Presentation on the management of abdominal injuries including the causes of abdominal injuries; the classification of abdominal injuries; the initial management of patients with abdominal injuries according to the ATLS; trauma laparotomy

1. ABDOMINAL INJURIES
PART 1
(16th JANUARY 2023)
Dr. M. Yigah

2. Introduction
• Trauma is the leading cause of death between ages 1 and
44
• The abdomen is third most injured region of the body.
• Abdominal injuries accounts for 15 - 20% of all trauma
deaths
• Abdominal trauma is traditionally classified as either
blunt or penetrating.
• Morbidity and mortality from abdominal injuries are due
haemorrhage and sepsis
• It is usually associated with injuries of other regions
of the body.
• Missed or delayed diagnoses are the most common cause
of death from these injuries

3. Epidemiology
• Epidemiology of abdominal injuries varies across the continent
• In Egypt it account for 82.7% of all trauma cases (Gad et al 2012)
• 14.2% of all trauma cases in Mbarara hospital in Uganda (Ruhinda et
al 2008)
• Ghana
• Ghana Medical Journal– 234 abdominal injuries were seen between
1983 and 1989 (Naaedar 1990)
• 411 patients were seen with penetrating injuries in KBTH and KATH
between 1998 to 2008
(Dakubo et al 2010)
• KBTH – General Surgery Logs
• 1772 cases in total were done between August and December
• 5 Trauma laparotomies
• Spleen was the most injured viscus – 3 cases
• Small bowel and mesenteric injuries – 2 cases

4. Boundaries of the Abdomen

5. Internal
Abdomen

6. Classification of Abdominal
Injuries
• Non-penetrating abdominal Injuries
• Damage to the abdomen and/or abdominal organs
secondary to the impact of blunt forces applied
across an abdominal region.
• Forces can be localised to one region of the body or
across a wide area.
• Penetrating abdominal Injuries
• Occurs when there is a full thickness violation of
the abdominal wall which may or may not be
associated with visceral injuries.
• Visceral injury is more likely when the fascia is
breached.

7. Blunt Injuries
• Automobile accidents
• Fall from heights
• Impalement of blunt
objects
• Assaults – kicks and
blows
• Blast injuries
• Sports injury
Penetrating
Injuries
• Stab wound
• Gunshot wound
• RTA
• Impalement of sharp
objects
• Flying objects
• Falls from height

8. Frequency of Injured Organs
Blunt Injuries
Spleen –
26%
Kidney –
24%
Intestines
– 16%
Liver –
16%
Other –
20%
Penetrating
Injuries
Stab wounds
• Liver (40%)
• Small bowel (30%)
• Diaphragm (20%)
• Colon (15%)
Gunshot wounds
• Small bowel (50%)
• Colon (40%)
• Liver (30%)
• Abdominal vascular
structures 25%

9. Mechanisms of Abdominal
Injuries
1. Blunt Abdominal Injuries
• Deceleration forces – generates shearing forces that avulse
structure near fix points
• Crushing forces – compression of visceral between abdominal
wall and vertebrae
• Blow-out forces – sudden increase in intra-luminal pressures
cause hollow viscus to rupture
2. Penetrating Abdominal Injuries
• Construction of injuring agent – e.g., length of knife,
calibre of bullet.
• Energy behind injury – e.g., stabbing forces vs

10. Pathophysiology
• Haemorrhage
• Injury to solid viscera – early death if not managed
efficiently
• Injury to major abdominal vessel – immediate death
• Sepsis
• Spillage hollow viscus contents - chemical and
bacterial peritonitis.
• Death is usually slow.

11. ATLS Protocol
• Primary survey
• Airway and Cervical spine control
• Breathing
• Circulation and Control of Haemorrhage
• Assessment of level of consciousness, Pulse rate and Volume,
BP, Skin perfusion
• Identify any source of external or internal bleeding
• Venous access with 2 wide bore cannulae
• Samples for baseline investigations – FBC, GXM, Clotting
profile, Serum Lactate, Serum Amylase,
• Administration of warmed crystalloids, blood and plasma
• Disability – assessing level of consciousness,
• Exposure and Environmental Control
• Adjuncts of Primary Survey
• ECG, Pulse Oximetry, ABG, NG tube, Urinary Catheter,
• Chest X-ray, Cervical and Pelvic X-ray
• FAST, eFAST, DPL

12. Categorization of Patients
• Haemodynamically ‘normal’
• investigation can be completed before treatment is
planned;
• Haemodynamically ‘stable’ –
• Investigation is more limited.
• It is aimed at establishing whether the patient can be
managed non-operatively, whether angioembolization can be
used or whether surgery is required;
• Haemodynamically ‘unstable’ –
• Investigations need to be suspended as immediate surgical
correction of the bleeding is required.

13. ATLS Protocol
• Secondary Survey
• Short Concise Relevant History (AMPLE)
• Allergies
• Medications currently used
• Past illnesses/Pregnancy
• Last meal
• Events/Environment related to the injury
• Speed and Type of collision (frontal, lateral, sideswipe, rear,
rollover)
• Types of restraints
• Patient's position in vehicle
• Fatalities at scene
• Height of fall
• Type of gun or knife used
• Physical Examination
• Head to toe

14. Evidence of Abdominal Injuries
• Obvious penetrating instrument
• Evisceration of bowel, omentum etc.
• Ecchymosis on abdominal wall: Grey-Turner sign, Cullen sign,
Seatbelt sign
• Peritonism
• Tenderness, guarding and Rebound tenderness
• BS may be abolished
• Tenderness on DRE
• Balance sign – Dull percussion in the LUQ (Blood in
subcapsular or extracapsular spleen)
• Kehr sign - Left shoulder pain while supine; caused by
diaphragmatic irritation

15. Cullen’s
Sign
Evisceration of Intra-
abdominal Organs
Seatbelt
Sign
Grey-Turner
Sign
Penetrating Agents

16. Investigations
• Baseline labs
• FBC
• Grouping and Cross matching.
• Coagulation profile, ß-HCG,
• Amylase
• X-rays - Chest, Cervical and Pelvic x-ray
• It should not delay in resuscitation
• Chest x-rays can show potentially life-threatening injuries
• Pelvic X-ray – fracture responsible for haemoperitoneum
• Abdominal X-ray –
• Has been superseded by FAST
• Can demonstrate trajectory of penetrating agent

17. FAST
• Focused Assessment with Sonography for Trauma
• Blood in the pericardial sac, hepatorenal fossa, splenorenal and
POD.
• Not to assess visceral injury
• A positive FAST and Haemodynamically unstable patient is an
indication for Exploratory Laparotomy

18. Diagnostic
Peritoneal
Lavage
To detect haemorrhage, bowel
and biliary contents in
unstable patients
Abdominal evaluation in
stable patients in settings
where FAST and CT are not
available.
• Relative contraindications
• previous abdominal
operations,
• morbid obesity,
• advanced cirrhosis

19. Positive DPL
• Aspiration of 10ml or more
of free blood.
• RBC of >100000/ml.
• Aspiration of GIT contents, vegetable
fibers, or bile.
• WBC >500/ml
• Amylase > 19 IU/L
• Alkaline phosphatase > 12IU/L
• Bilirubin level - > 0.01mg/dL

20. CT Scan
• Gold standard for evaluating solid organ blunt abdominal injury.
• It is however time-consuming and requires a co-operative patient.
• Used only in hemodynamically normal patients in whom there is no
apparent indication for an emergency laparotomy
• Can be used to used to detect and grade solid organ injuries
(Based on the AAST)
• Help quantify the volume of intra-peritoneal haemorrhage
• Used to assess retroperitoneal and pelvic organ injuries

21. Selective Angiography

22. Laparoscopy
To be done in stable patients
only
Applications
• Screening: to exclude a
penetrating injury with
breach of the peritoneum.
• Diagnostic: finding evidence
of injury to viscera.
• Therapeutic: used to repair
the injury
Still not fully developed

23. Indications for Exploratory
Laparotomy
1. Blunt abdominal trauma with hypotension with
• positive FAST or
• clinical evidence of intraperitoneal bleeding, or
• without another source of bleeding
2. Hypotension with an abdominal wound that penetrates
the anterior fascia
3. Gunshot wounds that traverse the peritoneal cavity
4. Evisceration
5. Peritonitis
6. Free air, retroperitoneal air, or rupture of the
hemidiaphragm
7. Contrast-enhanced CT that demonstrates
• Ruptured gastrointestinal tract, renal pedicle injury, or
• Severe visceral parenchymal injury after blunt or penetrating
trauma

24. Trauma Laparotomy
• Team Preparation
1. Assemble and coordinate the operating team:
• Notify the emergency scrub team to create theatre space, prepare equipment
and call other colleagues.
• Inform the anesthetic team
• Ensures there is an understanding of the available equipment and
definition of role
• Discussion of injury burden, time frame if getting knife to skin and agree
on definitive vs DCS goals.
• Request for likely equipment one will need
• An open vascular set with vascular clamps
• Multiple large abdominal swabs
• Bowel stapler
• Self-retainer retractors if the patient is obese
• Long needle holders with desired sutures
• Cell saver suction device
• An energy device such as a Harmonic scalpel or LigaSureTM.

25. Trauma
Laparotomy
• Perioperative preparation
• 2 large bore venous access
• Foleys catheter and an NG tube passed
• Blood products should be obtained
• Temperature control of the room and the
patient
• Administration of perioperative
antibiotics
• Positioning and skin preparation
• Supine position with arms fully abducted
at 90o
• Skin is prepared from the chin to the
knees and between the posterior axillary
lines
• Draped from chine to above the knee (risk
of hypothermia)

26. Operative Sequence

27. Trauma Laparotomy
• Abdominal access
• Bold midline incision from xiphisternum to pubis.
• Use the scalpel (diathermy is time consuming)
• Divide the falciform ligament if necessary.
• Use a virgin territory if there are previous scars
• Complete evisceration of small bowel
• Securing haemostasis
• Evacuate the liquid and clotted blood from all 4 quadrants
• Deliver the small bowel in two large abdominal packs to the patients
right
• Systematically empirical pack the abdomen –
• Liver, Right Paracolic gutter, Spleen and Left paracolic gutters
and pelvis
• Inspection and clamping of any bleeding mesenteric vessels.
• Aortic clamping – in rapidly exsanguinating patients

28. Packing of Abdomen

29. Trauma Laparotomy
• Exploring the abdomen
• Run the gut from the ligament of Treitz to the rectum
• Systematically remove the pack around the liver and asses its
injuries.
• Assess the gallbladder and the biliary tree
• Palpate the right kidney
• Carefully Inspect the spleen after removing the pack
• Palpate the left kidney
• Inspect the hemi-diaphragms
• Enter and inspect the lesser sac through the left side of the
greater omentum.
• Mattox manoeuvre or Cattell–Braasch maneuver

30. (Cattell-Braasch
manoeuvre) (Mattox manoeuvre)

31. Trauma Laparotomy
• Choosing an operative profile
a. Definitive repair of the injuries with formal abdominal closure
b. Damage Control techniques and temporary abdominal closure
• Factors to consider
a. Pattern of injury – e.g., major vascular injury – definitive
repair but a hollow viscus injury – DCS
b. Overall trauma burden e.g., serious injury to another region (head
injury)
c. Operating room system and circumstances - small rural facility,
limited trauma experience etc.
d. Physiological insult
a. Duration of hypotension, Realistic estimate of blood loss and
transfusion requirements
b. Onset of metabolic acidosis (pH< 7.3) and hypothermia – late
indicators

32. Damage Control Surgery
• Principles of DCS
• Control of bleeding
• Identification of injury
• Control of contamination
• Protection from further injury e.g., abdominal
compartment syndrome

33. Trauma Laparotomy
• Abdominal Wound Closure
• Definitive Repair – Standard closure as with
Laparotomy
• Dictated by level of contamination of wound
• Damage Control Surgery (DCS) – Closure is temporary
with 4 objective
• Containment of viscera,
• Control of abdominal secretion,
• Maintenance of pressure on tamponaded areas, and
• Optimization of the likelihood of eventual closure
• Techniques – Running sutures, Bogota bag, towel
clips, Ioban, Vacuum closures

35. Management after DCS
• Continued resuscitation and restoration of normal
physiology
• Reversal of Hypothermia
• Nurse patient in a warm room,
• Administer warm intravenous fluid and blood products,
• Application of external warming devices (Bair Hugger).
• Reversal of acidosis
• Correction of shock will correct metabolic acidosis
• Patient’s ability to normalize lactate is strongly correlated with
survival
• Correction of Coagulopathy
• Correction of acidosis and hypothermia corrects it
• Replacement of blood products
• Recent – use of recombinant factor VIIa

36. Abdominal Compartment Syndrome
• Causes
• bowel wall oedema
• Third space fluid loss
• Intra-abdominal packing
• Diagnosis
• Intra-vesical pressure with foleys catheter connected to a
transducer or manometer
• Treatment
• Management is dependent of pressure levels
• 10-15cm/H2O Maintain euvolaemia
• 16-25cm/ H2O Hypervolaemic resuscitation
• 26-35cm/H2O Decompress
• > 35cm/ H2O Decompress/re-explore abdomen looking for bleeding

37. Reoperation after DCS
• Should be done within 48 – 72hrs before the
onset of SIRS
• It involves
• Removal of abdominal packs
• Confirming haemostasis
• Inspection of abdomen for any missed injuries
• Restoration of intestinal integrity and abdominal
wound closure.

38. END OF PART 1