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Emergency Abdominal Surgery For

Penetrating Injury
BY
PROF/ GOUDA ELLABBAN
EGYPT

Penetrating abdominal trauma


More common in areas of:

High levels of poverty


Low levels of education
High alcohol consumption
Larger populations

Mechanisms
Gunshot wounds (GSW)
Stab wounds

Firearms
Low velocity: <2000ft/s (<609m/s)
High velocity: >2000ft/s (>609 m/s)
Most hand guns are low velocity
High velocity weapons are
increasing in availability

Wounding capability
KE = mv2
Double the bullet size 2x the energy
Double the muzzle velocity 4x the energy

Critical velocity: 600 m/s


Above this (high velocity):
tissue compressed at periphery of
impact by a shock wave temporary cavity
created (ATLS student manual)
Cavity can be 30 times the diameter of the bullet

Yaw and tumble


Increase the surface area of the bullet with respect
to the tissue it contacts

Shotgun wounds
Low muzzle velocity (usually 630 m/s)
Multiple spherical pellets
Pellets lose energy very quickly
Close range (0.3-0.9m)
Massive contaminated wounds
Similar to high velocity GSW

Long range (>18.2m)


Minimal torso injury

Stab wounds (non-ballistic


penetrating trauma)
Most occur in upper quadrants
Injuries dependent on:
Instrument used
Patient motion

Parietal peritoneum penetrated in 70%


Only 50% of these (35% total) cause visceral
injury

Different management
Low velocity GSW / stab wounds
Damage due to direct injury to vital
structures

High velocity GSW


Wide debridement necessary
Organ injury generally requires more complex
techniques

Management priorities of
penetrating abdominal trauma

1.
Management based on
haemodynamic criteria

Three haemodynamic groups


Moribund patients
No spontaneous ventilatory effort, no femoral pulse and
no response to painful stimuli
Laparotomy
Some recommend thoracic aorta occlusion prior to
laparotomy to prevent cardiac arrest from sudden release
of abdominal wall tamponade (Ledgerwood et al 1976)

Unstable patients
Any vital sign (BP, HR, RR) is altered
ABC if fluids do not help, or only help temporarily,
laparotomy is required

Stable patients
Decision based on mechanism of injury and physical
examination

The idea of damage control


In the past, definitive repair of most lesions was
attempted initially
Multivisceral injuries and exsanguinated patients are
bad candidates for major resections and
time-consuming reconstructions
The combination of trauma plus the surgical insult
exceeds the physiological reserves of many patients

Aims:
1. Initial damage control operation
2. Resuscitation in the surgical ICU
3. Planned reoperation after 24 - 48 hours

Indications for damage control


Bleeding caused by coagulopathy
Severe metabolic acidosis (pH <7.3)
Severe base deficit (pH >10)
Hypothermia during operation (T <34)
Inability to control the haemorrhage
(hepatic, retroperitoneal, pelvic, thoracic
or cervical)
Inability to formally close the abdomen
because of intestinal oedema

Techniques of damage control


Haemorrhage control
Packing angiographic embolisation
Ligation of vessels instead of repair
Balloon catheter tamponade for deep or
hepatic wounds

Contamination control
Hollow viscus ligation instead of repair
External tube drainage of biliary and pancreatic
injury instead of pancreatoduodenectomy
Avoidance of formal colostomy

Abdominal hypertension
Intraabdominal pressure rise to:
10 mmHg decreased venous return & CO
25 mmHg increased airway pressures

How does it occur?


Capillary leak gastrointestinal oedema
Ongoing bleeding

Bogot bag
(actually developed at University Hospital, Cali)

Cloth zippered mesh with


i.v. plastic fluid bag underneath
Allows reduction in
intraabdominal pressures

Other aspects of care


Early enteral nutrition (even after bowel
anastomosis) is better than parenteral,
especially in the most severe trauma
Antibiotics: 1 day is as good as 3 or 5
days (Kirton OC et al 2000)
Abdominal sepsis occurs 20% (Rotondo MF, Zonies DH
1997)

2.

Management based on area of


abdomen injured

Upper abdomen
(thoraco-abdominal area)
between diaphragm and lower costal margin
Insertion of diaphragm
Xiphoid process anteriorly
9th ICS midaxillary line
11th space posteriorly

Remember that diaphragm moves from T10 at endinspiration to T5 at end-expiration


Contains:

Liver
Spleen
Stomach
Pancreas
Great vessels
Visceral arterial branches

Thoracoabdominal penetrating
injuries
Explore ALL patients due to risk of diaphragmatic
injury
Occurs in 15% of stab wounds, 46% GSW to TA area

(Reynolds MA,

Richardson JD, 1996)

Right side equally affected as left side


Only 15% are > 2cm long (Wise L et al, 1973)
Therefore, visceral herniation rarely occurs immediately
85% result in herniation within 3 years

CXR rarely diagnostic of diaphragmatic injury


DPL, pneumoperitoneum on Xray, USS - all have low sensitivity

Laparoscopy vs. laparotomy


Difficulty to view all small bowel with laparoscope
Difficult to see right-sided diaphragmatic injury
May cause tension pneumothorax

Diaphragmatic rupture

(adapted from Ferrada R, Birolini D. 1999)

Middle abdomen
Between lower costal margin and ASIS

Bowel Small bowel and colon


Kidneys
Aorta
IVC

Lower abdomen
False pelvis within the iliac bones to
sacral promontory (S1)
True pelvis below sacral promontory

Small bowel
Rectosigmoid colon
Rectum
Genitourinary system
Iliac vasculature

Anteroposterior division of the


abdomen
Anterior (between anterior axillary
lines)
Flanks (between anterior and
posterior axillary lines)
Back (between posterior axillary
lines)

EMST guidelines for management


of anterior abdominal injuries
Laparotomy for all penetrating abdominal injuries with:
Hypotension
Peritonitis
Evisceration

GSW
99% risk of significant injury
Therefore, explore ALL patients
Some evidence to contrary (after imaging)

(Saadia R, Degiannis E. 2000)

If the injury is tangential, and the patient is stable, consider


laparoscopy

Stab wounds
Local exploration of wound
Observe if no signs on examination. Perform serial examinations
or DPL

Flank and back injuries


The thickness of the flank and back
muscles is protective (skin to peritoneum:
10-20cm)

Wounds are more frequently tangential


Serial physical examinations are very
accurate in detecting retroperitoneal
or intraperitoneal injuries to flanks or
back
Contrast CT scans are useful too
(EMST student manual)

3.
Management based on anatomical
structure injured

Outline
Upper abdominal injuries
Spleen
Liver
Stomach
Duodenum
Pancreas

Middle abdominal injuries


Small bowel and mesentery
Colon
Renal

Lower abdominal injuries


Rectal
Perineal
Bladder

Vascular injuries

Splenic injuries

Splenic injury
In recent years there has been an
appreciable shift from operative
management toward nonoperative
management
(Corson & Williamson, 2001)

AAST Splenic injury grading system

Non-operative management
Can avoid post-splenectomy sepsis
Only applicable when operating theatre is available at
short notice
Failure rates of conservative management:
Grades I,II,III 5%
Grades IV,V 18%

(Davis et al 1998)

Probably more dependent of amount of haemoperitoneum.


Attempts have been made to classify this by CT
Note delayed rupture occurs between
1 and 9 days (mean 3.5 days)
Beware splenic artery false
aneurysms (causing contrast blush)
62% failure rate

Operative management
Splenorrhaphy
Uncommon if the patient needs a
laparotomy, splenectomy is usually indicated
Use of superficial haemostatic agents
(electrocautery, argon beam, topical thrombin,
oxidised cellulose, absorbable gelatin sponge)
Pledgeted repair
Resectional debridement
Mesh wrap

Splenectomy

Liver injuries

Liver injury
Non-operative management is increasing
Significantly lower transfusion requirements (where
injuries were matched for severity)
(Croce MA et al 1995)

Most hepatic bleeding is venous, most splenic


bleeding is arterial
Maybe 80% of hepatic injury can be managed
conservatively

Unstable patients require emergency laparotomy


Discrete contrast blush or frank contrast
extravasation probably mandates embolisation or
laparotomy

Operative management of liver


injury
Gauze packing
may have infective complications

(Ivatury RR et al 1986)

Omental packing
Resectional debridement
Mass liver suture- risk of injury to large vessels and bile ducts
- poor efficacy of producing haemostasis
Hepatic artery ligation
Total hepatic isolation - good for retrohepatic venous injuries
Atriocaval shunt

Stomach injuries

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

Management of stomach
trauma
Thorough intraoperative examination
Divide the gastrohepatic or gastrocolic
ligaments if required

If there is an injury to the anterior wall,


assume an injury to the posterior wall
Divide gastrocolic ligament and enter lesser
sac

Debride and close all injuries


Complications - mainly infective

Duodenal injuries

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

Diagnosis of duodenal injuries


Difficult
AXR changes (in 50%) - Air:
Outlining the right kidney
Along the psoas muscle

Water-soluble contrast (Gastrograffin)


follow-through examination
CT with i.v. and oral contrast

Repair of the duodenum


Most duodenal wounds can be closed
primarily by duodenorrhaphy
Debride devitalised tissue
One or two layer closure
Pyloric exclusion for more difficult injuries
(Vauhgn GD et al 1977)

Primary repair, followed by


Side-to-side gastrojejunostomy
along the greater curvature

Pancreatic injuries

Pancreatic injury
Associated injuries in penetrating trauma
75% have injury to one of:

(JurkovichGJ, Carrico CJ. 1990)

Aorta
Portal vein
Inferior vena cava

Mortality rate: 10% 30%


Manage haemorrhage and contamination
first

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

AAST pancreatic injury grade


Grade

Description of injury

Minor contusion / superficial laceration without duct


injury

II

Major contusion / major laceration without duct


injury or tissue loss

III

Distal transection or parenchymal injury with ductal


injury

IV

Proximal transection (to right of SMV) or


parenchymal injury involving ampulla

Massive disruption of pancreatic head

Advance one grade for multiple injuries to the same organ

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 pancreatoduodenectomy

Colonic injuries

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)

Destructive colon wounds


There is quite strong evidence (nonrandomised
prospective trials and controlled retrospective studies)
(Steel M et al ANZ J Surg 2002) that:

Destructive wounds requiring resection,


can undergo primary anastomosis if:
Haemodynamically stable
No severe underlying disease
Minimal associated injuries
Do not have peritonitis

This probably applies equally well to small bowel


injury

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 injuries

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

Surgical management of renal


injuries
Only a small proportion due to penetrating injury
Best management is unclear
A grading system exists to suggest indications for
conservative management

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

Management of perineal injury


Broad-spectrum antibiotics
Laparotomy
Diversion of faecal stream to prevent
sepsis
Washout of distal rectum
Feeding jejunostomy
Often have difficult to manage wounds
Frequent debridement and lavage
Grafts or flaps

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 be
inserted

Abdominal Vascular Injuries

Incidence of abdominal vascular


trauma
27% - 33% of all vascular trauma is
intraabdominal
Incidence of abdominal vascular injuries
is rising

Mechanisms of injury to abdominal


vasculature
Penetrating injuries most common
90% to 95% of all abdominal vascular injuries

Of patients undergoing laparotomy for


abdominal GSW
25% have abdominal vascular injuries
(compared to 10% for stab wound laparotomies)

Usually associated with multiple other


injuries
Multiple vessels occasionally involved

ED management
Follows usual EMST protocols

BUT
REMEMBER, do not place i.v. cannulae in
femoral veins
Cross-clamping of descending thoracic
aorta
Stops intraabdominal haemorrhage
Improves perfusion of carotid and coronary
arteries
Risk of distal ischaemia and reperfusion injury

Intraoperative management
Prepare skin from neck to mid-thigh

(in case an

autogenous saphenous vein graft is required)

Midline incision
If laparotomy has commenced, and the patient
decompensates haemodynamically, cross-clamp
the aorta. The diaphragmatic crura may require
transection

Zone I aortic
hiatus to sacral
promontory, over
vertebrae;
supramesocolic and
inframesocolic parts

Zone II Pericolic
gutters

Zone III sacral


promontory to pelvis

Zone I supramesocolic
(Asensio JA et al. 2002)

Coeliac axis ligation


SMA (1st & 2nd parts) repair
ligation is theoretically possible
grafts and temporary shunts have been
used

Infrahepatic suprarenal IVC primarily


repair from within the vessel
where there has been massive destruction
ligate
(5% survival), or use prosthetic graft

Zone I inframesocolic
SMA (3rd & 4th parts) primarily repair

can individually ligate the main jejunal and colic branches of 4 th


part

Infrahepatic infrarenal IVC primarily


repair, ligating the lumbar veins
Ligation in cases of massive destruction is well tolerated

Zone II
Renal arteries
primarily repair
OR
resect and replace with graft (prosthetic or
autogenous)

Renal veins repair or ligate


Right renal vein ligation requires right nephrectomy
Left renal vein ligation is better tolerated due to
collaterals from left gonadal vein and renolumbar veins

Zone III
Often associated colonic and genitourinary
injuries with significant contamination

Common iliac arteries repair


can use autogenous or prosthetic grafts

Internal iliac arteries ligation


External iliac arteries repair
Iliofemoral graft can be performed
Iliac veins ligation is well tolerated

Cautions
Second look operations are important
after SMA repair (assessing bowel
viability)
In contaminated wounds, all grafts should
be retroperitonealised

References

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;6:1331-1356
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
Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am. 1997;77:761-777
Kirton OC, ONeill PA, Kestner M, Tortella BJ. Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind,
placebo-controlled trial of 24 hours versus 5 days. J Trauma 2000;49:822-832
Saadia R, Degiannis E. Non-operative treatment of abdominal gunshot injuries. BJS 2000;87:393-397
Davis KA, Fabian TC, Croce MA et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery
pseudoaneurysms. J Trauma 1998;44:1008-1015
Ivatury RR, Nallathambi M, Gunduz Y et al. Liver packing for uncontrolled hemorrhage: a reappraisal. J Trauma 1986;26:744-751
Croce MA, Fabian TC, Menke PG et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients:
results of a prospective trial. Ann Surg 1995;221:744-755
Lucas CE, Ledgerwood AM. Factors influencing outcome after blunt duodenal injury. J Trauma 1975;15:839-846
Vaughn GD, Frazier OH, Graham DY et al. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg 1977;134:785-790
Jurkovich GJ, Carrico CJ. Pancreatic trauma. Surg Clin North Am 1990;70:575-593
Fabian TC, Kudsk KA, Croce MA et al. Superiority of closed suction drainage for pancreatic trauma: a randomized, prospective study. Ann Surg 1990;211:724730
Eastern association for the surgery of trauma website. www.east.org
Demetrios D et al. Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma
2001;50:765-775
Demetriades D et al. Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: A multicenter study. J Trauma 2002;52:117-121
Kirton OC et al. Perioperative antibiotic use in high-risk penetrating hollow viscus injury: A prospective randomised, double-blind, placebo-control trial of 24
hours versus 5 days. J Trauma 2000;49:822-832
Dudley H (ed) Rob & Smiths operative surgery. 4 th ed. 1989. Butterworth and Co. UK
Asensio JA et al. Abdominal vascular injuries. Injuries to the aorta. Surg Clin North Am 2002
Steel M, Danne P, Jones I. Colon trauma: Royal Melbourne Hospital experience. ANZ J Surg 2002;72:357-359

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