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Abdominal Trauma Schwartz

Liver and Extrahepatic Biliary Tract

Susceptibility and Epidemiology

  • Liver:
    • Most susceptible to blunt trauma due to its large size.
    • Frequently involved in upper torso penetrating wounds.

Management Strategies

Nonoperative Management

  • Indications:
    • Hemodynamically stable patients.
    • No overt peritonitis.
    • No other indications for laparotomy.
  • Criteria for Admission:
    • >Grade II injuries.
    • Admitted to the SICU with:
      • Frequent hemodynamic monitoring.
      • Hemoglobin determination.
      • Abdominal examinations.
  • Contraindications:
    • Hemodynamic instability from intraperitoneal hemorrhage.
  • Predictors of Complications or Failure:
    • High injury grade.
    • Large hemoperitoneum.
    • Contrast extravasation.
    • Pseudoaneurysms.
  • Adjuncts to Improve Success:
    • Angioembolization.
    • Endoscopic Retrograde Cholangiopancreatography (ERCP).
  • Indication for Angiography:
    • Transfusion of 4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours attributable to the liver.

Operative Management

  • Indications:
    • Emergent laparotomy mandated in 15% of patients.
  • Primary Goals:
    • Arrest hemorrhage.
  • Hemorrhage Control Techniques:
    • Perihepatic packing.
    • Manual compression.
    • Pringle maneuver:
      • Immediate application in extensive injuries.
      • Intermittent release to reduce hepatic cellular loss.
  • Persistent Bleeding Management:
    • Consider injuries to:
      • Hepatic artery.
      • Portal vein.
      • Retrohepatic vasculature.
    • Pringle maneuver to delineate hemorrhage source:
      • Hepatic artery and portal vein: Bleeding halts with vascular clamp across the portal triad.
      • Hepatic veins and retrohepatic vena cava: Bleeding continues despite Pringle maneuver.
  • Portal Triad Vasculature Injuries:
    • Immediate address required.
    • Ligation:
      • From celiac axis to common hepatic artery at gastroduodenal arterial branch tolerated due to extensive collaterals.
      • Proper hepatic artery should be repaired.
      • Right/Left hepatic artery or portal vein may be selectively ligated.
      • Lobar necrosis may necessitate delayed anatomic resection.
    • Repair Techniques:
      • Primary end-to-end repair for clean transections (stab wounds).
      • Temporary shunting followed by interposition reversed saphenous vein graft (RSVG) for destructive injuries.
    • Blunt Avulsions:
      • Directed packing or Fogarty catheters for hemorrhage control.
      • Transection of the pancreas if proximal injuries require access.
  • Massive Venous Hemorrhage:
    • Hepatic vein or retrohepatic vena cava injury suspected.
    • Perihepatic packing:
      • Leave packing undisturbed if controlled.
      • Hepatic vein stent placement by interventional radiology may be considered.
    • Persistent Bleeding:
      • Direct repair with or without hepatic vascular isolation:
        • Direct repair techniques:
          1. Suprahepatic and infrahepatic clamping of the vena cava.
          2. Stapled assisted parenchymal resection.
        • Temporary shunting of the retrohepatic vena cava.
        • Venovenous bypass.

Definitive Control of Hepatic Parenchymal Hemorrhage

  • Minor Lacerations:
    • Manual compression.
    • Topical hemostatic techniques:
      • Electrocautery (100 watts).
      • Argon beam coagulator.
      • Microcrystalline collagen.
      • Thrombin-soaked gelatin foam sponge.
      • Fibrin glue.
      • BioGlue.
  • Suturing Techniques:
    • Blunt tipped 0 chromic suture (e.g., “liver suture”):
      • Running suture for shallow lacerations.
      • Interrupted horizontal mattress sutures for deeper lacerations.
      • Tension applied until hemorrhage ceases or liver blanches.
    • Prevent hepatic necrosis by avoiding excessive tension.
  • Lobar Arterial Ligation:
    • For recalcitrant arterial hemorrhage from deep liver.
    • Alternative to deep hepatotomy in unstable patients.
  • Omentum Usage:
    • Fill large liver defects.
    • Provide macrophages and buttressing support for parenchymal sutures.
  • Translobar Penetrating Injuries:
    • Options:
      • Intraparenchymal tamponade with Foley catheter or balloon occlusion.
      • Leave balloon inflated for 24-48 hours, followed by deflation and removal at second laparotomy.
      • Hepatotomy with ligation of individual bleeders.
      • Angioembolization as an early adjunct.

Hepatic Transplantation

  • Indications:
    • Devastating hepatic injuries or necrosis of the entire liver.
  • Requirements:
    • All other injuries delineated.
    • Excellent survival chance excluding hepatic injury.
  • Limitations:
    • Donor availability restricts use to extraordinary circumstances.

Extrahepatic Biliary Tract Injuries

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  • Gallbladder Injuries:
    • Cholecystectomy performed for injuries.
    • Postoperative ligation of the right hepatic artery.
  • Extrahepatic Bile Ducts:
    • Challenges due to small size and thin walls.
    • Associated vascular injuries common due to proximity to portal structures and vena cava.
    • Primary Repair:
      • Small lacerations: T-tube insertion or lateral suturing with 6-0 monofilament absorbable suture.
    • Transections and Significant Tissue Loss:
      • Roux-en-Y choledochojejunostomy:
        • Single-layer interrupted technique with 5-0 monofilament absorbable suture.
        • Reduce anastomotic tension by suturing the jejunum to the areolar tissue of the hepatic pedicle or porta hepatis.
    • Hepatic Duct Injuries:
      • Impossible to satisfactorily repair under emergent circumstances.
      • Management Options:
        • Intubate duct for external drainage and attempt repair upon recovery.
        • Stenting via ERCP.
        • Ligation if opposite lobe is normal and uninjured.

Postoperative Management

  • Perihepatic Packing:
    • Return to OR for pack removal 24 hours after initial injury.
    • Earlier exploration if ongoing hemorrhage:
      • Signs of rebleeding:
        • Falling hemoglobin.
        • Accumulation of blood clots under temporary abdominal closure device.
        • Bloody output from drains.
        • Ongoing hemodynamic instability.
        • Metabolic monitoring.
    • Postoperative Hemorrhage:
      • Reevaluate in OR after correction of coagulopathy.
      • Angioembolization for complex injuries.
  • Hepatic Ischemia:
    • Prolonged Pringle maneuver: Elevation then resolution of transaminase levels.
    • Hepatic artery ligation: Frank hepatic necrosis.
  • Infectious Complications:
    • Febrile patients: Evaluate for infection.
    • Complex hepatic injuries: Intermittent “liver fever” for first 5 days after injury.

Complications and Management

  • Hemorrhage and Hepatic Necrosis:
    • Controlled with:
      • Angioembolization.
      • Hepatic vascular isolation techniques.
  • Additional Complications:
    • Bilomas:
      • Loculated collections of bile.
      • Infected: Percutaneous drainage like an abscess.
      • Sterile: Reabsorbed if small; drain larger collections.
    • Biliary Ascites:
      • Due to major bile duct disruption.
      • Requires reoperation and wide drainage.
      • Primary repair unlikely; reseccional debridement for nonviable hepatic parenchyma.
    • Pseudoaneurysms and Biliary Fistulas:
      • Rare complications.
      • Arterial pseudoaneurysms:
        • Potential for rupture.
        • Hemobilia: Right upper quadrant pain, upper GI hemorrhage, jaundice.
        • Portal vein rupture: Portal venous hypertension, bleeding esophageal varices.
        • Management: Hepatic arteriography and embolization.
      • Biliovenous Fistulas:
        • Cause jaundice due to rapid serum bilirubin increase.
        • Management:
          • ERCP and sphincterotomy.
      • Bronchobiliary or Pleurobiliary Fistulas:
        • Formed with diaphragm injuries.
        • Operative closure required due to pressure differential.
        • Endoscopic sphincterotomy with stent placement may be needed; pleurobiliary fistula may close spontaneously.

Definitive Control Techniques

  • Manual Compression: For minor lacerations.
  • Topical Hemostatic Techniques:
    • Electrocautery (100 watts).
    • Argon beam coagulator.
    • Microcrystalline collagen.
    • Thrombin-soaked gelatin foam sponge.
    • Fibrin glue.
    • BioGlue.
  • Suturing Techniques:
    • Blunt tipped 0 chromic suture (e.g., “liver suture”):
      • Running suture for shallow lacerations.
      • Interrupted horizontal mattress sutures for deeper lacerations.
      • Prevent hepatic necrosis by avoiding excessive tension.
  • Hepatic Lobar Arterial Ligation:
    • For recalcitrant arterial hemorrhage.
    • Alternative to deep hepatotomy in unstable patients.
  • Omentum Usage:
    • Fill large liver defects.
    • Provide macrophages and buttressing support for parenchymal sutures.
  • Translobar Penetrating Injuries:
    • Intraparenchymal tamponade with Foley catheter or balloon occlusion.
    • Leave balloon inflated for 24-48 hours, followed by deflation and removal at second laparotomy.
    • Hepatotomy with ligation of individual bleeders if necessary.
    • Angioembolization as an early adjunct.

Key Points

  • Liver is most susceptible to blunt trauma due to its large size.
  • Nonoperative management is preferred for hemodynamically stable patients without overt peritonitis.
  • Hemodynamic instability from intraperitoneal hemorrhage is the only absolute contraindication to nonoperative management.
  • High injury grade, large hemoperitoneum, contrast extravasation, and pseudoaneurysms are predictors of complications or failure of nonoperative management.
  • Angioembolization and ERCP are useful adjuncts to improve nonoperative management success.
  • Emergent laparotomy focuses on hemorrhage control using techniques like perihepatic packing, manual compression, and the Pringle maneuver.
  • Persistent bleeding necessitates evaluation and management of hepatic artery, portal vein, and retrohepatic vasculature injuries.
  • Definitive control of hepatic hemorrhage includes manual compression, topical hemostatic techniques, and suturing.
  • Postoperative complications such as bilomas, pseudoaneurysms, and biliary fistulas require active management.
  • Hepatic transplantation is reserved for extraordinary circumstances due to donor availability constraints.
  • Early identification and expeditious surgical intervention are critical to reduce mortality in extensive liver injuries.

Spleen

Historical Context

  • Splenectomy was mandatory for all splenic injuries until the 1970s.
  • 1980s: Shift towards operative splenic salvage recognizing the spleen's immune function.
  • Nonoperative management became the preferred means of splenic salvage following success in pediatric patients.

Epidemiology

  • Isolated splenic injury comprises approximately 42% of abdominal trauma.
  • Penetrating splenic trauma accounts for 8.5% of all penetrating abdominal injuries (2012 NTDB).

Management Strategies

Nonoperative Management

  • Indications:
    • Hemodynamically stable patients.
    • No overt peritonitis.
    • No other indications for laparotomy.
  • Criteria for Admission:
    • >Grade II injuries.
    • Admitted to the SICU with:
      • Frequent hemodynamic monitoring.
      • Hemoglobin determination.
      • Abdominal examinations.
  • Contraindications:
    • Hemodynamic instability from intraperitoneal hemorrhage.
  • Predictors of Complications or Failure:
    • High injury grade.
    • Large hemoperitoneum.
    • Contrast extravasation.
    • Pseudoaneurysms.
  • Adjuncts to Improve Success:
    • Angioembolization.
    • Endoscopic Retrograde Cholangiopancreatography (ERCP).
  • Indication for Angiography:
    • Transfusion of 4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours attributable to the liver.

Operative Management

  • Indications:
    • Early intervention warranted in 15%–20% of patients.
    • Hemodynamic instability.
    • Initiation of blood transfusion within the first 12 hours.
    • Failure of nonoperative management due to inappropriate patient selection.
  • Primary Goals:
    • Arrest hemorrhage.
  • Surgical Approaches:
    • Splenectomy:
      • Indicated for:
        • Significant hilar injuries.
        • Pulverized splenic parenchyma.
        • >Grade II injury in patients with coagulopathy or multiple life-threatening injuries.
      • Techniques:
        • Autotransplantation of splenic implants for partial immunocompetence in younger patients without enteric injury.
        • No drains used.
    • Partial Splenectomy:
      • Indicated for:
        • Injuries to the superior or inferior pole only.
      • Techniques:
        • Control hemorrhage from the raw splenic edge with horizontal mattress sutures.
        • Gentle compression of the parenchyma.
    • Splenic Repair (Splenorrhaphy):
      • Indicated for:
        • Non-pulverized injuries with manageable tissue loss.
      • Techniques:
        • Topical hemostatic methods:
          • Electrocautery.
          • Argon beam coagulation.
          • Thrombin-soaked gelatin foam sponges.
          • Fibrin glue.
          • BioGlue.
        • Envelopment of the injured spleen in absorbable mesh.
        • Pledgeted suture repair.

Splenic Salvage Techniques

  • Autotransplantation of Splenic Implants:
    • Achieves partial immunocompetence in younger patients.
    • Not used in the presence of associated enteric injuries.
  • Partial Splenectomy:
    • Superior or inferior pole injuries.
    • Hemorrhage control with horizontal mattress sutures and parenchymal compression.
  • Splenorrhaphy:
    • Topical hemostatic agents and suture techniques to control bleeding.
    • Absorbable mesh and pledgeted sutures for reinforcement.

Postoperative Management

  • Post-Splenectomy Care:
    • Postoperative hemorrhage may result from:
      • Improperly ligated or unrecognized short gastric artery.
      • Recurrent bleeding from splenic parenchyma if splenic repair was performed.
    • Normal Postoperative Changes:
      • Immediate increase in platelets and WBCs.
    • Signs of Sepsis (beyond postoperative day 5):
      • WBC count >15,000/mm³.
      • Platelet/WBC ratio <20.
      • Action: Thorough search for underlying infection.
    • Common Infectious Complications:
      • Subphrenic abscess: Managed with percutaneous drainage.
      • Overwhelming postsplenectomy sepsis:
        • Caused by: Encapsulated bacteria (e.g., Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis).
        • Prevention: Vaccination administered >14 days post-injury.
        • Mortality: 30%–70% if sepsis occurs.

Complications and Their Management

  • Postoperative Hemorrhage:
    • Sources:
      • Short gastric artery.
      • Splenic parenchyma.
    • Management:
      • Re-exploration if ongoing hemorrhage.
      • Angioembolization for complex injuries.
  • Infections:
    • Subphrenic abscess: Percutaneous drainage.
    • Overwhelming postsplenectomy sepsis: High mortality, requires immediate intervention.
  • Iatrogenic Injuries:
    • Pancreatic tail injury: Pancreatic ascites or fistula.
    • Gastric perforation: During short gastric vessel ligation.
  • Overwhelming Postsplenectomy Sepsis:
    • Caused by: Encapsulated bacteria.
    • Prevention: Vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.

Vaccination Protocol

  • Timing: >14 days post-injury.
  • Purpose: Protection against encapsulated bacteria to prevent overwhelming postsplenectomy sepsis.

Key Points

  • Nonoperative management is the preferred approach for hemodynamically stable patients without overt peritonitis.
  • Hemodynamic instability from intraperitoneal hemorrhage is the only absolute contraindication to nonoperative management.
  • High injury grade, large hemoperitoneum, contrast extravasation, and pseudoaneurysms are predictors of complications or failure of nonoperative management.
  • Angioembolization and ERCP are useful adjuncts to improve nonoperative management success.
  • Emergent laparotomy focuses on hemorrhage control using techniques like perihepatic packing, manual compression, and the Pringle maneuver.
  • Persistent bleeding necessitates evaluation and management of hepatic artery, portal vein, and retrohepatic vasculature injuries.
  • Splenic salvage techniques aim to preserve immune function and reduce the risk of overwhelming postsplenectomy sepsis.
  • Postoperative complications such as subphrenic abscesses, infections, and hemorrhage require active management to ensure optimal patient outcomes.
  • Vaccination against encapsulated bacteria is essential post-splenectomy to prevent sepsis.

Stomach and Small Intestine

Repair of Injuries

  • Rich Blood Supply of the stomach and small bowel minimizes controversy in repair approaches.
  • Gastric Wounds:
    • Oversewn with a running single-layer suture line.
    • Closed using a stapler.
    • Single-layer closure:
      • Full-thickness bites ensure hemostasis from the well-vascularized gastric wall.
  • Commonly Missed Injuries:
    • Posterior wounds of through and through penetrating injuries.
    • Wounds within the mesentery of the lesser curvature or high in the fundus.

Diagnostic Techniques

  • Delineating Questionable Injuries:
    • Methylene blue-colored saline instilled via a nasogastric (NG) tube while digitally occluding the stomach at the pylorus.
    • Air introduced via the NG tube with the abdomen filled with saline.
  • Partial Gastrectomy:
    • Required for destructive injuries.
    • Resections of the distal antrum or pylorus.
    • Reconstructed using a Billroth procedure.

Injuries Involving Nerves

  • Damage to Latarjet nerves or vagi:
    • Require a drainage procedure (see Chapter 26).

Small Intestine Injuries

  • Repair Techniques:
    • Transverse running 3-0 PDS suture for injuries <1/3 circumference.
    • Segmental resection for destructive injuries or multiple close injuries.
      • End-to-end anastomosis using continuous, single-layer 3-0 polypropylene suture.
  • Mesenteric Injuries:
    • May cause ischemic segments requiring resection.

Post-Repair Complications

  • Postoperative Ileus:
    • Indicated by a decrease in gastrostomy or nasogastric tube output.
  • Nutrition Management:
    • Early Total Enteral Nutrition (TEN):
      • Reduces septic complications.
      • Route (stomach vs. small bowel) is less important unless upper GI tract pathology exists.
    • Cautions:
      • Overzealous jejunal feeding can lead to small bowel necrosis in patients recovering from profound shock.
    • Special Considerations:
      • Patients with nonoperative management of grade III+ solid organ injuries:
        • Receive nothing by mouth for at least 48 hours in case of operation necessity.
      • TEN in Open Abdomen:
        • Feasible and associated with higher fascial closure rates, decreased complications, and decreased mortality in patients without bowel injury.
        • Does not alter outcomes in patients with bowel injuries.
        • Initiate TEN once resuscitation is complete, even at trophic levels (20 mL/h).

Operative Management

Gastric Injuries

  • Indications:
    • Presence of peritonitis.
    • Hemodynamic instability.
    • High suspicion based on clinical and imaging metrics.
  • Surgical Approach:
    • Full Evaluation:
      • Visualize both anterior and posterior walls of the stomach.
      • Enter the lesser sac to avoid missing injuries.
    • Repair Techniques:
      • Evacuate hematomas to ensure no perforation.
      • Control bleeding.
      • Close 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 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 a fistula occurs.
  • Damage Control:
    • Resection, wide drainage, and temporary discontinuity to control contamination.

Small Intestine Injuries

  • Repair Techniques:
    • Transverse running 3-0 PDS suture for injuries <1/3 circumference.
    • Segmental resection for destructive or multiple close injuries.
      • End-to-end anastomosis with continuous, single-layer 3-0 polypropylene suture.
  • Mesenteric Injuries:
    • Ischemic segments require resection.

Management of Duodenal Hematoma

  • Nonoperative Management:
    • Nasogastric suction.
    • Parenteral nutrition.
  • Resolution Indicators:
    • Marked drop in nasogastric tube output within 2 weeks.
  • Follow-Up:
    • Repeat imaging is optional.
    • Operative evaluation if no improvement within 3 weeks.
  • Operative Evaluation:
    • 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:
    • Return to OR for pack removal 24 hours after initial injury.
    • Earlier exploration if ongoing hemorrhage.
      • Signs of rebleeding:
        • Falling hemoglobin.
        • Accumulation of blood clots under temporary abdominal closure device.
        • Bloody output from drains.
        • Ongoing hemodynamic instability.
        • Metabolic monitoring.
  • Postoperative Hemorrhage:
    • Reevaluate in OR after correction of coagulopathy.
    • Angioembolization for complex injuries.
  • Hepatic Ischemia:
    • Prolonged Pringle maneuver: Elevation and resolution of transaminase levels.
    • Hepatic artery ligation: Frank hepatic necrosis.
  • Infectious Complications:
    • Febrile patients: Evaluate for infection.
    • Complex hepatic injuries: Intermittent “liver fever” for first 5 days after injury.

Nutrition Management

  • Early Total Enteral Nutrition (TEN):
    • Reduces septic complications.
    • Routes:
      • Stomach vs. small bowel: Equivalent tolerance unless upper GI tract pathology exists.
    • Cautions:
      • Evidence of bowel function required before advancing to goal tube feedings.
      • Avoid overzealous jejunal feeding to prevent small bowel necrosis.
  • Patients with Open Abdomen:
    • Early TEN:
      • Higher fascial closure rates.
      • Decreased complications.
      • Decreased mortality.
    • TEN in Bowel Injuries:
      • Neither advantageous nor detrimental.
    • Initiate TEN once resuscitation is complete, even at trophic levels (20 mL/h).

Key Points

  • Repair of stomach and small intestine injuries is straightforward due to a rich blood supply.
  • Gastric wounds can be oversewn or stapled; ensure hemostasis with full-thickness bites.
  • Missed injuries often occur in posterior wounds or mesenterylocated injuries; use methylene blue saline or air with saline techniques for delineation.
  • Partial gastrectomy may be necessary for destructive injuries, with Billroth procedures for reconstruction.
  • Small intestine injuries:
    • Simple repairs with running suture.
    • Resections and anastomosis for destructive or multiple injuries.
    • Ischemic segments from mesenteric injuries require resection.
  • Post-repair complications include postoperative ileus, infections, and hemorrhage; manage with early recognition and appropriate interventions.
  • Early total enteral nutrition (TEN) is crucial for reducing septic complications; monitor gut tolerance and adjust feeding accordingly.
  • Maintain a low threshold for exploration in cases of suspicion of injury to prevent increased mortality.

Duodenum and Pancreas Injuries

Spectrum of Duodenal Injuries

  • Types of Injuries:
    • Hematomas
    • Perforations:
      • Blunt blow-outs
      • Lacerations from stab wounds
      • Blast injuries from gunshot wounds
    • Combined Pancreaticoduodenal Injuries

Duodenal Injuries Management

Nonoperative Management

  • Duodenal Hematomas:
    • Managed nonoperatively with:
      • Nasogastric suction
      • Parenteral nutrition
    • Resolution Indicators:
      • Marked drop in nasogastric tube output within 2 weeks
    • Follow-Up:
      • Repeat imaging is optional
      • Operative evaluation if no improvement within 3 weeks

Operative Management

  • Indications:
    • Suspected associated perforation:
      • Clinical deterioration
      • Imaging findings: Retroperitoneal free air, contrast extravasation
    • High suspicion based on multiple 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 to ensure no perforation
      • Control bleeding
      • Close 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 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 with a contrast study after 5 to 7 days
    • Operative exploration if obstruction persists after ~14 days
  • Intraoperative Hematoma Management:
    • Decompress hematoma during duodenum mobilization
    • Evaluate for injury
    • Do not intentionally open hematomas unless full-thickness injury is suspected

Pancreatic Trauma Management

Determining Management Approach

  • Factors:
    • Location of parenchymal damage
    • Integrity of intra-pancreatic common bile duct and main pancreatic duct

Types of Pancreatic Injuries

  • Pancreatic Contusions:
    • Ductal system intact
    • Management:
      • Nonoperative
      • Closed suction drainage if undergoing laparotomy for other reasons
  • Proximal Pancreatic Injuries:
    • Location: Right of the superior mesenteric vessels
    • Management:
      • Closed suction drainage
  • Distal Pancreatic Injuries:
    • Based on ductal integrity:
      • Pancreatic duct disruption:
        • Identification Methods:
          • Direct exploration
          • Operative pancreatography
          • ERCP
          • Magnetic resonance cholangiopancreatography (MRCP)
        • Management:
          • Distal pancreatectomy with splenic preservation
  • Pancreatic Head Injuries:
    • Complexity due to common bile duct:
      • Identification:
        • Squeeze the gallbladder for bile leakage
        • Cholangioography via the cystic duct
      • Definitive Treatment:
        • Division of the common bile duct superior to the first portion of the duodenum
        • Ligation of the distal duct
        • Reconstruction with Roux-en-Y choledochojejunostomy
  • Main Pancreatic Duct Injuries:
    • In the pancreatic head:
      • Options:
        • Central pancreatectomy with:
          • Drainage into a posterior wall pancreaticogastrostomy or
          • Roux-en-Y pancreaticojejunostomy
        • Pancreaticoduodenectomy (Whipple procedure) in:
          • Multiple injuries
          • Damage control scenarios
    • Major ductal disruption in distal pancreas:
      • Options:
        • Spleen-preserving distal pancreatectomy in stable patients
        • Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy preserving the spleen
        • Distal pancreatectomy with splenectomy if physiologically compromised

Additional Management Techniques

  • Pyloric Exclusion:
    • Purpose: Divert GI stream after high-risk, complex duodenal repairs
    • Procedure:
      • Gastrostomy on the greater curvature near the pylorus
      • Grasp pylorus with a Babcock clamp via the gastrostomy
      • Oversew with an O polypropylene suture
      • Perform gastrojejunostomy to restore GI tract continuity
      • Double external staple line using a TA stapler for durable closure
    • Complications:
      • End fistula: Heals in 6 to 8 weeks with adequate drainage
      • Delayed hemorrhage: Managed by angioembolization
  • Drain Management:
    • Closed suction drains:
      • Remain in place until the patient is tolerating an oral diet or enteral nutrition

Complications and Their Management

  • Septic Complications:
    • Related to repair failure
    • Managed with:
      • Antibiotic therapy
      • Additional surgical or endoscopic interventions
  • Pancreatic Fistula:
    • Diagnosis:
      • Post-operative day 5
      • Drain output >30 mL/day
      • Drain amylase level: Three times the serum value
    • Management:
      • Similar to fistulas after elective surgery
  • Duodenal Fistula:
    • Typically an end fistula if pyloric exclusion performed
    • Heals in 6 to 8 weeks with adequate drainage and control of intra-abdominal sepsis
  • Pancreatic Pseudocysts:
    • Nonoperative management suggests a missed injury
    • Managed with:
      • ERCP to evaluate pancreatic duct integrity
      • Percutaneous drainage if late pseudocysts develop
  • Intra-abdominal Abscesses:
    • Commonly managed with percutaneous drainage

Key Points

  • Duodenal and pancreatic injuries require a high index of suspicion due to retroperitoneal location.
  • Penetrating duodenal injuries are more common but pose diagnostic challenges.
  • Blunt duodenal 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, with options ranging from simple suturing to complex reconstructions.
  • Maintain a low threshold for exploration to avoid missed injuries and increased mortality.
  • Postoperative complications should be actively monitored and managed to ensure optimal patient outcomes.

Colon and Rectum

Colon Injuries

Treatment Methods

There are three primary methods for treating colonic injuries:

  1. Primary Repair
    • Techniques:
      • Lateral Suture Repair
      • Resection of the Damaged Segment followed by Reconstruction:
        • Ileocolostomy
        • Colocolostomy
    • Suturing Technique:
      • Running single-layer sutures (see Fig. 7-67)
    • Advantages:
      • Definitive treatment without the need for a stoma.
      • Avoids the risks associated with stoma formation.
    • Disadvantages:
      • Risk of anastomotic leakage if performed under suboptimal conditions.
  2. End Colostomy
    • Description:
      • Formation of a colostomy to divert fecal matter, avoiding anastomosis.
    • Advantages:
      • Avoids unprotected suture lines, reducing the risk of leakage.
    • Disadvantages:
      • Requires a second operation for stoma reversal.
      • Impact on patient's quality of life due to stoma presence.
  3. Primary Repair with Diverting Loop Ileostomy
    • Description:
      • Combination approach where primary repair is performed along with the creation of a loop ileostomy to divert fecal flow.
    • Indications:
      • High-risk patients where there is a significant chance of anastomotic leakage.
      • Devastating left colon injuries requiring damage control.
    • Advantages:
      • Provides fecal diversion while maintaining primary repair.
      • Reduces the risk of contamination and leakage.
    • Disadvantages:
      • Increased complexity of surgery.
      • Requires management of the ileostomy post-recovery.

Decision-Making Factors

  • Overall Physiologic Status is prioritized over local factors in directing treatment decisions.
  • Primary repair is safe and effective for virtually all patients with penetrating wounds.
  • End colostomy remains appropriate in selected cases, particularly where high leak rates (>40%) are anticipated.
  • Diverting ileostomy with colocolostomy is considered for high-risk patients to mitigate the risk of anastomotic complications.

Rectal Injuries

Characteristics

  • Similar to colonic injuries in terms of luminal contents ecology, wall structure, and blood supply.
  • Limited access to extraperitoneal injuries due to the surrounding bony pelvis, necessitating indirect treatment.

Treatment Methods

  1. Indirect Treatment with Intestinal Diversion
    • Options:
      1. Loop Ileostomy
      2. Sigmoid Loop Colostomy (Preferred)
        • Advantages:
          • Quick and easy to perform.
          • Provides essentially total fecal diversion.
        • Technical Elements:
          1. Adequate Mobilization of the sigmoid colon to prevent tension on the stoma.
          2. Maintain the spur of the colostomy above skin level using a half-inch Penrose drain or similar device.
          3. Longitudinal incision in the tenia coli.
          4. Immediate maturation of the stoma in the operating room (see Fig. 7-68).
  2. Direct Repair (If Accessible)
    • Indications:
      • Injuries accessible (e.g., posterior intraperitoneal rectum).
    • Approach:
      • Attempt repair of the injury.
      • Not necessary to explore the extraperitoneal rectum for distal perforations.
  3. Hartmann’s Procedure
    • Description:
      • Divide the rectum at the injury level.
      • Oversew or staple the distal rectal pouch.
      • Create an end colostomy.
    • Indications:
      • Extensive rectal injuries requiring significant resection.
      • Aversion of lethal pelvic sepsis.
  4. Abdominoperineal Resection (For Destructive Injuries)
    • Description:
      • Resection of the rectum and anus, typically resulting in a permanent colostomy.
    • Indications:
      • Highly destructive injuries.
      • Preventing lethal pelvic sepsis.

Complications

  1. Intra-abdominal Abscess
    • Incidence: ~10% of patients.
    • Management:
      • Percutaneous drainage.
  2. Fistulas
    • Incidence: 1%–3% of patients.
    • Presentation:
      • Abscess or wound infection.
      • Continuous fecal drainage.
    • Management:
      • Routine care; majority heal spontaneously (see Chapter 29).
  3. Stomal Complications
    • Includes: Necrosis, stenosis, obstruction, prolapse.
    • Incidence: 5% of patients.
    • Management:
      • Immediate or delayed reoperation as necessary.
      • Stomal necrosis requires close monitoring to prevent septic complications like necrotizing fasciitis of the abdominal wall.
  4. Osteomyelitis
    • Associated with: Penetrating injuries involving rectum and adjacent bony structures.
    • Diagnosis:
      • Bone biopsy for bacteriologic analysis.
    • Treatment:
      • Long-term IV antibiotics.
      • Occasionally debridement.

Operative Management

  1. Primary Repair
    • Indications:
      • Suitable conditions with low risk of anastomotic leakage.
    • Advantages:
      • Definitive treatment.
      • Avoids stoma formation.
    • Disadvantages:
      • Risk of anastomotic leakage if performed under suboptimal conditions.
  2. End Colostomy
    • Indications:
      • High-risk patients where anastomotic leakage is likely.
    • Advantages:
      • Avoids unprotected suture lines.
    • Disadvantages:
      • Requires a second surgery for reversal.
  3. Primary Repair with Diverting Loop Ileostomy
    • Indications:
      • High-risk patients with potential for leakage.
    • Advantages:
      • Provides fecal diversion while maintaining primary repair.
    • Disadvantages:
      • Increased complexity of surgery.

Postoperative Care

  1. Monitoring and Management
    • Postoperative Ileus
      • Indicated by: Decrease in gastrostomy or nasogastric tube output.
    • Nutrition
      • Early Total Enteral Nutrition (TEN):
        • Reduces septic complications.
        • Routes: Stomach vs. small bowel (equivalent tolerance unless upper GI tract pathology exists).
      • Cautions:
        • Evidence of bowel function required before advancing to goal tube feedings.
        • Avoid overzealous jejunal feeding to prevent small bowel necrosis in patients recovering from profound shock.
      • Special Considerations:
        • Patients with nonoperative management of grade III+ solid organ injuries:
          • Receive nothing by mouth for at least 48 hours in case of operation necessity.
        • Open Abdomen:
          • Early TEN:
            • Higher fascial closure rates.
            • Decreased complications.
            • Decreased mortality.
          • TEN in Bowel Injuries:
            • Neither advantageous nor detrimental.
          • Initiate TEN once resuscitation is complete, even at trophic levels (20 mL/h).
  2. Complications and Their Management
    • Intra-abdominal Abscess:
      • Occurs in ~10% of patients.
      • Managed with percutaneous drainage.
    • Fistulas:
      • Continuous fecal drainage.
      • Majority heal spontaneously with routine care.
    • Stomal Complications:
      • Necrosis, stenosis, obstruction, prolapse.
      • Managed with: Immediate or delayed reoperation.
    • Osteomyelitis:
      • Associated with penetrating injuries involving rectum and bony structures.
      • Managed with: Bone biopsy, long-term IV antibiotics, occasionally debridement.

Key Points

  • Three primary treatment methods for colonic injuries:
    1. Primary repair
    2. End colostomy
    3. Primary repair with diverting loop ileostomy
  • Primary repair is safe and effective for virtually all patients with penetrating wounds.
  • End colostomy avoids unprotected suture lines but requires a second operation.
  • Primary repair with diverting loop ileostomy is an option for high-risk patients.
  • Overall physiologic status guides treatment decisions more than local factors.
  • Rectal injuries often require intestinal diversion due to limited access to extraperitoneal injuries.
  • Loop ileostomy and sigmoid loop colostomy are current options, with sigmoid loop colostomy being preferred.
  • Complications include intra-abdominal abscess, fistulas, and stomal complications, which require active management.
  • Early total enteral nutrition (TEN) is important for reducing septic complications; monitor gut tolerance and adjust feeding accordingly.
  • Maintain a low threshold for exploration in cases of suspicion of injury to prevent increased mortality.

Abdominal and Pelvic Vasculature

Susceptibility and Epidemiology

  • Injury Mechanisms:
    • Penetrating Trauma:
      • Indiscriminately affects all blood vessels.
      • Commonly involves major arteries and veins.
    • Blunt Trauma:
      • Most commonly involves renal vasculature.
      • Occasionally affects the abdominal aorta.
  • Specific Vascular Injuries:
    • Abdominal Aorta:
      • Frequently involves supraceliac and infrarenal segments.
      • Penetrating wounds often present with a contained retroperitoneal hematoma.
    • Superior Mesenteric Artery (SMA):
      • Typically encountered after exploration for a gunshot wound.
      • "Black bowel" and supramesocolic hematoma are pathognomonic.
    • Superior Mesenteric Vein (SMV):
      • Injuries may lead to marked bowel edema.
    • Iliac Arteries:
      • Commonly injured in transpelvic gunshot wounds or blunt injuries with associated pelvic fractures.

Management Strategies

1. Aortic Injuries

a. Penetrating Aortic Wounds

  • Challenges:
    • Limited mobility of the abdominal aorta makes primary repair difficult.
    • Supraceliac aortic wounds require proximal control.
  • Management Options:
    1. Small Lateral Perforations:
      • Control Techniques:
        • 4-0 Polypropylene Suture
        • PTFE Patch
    2. End-to-End Interposition Grafting:
      • Procedure:
        • Utilize a PTFE tube graft for reconstruction.

b. Blunt Aortic Injuries

  • Characteristics:
    • Extensive intimal tears of the infrarenal aorta.
    • Resultant thrombosis often requires surgical intervention.
  • Management Options:
    1. Interposition Grafting:
      • Procedure:
        • Replacement of the injured aortic segment with an interposition graft.

2. Superior Mesenteric Artery (SMA) Injuries

a. Penetrating SMA Injuries

  • Presentation:
    • "Black bowel" indicating ischemia.
    • Supramesocolic hematoma.
  • Management Options:
    1. Temporary Damage Control:
      • Pruitt-Inahara Shunt:
        • Prevents extensive bowel necrosis by maintaining blood flow.
    2. Definitive Repair:
      • End-to-End Interposition Reversed Saphenous Vein Graft (RSVG):
        • Condition: No associated pancreatic injury.
      • Alternate Approach (with Pancreatic Injury):
        • Tunnel graft from the distal aorta beneath the duodenum to the distal SMA.

b. Blunt SMA Avulsions

  • Considerations:
    • Rare; consider in patients with seat belt sign, midepigastric pain, or hypotension.
  • Management Options:
    1. Temporary Damage Control:
      • Pruitt-Inahara Shunt
    2. Definitive Repair:
      • End-to-End Interposition RSVG
      • Tunnel Grafting (if pancreatic injury is present)

3. Superior Mesenteric Vein (SMV) Injuries

  • Characteristics:
    • May lead to marked bowel edema.
  • Management Options:
    1. Hemorrhage Control:
      • Digital Compression
    2. Venorrhaphy:
      • Repair Technique:
        • Suturing of the vein to restore continuity.
    3. Ligation:
      • Indication:
        • Life-threatening situations where repair is not feasible.
      • Post-Procedure Care:
        • Aggressive fluid resuscitation due to resultant bowel edema.
        • Abdominal pressure monitoring.

4. Iliac Artery Injuries

  • Common Scenarios:
    • Transpelvic gunshot wounds.
    • Blunt injuries with associated pelvic fractures.
  • Management Options:
    1. Temporary Shunting for Damage Control:
      • Pruitt-Inahara Shunt
    2. Definitive Interposition Grafting:
      • Excision of the injured segment.
      • Vascular Repair Techniques:
        • Refer to “Vascular Repair Techniques” section.
  • Post-Repair Considerations:
    • Monitor for:
      • Distal embolic events.
      • Reperfusion injury necessitating fasciotomy.

Complications and Their Management

  1. Hemorrhage and Vascular Repair Failures
    • Hepatic Vein or Retrohepatic Vena Cava Injury:
      • Management:
        • Perihepatic Packing.
        • Hepatic Vein Stent Placement by Interventional Radiology (if necessary).
        • Direct Repair with or without Hepatic Vascular Isolation:
          1. Suprahepatic and Infrahepatic Clamping of the Vena Cava.
          2. Stapled Assisted Parenchymal Resection.
          3. Temporary Shunting of the Retrohepatic Vena Cava.
          4. Venovenous Bypass.
  2. Soft Tissue and Nerve Injuries
    • Outcome Related To:
      • Technical success of vascular reconstruction.
      • Associated soft tissue and nerve injuries.
    • Vascular Repairs:
      • Rarely fail after the first 12 hours.
    • Soft Tissue Infections:
      • Limb-threatening for several weeks post-injury.
  3. Postoperative Considerations
    • Aortic Interposition Grafting:
      • SBP should not exceed 120 mmHg for at least 72 hours postoperatively.
    • Inferior Vena Cava (IVC) Ligation:
      • Marked bilateral lower extremity edema.
      • Management:
        • Elastic bandages from toes to hips.
        • Leg elevation.
  4. Superior Mesenteric Vein (SMV) Injuries
    • Postoperative Edema:
      • Bowel edema due to ligation or thrombosis after venorrhaphy.
      • Management:
        • Aggressive fluid resuscitation.
        • Abdominal pressure monitoring.
  5. Prosthetic Graft Complications
    • Infections:
      • Prevention:
        • Perioperative antibiotics.
      • Management:
        • Treatment of secondary infections as needed.
    • Long-term Complications:
      • Stenosis.
      • Pseudoaneurysms.
      • Routine graft surveillance is rarely performed.
      • Antiplatelet/antithrombotic agents are not routinely administered long-term.

Key Points

  • Major abdominal and pelvic vascular injuries require prompt and effective management to control hemorrhage and prevent complications.
  • Penetrating trauma affects all blood vessels indiscriminately, while blunt trauma predominantly involves the renal vasculature and abdominal aorta.
  • Nonoperative management is limited and typically unsuitable for major arterial injuries; operative intervention is often necessary.
  • Angioembolization and interventional radiology play supportive roles but are not primary treatments for major vessel injuries.
  • Postoperative care focuses on monitoring for hemorrhage, vascular complications, and associated soft tissue injuries.
  • Prosthetic graft infections are rare but necessitate preventative measures and prompt treatment if they occur.
  • Long-term outcomes are primarily influenced by the success of vascular reconstruction and the management of associated injuries.