% Colon
Capacidad de lesin
Velocidad crtica: 600 m/s
Se presenta compresin de tejidos en la periferia del impacto por onda de choque se crea una cavidad temporal La cavidad puede ser hasta 30 veces ms grande que el proyectil
Clasificacin
Paciente moribundo Paciente inestable Paciente estable
Paciente inestable
Signos vitales alterados
ABC Se requiere laparotomia si la resucitacin inicial no es efectiva
Paciente moribundo
Sin esfuerzo ventilatorio espontneo, sin pulso femoral ni respuesta a estimulos dolorosos
Laparotomia Algunos recomiendan clipaje de aorta abdominal antes del procedimiento (Ledgerwood
et al 1976)
Paciente estable
La intervencin quirrgica se realiza con base en el mecanismo de la lesin y el exmen fsico
Trauma Cerrado
Resulta del impacto directo
Magnitud de las fuerzas compresivas Masa de los objetos relacionados Aceleracin y desaceleracin al momento del impacto Frecuente como resultado de explosiones ( Orgnos que
contienen gas)
Trauma cerrado
Compresion o aplastamiento:
deformidad de organos slidoso huecos y cursar con ruptura
Accidentes automovilsticos
Bicicletas
Deporte
Das a semanas, depende de la calidad de las etapas previas, dada por Sepsis o Falla Organica Mltiple (FOM)
Mecanismo
(volante, tablero, parabrisas)
Lesin
Ruptura de Hgado o bazo Trax inestable Hemo-Neumotrx TCE Ruptura de diafragma, Trax inestable Fx Pelvis Acetbulo Ruptura de Aorta Todos
Frontal
Hgado y bazo
Lateral
Eyeccin
Atropellamiento
abdominales
Dficit Neurolgico
Desorden Psiquitrico Anticoagulacin y Coagulopatas
Evaluacin y Manejo
Determinar el estado de la va area y mantener su permeabilidad total
Establecer si hay dificultad de la respiracin y proceder a solucionarla Control de hemorragia y corregir el volumen circulatorio
Evaluacin Inicial
Accesos Venosos Histora (cerrado o penetrante) Exmen Fsico (I, A, P, P)
Evaluacin Inicial
Cateterismo Vesical
Exmenes de Laboratorio
Estudios Imagenolgicos
Lavado Peritoneal Diagnstico
Invasivo
Documentar sangrado Controversia con el Us FAST y TC y Helicoidal
Rpido No invasivo Dx de lesiones intraabdominales Repetido frecuentemente Umbral de detecion es de +- 600ml (l000 cc -98%) Confiabilidad 86-97%
USG FAST
TAC
Pacientes estables
Confiabilidad 92-98% rganos retroperitoneales ? Costoso ? Consume tiempo ? Lesiones diafragma, GI pancreas.
Indicaciones de Laparotoma
Indicaciones por RX
Aire libre: retroperitoneo o ruptura de hemidiafragma (cerrado)
TAC con ruptura TGI, lesin de vejiga, de pedculo renal o parnquima visceral
Manejo No Operatorio
Restauracin de la estabilidad hemodinmica con mnima resucitacin con lquidos parenterales
No hay lesin craneoenceflica
Control de Dao
Objetivos:
1.Ciruga inicia para limitar el dao 2.Resucitacin en UCI 3.Reoperacin planificada 24 - 48 h
Indicaciones
Sangrado ocasionado por coagulopata Acidosis metablica severa (pH <7.3) Deficit severo de base (pH >10) Hipotermia durante la operacin (T <34) Incapacidad para controlar la hemorragia Incapacidad para el cierre abdominal
Control de la contaminacin
Drenajesexternos de lesiones pancreaticas o biliares en lugar de intentar pancreatoduodenectomia Evitar una colostomia formal
III
IV V
Manejo no-quirrgico
Se puede desarrollar sepsis postesplenectoma Tasas de fallo con manejo conservador:
Grados I,II,III 5% Grados IV,V 18%
(Davis et al 1998)
Manejo no-quirrgico
La ruptura se puede presentar entre el 1 y 9 das (media 3.5 das) Los aneurismas de la aretria esplnica pueden condicionar falsos positivos (62%)
Manejo operatorio
Esplenorrafia
Si el paciente requiere laparotoma habitualmente esta indicada la esplenectoma
Usar agentes hemostticos superficiales Debridamiento y reseccin
Esplenectoma
Lesin heptica
La mayora de los sangrados hepticos es venoso y la mayoria del sangrado esplnico es de origen arterial
hasta el 80% de las lesiones hepaticas se puede manejar conservadoramente
Stomach injuries
Quite common after penetrating trauma. Very rare after blunt trauma Diagnosis
At laparotomy for GSW to anterior abdomen Haematemesis or grossly bloody nasogastric aspirate after LUQ stab wound
Remember: the stomach is mobile and can be injured even from a stab wound to the lower abdomen
If there is an injury to the anterior wall, assume an injury to the posterior wall
Divide gastrocolic ligament and enter lesser sac
Duodenal injuries
Relatively uncommon. 80% due to penetrating trauma (Corson & Williamson) Retroperitoneal organ diagnosis of injury difficult Mortality 5%-30%
Three times more likely to die if operation delayed > 24 hours (Lucas CE, Ledgerwood AM. 1975) Early death exsanguination due to associated vascular injury Late death sepsis
Water-soluble contrast (Gastrograffin) follow-through examination CT with i.v. and oral contrast
Pancreatic injury
Associated injuries in penetrating trauma
75% have injury to one of:
Aorta Portal vein Inferior vena cava
(JurkovichGJ, Carrico CJ. 1990)
Exposure of pancreas
All penetrating injuries in the vicinity of the pancreas mandate exposure and inspection of the whole gland
Enter the lesser sac by incising the gastrocolic ligament Retract stomach superiorly Retract transverse colon inferiorly Mobilise hepatic flexure Kochers manoeuver Remember to visualise posterior part of gland
Signs of injury
Parenchymal injury
Central retroperitoneal haematoma Oedema around the gland and in the lesser sac Bile staining of the retroperitoneum
Ductal injury
Direct visualisation of a ductal injury Complete transection of the gland Laceration of more than one half of the gland Central perforation Severe maceration
IV
V
Proximal transection (to right of SMV) or parenchymal injury involving ampulla Massive disruption of pancreatic head
Operative management
Minor injuries (grades I and II)
No ductal injury External drainage alone
Closed systems superior to sump systems
(Fabian TC et al 1990)
Grade III
Distal pancreatectomy (up to 80% of gland is well
tolerated) Spleen can be preserved in 50%
Grade IV
Most result in death Wide external drainage is becoming more common Distal resection (up to 95% of gland)
Grade V
Most die. Diversion procedures or
Colon injury
20% of GSW cause colonic injury Management recommendations (EAST) depend on whether destruction is such that resection is required
Very strong evidence (RCT) supporting primary repair of nondestructive wounds in the absence of peritonitis (EAST)
Primary anastomoses
Anastomoses:
(EAST)
Single layer vs. double layer (double is slower but no better) Absorbable vs. non-absorbable (probably no difference) Stapled vs. hand-sewn (probably no difference)
Rectal injury
Lack of adequate evidence Rectum is different from rest of colon no serosa over upper 2/3 posteriorly and lower 1/3 circumferentially Serosa is important for secure suturing Maybe?:
Primary repair is appropriate Distal rectal washout not important Post-exploration, lower wounds do not need retrorectal drainage
Renal injuries
Life-threatening injuries do not attempt renal salvage (unless there is only one kidney) Debride devitalised segments partial nephrectomy Obtain haemostasis with a horizontal mattress and a piece of omentum Major laceration wrap kidney in absorbable mesh
Perineal injuries
Perineal injury
50% are associated with pelvic fracture Mortality 32% - 60% (Corson & Williamson)
Early death from exsanguination Late death from sepsis
Bladder injury
When due to penetrating trauma it is usually identified at laparotomy When identified:
Explore bladder through cystostomy on dome of bladder Extraperitoneal injury Foley catheter drainage alone Intraperitoneal injury:
Repair in three layers with absorbable sutures Some say that suprapubic catheter should
Zone I supramesocolic
Coeliac axis ligation SMA (1st & 2nd parts) repair
ligation is theoretically possible grafts and temporary shunts have been used
Zone I inframesocolic
SMA (3rd & 4th parts) primarily repair
can individually ligate the main jejunal and colic branches of 4th part
Zone II
Renal arteries
primarily repair
OR
resect and replace with graft (prosthetic or autogenous)
Zone III
Often associated colonic and genitourinary injuries with significant contamination
Internal iliac arteries ligation External iliac arteries repair Iliofemoral graft can be performed Iliac veins ligation is well tolerated
Bibliografa
Manual ATLS Ledgerwood AM, Kazmers M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma 1976;16:610 Corson JD, Williamson RCN (eds). Surgery. 2001. Mosby. London Ferrada, Birolini D. New concepts in the management of patients with penetrating abdominal wounds. Surg Clin North Am 1999 76;6:13311356 Reynolds MA, Richardson JD. Chest wall and diaphragmatic injuries. In: Maul KI, Rodriguez A, Wiles CE III (eds). Complications in trauma and critical care. Philadelphia: WB Saunders; 1996:313-323 Wise L, Connors J, Hwang YH et al. Traumatic injuries to the diaphragm. J Trauma 1973;13:946-950