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Abdominal Trauma [Sabi & Schwartz]

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.

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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.

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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.

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  • 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.

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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 of Abdominal Trauma

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 Revision Notes

1. Introduction

  • Prevalence
    • Spleen is the first or second most commonly injured abdominal organ, alongside the liver.
    • Isolated splenic injury accounts for approximately 42% of abdominal trauma.
  • Spectrum of Trauma
    • Ranges from self-limiting cases and observation to immediate splenectomy in cases of hemodynamic instability.

2. Mechanism of Injury

  • Blunt Trauma
    • Direct compression of the spleen with parenchymal fracture.
    • Rapid deceleration causing tears in the splenic capsule and/or parenchyma fixed to the retroperitoneum.
    • Can lead to a subcapsular hematoma.
  • Penetrating Trauma
    • Less common, accounting for 8.5% of penetrating abdominal injuries (2012 NTDB).
    • Can result in ongoing hemorrhage or spontaneous resolution.

3. Diagnosis

  • Initial Assessment
    • FAST (Focused Assessment with Sonography for Trauma) used to detect intraabdominal fluid.
    • Nonresponders to resuscitation with positive FAST require exploration.
    • Responders with normalized physiology can often be managed nonoperatively.

  • Imaging

    • Abdominal CT with IV contrast is the most valuable diagnostic tool.
      • Sensitivity/Specificity: 96%–100%.

      • Findings:

        • Disruptions in splenic parenchyma.
        • Surrounding hematoma and free intraabdominal blood.
        • Active bleeding indicated by contrast extravasation (high-density blush or accumulation).
        • Subtypes: Free extravasation into the peritoneal space or intraparenchymal pseudoaneurysm.

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  • Injury Grading

    • AAST Injury Scoring Scale based on parenchymal/subcapsular abnormalities and vascular involvement.

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4. Management

A. Nonoperative Management

  • Indications
    • Hemodynamically stable patients.
    • Responders to initial resuscitation.
  • Success Rates
    • Approximately 90% in blunt splenic trauma for high-volume centers.
    • Nonoperative management failure rates reduced to 5% in AAST Grades III to V with angiography and embolization.
  • Advantages
    • Reduced hospital costs
    • Fewer intraabdominal complications
    • Less need for blood transfusions
    • Lower rates of nontherapeutic laparotomies
    • Decreased mortality
  • Protocolized Approach
    • Stable patients with active extravasation or pseudoaneurysm undergo interventional radiology or angiography and embolization.
    • High-grade injuries (III–V) without these findings also evaluated by interventional radiology and proceed to angiography and embolization within 24 hours.
  • Monitoring
    • High-grade injuries require intensive care monitoring with a low threshold for surgical intervention if the patient’s condition declines.
    • Rebleeding: max chance ~ 3-4 days with incidence of 10.6% and latent period of baudet.

B. Operative Management

  • Indications
    • Hemodynamic instability at admission or after failed nonoperative management.
    • Early intervention indicators include:
      • Initiation of blood transfusion within the first 12 hours.
      • Hemodynamic instability.

  • Surgical Approaches

    • Midline incision with packing of all four quadrants.
    • Splenectomy
      • Indicated for significant hilar injuries, pulverized splenic parenchyma, or >Grade II injuries in patients with coagulopathy or multiple life-threatening injuries.
      • Procedure Steps:
        • Mobilize the spleen by dividing the peritoneum starting at the white line of Toldt (splenocolic ligament).
        • Ligate and clamp the hilar vessels.
        • Remove the spleen, ensuring no injury to the pancreatic tail or greater curve of the stomach.
        • Post-Splenectomy Vaccines: Protect against encapsulated bacteria (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae).
    • Partial Splenectomy
      • For injuries limited to the superior or inferior pole.
      • Hemostasis: Use horizontal mattress sutures and gentle compression.
    • Splenorrhaphy (Splenic Repair)

      • Achieve hemostasis using:

        • Topical methods (e.g., electrocautery, argon beam coagulation).
        • Absorbable mesh envelopment.
        • Pledgeted suture repair.

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  • Postoperative Considerations

    • Post-Splenectomy Vaccines: Administered >14 days post-injury.
    • Complications:
      • Overwhelming postsplenectomy sepsis (0.5%–2% incidence, 30%–70% mortality).
      • Subphrenic abscess: Managed with percutaneous drainage.
      • Pancreatic injuries leading to pancreatic ascites or fistula.
      • Gastric perforation during short gastric vessel ligation.

5. Complications

  • Overwhelming Postsplenectomy Sepsis (OPSS)
    • Caused by encapsulated bacteria: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae.
    • Prevention: Vaccination post-splenectomy.
  • Postoperative Hemorrhage
    • Improper ligation of short gastric artery.
    • Recurrent bleeding from splenic parenchyma after splenic repair.
  • Infectious Complications
    • Subphrenic abscess: Requires percutaneous drainage.
  • Iatrogenic Injuries
    • Pancreatic tail injuries: Can lead to pancreatic ascites or fistula.
    • Gastric perforation during surgical procedures.

6. Key Points on Management Options for Different Scenarios

  • Hemodynamically Unstable Patients
    • Immediate operative management (e.g., splenectomy).
  • Hemodynamically Stable Patients
    • Nonoperative management with close monitoring.
    • Angiography and embolization for active extravasation or pseudoaneurysm.
  • High-Grade Injuries (AAST Grades III–V)
    • Nonoperative management is preferred but requires angiography and embolization.
    • Intensive care monitoring with readiness for surgical intervention if the patient deteriorates.
  • Patients Requiring Splenectomy
    • Postoperative vaccination to prevent OPSS.
    • Monitor for complications such as hemorrhage and infections.

  • Partial Splenectomy or Splenic Repair

    • Suitable for localized injuries (e.g., superior or inferior pole).
    • Aim to preserve splenic function and immune competence where possible.

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Hepatic Injuries Revision Notes

1. Introduction

  • Prevalence
    • Liver injuries are highly common in abdominal trauma:
      • Blunt Trauma: 22.2% incidence within the 2012 NTDB.
      • Penetrating Trauma: 26.1% of cases. = Most Common injury after penetrating trauma.
  • Mechanisms of Injury
    • Blunt Trauma:
      • Compression with direct parenchymal damage.
      • Shearing forces tearing hepatic tissue and disrupting vascular and ligamentous attachments.
      • Partial protection by the thoracic cage, though ribs offer limited support during high-energy mechanisms.
    • Penetrating Trauma:
      • Direct laceration of the hepatic parenchyma.
      • Causes adjacent tissue contusion.

2. Pathophysiology and Diagnosis

  • Pathophysiology
    • Blunt Trauma:
      • Parenchymal fracture and shearing can disrupt vascular structures.
    • Penetrating Trauma:
      • Lacerations lead to hemorrhage and tissue damage.

  • Diagnosis

    • Initial Assessment

      • FAST (Focused Assessment with Sonography for Trauma) to detect free intraabdominal fluid.
      • Hemodynamically unstable patients with positive FAST require immediate exploration.
      • Hemodynamically stable patients should undergo abdominal CT with IV contrast.
        • Sensitivity/Specificity: Highly accurate (96%–100%).

        • CT Findings:

          • Disruption of hepatic parenchyma.
          • Perihepatic hematoma and hemoperitoneum.
          • Active bleeding shown by contrast extravasation (e.g., high-density blush).
          • Hepatic pseudoaneurysm.

          image.png

    • Injury Grading

      • AAST Organ Injury Scale (OIS) based on parenchymal involvement and vascular injury (Refer to Table 17.7).

        image.png

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3. Management

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A. Nonoperative Management

  • Indications
    • Hemodynamically stable patients.
    • No overt peritonitis or other indications for immediate laparotomy.
    • Responders to initial resuscitation.
  • Success Rates
    • Majority of Grades I to III managed nonoperatively.
    • Two-thirds of Grades IV and V may still require surgical intervention.
    • Nonoperative management failure rate: 9.5% (systematic review).
  • Advantages
    • Decreased in-hospital mortality.
    • Reduced need for operative intervention.
    • Lower morbidity associated with nonoperative approaches.
  • Protocolized Approach
    • Stable patients with contrast extravasation or pseudoaneurysm undergo interventional radiology (angiography and embolization).
    • High-grade injuries (II–V) are admitted to the SICU with frequent monitoring, hemoglobin checks, and abdominal examinations.
    • Angioembolization and ERCP improve success rates of nonoperative management.
  • Monitoring and Follow-Up
    • Intensive care surveillance for all nonoperatively managed hepatic injuries.
    • No standardized laboratory monitoring interval.
    • Manage complications such as biloma formation, hemobilia, and liver abscesses as they arise.

B. Operative Management

  • Indications
    • Hemodynamic instability at admission or failure of nonoperative management.
    • Emergent laparotomy required for ongoing hemorrhage or hemodynamic decline.
    • Initiation of blood transfusion within the first 12 hours or 6 units of RBCs within 24 hours.
  • Surgical Approaches
    • Midline laparotomy as the primary surgical approach.
    • Perihepatic packing and manual compression to control bleeding.
    • Pringle Maneuver:
      • Temporary occlusion of the hepatoduodenal ligament to control hepatic blood flow.
      • Helps differentiate between arterial/portal venous bleeding and venous bleeding.
    • Hemostasis Techniques:
      • Suture ligation of bleeding vessels.
      • Topical hemostatic agents (e.g., electrocautery, argon beam coagulation).
      • Splenorrhaphy and partial hepatectomy for severe parenchymal injuries.
    • Damage Control Surgery:
      • Control surgical bleeding.
      • Temporary abdominal closure.
      • Resuscitation in the ICU until physiological stability is achieved.
      • Re-exploration and pack removal once stable.

  • Advanced Surgical Techniques

    • Hepatic Vascular Isolation:

      • Atriocaval (Shrock) shunt for retrohepatic vena cava injuries.
      • Venovenous bypass.

      image.png

    • Hepatic Transplantation:

      • Rare and extraordinary circumstances due to donor limitations.
    • Postoperative Care
    • Monitor for ongoing hemorrhage signs:
      • Falling hemoglobin.
      • Blood clots under temporary closure.
      • Bloody output from drains.
    • Manage hepatic ischemia and necrosis if present.
    • Address infectious complications like liver abscesses or bilomas.

4. Complications

  • Hemorrhage

    • Immediate and delayed bleeding.
    • Persistent bleeding from hepatic artery, portal vein, or retrohepatic vena cava.

  • Biliary Complications

    • Bile Leaks
      • Biloma Formation: Loculated collections of bile, may be infected or sterile.
      • Management:
        • Percutaneous drainage for infected bilomas.
        • Observation for small, sterile bilomas as they may reabsorb spontaneously.
    • Hemobilia
      • Clinical Features: Intermittent right upper quadrant pain, upper GI hemorrhage, jaundice.
      • Management: Angiography and embolization of the bleeding hepatic vessel.
    • Biliary Fistulas
      • Biliovenous Fistulas: Causes jaundice due to rapid increases in serum bilirubin.
        • Management: Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy.
      • Bronchobiliary or Pleurobiliary Fistulas:
        • Formation: Due to diaphragm injuries.
        • Management:
          • Operative closure due to pressure differential.
          • Endoscopic sphincterotomy with stent placement may be required for closure.

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  • Infectious Complications
    • Liver Abscesses
    • Subphrenic Abscesses: Managed with percutaneous drainage.
  • Vascular Complications
    • Pseudoaneurysms: Risk of rupture, managed with angioembolization.
    • Portal Venous Hypertension: Can lead to bleeding esophageal varices.
  • Iatrogenic Injuries
    • Pancreatic Injuries: Leading to pancreatic ascites or fistulas.
    • Gastric Perforations: During surgical procedures like short gastric vessel ligation.

5. Extrahepatic Biliary Tree Injuries

  • Overview

    • Injuries to the extrahepatic bile ducts are challenging due to their small size and thin walls.
    • Associated Vascular Injuries: Common with vena cava due to proximity.

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  • Types of Injuries

    • Small Lacerations:
      • Management:
        • Insertion of a T-tube through the wound.
        • Lateral suturing using 6-0 monofilament absorbable suture.
    • Transected Ducts:
      • Management:
        • Roux-en-Y Choledochojejunostomy: Required for transections and injuries with significant tissue loss.
          • Technique:
            • Single-layer interrupted technique with 5-0 monofilament absorbable suture.
            • Anastomosis Placement: Jejunum sutured to the areolar tissue of the hepatic pedicle or porta hepatis to reduce tension.
        • ERCP with Stent Placement: For decompression and healing of bile leaks.
        • External Drainage: Via intubation of the duct when immediate repair is not feasible.
        • Ligature: If the opposite lobe is normal and uninjured, the duct can be ligated.
  • Postoperative Management
    • Percutaneous Drainage: For bilomas and abscesses.
    • ERCP: For biliary fistulas and decompression.
    • Surgical Repair: Required for biliovenous fistulas and significant ductal injuries.
  • Considerations
    • Primary Repair Challenges: Due to proximity to other portal structures and the vena cava.
    • Delayed Repair: Preferred when patient is hemodynamically stable and other injuries are managed.

6. Key Points on Management Options for Different Scenarios

  • Hemodynamically Unstable Patients
    • Immediate operative management with perihepatic packing and Pringle maneuver.
    • Control hemorrhage through suture ligation or topical agents.
    • Damage control surgery for physiologic stabilization.
  • Hemodynamically Stable Patients
    • Nonoperative management with close monitoring in the SICU.
    • Angiography and embolization for active extravasation or pseudoaneurysm.
    • Endoscopic retrograde cholangiopancreatography (ERCP) for biliary injuries.
  • High-Grade Injuries (AAST Grades II–V)
    • Nonoperative management preferred with interventional radiology support.
    • Intensive care monitoring and readiness for surgical intervention if condition deteriorates.
  • Patients Requiring Operative Intervention
    • Midline laparotomy with perihepatic packing.
    • Pringle maneuver to control hepatic blood flow.
    • Hepatic vascular isolation techniques for complex vascular injuries.
    • Postoperative surveillance for hemorrhage and infectious complications.
  • Management of Extrahepatic Biliary Tree Injuries
    • T-tube placement or Roux-en-Y choledochojejunostomy for significant ductal injuries.
    • ERCP with stent placement for decompression and healing of bile leaks.
  • Addressing Complications
    • Percutaneous drainage for bilomas and abscesses.
    • Angioembolization for pseudoaneurysms and hemobilia.
    • Surgical repair for biliovenous fistulas and ductal injuries.

7. Postoperative Considerations

  • Monitoring
    • Hemodynamic stability.
    • Laboratory parameters: Hemoglobin, transaminase levels, WBC count.
  • Infection Prevention
    • Antibiotic therapy as needed.
    • Vaccination if splenectomy is performed concurrently.
  • Long-Term Management
    • Rehabilitation for patients with extensive hepatic injuries.
    • Regular follow-up to monitor for late complications like portal hypertension or liver dysfunction.

Gastric and Small Bowel Injuries Revision Notes

1. Gastric Injuries

A. Introduction

  • Prevalence
    • Penetrating Mechanisms: 11%–18% of gastric injuries.
    • Blunt Mechanisms: <1% incidence.
  • Mortality Rates
    • Blunt Gastric Trauma: 28.2% (EAST multi-institutional trial).
      • Higher Injury Severity Score (ISS) linked to mortality.
      • Mortality often due to associated injuries (liver, spleen, pancreas, small bowel).
    • Penetrating Gastric Trauma: 2.2% mortality.

B. Mechanism of Injury

  • Blunt Trauma
    • Rupture Causes:
      • Acute increase in intraluminal pressure from external forces.
      • Bursting of the gastric wall.
    • Associated Injuries: Common with high-energy mechanisms affecting liver, spleen, pancreas, small bowel.
  • Penetrating Trauma
    • Full-Thickness Perforations: Spillage of gastric contents into the abdomen.
    • Missed Injuries:
      • Posterior wounds.
      • Injuries within the mesentery of the lesser curvature or high in the fundus.

C. Diagnosis

  • Clinical Presentation
    • Peritonitis: Presence of peritonitis on physical examination.
      • Faster onset compared to small bowel perforation due to lower pH of gastric contents.
    • Location of Wounds: Penetrating wounds may suggest gastric injury.

  • Imaging

    • Computed Tomography (CT) Scan

      • Commonly employed in hemodynamically stable patients before operation.
      • Sensitivity: 55%–95%.
      • Specificity: 48%–92%.
      • Secondary Signs:
        • Bowel wall thickening, irregular wall enhancement.
        • Mesenteric defects, abdominal free fluid without solid organ trauma.

      • Limitations:

        • Isolated pneumoperitoneum is unreliable for hollow viscus injury.

        image.png

    • Diagnostic Techniques:

      • Methylene Blue Test: Instill methylene blue-colored saline via nasogastric (NG) tube and digitally occlude the pylorus.
      • Air Test: Introduce air via NG tube with abdomen filled with saline.

D. Management

Gastric Injuries and Management Based on AAST Grading:

Grade Injury Management
I Contusion or Hematoma Partial thickness laceration Hematoma needs to be evacuated to rule out perforation, control bleeding, and seromuscular closure with nonabsorbable suture.
II Laceration in stomach:
a. GE junction or pylorus <2cm b. Proximal one third <5 cm
c. Distal two third <10 cm Non-viable tissue debrided and closed in two layers.
III Laceration in stomach:
a. GE junction or pylorus >2 cm b. Proximal one third >5 cm
c. Distal two third >10 cm Debridement and primary closure in two layers.
IV Tissue loss or devascularization less than 2/3 of stomach Partial gastrectomy with Bilroth I or II.
V Tissue loss or devascularization more than 2/3 of stomach Total gastrectomy with Roux-en-Y esophagojejunostomy.
- Nonoperative Management
- Indications: Rare for gastric injuries; typically reserved for select cases with contained perforations.
- Monitoring: Close clinical observation for signs of peritonitis or sepsis.
- Operative Management
- Indications:
- Peritonitis.
- Evidence of perforation on imaging.
- Hemodynamic instability.
- Surgical Approach
- Full Evaluation: Visualization of anterior and posterior walls by entering the lesser sac.
- Repair Techniques:
- Evacuate Hematomas 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.
- Common Techniques:
- Absorbable Suture with inversion using nonabsorbable seromuscular stitches.
- Stapler Closure for redundant gastric tissue.
- Complex Injuries:
- Partial/Total Gastrectomy for highly destructive injuries.
- Reconstruction Options:
- Billroth I or II Gastroenterostomy.
- Roux-en-Y Esophagojejunostomy.
- Postoperative Care
- Monitor for Signs of Leak or Infection.
- Early Enteral Nutrition (TEN) once bowel function returns.

E. Complications

  • Missed Injuries: Can lead to subsequent morbidity.
  • Postoperative Ileus: Indicated by decreased gastrostomy or NG tube output.
  • Infectious Complications: Abscess formation, sepsis.
  • Leakage at Repair Site: Managed with reoperation or endoscopic interventions.

F. Key Points on Management Options for Different Scenarios

  • Hemodynamically Unstable Patients
    • Immediate operative management with exploratory laparotomy.
    • Control hemorrhage and repair perforations promptly.
  • Hemodynamically Stable Patients
    • CT Imaging for diagnosis.
    • Operative management if peritonitis or evidence of perforation exists.
    • Nonoperative management is rarely indicated.
  • High Suspicion of Injury
    • Expedient surgical exploration to prevent increased mortality due to surgical delay.
  • Complex Injuries Involving Gastroesophageal Junction or Fundus
    • Enhanced exposure of the upper abdomen.
    • Potential for partial or total gastrectomy and appropriate reconstruction.

2. Small Bowel Injuries

A. Introduction

  • Prevalence
    • Penetrating Trauma: One of the more frequently injured organs.
    • Blunt Trauma: Rarely injured (0.3% incidence).
  • Mortality Rates
    • Overall: 15%–20%.
      • Mostly due to associated vascular injuries.

B. Mechanism of Injury

  • Blunt Trauma
    • Crushing Mechanism: Small bowel crushed between steering wheel/seat belt and rigid structures (e.g., vertebral column).
    • Rupture: Blow-out along the antimesenteric border due to rapid increase in intraluminal pressure.
    • Shearing: Shearing of the serosa or muscularis throughout a segment of small bowel due to deceleration.
    • Mesenteric Injury: Devascularization leading to intestinal necrosis without direct tissue injury.
  • Penetrating Trauma
    • Range of Injuries: From tiny perforations to large destructive injuries causing devitalization of circumferential segments.

C. Diagnosis

  • Clinical Presentation
    • Peritonitis: Present on initial examination or worsens over hours.
    • High Index of Suspicion: Necessary to avoid missed injuries.

  • Imaging

    • Computed Tomography (CT) Scan
      • Limited Sensitivity and Specificity for small bowel injuries.
      • Secondary Signs: Similar to gastric injuries.
    • Diagnostic Challenges: Similar to gastric and other hollow viscus injuries.

    image.png

D. Management

  • Nonoperative Management
    • Rarely Indicated due to high risk of missed injuries and complications.
  • Operative Management
    • Indications:
      • Peritonitis.
      • Hemodynamic instability.
      • Evidence of perforation on imaging or clinical signs.
    • Surgical Approach
      • Exploratory Laparotomy to identify and assess injuries.
    • Repair Techniques:
      • Primary Repair:
        • Small Perforations: Repaired with one or two layers after debridement.
        • Techniques: Interrupted nonabsorbable suture to reinforce.
      • Resection and Anastomosis:
        • Multiple Perforations or Destructive Injuries:
          • Segmental Resection with end-to-end anastomosis.
          • Anastomosis Techniques:
            • Stapled vs. Hand-Sewn: No difference in leak rates.
            • Selection Based on Surgeon Preference and experience.
            • Hand-Sewn Anastomoses: Often two layers, but single-layer is equally efficacious.
        • Injuries Involving >50% of Intestinal Wall Circumference:
          • Bowel Resection with anastomosis.
    • Damage Control Surgery:
      • Indications: Patients in shock or physiological derangements.
      • Approach:
        • Rapid closure of perforations to control contamination.
        • Resection when large injuries are present.
        • Temporary Abdominal Closure and resuscitation in the ICU.
        • Re-exploration and intestinal continuity reestablished once physiologically stable.
    • Postoperative Care
      • Monitor for Signs of Leak or Infection.
      • Early Total Enteral Nutrition (TEN):
        • Reduces septic complications.
        • Initiate after evidence of bowel function returns.
        • Caution: Avoid overzealous jejunal feeding to prevent small bowel necrosis.

E. Complications

  • Postoperative Ileus: Indicated by decreased gastrostomy or NG tube output.
  • Leakage at Repair Site: Managed with reoperation or endoscopic interventions.
  • Infectious Complications: Abscess formation, sepsis.
  • Anastomotic Dehiscence: Higher risk in patients in shock; may require reoperation.
  • Postoperative Nutrition Issues:
    • Early Enteral Nutrition (TEN): Benefits in reducing septic complications.
    • Potential for Small Bowel Necrosis if overfeeding*.

F. Key Points on Management Options for Different Scenarios

  • Hemodynamically Unstable Patients
    • Immediate operative management with exploratory laparotomy.
    • Control hemorrhage and repair or resect injured segments.
    • Damage control surgery for physiologic stabilization.
  • Hemodynamically Stable Patients
    • CT Imaging for diagnosis.
    • Operative management if peritonitis or evidence of perforation exists.
    • Nonoperative management is rarely indicated; focus on early detection and prompt surgical intervention.
  • High Suspicion of Injury
    • Expedient surgical exploration to prevent increased mortality due to surgical delay.
  • Multiple or Large Injuries
    • Resection with end-to-end anastomosis.
    • Avoid narrowing the bowel lumen.
    • Consider omitting anastomosis in unstable patients (damage control).

3. General Management Principles for Gastric and Small Bowel Injuries

A. Diagnostic Strategies

  • High Index of Suspicion: Essential due to limitations of imaging.
  • Physical Examination: Look for peritonitis, abdominal tenderness, rigidity.
  • Imaging Modalities:
    • CT Scan: Evaluate secondary signs.
    • Diagnostic Tests: Methylene blue or air tests via NG tube.

B. Operative Techniques

  • Full-Thickness Evaluation: Ensure complete assessment of the visceral organs.
  • Hemostasis: Control bleeding using sutures or topical agents.
  • Tissue Preservation: Debride nonviable tissue but preserve as much bowel as possible.
  • Reconstruction: Based on extent of injury and patient stability.

C. Postoperative Care

  • Monitoring for Complications:
    • Leaks, infections, ileus.
  • Nutritional Support:
    • Early Enteral Nutrition (TEN) when appropriate.
  • Follow-Up Imaging: If complications are suspected.

D. Special Considerations

  • Associated Injuries: High prevalence in blunt trauma requiring comprehensive assessment.
  • Surgical Delay: Increases mortality; prompt intervention is crucial.
  • Patient Stabilization: Essential before intensive surgical procedures.

4. Key Points on Management Options for Different Scenarios

  • Hemodynamically Unstable Patients
    • Immediate Operative Management: Perform exploratory laparotomy.
    • Control Hemorrhage: Use perihepatic packing, Pringle maneuver, and suture ligation as needed.
    • Damage Control Surgery: Focus on rapid stabilization and temporary abdominal closure.
  • Hemodynamically Stable Patients
    • Nonoperative Management: Rarely applicable; prioritize early detection and prompt surgical intervention if needed.
    • Close Monitoring: Observe for signs of peritonitis or sepsis.
    • Early Enteral Nutrition (TEN): Initiate once bowel function returns, especially in nonoperative management of solid organ injuries.
  • High-Grade Injuries (AAST Grades II–V)
    • Prefer Operative Management: Especially with evidence of perforation or peritonitis.
    • Interventional Radiology Support: Utilize angiography and embolization for associated vascular injuries.
  • Patients Requiring Operative Intervention
    • Comprehensive Evaluation: Ensure complete assessment of all abdominal organs.
    • Tissue Repair or Resection: Based on extent of injury.
    • Postoperative Surveillance: Monitor for hemorrhage, infections, and anastomotic integrity.
  • Management of Complications
    • Percutaneous Drainage: For bilomas, abscesses.
    • Endoscopic Interventions: Such as ERCP for biliary injuries.
    • Surgical Repair: For biliovenous fistulas, ductal injuries, and persistent leaks.

5. Postoperative Considerations

  • Monitoring
    • Hemodynamic Stability: Continuous assessment for hypotension, tachycardia.
    • Laboratory Parameters:
      • Hemoglobin Levels: Monitor for ongoing bleeding.
      • Transaminase Levels: Elevated in hepatic ischemia.
      • White Blood Cell (WBC) Count: Elevated counts may indicate infection or sepsis.
  • Infection Prevention
    • Antibiotic Therapy: Administer as needed based on clinical signs and culture results.
    • Vaccination: If splenectomy is performed concurrently, ensure post-splenectomy vaccines to prevent overwhelming sepsis.
  • Long-Term Management
    • Rehabilitation: For patients with extensive gastric or small bowel injuries.
    • Regular Follow-Up: Monitor for late complications such as portal hypertension, liver dysfunction, or intestinal strictures.
    • Nutritional Support: Ensure adequate nutrition and address any deficiencies resulting from intestinal resection or damage control surgery.

Duodenal and Pancreatic Injuries Revision Notes

I. Duodenal Injuries

A. Epidemiology

  • Uncommon in abdominal trauma, comprising <2% of cases.
  • Penetrating injuries account for approximately 80%, primarily due to gunshot wounds (GSWs).
  • Associated mortality is around 24%.
  • 70% have associated abdominal injuries.

B. Mechanism of Injury

  • Penetrating Mechanisms:
    • Gunshot wounds (GSWs) are the most common cause.
  • Blunt Mechanisms:
    • Caused by a blow to the epigastrium with a narrow object.
    • Examples include steering wheel impact in adults and bicycle handlebar injuries in children.
    • Results in contusion or rupture due to acute elevation of intraluminal pressure.

C. Diagnosis

  • Challenges:
    • Retroperitoneal location makes physical examination less reliable.
    • Peritoneal signs may be absent unless intraperitoneal segments are involved.

  • Diagnostic Tools:

    • Abdominal CT Scan: Most valuable tool; look for thickened duodenal wall, periduodenal air and fluid, or duodenal hematoma.
    • Oral Contrast-Enhanced CT or Upper GI Fluoroscopy: For hemodynamically stable patients.
    • Low Threshold for Operative Exploration: Due to potential false-negative CT results.

    image.png

D. Management

Duodenal Injuries and Management Based on AAST Grading:

Grade Injury Management
I Hematoma involving single portion of the wall Partial thickness laceration Hematomas do not need exploration. NG tube insertion and TPN started. Evaluation of gastric emptying by contrast studies after 1 week. Resolve within 2 weeks as evident by marked drop in NG tube collection. If it does not, requires surgery.
II Hematoma involving >1 portion Laceration <50% circumference Small lacerations or perforation need primary repair in a single layer using 3-0 monofilament suture.
III Laceration >50-100% in D1, D3, and D4 Between 50-70% in D2 Kocher maneuver.
Debridement of devitalized tissue.
Resection and primary anastomoses with injuries in D1.
D3 proximal to SMA - Duodenojejunostomy proximal to SMA with distal end sewn.
D3 distal to SMA & D4 - Resection of that segment and Duodenojejunostomy distal to SMA.
D2 requires patching with a vascularized jejunal graft.
IV Laceration >75% in D2 or involving ampulla or CBD Pancreaticoduodenectomy/Damage control procedures.
V Massive laceration of pancreaticoduodenal complex or devascularization of duodenum Pancreaticoduodenectomy/Damage control procedures like Tube duodenostomy and closed suction drainage.

1. Hematomas

  • Nonoperative Management:
    • Nasogastric suction and parenteral nutrition.
    • Marked drop in nasogastric tube output indicates resolution.
  • Obstructing Hematomas:
    • Gastric decompression, total parenteral nutrition.
    • Reevaluation with a contrast study after 5-7 days.
    • Operative Exploration if obstruction persists after 14 days.

2. Perforations and Lacerations

  • Small Perforations/Lacerations:
    • Primary Repair: Using a running single-layer suture of 3-0 monofilament.
    • Direction of Closure: To result in the largest residual lumen.
  • Substantial Tissue Loss:
    • First Portion (Proximal to Duct of Santorini):
      • Debridement and end-to-end anastomosis.

    • Second Portion:

      • Roux-en-Y Duodenojejunostomy for defects.
      • Patches with Roux-en-Y Duodenojejunostomy recommended for distal injuries.

      image.png

3. Extensive Tissue Loss

  • Large Tissue Loss or Transection:
    • Resection and Primary Anastomosis: If ampulla is not involved and injury segment is short.
    • Enteric Bypass with Roux-en-Y Reconstruction: For longer segments or areas near the ampulla.
  • Damage Control:
    • Resection, wide drainage, and temporary discontinuity for contamination control.

4. Additional Management Options

  • Omental Reinforcement: Place a healthy piece of omentum over repairs.
  • Drain Placement: Not mandatory but may help in controlled fistula creation if leaks occur.
  • Pyloric Exclusion: To divert GI stream after high-risk repairs, creating a controlled end fistula.

II. Pancreatic Injuries

A. Epidemiology

  • Low incidence in abdominal trauma (0.2%–12%).
  • Associated with duodenal injuries due to anatomical proximity.
  • Morbidity and mortality increase with AAST grade (up to 40% in Grade V).

B. Mechanism of Injury

  • Penetrating Mechanisms: More common cause, with 4.4% incidence in penetrating abdominal trauma.
  • Blunt Mechanisms:
    • Crushing of the pancreas between a rigid structure (e.g., steering wheel, seat belt) and the vertebral column.
    • Results range from mild contusion to complete transection with ductal disruption.

C. Diagnosis

  • Challenges:
    • Retroperitoneal location limits physical examination findings.
    • Missed injuries in approximately 15% of cases on initial CT.

  • Diagnostic Tools:

    • Abdominal CT with IV Contrast: Best for visualizing the pancreas and associated injuries.
      • Findings: Malperfusion, surrounding fluid or hematoma, soft tissue stranding.
    • Repeated CT Imaging: If initial imaging is inconclusive and patient remains unwell.
    • Serum Amylase Levels: Elevated if obtained >3 hours post-injury; sensitive but not specific.
    • ERCP or MR Cholangiopancreatography: For increased diagnostic yield, especially for ductal injuries.

    image.png

    image.png

D. Management

image.png

Pancreatic Injuries and Management Based on AAST Grading:

Grade Injury Management
I Minor contusion or hematoma without duct injury Superficial laceration without duct injury Nonoperative management or closed suction drainage system if operated for other conditions.
II Major contusion or hematoma without duct injury Major laceration without duct injury or tissue loss Exploration of parenchymal injury, closed suction drainage with distal feeding access.
III Distal transection or parenchymal injury with duct injury Ductal injuries to the left of SMA: Distal pancreatectomy with proximal ductal stump ligated or stapled, with healthy omentum to cover it along with closed suction drainage.
Ductal injuries in the head: Closed suction drainage creating controlled fistula and later ERCP to facilitate fistula closure.
IV Proximal transection or parenchymal injury involving ampulla Proximal transection with duct injury to intrapancreatic bile duct alone: Transect supraduodenal CBD and do Roux-en-Y choledochojejunostomy.
If no intrapancreatic CBD is involved, only proximal MPD involved: Can undergo central pancreatectomy with Roux-en-Y pancreatico-jejunostomy or pancreaticoduodenectomy.
V Massive disruption of pancreatic head Pancreaticoduodenectomy or Tube duodenostomy, closed suction drainage.

1. Pancreatic Contusions (Grades I & II)

  • Nonoperative Management:
    • External Drainage if undergoing laparotomy for other reasons.
  • Closed Suction Drainage: Recommended to reduce abscess development.

2. Distal Pancreatic Injuries

  • With Ductal Integrity:
    • Closed Suction Drainage.
  • With Ductal Disruption:
    • Distal Pancreatectomy, preferably with splenic preservation.
    • Alternative: Roux-en-Y Pancreaticojejunostomy or Pancreaticogastrostomy to preserve the spleen and distal pancreas.
    • In Physiologically Compromised Patients: Distal Pancreatectomy with Splenectomy.
    • Pancreatic Duct Management: Individually ligate or occlude with a stapling device; consider fibrin glue over the stump.

3. Pancreatic Head Injuries

  • With Ductal Injury:

    • Distal Pancreatectomy: If involving the main duct but not the intrapancreatic bile duct.

    • Pancreaticoduodenectomy (Whipple Procedure): For massive destruction involving both ducts.

      • Candidates: Patients with normalized physiology.
      • Damage Control: Hemorrhage control, external drainage, temporary closure with plans for re-exploration.

      image.png

  • Without Ductal Injury:

    • External Drains: If no clear ductal injury is present.

  • Complex Injuries:

    • Combined Pancreaticoduodenal Injuries: May require pancreaticoduodenectomy or damage control approaches.

    image.png

4. Complications Management

  • External Drainage: Essential to divert pancreatic enzymes and prevent retroperitoneal exposure.
  • Pancreatic Fistula:
    • Diagnosis: Post-operative day >5, drain output >30 mL/day, drain amylase ≥3x serum levels.
    • Management: Similar to fistulas after elective surgery.
  • Delayed Hemorrhage: Managed by angioembolization.
  • Pancreatic Pseudocysts:
    • Nonoperative Management: Suggests missed injury; ERCP for ductal integrity.
    • Operative Management: Similar to pseudocysts in pancreatitis.
  • Intra-Abdominal Abscesses: Managed with percutaneous drainage.

5. Additional Management Options

  • Omental Coverage: Place healthy omentum over pancreatic repairs.
  • Pyloric Exclusion:
    • Purpose: Divert GI stream after high-risk duodenal repairs.
    • Procedure:
      • Gastrostomy on the greater curvature near the pylorus.
      • Oversewn pylorus with an O polypropylene suture or double external staple line.
      • Gastrojejunostomy to restore GI continuity.
    • Duration of Diversion: 3-4 weeks.
    • Fistula Management: Results in an end fistula, easier to manage and likely to close.

Key Points on Management Options for Different Scenarios

  • Duodenal Hematomas:
    • Nonoperative unless causing gastric outlet obstruction.
    • Operative exploration if obstruction persists beyond 14 days.
  • Duodenal Perforations:
    • Primary repair for small perforations.
    • Roux-en-Y Duodenojejunostomy for defects in the second portion.
  • Pancreatic Contusions:
    • Nonoperative or external drainage if undergoing laparotomy.
  • Distal Pancreatic Ductal Injuries:
    • Distal pancreatectomy with or without splenic preservation.
  • Pancreatic Head Injuries:
    • Pancreaticoduodenectomy for extensive injuries involving ducts.
    • Drain placement if no ductal injury is present.
  • Complex Pancreaticoduodenal Injuries:
    • Damage control strategies including external drainage and temporary closure.
  • Pancreatic Fistulas and Pseudocysts:
    • Drainage and control of sepsis.
    • ERCP for evaluating ductal integrity in pseudocysts.

Colon and Rectal Injuries Revision Notes

I. Epidemiology

  • Common Mechanism:
    • Penetrating abdominal trauma is the most frequent cause.
    • Blunt trauma accounts for only 0.3% of colon and rectal injuries.
  • Types of Injuries:
    • Hematomas and serosal tears are the majority in blunt injuries.
    • Destructive vs. Nondestructive: Classification based on the extent of tissue damage.

II. Classification of Injuries

A. Destructive Injuries

  • Penetrating Trauma:
    • Wounds >50% of colonic circumference.
    • Complete transection of the colon.
    • Presence of devascularized segments.
  • Blunt Trauma:
    • Serosal tears >50% of colon circumference.
    • Full-thickness perforation.
    • Mesenteric devascularization.
  • Rectal Injuries:
    • Destructive rectal injuries defined as >25% circumference involvement.

B. Nondestructive Injuries

  • Hematomas and serosal tears without significant tissue loss.
  • Small perforations or lacerations not involving major blood vessels.

III. Mechanism of Injury

A. Penetrating Mechanisms

  • Gunshot wounds (GSWs) are the most common cause.
  • Sharp bone fragments from severe pelvic fractures can cause rectal lacerations.

B. Blunt Mechanisms

  • Direct crush or rupture leading to rapid intraluminal pressure elevation.
  • Shearing forces causing separation of serosa or muscularis from mucosa, especially in retroperitoneal colon segments.

IV. Clinical Presentation

  • Varied Physiology:
    • Hemodynamic instability may prompt immediate laparotomy.
    • Peritonitis may be present with free perforation but can be obscured in retroperitoneal injuries.
  • Stable Patients:
    • Similar evaluation to other hollow viscus injuries.
    • High index of suspicion needed to avoid missed injuries.

V. Diagnosis

A. Physical Examination

  • Peritoneal signs may be absent in retroperitoneal injuries.
  • Digital Rectal Examination:
    • Absence of blood can rule out rectal injury.
    • Presence of blood does not confirm injury; requires further evaluation.

B. Imaging Studies

  • Abdominal CT Scan:
    • Limited capability for colon injuries.
    • Look for colonic wall thickening, surrounding stranding, or fluid.
    • Triple contrast (oral, rectal, IV) may increase diagnostic yield but is subject to surgical discretion.

  • Exam Under Anesthesia with Rigid Proctosigmoidoscopy:

    • Useful for visualizing rectal and distal sigmoid injuries.
    • Identifies clear injuries, hematomas, or blood in rectal vault.

    image.png

VI. Management

A. General Principles

  • Operative Repair depends on:
    • Presence or absence of destructive injury.
    • Physiologic status of the patient.
  • Historical Approach: Mandatory colostomy for all colon injuries.

B. Colon Injuries

1. Nondestructive Injuries

  • Primary Repair:
    • One or two-layer suturing (running single-layer technique).
    • Safe and effective in virtually all patients with penetrating wounds.

  • Advantages:

    • Lower intra-abdominal infection rates compared to colostomy.

    image.png

2. Destructive Injuries

  • In Healthy, Minimally Transfused Patients:
    • Resection and anastomosis.
  • In Comorbid or Severely Resuscitated Patients (>6 units PRBC):
    • Fecal diversion (e.g., colostomy).
    • High anastomotic leak rates if primary anastomosis attempted.
  • Damage Control Laparotomy:
    • Resection without immediate anastomosis.
    • Temporary colostomy or GI tract discontinuity until resuscitation.

3. Distal Colon Injuries

  • Segmental Resection with colocolonic anastomosis.

4. Management Options Based on Scenario

  • Primary Repair: Nondestructive injuries in stable patients.
  • Resection and Anastomosis: Destructive injuries in healthy patients without extreme physiological compromise.
  • Fecal Diversion (Colostomy): Destructive injuries in comorbid, severely resuscitated, or unstable patients.

C. Rectal Injuries

1. Classification and Initial Assessment

  • Extraperitoneal vs. Intraperitoneal:
    • Extraperitoneal: Often require intestinal diversion.
    • Intraperitoneal: Managed similarly to colonic injuries.
  • Destructive Injuries (>25% circumference):
    • Fecal diversion with loop ileostomy or colostomy.
    • Consideration of presacral drainage.

2. Management Strategies

  • Primary Repair:
    • Attempted if injury is accessible (e.g., posterior intraperitoneal rectum).

  • Fecal Diversion:

    • Loop Ileostomy or Sigmoid Loop Colostomy [preferred] for indirect treatment.

    image.png

    • Hartmann’s Procedure: Division of rectum, oversew distal pouch, and create end colostomy for extensive injuries.
    • Presacral Drainage:
    • Limited to specific cases; not routinely practiced.
    • Abdominoperineal Resection:
    • Rare, for extensive destructive injuries to prevent pelvic sepsis.

3. Management Options Based on Scenario

  • Accessible Injuries:
    • Primary Repair if feasible.
  • Extensive or Destructive Injuries:
    • Fecal Diversion with loop ileostomy or colostomy.
    • Hartmann’s Procedure for severe cases.
  • Damage Control:
    • Temporary closure with planned re-exploration in physiologically compromised patients.

VII. Complications

  • Intra-Abdominal Abscess:
    • Occurs in ~10% of patients.
    • Managed with percutaneous drainage.
  • Fistulas:
    • Fecal fistulas occur in 1-3% of patients.
    • Often present as abscesses or wound infections with continuous fecal drainage.
    • Management: Typically heal spontaneously with routine care.
  • Wound Infections:
    • Common and managed with standard wound care.
  • Stomal Complications:
    • Necrosis, stenosis, obstruction, prolapse in 5% of patients.
    • May require immediate or delayed reoperation.
    • Stomal necrosis: Monitor closely to prevent septic complications.
  • Osteomyelitis:
    • Associated with penetrating injuries involving rectum and adjacent bones.
    • Diagnosis: Bone biopsy.
    • Treatment: Long-term IV antibiotics and possible debridement.

VIII. Key Points on Management Options for Different Scenarios

  • Nondestructive Colon Injuries:
    • Primary Repair using running single-layer sutures.
  • Destructive Colon Injuries:
    • Primary Repair in healthy, stable patients without extensive resuscitation.
    • Resection and Anastomosis in healthy patients with manageable tissue loss.
    • Fecal Diversion (Colostomy) in comorbid, severely resuscitated, or unstable patients.
  • Destructive Rectal Injuries:
    • Fecal Diversion with loop ileostomy or colostomy.
    • Presacral Drainage in selected cases.
  • Damage Control Situations:
    • Resection without immediate anastomosis.
    • Temporary Colostomy or GI discontinuity pending patient stabilization.
  • Rectal Fistulas:
    • End Fistulas (with pyloric exclusion) are easier to manage and more likely to close.
  • Stomal Management:
    • Monitor for complications such as necrosis, stenosis, and prolapse.
    • Immediate or delayed reoperation may be necessary based on severity.
  • Pelvic Sepsis Prevention:
    • Fecal diversion and adequate drainage to prevent contamination and sepsis.
  • Postoperative Care:
    • Percutaneous drainage for abscesses.
    • Routine monitoring for fistulas and wound infections.
    • Antibiotic therapy for osteomyelitis in penetrating injuries.

Abdominal Great Vessel Injuries Revision Notes

I. Epidemiology

  • Major Abdominal Vessels Location:
    • Predominantly retroperitoneal.
    • Some located within intestinal mesenteries.
  • Common Mechanisms:
    • Penetrating Trauma: Most major abdominal vascular injuries are due to penetrating mechanisms.
    • Blunt Trauma: Rare, often secondary to pelvic fractures with bleeding from pelvic vessels.
  • Mortality and Morbidity:
    • Massive Blood Loss and hemodynamic instability are common.
    • Associated Challenges: Visualization and management are complicated by significant blood loss and retroperitoneal location.

II. Mechanism of Injury

  • Penetrating Mechanisms:
    • Gunshot Wounds (GSWs) and stab wounds are primary causes.
    • Sharp Bone Fragments: From severe pelvic fractures can cause rectal lacerations.
  • Blunt Mechanisms:
    • Pelvic Fractures: Lead to retroperitoneal hematomas and bleeding from pelvic vessels.
    • Shearing Forces: Cause separation of serosa or muscularis from mucosa, especially in retroperitoneal segments.
    • Examples: Crushing of the aorta or renal vessels due to seat belts or steering wheel impact.

III. Clinical Presentation

  • Hemodynamic Status:
    • Unstable Patients: Often present with significant ongoing blood loss and hemodynamic instability.
    • Stable Patients: May require high index of suspicion for diagnosis; injuries may first be identified during imaging or laparotomy for other reasons.
  • Physical Examination:
    • Peritoneal Signs: May be absent in retroperitoneal injuries.
    • Associated Injuries: High likelihood of other abdominal or pelvic injuries.

IV. Diagnosis

  • Imaging Studies:
    • Abdominal CT Scan with Contrast:
      • Penetrating Trauma: Identifies the path of injury and potential involvement of adjacent structures.
      • Blunt Trauma: Best for evaluating retroperitoneal vasculature; look for hematomas, vascular disruptions, and active bleeding.
    • Three-Dimensional Imaging: Particularly useful for penetrating injuries to the back.
    • Endovascular Imaging: Considered for non-actively bleeding blunt injuries.

  • Exploratory Laparotomy:

    • Often necessary for penetrating injuries presenting with instability.
    • Exam Under Anesthesia with Rigid Proctosigmoidoscopy: Useful for rectal and distal sigmoid injuries.

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V. Management

A. General Principles

  • Initial Assessment:
    • Hemodynamic Stabilization: Priority in all vascular injuries.
    • Rapid Identification: Essential due to high mortality associated with major vessel injuries.
  • Surgical Exposure:
    • Cattell-Braasch Maneuver: For infra-renal vasculature and right renal hilum injuries.
    • Mattox Maneuver (Left Medial Visceral Mobilization): For suprarenal great vessels and left renal hilum injuries.
    • Kocher Maneuver: Mobilizes the pancreatic head and facilitates exposure.
  • Vascular Repair:
    • Proximal and Distal Control: Essential before repairing the injured vessel.
    • Omental Coverage: Cover vascular suture lines with omentum to prevent fistulas.

B. Penetrating Vascular Injuries

  • Exploration and Repair:

    • Retroperitoneal Injuries: Require immediate exploration and repair.

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    • Aortic Wounds:
      • Primary Repair: Rarely feasible; often requires interposition grafting with PTFE grafts.
      • Supraceliac Aortic Wounds: Challenging due to need for proximal control.
    • Superior Mesenteric Artery (SMA) Injuries:
      • Damage Control: Use of Pruitt-Inahara shunt to prevent bowel necrosis.
      • Definitive Repair: End-to-End Interposition RSVG or tunneling graft if associated with pancreatic injury.
    • Iliac Artery Injuries:
      • Temporary Shunting: Pruitt-Inahara shunt for damage control.
      • Definitive Repair: Interposition grafting with excision of injured segment.

C. Blunt Vascular Injuries

  • Management Options:
    • Operative Repair: Required for actively bleeding injuries.
    • Endovascular Therapy: Considered for non-actively bleeding injuries depending on vascular damage.
  • Specific Approaches:
    • Abdominal Aorta:
      • Intimal Tears: Often require interposition grafts.
      • Blunt Injuries: Extensive and typically require surgical intervention.
    • Renal Vasculature:
      • Common in Blunt Trauma: Managed based on extent of injury; may require repair or ligation.
    • Superior Mesenteric Vein (SMV) Injuries:
      • Temporary Abdominal Closure: Followed by second-look operation to assess bowel viability.

VI. Specific Vascular Injuries

A. Aortic Injuries

  • Penetrating Aortic Wounds:
    • Contained Hematoma: Common in survivors reaching OR.
    • Repair Challenges: Limited mobility; PTFE grafts commonly used.
  • Blunt Aortic Injuries:
    • Intimal Tears: Require interposition grafting.
    • Vascular-Enteric Fistulas: Prevented by omental coverage of suture lines.

B. Superior Mesenteric Artery (SMA) Injuries

  • Presentation:
    • "Black Bowel" and supramesocolic hematoma are pathognomonic.
  • Management:
    • Damage Control: Use of Pruitt-Inahara shunt.
    • Definitive Repair: End-to-End Interposition RSVG or tunneled graft if pancreatic injury is present.

C. Superior Mesenteric Vein (SMV) Injuries

  • Management:
    • Hemorrhage Control: Digital compression followed by venorrhaphy or ligation in life-threatening cases.
    • Post-Operative Care: Aggressive fluid resuscitation and abdominal pressure monitoring.

D. Iliac Artery Injuries

  • Common Scenarios:
    • Transpelvic Gunshot Wounds or blunt injuries with pelvic fractures.
  • Management:
    • Temporary Shunting: Pruitt-Inahara shunt for damage control.
    • Definitive Repair: Interposition grafting with excision of injured segment.
    • Post-Repair Monitoring: Watch for distal embolic events and reperfusion injury requiring fasciotomy.

VII. Complications and Postoperative Management

  • Postoperative Blood Pressure:
    • After Aortic Grafting: SBP should not exceed 120 mmHg for at least the first 72 hours.
  • Lower Extremity Edema:
    • After IVC Ligation: Use elastic bandages from toes to hips and elevate legs.
  • Vascular Graft Complications:
    • Infections: Prevent bacteremia with perioperative antibiotics.
    • Long-Term Issues: Stenosis or pseudoaneurysms are rare; antiplatelet agents not routinely required.
  • Soft Tissue and Nerve Injuries:
    • Infection Risk: High risk of soft tissue infections requiring prolonged management.
  • Fistulas and Fistula Management:
    • Vascular-Enteric Fistulas: Prevented with omental coverage; manage if present with appropriate surgical interventions.

VIII. Key Points on Management Options for Different Scenarios

  • Penetrating Vascular Injuries:
    • Immediate Exploration and Repair: Essential for retroperitoneal injuries.
    • Use of PTFE Grafts: Common for aortic repairs.
    • Pruitt-Inahara Shunt: Utilized for SMA and iliac artery damage control.
  • Blunt Vascular Injuries:
    • Operative Repair or Endovascular Therapy: Based on active bleeding and extent of vascular damage.
    • Interposition Grafting: Required for extensive intimal tears in the aorta.
  • Zone-Based Retroperitoneal Hematoma Management:
    • Zone 1: Explore immediately due to high likelihood of major vessel involvement.
    • Zone 2: Explore if expanding or actively bleeding.
    • Zone 3: Explore only if exsanguinating hemorrhage is present.
  • Specific Vessel Injuries:
    • SMA: Use of shunts and interposition grafts for effective repair.
    • SMV: Venorrhaphy or ligation with aggressive fluid management.
    • Iliac Arteries: Temporary shunting followed by definitive grafting.

  • Postoperative Strategies:

    • Blood Pressure Control: Maintain SBP ≤120 mmHg post aortic grafting.
    • Edema Management: Use of bandages and elevation for IVC ligation.
    • Infection Prevention: Perioperative antibiotics to prevent graft infections.
    • Monitoring: Regular assessment for graft integrity and limb perfusion.

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Mesenteric Vessel Injuries and Surgical Management

Introduction

  • Injuries to the mesenteric vessels are among the most challenging trauma injuries to expose and repair due to their deep retroperitoneal location.
  • Celiac trunk and superior mesenteric artery (SMA) injuries, in particular, require distinct approaches based on their anatomy and injury zones.

Celiac Trunk Injuries

  • Approach in Elective Setting:
    • Typically approached through the lesser sac.
    • However, in trauma, this approach can be complicated by large hematomas obscuring anatomical landmarks.
  • Approach in Trauma:
    • The best exposure is achieved through a left medial visceral rotation (mobilizing the spleen and tail of pancreas).
    • Repair vs. Ligation:
      • In most cases, ligation of the celiac trunk is preferred as repair is difficult.
      • Ligation is well tolerated in the majority of patients due to collateral circulation.

SMA Injuries

  • Proximity to Celiac Trunk:
    • SMA and celiac trunk arise 1-2 cm apart from the aorta but require different exposure and management approaches.
  • Fullen Classification of SMA Zones:
    • Zone I: Beneath the pancreas (proximal SMA).
    • Zone II: Between the inferior pancreaticoduodenal artery and middle colic artery.
    • Zone III: Beyond the middle colic artery.
    • Zone IV: Enteric branches of the SMA.
  • Management Based on Location:
    • Contained Central Hematoma at Root of Mesentery:
      • Best managed by a left medial visceral rotation for exposure and control.
      • Allows access to clamp the aorta proximal and distal to the SMA or the SMA itself.
    • Zone I and Zone II Injuries:
      • Exposed through the lesser sac by dividing the gastrocolic ligament.
      • Pancreas retracted inferiorly (for SMA origin) or superiorly (for proximal SMA).
      • In cases of severe injury, the pancreas may need to be divided to fully expose the SMA.
    • Zone III and Zone IV Injuries:
      • Approach involves reflecting the transverse colon and mesentery superiorly, with or without taking down the ligament of Treitz.
  • Repair Options:
    • All zones of SMA injuries, except for distal Zone IV injuries, should be repaired.
    • Options include:
      • Primary repair.
      • End-to-end anastomosis.
      • Interposition graft using a reversed saphenous vein.
    • For patients in extremis, the SMA can be shunted with plans for delayed repair.

Superior Mesenteric Vein (SMV) Injuries

  • Exposure: Similar approach to SMA exposure.
  • Management:
    • Repair or reconstruction is preferred.
    • Shunting with delayed repair is an option in unstable patients.
    • Ligation of the SMV may be necessary for patients at risk of exsanguination.

Inferior Mesenteric Artery and Vein Injuries

  • Inferior Mesenteric Artery (IMA):
    • Can be safely ligated if there is adequate collateral circulation from:
      • Middle colic branch of the SMA.
      • Inferior and middle hemorrhoidal branches of the internal iliac arteries.
  • Inferior Mesenteric Vein (IMV):
    • May also be safely ligated if required during surgery.

Surgical Maneuvers for Exposure

  1. Left Medial Visceral Rotation (Mattox Maneuver):
    • Provides exposure to the proximal trunk of the SMA by mobilizing the spleen and pancreas.
  2. Cattell-Braasch Maneuver:
    • Provides extensive retroperitoneal exposure to the root of the mesentery and the SMA.

Key Takeaways

  • Early diagnosis and prompt surgical intervention are critical for improving outcomes in mesenteric vessel injuries.
  • Ligation of major vessels, such as the celiac trunk and IMA, can be performed safely due to adequate collateral circulation.
  • Zone-specific approaches are essential for effective management of SMA injuries, with repair being the preferred approach unless the patient is in extremis.

SMA Trauma - Fullen Zones

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Mortality Rates by Fullen Zones:

  1. Zone I:
    • Location: The trunk proximal to the inferior pancreaticoduodenal artery.
    • Mortality Rate: 76-100%.
  2. Zone II:
    • Location: Between the inferior pancreaticoduodenal artery and the middle colic artery.
    • Mortality Rate: 44%.
  3. Zone III:
    • Location: The segment distal to the middle colic artery.
    • Mortality Rate: 25%.
  4. Zone IV:
    • Location: Gives off the segmental branches.
    • Mortality Rate: 25%.

Surgical Maneuvers for SMA Exposure:

  1. Mattox Maneuver:

    • Left-sided medial visceral rotation.
    • Provides exposure to the proximal trunk of the superior mesenteric artery.

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  2. Cattell-Braasch Maneuver:

    • Provides extensive retroperitoneal exposure.
    • Access to the root of the mesentery and the superior mesenteric artery.

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