Surgical Management of Acute Abdominal Injuries

Dr. Wifanto S Jeo SpB-KBD

Digestive Surgery Division Faculty of Medicine University of Indonesia Cipto Mangunkusumo Hospital JAKARTA

Topic of Discussion

• Abdomen and Abdominal Injuries • Decision Making in Abdominal Trauma • Trauma Laparotomy • Damage Control Surgery

Topic of Discussion

•

Abdomen and Abdominal Injuries

• Decision Making in Abdominal Trauma • Trauma Laparotomy • Damage Control Surgery

Abdomen and Abdominal Injuries

• One of the five sites of life-threatening hemorrhage in the trauma patient • Abdominal cavity : BLACK BOX ! • Should be assessed as part of the circulatory assessment in the primary survey • Diagnosis of an abdominal injury is very difficult particularly in a multiple injury patient who may have reduced conscious level or distracting injury Emergency in Trauma. Oxford, 2010.

Spectrum of emergent operations Emergency Abdominal Surgery in Trauma = 48%

J Trauma 2005;58:657–662

Mechanism of Injury BLUNT PENETRATING

Common Injuries in Blunt Trauma

Trauma Biomechanics 4 th ed. Springer 2014

West J Med 1974; 120:502-506

Clinical Problems in Abdominal Trauma

1.Intra-peritoneal Hemorrhage

2. Associated Injuries … POLYTRAUMA ? • Secondary Abdominal Compartment Syndrome 3. Hollow-organ Perforation

Surgeon’s main Question: To OPEN or NOT ?

ACUTE CARE SURGICAL CASE PRIORITY

Topic of Discussion

• Abdomen and Abdominal Injuries •

Decision Making in Abdominal Trauma

• Trauma Laparotomy • Damage Control Surgery

Decision Making

• • • • Stable patient CT Scan Operative – Solid organ injury, hypotensive – Hollow viscus organ injury – Intraperitoneal bladder injury – Diaphragmatic injury Non-operative management – Observation – Interventional Radiology

Clinical Examination in Abdominal Trauma

• Unlike penetrating abdominal trauma, where management is largely determined clinically, the

diagnosis of blunt abdominal injury by clinical

examination is unreliable, particularly in patients with a decreased level of consciousness BMJ 2008;336:938-42

Clinical Finding in Abdominal Injuries

Likelihood ratios for useful examination and diagnostic tests in blunt abdominal trauma No single clinical finding reliably excludes significant injury in blunt abdominal trauma, but a positive bedside ultrasonographic result confirms injury when clinical suspicion is high Ann Emerg Med. 2014 Apr;63(4):463-4

• FAST – initial diagnostic tool • DPL – more restricted indication • CT scan – modality of choice in haemodynamically stable

These three modalities are complementary and not competitive

Afr Health Sci. 2006 September; 6(3): 187–190.

ATLS Summary of Clinical Action Haemodynamic Abdominal Sign Action

Unstable Unstable + Uncertain Laparotomy FAST or DPL Stable + / Uncertain CT Emergency in Trauma. Oxford, 2010.

Clinical abdominal scoring system (CASS)

STABILITY

Score

< 9 9 - 11 > 11

Action

Clinical Observations Auxiliary investigations Immediate Laparotomy *Auxiliary investigations include US, CT, DPL * “… is helpful in ensuring

rapid diagnosis and

treatment, reduces time, costs and mortality …” LOCAL STATUS International Journal of Surgery 2008; 6: 91e95

Algorithm for Blunt Abdominal Trauma

BMJ 2008;336:938-42

Important Notes …

• Signs of blood loss and hollow viscus injury may initially be subtle • A normal FAST does not exclude injury • The diagnosis or exclusion of hollow viscus injuries can be problematic

Hollow Viscus ???

BMJ 2008;336:938-42

The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively Am J Emerg Med. 2012 May;30(4):570-3

CT was more sensitive (86% vs 53%) and more specific (88% vs 69%) than physical exam Am J Surg. 2013 Apr;205(4):414-8.

SOP FKUI RSCM

SOP FKUI RSCM

Laparoscopy

• • • Most useful in penetrating trauma to thoraco abdominal region in haemodynamically stable – esp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscope – diaphragm, solid viscera, stomach, small bowel. Disadvantages: – poor sensitivity for hollow visceral injury, retroperitoneum – – Complications from trocar misplacement. If diaphragm injury, PTX during insufflation Rosen ’ s Emergency Medicine, 7 th ed. 2009

Topic of Discussion

• Abdomen and Abdominal Injuries • Decision Making in Abdominal Trauma •

Trauma Laparotomy

• Damage Control Surgery

Trauma Laparotomy

• (Big) Incision • (Thorough) Exploration • (Adequate) Exposure • (Hemorrhage) Control Acute Care Surgery. Springer, 2008

(Thorough) Exploration

• • A systematic evaluation of all abdominal contents Sequence of exploration may vary among surgeons – Liver & spleen - root of the mesentery - stomach, duodenum, small bowel, and colon retroperitoneal structures Acute Care Surgery. Springer, 2008

Exposure : R & L medial visceral rotations

Acute Care Surgery. Springer, 2008

Exposure : Exposure of the pancreas

Acute Care Surgery. Springer, 2008

(Hemorrhage) Control

Apply a Pringle clamp early to control major bleeding from the liver Operative Technique Severe Liver Injury. Springer, 2015

Damage Control Surgery

• • The decision to abort operative intervention must be made early, even prior to the arrival of the patient if there is hypotension in transport or in the trauma resuscitation area Phases of DCS: – Ph 0 : Damage control resuscitation – Ph 1 : Abreviated Surgery – Ph 2 : ICU – Ph 3 : Second Operation Damage Control Management in Polytrauma. Springer, 2010

Damage Control Resuscitation

• Must address all three components of the “lethal triad” • Integrates permissive hypotension, haemostatic resuscitation, and damage control surgery • In trauma patients predicted to require massive transfusion, FFP:PRC:platelets in a 1:1:1 ratio (of individual units) is associated with improved survival BMJ 2009;338:b1778

Abreviated Surgery

• Approx. 60 – 90 minutes • If definitive repair is feasible, DO IT !

“Trauma surgery is just general surgery, but faster and under blood.” – Anonymous

Damage Control Management in Polytrauma. Springer, 2010

Summary

• Acute abdominal injuries require early surgical consult to assess the need for Surgical Intervention • “Damage Control” should begin as early as possible, even from pre hospital period • Abbreviated Trauma Laparotomy is the key for successful management