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Abdominal Trauma

Esophageal Injuries

Overview

  • Thoracic Esophagus: Uncommonly injured by blunt or penetrating mechanisms.
  • Incidence:
    • Penetrating injuries slightly more common.
    • Historically, <1% of chest injuries in the NTDB involve the esophagus.
  • Mortality:
    • 35% associated with penetrating esophageal injuries.
    • High mortality due to mediastinal sepsis and injury to adjacent vital structures.
  • Challenges:
    • Timely diagnosis and treatment are difficult, contributing to high mortality.

Types of Esophageal Injuries

Penetrating Injuries

  • Common Causes:
    • Gunshot Wounds (GSWs)
    • Stab Wounds
  • Mechanism:
    • Direct tissue laceration.

Blunt Injuries

  • Mechanism:
    • Rapid elevation in intraluminal pressure during chest or abdominal compression.
    • Impact to upper abdomen compresses the distended stomach.
    • Transmission of air and fluid up the esophagus leading to perforation, usually in the distal segment.

Diagnosis

  • Suspicion Factors:
    • Location of penetrating injuries near the mediastinum.
    • Presumed trajectory of the injury.
  • Diagnostic Modalities:
    • Contrast Esophagography:
      • Water-soluble first, followed by thin barium.
    • Esophagoscopy.
    • Helical CT Esophagography:
      • Alternative to fluoroscopic esophagram.
      • Useful for intubated patients.
  • Findings:
    • Leak of contrast material from the esophageal lumen.
    • Disruption of the mucosa visualized during endoscopy.
    • Chest CT:
      • Air adjacent to the esophagus outside the lumen.
      • Soft tissue inflammation.
      • High-resolution CT may show an esophageal wall defect.

  • Sensitivity:

    • Combined modalities result in almost 100% sensitivity for esophageal injury.

    image.png

Management

Operative Repair

  • Immediate Identification and Repair required for injuries with mediastinal contamination.
  • Goals:
    • Close the esophageal defect ideally in two layers (mucosal/muscular).
    • Provide adequate drainage.

Surgical Approaches

  • Upper and Midthoracic Esophagus:
    • Right posterolateral thoracotomy through the fourth or fifth interspace.
  • Lower Esophagus:
    • Left thoracotomy through the sixth or seventh interspace.
  • Coverage of Repair:
    • Vascularized intercostal muscle flap.
    • Alternatives: Pleura, pericardium, or diaphragm.
  • Gastroesophageal Junction Injuries:
    • Approach through a laparotomy.
    • Expose injury by opening the muscle layer superiorly and inferiorly.
    • Closure:
      • One or two layers.
      • Absorbable mucosal suture followed by interrupted muscle sutures.
    • Coverage:
      • Muscle flap or adjacent tissue.
      • Fundoplication of gastric tissue for coverage.
    • Drainage:
      • Wide drainage of the mediastinum and chest.
    • Decompression and Feeding Access:
      • Nasoenteral tube or surgical gastrostomy and feeding jejunostomy.
    • Post-Repair:
      • Esophagram at day 5 to confirm healing and liberalization of oral intake.

Postoperative Care and Complications

  • Inflammation in Mediastinum:
    • Develops quickly; late identification may preclude primary repair.
  • Salvage Techniques:
    • Repair over a T-tube for a controlled fistula.
    • Esophageal diversion through a cervical incision.
    • Esophageal stenting.
    • Esophagectomy:
      • Rare in trauma.
      • May require planned elective reconstruction.

Key Points

  • Early diagnosis and prompt surgical intervention are crucial to reduce mortality.
  • Comprehensive imaging ensures accurate detection and localization of injuries.
  • Surgical approach depends on the location of the injury.
  • Adequate drainage and tissue coverage are essential to prevent mediastinal sepsis.
  • Postoperative monitoring with esophagram is important to ensure healing.

Diaphragmatic Injuries

Overview

  • Incidence:
    • Analyzed in the NTDB 2012 with >800,000 patients.
    • Overall incidence: 0.46%.
  • Types of Trauma:
    • Penetrating Trauma: 67%.
    • Blunt Trauma: 33%.
  • Common Mechanisms:
    • Gunshot Wounds (GSWs)
    • Stab Wounds
    • Motor Vehicle Collisions
  • Mortality:
    • Blunt Trauma: 19.8%
    • Penetrating Trauma: 8.8%
    • Cause: Mostly due to injury to adjacent vital organs rather than the diaphragmatic injury itself.

Epidemiology

  • Side of Injury:
    • Left Diaphragm: Injured in approximately 75% of cases.
    • Right Diaphragm: Less commonly injured due to liver coverage.
  • Morbidity:
    • Injuries may be identified months to years later if not initially repaired.
    • Natural History: Progressive enlargement with herniation of abdominal viscera into the chest.

Types of Diaphragmatic Injuries

Penetrating Injuries

  • Causes:
    • Gunshot Wounds (GSWs)
    • Stab Wounds
  • Detection:
    • Usually discovered during operative exploration of the chest or abdomen.
    • Trajectory analysis helps identify the diaphragmatic defect.

Blunt Injuries

  • Mechanism:
    • Rapid increase in intraabdominal pressure during an anterior impact.
    • Causes a blow-out of the diaphragmatic tissue.

Diagnosis

  • Challenges:
    • High index of suspicion required.
    • Injuries can be diagnostic challenges with subtle indicators.
  • Imaging Modalities:
    • Chest Radiograph:
      • May show abdominal viscera (e.g., stomach) within the chest.
      • Nasogastric tube identified in the lower left hemithorax assists diagnosis.
      • Gastric contrast material injection can enhance detection.
    • Computed Tomography (CT) Scan:
      • Detects abdominal viscera in the chest.
      • Identifies diaphragmatic abnormalities: thickening, elevation, or defect.
    • Laparoscopy:
      • Recommended for hemodynamically stable patients without peritonitis.
      • Decreases the incidence of missed injuries compared to CT alone.
    • Video-Assisted Thoracoscopic Surgery (VATS):
      • An alternative for visualizing the diaphragm.
      • No proven superiority over laparoscopy.
  • Penetrating Injuries:
    • Often discovered during operative exploration.
  • Blunt Injuries:
    • More elusive without radiographic signs.
    • Laparoscopic evaluation may be required when imaging is suggestive.

Management

Operative Repair

  • Indications:
    • All diaphragmatic injuries typically require surgical intervention.
  • Surgical Approach:
    • Penetrating Injuries:
      • Operative exploration via chest or abdomen.
      • Follow the trajectory to identify the defect.
    • Blunt Injuries:
      • Laparoscopy recommended for stable patients.
      • VATS as an alternative visualization method.
  • Repair Techniques:
    • Debridement of non-viable tissue.
    • Closure of the defect:
      • Single layer with nonabsorbable suture.
      • Large full-thickness bites of healthy diaphragmatic tissue.
    • Hemostasis:
      • Crucial due to potential bleeding from phrenic artery branches.
  • Large Defects:
    • Primary closure possible for most defects.
    • Prosthetic Reconstruction:
      • Nonabsorbable synthetic materials for clean surgical fields.
      • Avoid in settings of contamination.
  • Peripheral Detachment:
    • Repair by reinserted injured tissue one or two interspaces superior.

Nonoperative Management

  • Right-Sided Delayed Hernia:
    • Considered for nonoperative management due to its rare incidence.

Complications

  • Delayed Identification:
    • Leads to progressive enlargement and herniation.
    • Salvage Techniques if primary repair not possible:
      • Repair over a T-tube for a controlled fistula.
      • Esophageal diversion through a cervical incision.
      • Esophageal stenting.
      • Esophagectomy (rare, may require planned elective reconstruction).

Key Points

  • Higher Mortality associated with blunt trauma compared to penetrating.
  • Left diaphragm is more commonly injured due to right side liver protection.
  • Early diagnosis is critical to prevent progressive herniation and morbidity.
  • Comprehensive imaging (e.g., CT scan, chest radiograph) is essential for accurate detection.
  • Surgical repair should focus on debridement, closure, and ensuring hemostasis.
  • Prosthetic materials are used cautiously, avoiding in contaminated fields.
  • Postoperative monitoring and long-term follow-up are important to manage potential complications.

Injuries to the Abdomen

Epidemiology

  • Abdomen is a commonly injured body region.
  • 2016 NTDB data:
    • 11.7% of all patients sustained abdominal injuries.
    • Case fatality rate: 12.9%.

Pathophysiology

  • Vital organs within the abdomen make evaluation and management a priority.
  • Morbidity and Mortality:
    • Bleeding.
    • Visceral perforation with associated sepsis.
  • Blunt Trauma:
    • Solid organs: contusion or laceration → bleeding requiring surgical management.
    • Hollow viscera: rupture due to rapid compression → fluid and air leakage.
  • Penetrating Trauma:
    • Direct laceration of solid and hollow viscera → bleeding and intra-abdominal contamination needing operative repair.

Initial Evaluation

  • Varies based on blunt vs. penetrating mechanisms.
  • Priority: Determine presence or absence of ongoing hemorrhage.
    • Responders: Maintain appropriate hemodynamics after resuscitation.
    • Nonresponders: Persistent physiological instability → immediate intervention.
    • Transient responders: Initial improvement with resuscitation, followed by instability.
  • ATLS Surveys: Identify cavitary hemorrhage after airway and breathing assessment.

Blunt Abdominal Trauma Evaluation

Ultrasound (FAST)

  • FAST: Focused Assessment with Sonography for Trauma.
  • Uses:
    • Evaluates pericardium, hepatorenal fossa, splenorenal fossa, retrovesicular space (pouch of Douglas).
  • Advantages:
    • Rapid bedside performance.
    • Can be repeated if physiologic decline occurs.
  • Indications:
    • Presence or absence of hemodynamic instability.
    • Classical indication: Nonresponders with intraabdominal fluid on FAST → abdominal exploration.
  • Limitations:
    • Operator familiarity.
    • Body habitus.
    • Subcutaneous emphysema/bowel gas.

Diagnostic Peritoneal Lavage

  • When FAST unavailable.
  • Positive Findings:
    • GI contents, bile, or >10 mL of gross blood → operative intraabdominal trauma.
  • Limitations:
    • Rarely performed.
    • Iatrogenic injury.
    • Contraindicated in obesity.
    • Low specificity.
    • Cannot evaluate retroperitoneum.

CT Scan

  • Primary method for comprehensive workup.
  • Procedure:
    • IV contrast agent.
    • Portal venous phase timing → solid abdominal organs visualization.
  • Provides:
    • Injury severity.
    • Presence of active bleeding.
  • Guides:
    • Operative, nonoperative, or angiographic therapy.
  • Advantages:
    • Supports nonoperative management for many solid organ injuries.
    • Facilitates damage control resuscitation.

Nonoperative Management

  • Hemoperitoneum with stable vital signs can consider nonoperative management.
  • CT Advancements:
    • Enable rapid diagnostic window.
    • Allow whole-body CT scanning in hypotension (systolic <90).

Limitations of Diagnostic Techniques

  • FAST and Diagnostic Peritoneal Lavage:
    • Cannot evaluate retroperitoneum → potential hemorrhage source.
  • CT:
    • Less capable of detecting hollow viscera injuries.
    • Signs of GI tract injury:
      • Bowel wall thickening.
      • Adipose tissue inflammation (stranding).
      • Free intraperitoneal fluid.
    • Unexplained free fluid → high risk for bowel injury or mesenteric tear.

Management Pathways

  • Stable Patients:
    • Serial abdominal examinations.
    • Laparoscopy as an alternative to open exploration.
  • Laparotomy:
    • Peritonitis, hemodynamic instability, significant hemoglobin decrease, leukocytosis.

  • Discharge:

    • No fascial penetration.
    • No clinical change after 24 hours.

    image.png

Penetrating Abdominal Trauma Evaluation

General Approach

  • ATLS Protocol:
    • Assess airway and breathing first.
    • Identify all penetrating trauma.
  • Gunshot Wounds (GSWs):
    • Radiopaque markers and plain radiographs to determine trajectory and pneumoperitoneum.
    • FAST: Controversial utility.
      • Positive FAST: May support abdominal exploration.
      • Insufficient to rule out major hemorrhage.
    • Management:
      • Patients in extremis: Immediate OR with intubation before incision.
      • Normal physiology: Proceed to CT scan for injury delineation.
    • Thoracoabdominal GSWs:
      • Evaluate chest for mediastinal, pleural, or pulmonary injuries.

Stab Wounds

  • Immediate Laparotomy if:
    • Hemodynamic instability.
    • Peritonitis.
    • Evisceration.
  • Non-Immediate Cases:
    • Evaluate peritoneal violation via:
      • Local wound exploration.
      • Ultrasound.
      • CT.
      • Diagnostic laparoscopy.
  • Management Pathways:
    • Flank or Back Stab Wounds:
      • Contrasted CT imaging (+/- rectal contrast).
      • Active extravasation → angioembolization.
    • Anterior Stab Wounds:
      • Local wound exploration for fascial violation.
      • Serial clinical exams or diagnostic imaging.
      • Discharge if no fascial penetration.
      • Monitor and consider CT or laparoscopy if fascial penetration.
  • Thoracoabdominal Stab Wounds:
    • Chest X-ray for pneumothorax.
    • Pericardial ultrasound for effusion.
    • Laparoscopy for diaphragmatic assessment in left upper quadrant wounds.

Diagnostic Pathways

  • Diagnostic Laparoscopy:
    • Highly accurate for peritoneal violation.
    • Controversial for intraabdominal injury.
    • Highly user-dependent.

Management Pathways

  • Peritonitis, hemodynamic instability, significant hemoglobin decrease, leukocytosis → Laparotomy.
  • No Clinical Change after 24 hours → Diet and discharge (requires close surveillance infrastructure).

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Management

Laparotomy

  • Purpose:
    • Explore the abdomen and repair identified injuries.
  • Systematic Exploration:
    • Avoid missing subtle injuries by performing a systematic approach.
  • Damage Control:
    • Abbreviate the procedure if there is a deteriorating physiologic condition.
    • Implement damage control methods when necessary, including temporary abdominal closure.
    • Effective two-way communication between surgical and anesthesia teams is crucial.

Surgical Technique

  • Incision:
    • Open the abdomen from the xiphoid process to the pubic symphysis to ensure adequate exposure.
  • Falciform Ligament:
    • Divide the falciform ligament to:
      • Separate the liver from the abdominal wall.
      • Improve retraction.
      • Facilitate perihepatic packing.
  • Blood Evacuation:
    • Use a handheld retractor to quickly evacuate blood from all four quadrants of the abdomen.
    • Place laparotomy sponges to provide temporary hemostasis.
    • Utilize a fixed retractor to maintain optimal exposure.
    • Remove and replace sponges as needed during damage control.

Gastrointestinal (GI) Tract Evaluation

  • Comprehensive Assessment:
    • Evaluate the entire GI tract, from the gastroesophageal junction to the proximal rectum at the peritoneal reflection.
    • Enter the lesser sac to visualize the posterior stomach and the pancreas.
  • Injury Identification and Repair:
    • Identify injuries throughout the GI tract.
    • Repair injuries as detailed in subsequent sections.

Handling Physiologic Compromise

  • Recognition:
    • Identify physiologic compromise during surgery.
  • Action:
    • Abbreviate the operation and proceed with damage control methods.
    • Implement temporary abdominal closure if needed.
  • Communication:
    • Ensure effective two-way communication between surgical and anesthesia teams for timely decision-making.

Closure and Post-Operative Management

  • If Operation Completed Successfully:
    • Close the abdominal fascia.
    • Address the subcutaneous wound based on the level of intraabdominal contamination.
  • Without Conversion to Damage Control:
    • Proceed with standard closure if the operation can be completed without the need for damage control.

Splenic Injuries

Epidemiology

  • Spleen is the first or second most commonly injured abdominal organ.
  • Isolated splenic injury accounts for approximately 42% of abdominal trauma.
  • Penetrating splenic trauma comprises 8.5% of all penetrating abdominal injuries (2012 NTDB).

Pathophysiology

  • Blunt Trauma:
    • Direct compression of the spleen causing parenchymal fracture.
    • Rapid deceleration can tear the splenic capsule and/or parenchyma.
    • Formation of a subcapsular hematoma.
  • Penetrating Trauma:
    • Less common than blunt trauma but significant.
    • Can result in ongoing hemorrhage or spontaneous resolution.

Clinical Presentation

  • Hemodynamic Instability:
    • Nonresponders to resuscitation with intraabdominal fluid on FAST require exploration.
  • Responders:
    • Normalized physiology after resuscitation.
    • Managed nonoperatively but at risk for delayed hemorrhage (majority within 72 hours).

Imaging and Diagnosis

  • Abdominal CT with IV Contrast:

    • Most valuable study for identifying and characterizing splenic injuries.
    • Sensitivity/Specificity: 96%–100%.

    • Findings:

      • Disruptions in splenic parenchyma.
      • Surrounding hematoma.
      • Free intraabdominal blood.
      • Active bleeding: Extravasion of contrast material (e.g., high-density blush, contrast-laden blood).
      • Pseudoaneurysm formation.

      image.png

  • FAST (Focused Assessment with Sonography for Trauma):

    • Identifies intraabdominal fluid but less specific for splenic injuries.

Classification

  • AAST Injury Scoring Scale:

    • Grades splenic injuries based on parenchymal/subcapsular abnormalities and vascular involvement.

    image.png

Management

Nonoperative Management

  • Success Rate: Approximately 90% in high-volume centers.
  • Advantages:
    • Reduces hospital costs.
    • Decreases intraabdominal complications.
    • Lowers the need for blood transfusions.
    • Minimizes nontherapeutic laparotomies.
    • Reduces mortality.
  • Criteria for Nonoperative Management:
    • Hemodynamically stable patients.
    • No evidence of ongoing hemorrhage on imaging.
  • Interventional Radiology:
    • Angiography and embolization for:
      • Active extravasation.
      • Pseudoaneurysm.
    • Protocol:
      • Stable patients with concerning imaging findings are evaluated and may undergo embolization.
      • High-grade injuries (III–V) are evaluated by interventional radiology and may proceed to embolization within 24 hours.
  • Considerations:
    • Delayed operative intervention does not increase complications or mortality.
    • No definitive risk factors identified for failure of nonoperative management.
    • Intensive care monitoring for high-grade injuries with a low threshold for surgical intervention if patient declines.

Operative Management

  • Indications:
    • Hemodynamic instability at admission.
    • Failed nonoperative management.
  • Surgical Approach:
    • Midline incision for optimal exposure.
    • Packing of all four quadrants to achieve temporary hemostasis.
    • Use of a fixed retractor to maintain exposure.
    • Removal of sponges to expose the injured spleen.
  • Splenectomy Procedure:
    • Mobilize the spleen:
      • Divide the peritoneum laterally starting at the white line of Toldt (splenocolic ligament).
      • Retract spleen posteromedially to expose retroperitoneal attachments.
      • Create a blunt plane posterior to the spleen towards the tail of the pancreas.
    • Vascular Control:
      • Ligate and clamp hilar vessels.
      • Avoid injury to the tail of the pancreas and greater curve of the stomach.
    • Final Steps:
      • Remove the spleen.
      • Place a drain if there is concern for pancreatic injury.

Postoperative Care

  • Postsplenectomy Vaccines:
    • Essential to protect against encapsulated bacteria:
      • Streptococcus pneumoniae.
      • Neisseria meningitidis.
      • Haemophilus influenzae.
    • Prevents overwhelming postsplenectomy sepsis:
      • Incidence: 0.5%–2%.
      • Mortality: 30%–70%.

Splenic Salvage

  • Techniques:
    • Well described but less utilized due to:
      • Effective nonoperative management.
      • Endovascular approaches.
  • Current Trend:
    • Preference for nonoperative and endovascular methods over splenic salvage techniques.

Hepatic Injuries

Epidemiology

  • Liver injuries are extremely common after:
    • Blunt trauma: 22.2% within the 2012 NTDB.
    • Penetrating trauma: 26.1% of cases.
  • Most commonly injured abdominal organ after penetrating trauma.

Pathophysiology

  • Blunt Trauma:
    • Compression with direct parenchymal damage.
    • Shearing forces:
      • Tear hepatic tissue.
      • Disrupt vascular and ligamentous attachments.
    • Protected partially by the thoracic cage.
    • High-energy mechanisms overcome rib protection.
  • Penetrating Trauma:
    • Direct laceration of hepatic parenchyma.
    • Causes adjacent tissue contusion.
  • Associated Morbidity:
    • Bleeding.
    • Biliary fistula (e.g., hemobilia).
    • Infection.
    • Hepatic necrosis.

Clinical Presentation

  • Unstable Patients:
    • Diagnosed on laparotomy in the presence of free fluid on FAST.
  • Stable Patients:
    • Imaged with abdominal CT enhanced with IV contrast if no immediate operation needed.

Imaging and Diagnosis

  • Abdominal CT with IV Contrast:

    • Excellent anatomic detail.
    • Sensitivity/Specificity: Highly accurate.
    • Phases:
      • Noncontrast.
      • Arterial.
      • Portal venous.

    • Findings:

      • Disruption of hepatic parenchyma.
      • Perihepatic hematoma.
      • Hemoperitoneum.
      • Active bleeding: Extravasion of contrast (e.g., high-density blush).
      • Pseudoaneurysm formation.

      image.png

  • FAST (Focused Assessment with Sonography for Trauma):

    • Identifies free fluid but less specific for liver injuries.

  • AAST OIS (Organ Injury Scale):

    • Grades injuries based on parenchymal involvement and vascular injury.

    image.png

Management

Nonoperative Management

  • Primary Approach for hemodynamically stable patients.
  • Success Rate:
    • Grades I-III: Majority managed nonoperatively.
    • Grades IV-V: Two-thirds require surgical care.
    • High-volume centers: 90% success rate.
  • Advantages:
    • Reduces hospital costs.
    • Decreases intraabdominal complications.
    • Lowers need for blood transfusions.
    • Minimizes nontherapeutic laparotomies.
    • Reduces mortality.
  • Interventional Radiology:
    • Angiography and embolization for:
      • Active extravasation.
      • Pseudoaneurysm.
    • Protocol:
      • Stable patients with concerning imaging → embolization.
      • High-grade injuries (III-V) → Angiography within 24 hours.
  • Considerations:
    • Delayed operative intervention does not increase complications or mortality.
    • No definitive risk factors for failure identified.
    • Intensive care monitoring for high-grade injuries with a low threshold for surgery if patient declines.

Operative Management

  • Indications:
    • Hemodynamic instability at admission.
    • Failed nonoperative management.
    • Nonresponders with intraabdominal fluid on FAST.
  • Surgical Approach:
    • Midline laparotomy for versatility.
    • Packing of all four quadrants to achieve temporary hemostasis.
    • Use of a fixed retractor for optimal exposure.
    • Removal of sponges to expose the injured liver.
  • Splenectomy Procedure (Adapted for Liver):
    • Mobilize the liver:
      • Divide the falciform ligament.
      • Expose retrohepatic attachments.
      • Create a blunt plane towards the tail of the pancreas.
    • Vascular Control:
      • Pringle maneuver: Occlude hepatic artery and portal vein.
      • Distinguish arterial vs. venous bleeding.
      • Suture ligation of actively bleeding vessels.
    • Final Steps:
      • Remove the liver if necessary.
      • Place a drain if pancreatic injury is suspected.
  • Damage Control Techniques:
    • Control surgical bleeding.
    • Pack the liver.
    • Temporary abdominal closure.
    • Re-explore after physiologic stabilization.
    • Angiography with embolization post-damage control if needed.
  • Special Considerations:
    • Retrohepatic vena cava injuries:
      • Pack and do not explore if not actively bleeding.
      • Atriocaval (Shrock) shunt as a potential method.

Postoperative Care

  • Intensive Care Surveillance:
    • For all nonoperatively managed hepatic injuries.
    • Monitor for complications:
      • Bile leaks.
      • Hemobilia.
      • Liver abscesses.
  • Management of Complications:
    • Bile Leaks:
      • Percutaneous drainage.
      • ERCP with stent placement if needed.
    • Hemobilia:
      • Angiography and embolization of affected vessels.
    • Liver Abscesses:
      • Percutaneous drainage guided by CT or ultrasound.

Historical Context and Advances

  • 1960-1975:
    • Aggressive operative management.
    • High morbidity and mortality (27%-65%) due to biliary/septic complications.
  • Post-1976:
    • Shift to bleeding management.
    • Introduction of temporary abdominal packing.
    • AAST OIS developed in 1989 for consistent injury grading.
  • Modern Advances:
    • Nonoperative management with endovascular/endoscopic support.
    • Reduced mortality with early major operations and advanced resuscitation techniques.

Outcomes and Prognosis

  • Nonoperative Management Failure Rate:
    • Blunt trauma: 9.5%.
    • Gunshot wounds (GSWs) to the liver: 5%.
  • Mortality Rates:
    • Resectional management: 9%.
    • Overwhelming postsplenectomy sepsis: 0.5%–2% with 30%–70% mortality.

Surgical Techniques and Maneuvers

  • Pringle Maneuver:
    • Encircle hepatoduodenal ligament with a vessel loop or vascular clamp.
    • Occlude hepatic artery and portal vein.
    • Distinguish between arterial and venous bleeding.
  • Liver Mobilization:
    • Divide triangular ligaments to mobilize hepatic lobes.
    • Optimize compression for hemostasis.
  • Hemostasis Techniques:
    • Superficial techniques: Compression, topical hemostatic agents, suture hepatorrhaphy.
    • Vascularized pedicle of omentum to reduce bleeding and promote healing.

Flow Diagrams and Algorithms

  • Surgical Approach:

    • Refer to Fig. 17.26 for detailed WTA surgical approach to hepatic injuries.

    image.png

Gastric Injuries

Epidemiology

  • Penetrating Mechanisms:
    • Incidence: 11%–18% of gastric injuries.
    • Mortality: Low at 2.2%.
  • Blunt Mechanisms:
    • Incidence: <1% of gastric injuries.
    • Mortality: High at 28.2% (EAST multi-institutional trial).
    • Associated with: Higher Injury Severity Score (ISS) due to high-energy mechanisms.

Pathophysiology

  • Blunt Trauma:
    • Rupture caused by acute increase in intraluminal pressure from external forces.
    • Bursting of gastric wall due to external compression.
    • Commonly Associated Injuries:
      • Liver, spleen, pancreas, small bowel.
    • Mortality often attributed to associated injuries rather than the gastric injury itself.
  • Penetrating Trauma:
    • Full-thickness perforations with spillage of gastric contents into the abdomen.
    • Less energy required compared to blunt trauma, resulting in faster onset of peritonitis.

Clinical Presentation

  • Peritonitis:
    • Faster onset compared to small bowel perforation due to lower pH of gastric contents.
  • Physical Examination:
    • Presence of peritonitis suggests gastric injury.
    • Location of penetrating wounds can be suggestive of gastric injury.

Imaging and Diagnosis

  • Computed Tomography (CT):
    • Commonly employed in stable trauma patients prior to operation.
    • Sensitivity: 55%–95%.
    • Specificity: 48%–92%.
    • Dependent on secondary signs:
      • Bowel wall thickening.
      • Irregular wall enhancement.
      • Mesenteric defects.
      • Abdominal free fluid without solid organ trauma.
    • Limitations:
      • Free fluid is unreliable as a single metric for operation (Therapeutic laparotomy: 27%–54%).
      • Isolated pneumoperitoneum in blunt trauma is untrustworthy for hollow viscus injury.
  • Focused Assessment with Sonography for Trauma (FAST):
    • Identifies free fluid but less specific for gastric injuries.
  • Clinical Algorithms:

    • Observation Period:

      • Injury to hollow viscus may become clinically apparent over time.
      • High suspicion based on multiple metrics necessitates expeditious surgical exploration to reduce mortality.

      image.png

Management

Operative Management

  • Indications:
    • Presence of peritonitis.
    • Hemodynamic instability.
    • High suspicion based on multiple clinical and imaging metrics.
  • Surgical Approach:
    • Full Evaluation:
      • Visualize anterior and posterior walls of the stomach.
      • Entry into the lesser sac to avoid missing injuries.
    • Repair Techniques:
      • Evacuate hematomas within the gastric wall to ensure absence of perforation.
      • Control bleeding.
      • Closure of seromusculature with nonabsorbable suture.
    • Full-Thickness Injuries:
      • Debride nonviable tissue.
      • Close gastric wall in one or two layers:
        • Absorbable suture for perforation closure.
        • Invert suture line with nonabsorbable seromuscular stitches.
        • Stapler can be used due to gastric tissue redundancy.
    • Complex Injuries:
      • Gastroesophageal junction, lesser curve, fundus, posterior wall:
        • Require better exposure of the upper abdomen.
    • Severe Injuries:
      • Large portions of the stomach lost:
        • Partial or total gastrectomy may be necessary.
        • Reconstruction Options:
          • Billroth I or II gastroenterostomy.
          • Roux-en-Y esophagojejunostomy based on extent of resection.

Postoperative Care

  • Monitoring:
    • Close observation for complications such as:
      • Infection.
      • Leakage from repair sites.
  • Complication Management:
    • Infections: Antibiotic therapy as needed.
    • Leaks: May require additional surgical intervention or endoscopic procedures.

Key Points

  • Penetrating gastric injuries are more common but have lower mortality compared to blunt injuries.
  • High-energy blunt trauma often results in multiple associated injuries, increasing mortality risk.
  • Early identification and expeditious surgical exploration are critical to reduce mortality.
  • CT imaging is valuable but not definitive; clinical judgment is essential.
  • Surgical repair depends on injury severity and location, with options ranging from simple suturing to gastrectomy and reconstruction.

Duodenal Injuries

Epidemiology

  • Uncommon in both blunt and penetrating trauma.
    • <2% of abdominal trauma cases.
  • Penetrating Injuries:
    • 80% due to gunshot wounds (GSWs).
    • Associated abdominal injuries in nearly 70% of cases.
    • Mortality: 24%.
  • Blunt Injuries:
    • Caused by blows to the epigastrium with a narrow object.
    • Examples: steering wheel impact, bicycle handlebar in children.

Pathophysiology

  • Penetrating Trauma:
    • Full-thickness perforations.
    • Spillage of gastric contents into the abdomen.
  • Blunt Trauma:
    • Contusion of the duodenal wall or rupture due to acute elevation of intraluminal pressure.
    • Mechanism Examples:
      • Steering wheel impact.
      • Bicycle handlebar in children.
  • Common Associated Injuries:
    • Renal failure.
    • Pancreatic injury.
  • Morbidity:
    • Septic complications, particularly related to repair failure.

Clinical Presentation

  • Peritonitis:
    • Faster onset compared to small bowel perforation due to the lower pH of gastric contents.
  • Physical Examination:
    • Presence of peritonitis suggests gastric injury.
    • Location of penetrating wounds can indicate duodenal injury.
  • Challenges in Diagnosis:
    • Retroperitoneal location: Less peritoneal signs unless intraperitoneal segment is involved.
    • Blunt injuries require a high index of suspicion to avoid missed injuries.

Imaging and Diagnosis

  • Computed Tomography (CT):
    • Most valuable tool for diagnosis.
    • Low threshold for operative exploration in suspected cases.
    • Phases:
      • Noncontrast.
      • Arterial.
      • Portal venous.
    • Findings:
      • Thickened duodenal wall.
      • Periduodenal air and fluid.
      • Duodenal hematoma.
      • Signs of perforation: Free air, contrast extravasation.
    • Sensitivity: 55%–95%.
    • Specificity: 48%–92%.
    • Secondary Signs:
      • Bowel wall thickening.
      • Irregular wall enhancement.
      • Mesenteric defects.
      • Abdominal free fluid without solid organ trauma.
    • Limitations:
      • Free fluid and isolated pneumoperitoneum are unreliable as single indicators.
      • Therapeutic laparotomy rate: 27%–54%.
  • Focused Assessment with Sonography for Trauma (FAST):
    • Identifies free fluid but less specific for duodenal injuries.
  • Additional Imaging:
    • Oral contrast-enhanced CT.
    • Upper GI fluoroscopy.

  • Diagnostic Challenges:

    • False-negative abdominal CT results necessitate maintaining a low threshold for surgical exploration.

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Management

Operative Management

  • Indications:
    • Presence of peritonitis.
    • Hemodynamic instability.
    • High suspicion based on multiple clinical and imaging metrics.
    • Evidence of perforation on imaging.
  • Surgical Approach:
    • Full Evaluation:
      • Visualize anterior and posterior walls of the stomach.
      • Enter the lesser sac to avoid missing injuries.
    • Repair Techniques:
      • Evacuate hematomas within the duodenal wall to ensure absence of perforation.
      • Control bleeding.
      • Close seromusculature with nonabsorbable suture.
  • Full-Thickness Injuries:
    • Debride nonviable tissue.
    • Close the gastric wall in one or two layers:
      • Absorbable suture for perforation closure.
      • Invert suture line with nonabsorbable seromuscular stitches.
      • Stapler as an alternative due to gastric tissue redundancy.
  • Complex Injuries:
    • Locations: Gastroesophageal junction, lesser curve, fundus, posterior wall.
    • Require better exposure of the upper abdomen.
  • Severe Injuries:
    • Large portion loss of the stomach:
      • Partial or total gastrectomy may be necessary.
      • Reconstruction Options:
        • Billroth I or II gastroenterostomy.
        • Roux-en-Y esophagojejunostomy based on extent of resection.
  • Additional Steps:
    • Place healthy omentum over the repair for reinforcement.
    • Drain placement is optional; beneficial if fistula occurs.
  • Damage Control:
    • Resection, wide drainage, and temporary discontinuity to control contamination.

Management of Duodenal Hematoma

  • Obstructing Hematomas:
    • Gastric decompression.
    • Total parenteral nutrition.
    • Reevaluation of gastric emptying with a contrast study after 5 to 7 days.
    • Operative exploration if obstruction persists after ~14 days:
      • Evacuate hematoma.
      • Evaluate for perforation, stricture, or associated pancreatic injury.
  • Intraoperative Hematoma Management:
    • Decompress hematoma during duodenum mobilization.
    • Evaluate for injury.
    • Do not intentionally open hematomas unless full-thickness injury is suspected.

Postoperative Care

  • Monitoring:
    • Close observation for complications such as:
      • Infection.
      • Leakage from repair sites.
  • Complication Management:
    • Infections: Antibiotic therapy as needed.
    • Leaks: May require additional surgical intervention or endoscopic procedures.

Key Points

  • Duodenal injuries are uncommon but present significant diagnostic and therapeutic challenges.
  • Penetrating injuries are more common than blunt injuries but have lower mortality.
  • Blunt injuries often result from high-energy mechanisms and are associated with multiple injuries, increasing mortality risk.
  • Early identification and expeditious surgical exploration are critical to reduce mortality.
  • CT imaging is valuable but not definitive; clinical judgment is essential.
  • Surgical repair varies based on injury location and severity:
    • From simple suturing to gastrectomy and reconstruction.
  • Maintain a low threshold for exploration to avoid missed injuries and increased mortality.

Pancreatic Injuries

Epidemiology

  • Incidence: Relatively low in abdominal trauma, ranging from 0.2% to 12%.
  • Common Associations:
    • Duodenal Injuries: Due to anatomical proximity.
    • Mechanisms:
      • Penetrating Trauma: Accounts for 4.4% of patients with penetrating abdominal trauma.
      • Blunt Trauma: Often results from high-energy impacts such as steering wheel or seat belt crush.

Pathophysiology

  • Injury Types:
    • Parenchymal Injury: Direct laceration of pancreatic tissue.
    • Ductal Injury: Disruption of the pancreatic duct, leading to enzyme leakage.
  • Mechanism of Blunt Injury:
    • Crushing of the pancreas between a rigid structure (e.g., steering wheel, seat belt) and the vertebral column.
    • Range of Injury: From mild contusion to complete transection with ductal disruption.

Clinical Presentation

  • Challenges:
    • Retroperitoneal Location: Makes physical examination less reliable.
    • Delayed Symptoms: Can result in delayed diagnosis.
  • Signs and Symptoms:
    • Abdominal Pain: Persistent and often severe.
    • Signs of Peritonitis: May be absent or delayed.
    • Systemic Signs: Sepsis, shock in severe cases.

Imaging and Diagnosis

  • Primary Diagnostic Tool: IV Contrast-Enhanced Abdominal CT
    • Advantages:
      • Best view of the pancreas and associated injuries.
    • Limitations:
      • Sensitivity: 47%–79% for parenchymal injury.
      • Sensitivity for Ductal Involvement: 52%–54%.
      • Specificity for Ductal Involvement: 90%–95%.
      • Missed Injuries: Approximately 15% incidence.
  • Additional Diagnostic Modalities:
    1. Repeat CT Imaging:
      • May reveal injuries that develop over time.
    2. Serum Amylase Levels:
      • Timing: More useful if obtained >3 hours post-injury.
      • Characteristics:
        • Sensitivity: Reasonably sensitive.
        • Specificity: Lacking; limited diagnostic value.
    3. ERCP (Endoscopic Retrograde Cholangiopancreatography):
      • Use: To visualize pancreatic ducts and enhance diagnostic accuracy.
    4. Magnetic Resonance Cholangiopancreatography (MRCP):
      • Use: Non-invasive imaging of pancreatic ducts.

  • CT Findings Suggestive of Pancreatic Injury:

    • Malperfusion of pancreatic parenchyma.
    • Surrounding Fluid or Hematoma.
    • Soft Tissue Stranding adjacent to the pancreas.

    image.png

Management

Pancreatic injuries require prompt surgical intervention. The management strategy depends on the extent of injury, ductal involvement, and the patient’s physiological status.

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  1. Initial Assessment and Exposure
    • Exposure Techniques:
      1. Mobilize the Hepatic Flexure.
      2. Divide the Gastrocolic Ligament.
      3. Retract the Transverse and Mesocolon Inferiorly.
      4. Perform a Kocher Maneuver to mobilize the pancreatic head and facilitate visualization.
    • Assessment Goals:
      • Determine parenchymal involvement.
      • Identify the location of injury.
      • Assess the presence of ductal trauma.

  2. Surgical Management Based on Injury Severity

    A. Injuries Left of the Superior Mesenteric Vessels (Distal Pancreas)

    • Ductal Integrity:
      1. Intact Duct:
        • Management: Distal Pancreatectomy.
      2. Disrupted Duct:
        • Management: Distal Pancreatectomy with Splenic Preservation.
        • Steps:
          • Remove the distal pancreas while preserving the spleen.
          • Ligature the pancreatic duct.
          • Cover the proximal stump with healthy omentum.
          • Place a closed suction drain to manage enzyme leaks.

    B. Injuries Involving the Pancreatic Head

    • Limited Tissue Destruction:
      1. Drainage Alone:
        • Creates a controlled fistula that may close spontaneously.
      2. Biliary Decompression:
        • Placement of stents via ERCP to divert bile and facilitate fistula closure.
    • Massive Tissue Destruction (Grade V):
      1. Pancreaticoduodenectomy (Whipple Procedure):
        • Indications:
          • Devitalized parenchyma.
          • Combined pancreatic and duodenal injuries.
        • Considerations:
          • High postoperative complication rate.
          • Only in patients with normalized physiology.
      2. Damage Control Surgery:
        • Hemorrhage control.
        • External drainage.
        • Temporary abdominal closure with plans for reexploration.
    • External Drainage
    • Importance:
      • Prevents retroperitoneal exposure to pancreatic enzymes.
      • Reduces inflammatory response and organ dysfunction.
    • Techniques:
      1. Closed Suction Systems:
        • Advantages: Reduced abscess development compared to open drains.
      2. Placement of Drains:
        • When to Place: In all significant pancreatic injuries to manage enzyme leaks.
    • Partial Gastrectomy (if applicable)
    • Indications:
      • Destructive gastric injuries requiring significant resection.
    • Reconstruction Options:
      1. Billroth I Procedure:
        • Description: End-to-end gastroduodenostomy.
      2. Billroth II Procedure:
        • Description: Gastrojejunostomy.

Complications and Their Management

  1. Pancreatic Enzyme Leak
    • Identification:
      • Persistent drainage from drains.
      • Signs of sepsis or abscess formation.
    • Management:
      • Ensure adequate drainage.
      • ERCP with stent placement to divert pancreatic secretions.
      • Antibiotic therapy if infected.
  2. Postoperative Ileus
    • Indication:
      • Decrease in gastrostomy or nasogastric tube output.
    • Management:
      • Monitor bowel function.
      • Gradually advance enteral nutrition.
  3. Postoperative Hemorrhage
    • Sources:
      • Incomplete hemostasis at repair sites.
      • Reperfusion injury.
    • Management:
      • Return to OR for surgical intervention.
      • Angioembolization if surgical control is inadequate.
  4. Intra-abdominal Abscess
    • Incidence: Common in pancreatic injuries.
    • Management:
      • Percutaneous drainage guided by imaging.
  5. Pancreatic Fistula
    • Diagnosis:
      • Drain output >30 mL/day.
      • Drain amylase level ≥3 times serum level.
    • Management:
      • Conservative treatment with drainage and nutrition.
      • Possible surgical intervention if persistent.
  6. Pancreatic Pseudocyst
    • Nonoperative Management:
      • Suggests a missed injury.
      • ERCP to evaluate duct integrity.
    • Operative Management:
      • Percutaneous drainage if symptomatic or enlarging.

Key Points

  • Pancreatic injuries are rare but carry significant morbidity and mortality, especially with ductal disruption.
  • Prompt surgical management is essential to reduce complications.
  • Diagnosis is challenging due to the retroperitoneal location; maintain a high index of suspicion.
  • Management Strategies are tailored based on the injury location, ductal involvement, and patient’s physiological status:
    1. Distal Pancreatectomy for injuries left of the superior mesenteric vessels.
    2. Drainage or Pancreaticoduodenectomy for injuries involving the pancreatic head.
    3. External drainage is crucial to manage enzyme leaks and prevent inflammatory complications.
  • Complications such as fistulas, abscesses, and hemorrhage require active and timely management to ensure optimal outcomes.
  • Early Total Enteral Nutrition (TEN) is beneficial in reducing septic complications, but should be initiated based on bowel function and patient stability.

Small Bowel Injuries

Epidemiology

  • Penetrating Trauma: One of the most frequently injured organs in penetrating abdominal trauma.
  • Blunt Trauma: Rarely injured (0.3% of cases).
  • Mortality Rates: 15% to 20%, mostly due to associated vascular injuries.

Mechanisms of Injury

  1. Crushing:
    • Occurs when the small bowel is compressed between a steering wheel or seat belt and the vertebral column.
  2. Rupture:
    • Results from a rapid increase in intraluminal pressure, causing a blow-out along the antimesenteric border.
  3. Shearing:
    • Deceleration forces can shear the serosa or muscularis across a segment of the bowel.
  4. Mesenteric Injury:
    • Injury to the small bowel mesentery can result in devascularization, leading to intestinal necrosis without direct tissue injury.

Clinical Presentation

  • Peritonitis: May be present at the time of examination or develop as the patient's condition worsens.
  • Abdominal Tenderness: Findings may worsen over time, requiring prompt attention.

Diagnosis

  • Challenges:
    • The evaluation of small bowel injuries is similar to the evaluation of the stomach and duodenum.
    • CT Imaging has limitations, requiring a high index of suspicion to avoid missing injuries.

  • Physical Examination: Can be unreliable; focus on worsening signs of peritonitis or abdominal tenderness.

    image.png

Surgical Management

  1. Primary Repair:
    • Indications:
      • Small perforations or injuries to the intestinal serosa.
      • Can also be performed in cases of multiple perforations, provided the repairs do not result in lumen narrowing.
    • Technique:
      • One or Two-Layer Closure: Use after debridement of devitalized tissue.
      • Reinforcement with interrupted nonabsorbable sutures.
      • Avoid overly compromising the size of the intestinal lumen.
  2. Resection with Anastomosis:
    • Indications:
      • Injuries involving more than 50% of the intestinal wall circumference.
      • Multiple perforations that would result in luminal narrowing if repaired primarily.
    • Technique:
      • Resection of the injured bowel segment.
      • Anastomosis:
        • Stapled or hand-sewn (no difference in leak rates).
        • Hand-sewn anastomoses may be performed in two layers, though single-layer methods are equally effective.
    • Surgeon's Preference: Selection based on surgeon's experience and comfort with the technique.
  3. Damage Control Surgery:
    • Indications:
      • Large injuries requiring rapid control of contamination.
      • Patients in shock at high risk of anastomotic dehiscence.
    • Technique:
      • Rapid closure of perforations or resection.
      • Temporary closure of the abdomen.
    • Follow-Up:
      • After resuscitation, intestinal continuity can be reestablished during a return to the OR.

Postoperative Considerations

  1. Postoperative Ileus:
    • Indicator: Decrease in nasogastric tube or gastrostomy output.
    • Management: Gradually advance enteral nutrition as bowel function returns.
  2. Anastomotic Leak:
    • Signs: Fever, sepsis, abdominal pain.
    • Management: May require reoperation or drainage.
  3. Infections:
    • Wound Infection: Treated with local care and antibiotics.
    • Intra-abdominal Abscess: Requires percutaneous drainage.

Key Points

  • Small bowel injuries are common in penetrating trauma but rare in blunt trauma.
  • High mortality rates are primarily due to associated vascular injuries.

Management Options for Different Scenarios:

  1. Small Perforations:
    • Primary Repair with nonabsorbable sutures. One or two layers can be used to ensure adequate closure without lumen narrowing.
  2. Multiple Perforations:
    • Primary Repair is still an option if there is no narrowing of the bowel lumen. However, if perforations are too close, resection with anastomosis is recommended.
  3. Injuries Involving >50% of Intestinal Wall Circumference:
    • Bowel resection with anastomosis is required to prevent luminal compromise. Either hand-sewn or stapled techniques can be used, with no significant difference in leak rates.
  4. Shock or Severe Physiologic Derangement:
    • Damage control surgery is indicated. Rapid closure of perforations and temporary abdominal closure should be performed. Resection without immediate anastomosis is recommended due to the high risk of anastomotic dehiscence.
  5. Large Destructive Injuries:
    • Bowel resection with anastomosis is the primary treatment. Post-resuscitation, intestinal continuity can be reestablished during reoperation.
  6. Postoperative complications such as ileus, anastomotic leaks, and infections must be managed promptly for optimal outcomes.
  7. Damage control surgery is essential for unstable patients, allowing for stabilization and planned reexploration.

Colon and Rectal Injuries

Epidemiology

  • Colon and Rectal Injuries: Most commonly occur after penetrating abdominal trauma and rarely from blunt mechanisms.
    • Blunt Injury Incidence: Approximately 0.3% of cases, mostly hematomas and serosal tears.
  • Historical Mortality Rates:
    • World War II: Mortality rates of 22% to 35% when colostomy creation was mandatory for colon trauma.
    • Contemporary Reports: Mortality as low as 1% due to advancements in treatment.

Classification of Colon Injuries

  1. Destructive Injuries:
    • Penetrating Trauma:
      • Involves more than 50% of the colonic circumference, complete transection, or devascularized segments.
    • Blunt Trauma:
      • Involves serosal tears >50%, full-thickness perforation, and mesenteric devascularization.
  2. Nondestructive Injuries:
    • Serosal tears or small perforations with intact vascular supply.

Mechanisms of Injury

  1. Penetrating Injuries:
    • Common in gunshot wounds (GSWs) and sharp trauma.
  2. Blunt Injuries:
    • Crush injuries or rupture from high intraluminal pressure due to rapid compression.
    • Retroperitoneal Injuries: Possible with perforations in the right or left colon.
  3. Rectal Injuries:
    • Can result from GSWs or pelvic fractures with sharp bone fragments causing laceration.

Clinical Presentation

  • Peritonitis: May indicate free perforation.
  • Retroperitoneal Injury: Peritonitis may be obscured due to retroperitoneal location of the colon.
  • Rectal Injuries: Presence of blood on digital rectal examination, but further evaluation is needed with CT imaging or rigid proctosigmoidoscopy if clinical suspicion persists.

Diagnosis

  1. Colon Injury:
    • CT Imaging: Limited sensitivity, but may show colonic wall thickening or surrounding fluid/stranding.
    • Triple Contrast (Oral, Rectal, IV): Improves diagnostic yield, especially in penetrating trauma.
  2. Rectal Injury:
    • Digital Rectal Examination (DRE): Presence of blood requires further evaluation.
    • CT Imaging: Negative findings suggest low likelihood of significant injury, but indeterminate results require further exploration.
    • Rigid Proctosigmoidoscopy: Useful for visualizing rectal wall injuries or hematoma.

Management

1. Nondestructive Colon Injuries

  • Primary Repair:
    • One or Two Layers of suturing are used for nondestructive injuries.
    • No proximal fecal diversion is required.

2. Destructive Colon Injuries

  • Resection with Anastomosis:
    • Performed in healthy patients without extremis or severe resuscitation needs.
  • Diversion:
    • For patients requiring resuscitation (e.g., >6 units of PRBC transfusion), comorbidities, or shock, a colostomy is preferred.
    • Delayed anastomosis may be considered after resuscitation.

3. Damage Control Surgery

  • Resection without Anastomosis:
    • Performed in unstable patients with destructive injuries during damage control laparotomy.
    • The GI tract is left in discontinuity, and colostomy or delayed anastomosis can be performed on returning to the OR after resuscitation.

4. Rectal Injuries

  • Destructive Injuries (>25% Circumference):
    • Managed with fecal diversion (loop ileostomy or colostomy) and, if necessary, presacral drainage.
  • Non-destructive Injuries:
    • Fecal diversion without drainage may be sufficient for extraperitoneal rectal injuries.
  • Intraperitoneal Rectal Injuries:
    • Managed like colon trauma, often requiring surgical repair or resection with anastomosis.

Complications

  1. Anastomotic Leakage:
    • Common in destructive injuries if anastomosis is performed in an unstable patient.
    • Mortality rates are higher with intraabdominal sepsis.
  2. Pelvic Sepsis:
    • Particularly a risk in destructive rectal injuries.
    • Managed with drainage and proximal diversion.
  3. Postoperative Abscesses and Fistulas:
    • Occur in up to 10% of cases, often managed with percutaneous drainage.

Key Points

  1. Nondestructive Colon Injuries:
    • Primary repair is safe and effective with one or two layers of suturing.
  2. Destructive Colon Injuries:
    • Resection with anastomosis is preferred in healthy patients.
    • Colostomy or diversion is necessary in unstable or comorbid patients.
    • Damage control strategies include resection without immediate anastomosis in unstable patients.
  3. Rectal Injuries:
    • Destructive injuries (>25% circumference) are managed with fecal diversion and may include presacral drainage.
    • Non-destructive extraperitoneal injuries can be managed without drainage, but diversion is often necessary.
  4. Complications:
    • Anastomotic leaks, pelvic sepsis, and abscess formation are the main risks, especially in destructive injuries.