Abdominal trauma SURGERY CASE PRESENTATION .pptx

ABDOMINAL TRAUMA SURGERY CLINICAL CASE SCENARIO

1. ABDOMINAL TRAUMA

2. Mechanism of injury: Blunt abdominal trauma: MC involved: SPLEEN>LIVER>SMALL INTESTINE Penetrating abdominal trauma: MC involved: LIVER> Small intestine> diaphragm Gun shot (GSW): MC : Small intestine> LIVER Deceleration injury: (without seat belt) MC: DJ FLEXURE Seatbelt syndrome: MESENTERY OF BOWEL OVERALL MC ORGAN: SPLEEN

3. BLUNT ABDOMINAL TRAUMA Hemodynamically stable First : FAST IOC: CECT Hemodynamically unstable First: FAST IOC: FAST

4. Focussed Assessment Sonogram in Trauma (FAST) USG in ER 4 probes in order: Sub- xiphoid space/ epigastrium : to look for cardiac tamponade Right upper quadrant/right hypochondrium : to look collections around liver/hepatic space Left upper quadrant/left hypochondrium : to look collections around spleen Suprapubic area:to look collections around pelvis

5. Advantages of FAST Very quick Can detect as little as 50-100cc of fluid Disadvantages of FAST Operator dependent Retroperitoneal injuries can be missed

6. EXTENDED FAST/ e- FAST: 6 Probes: 4 places as in FAST. Additional 2 kept at right & left thoracic cavity.

7. E-FAST Detects free fluid in the abdomen or peritoneum. Will not reliably detect less than 100ml of free blood Does not directly identify injury to hollow viscus . Cannot reliably exclude injury in penetrating trauma. May need repeating or supplementing with other investigations Is unreliable for assessment of retropritoneum .

8. Penetrating abdominal trauma Stable, no peritonitis, penetration superficial to peritoneum. Local wound care f/b CECT scan Unstable, signs of peritonitis, omentum hanging out, bile staining. LAPAROTOMY Never remove objects in ER , Always to be done in OT.

9. Diagnostic Peritoneal Lavage / DPL Done when FAST is not available DPL cannot evaluate retroperitoneum Procedure: Put ryles tube to empty stomach Put foleys to decompress bladder A cannula inserted just below umbilicus caudally & posteriorly & aspiration done If >10cc blood comes out: positive DPL

10. IF <10CC BLOOD: infuse 500ml RL from 1 litre bag. Bag with remaining 500ml is placed on floor Intraabdominal fluid drained through gravity >1 lakh RBC/ CU MM OR >500 WBC/ CU MM OR S.AMYLASE >175 IU/L OR Presence of fecal content DPL IS POSITIVE  LAPAROTOMY

11. Spenic Trauma

12. Splenic trauma MC organ injured overall MC organ injured in blunt abdominal trauma MC organ injured in children Suspected when : Fracture of 9-11 ribs Brusing over left chest wall

13. Kehr sign: Seen in splenic injury Raise left lower limb, blood accumulates below the left dome of diaphragm leading to referred pain to left shoulder tip.

14. Grading

15. Management STABLE  Conservative management : monitor vitals. haematocrit , serial 24 hr CECT If grade of injury increase or contrast blush on CT  ANGIOEMBOLISATION  FAILS/UNSTABLE  SURGERY (SPLENORRAPHY/ SPLENIC PRESERVATION)

16. unstable  SURGERY (SPLENECTOMY) Vertical midline incision is taken for quick access packing of all 4 quadrants peritoneum division start at white line of toldt ( splenocolic ligament) , superiorly till short gastric vessels. Short gastric vessels ligated and divided hilar vessels clamped & ligated  spleen removed Prevent injury to tail of pancreas an greater curvature of stomach. Drain placed if injury to tail of pancreas suspected. Splenic vessels are ligated within 1cm from splenic hilum to avoid injury to the tail of pancreas.

17. Splenorrphahy : variety of spleen sparing techniques aimed at controling hemorrhage Intraoperative decision after fully mobilisation and inspection of spleen Considered in less svere injury : grade 1,2,3. Manual compression of parenchyma to achieve hemostasis of simple lacerations. Topical hemostatic agents Monofilament suture , mattress technique piece of omentum or gelatin sponge ca be incorporated Wrapping entire spleen in absorbable mesh for effective tamponade .

18. Precautions Complications: MC Complication following splenectomy : Left lower lung complications/ atelectasis /pneumonia Hemorrhage Injury to pancreatic tail. Turbid discharge in drain Rich in amylase Hematological changes

19. Hemodynamic changes : Transient changes: Increase in wbc,rbc , platelets : 2 weeks Permanent changes: Basophilic stippling Howell jolley bodies (nuclear remants ) Reticulocytes Hypersegmented WBCs

20. Opportunistic post splenectomy infections/ OPSI: First 2 years Children>adults Splenectomy done for hematological conditions. High mortality Mc organism(encapsulated) : S.pnemonaiae > H.influenzae > N.meningitis

21. Vaccine Elective splenectomy : given 2 weeks before Emergency splenectomy : POD 1 or 2 Pneumococcus , meningococcus C – repeated 5 yearly Hib – repeated 10 yearly

22. Pancreatc trauma

23. Pancreatic trauma Pancreatic injuries are uncommon MC mechanism in pediatrics: Blunt trauma Direct compression of epigastrium against vertebral column (handlebar/bicycle injuries) Mc in adults: penetrating injury

24. Isolated pancreatic injuries – not common 90% ass with hepatic, gastric, splenic , renal, colonic, or vascular injuries

25. Diagnosis is straightforward in unstable pts with Retroperitoneal injuries Gunshot wounds Penetrating injuries

26. Diagnosis in Hemodynamically stable is challenging Undiagnosed pancreatic injuries (60%) – complications : Intrabdominal abscess Fistula Fluid collections

27. Ioc : CT W/A Pancreatic hematomas Free fluid in lesser sac Abnormal thickening of gerota fascia Mrcp can be done for better visualisation of pancreatic duct injuries, fractured segment.

28. Isolated pancreatic amylase is not recommended 40% of patients with transected pancreatic ducts have normal s.amylase levels Most reliable to demonstrate pancreatic duct integrity : ERCP (use is limited as risk of inducing pancreatitis, availability, severity of trauma)

29. Definitive treatment is based on surgical findings Stable: major pancreatic resections Unstable/ complex injury: Damage control surgery, temporary control with drains Upto 75% deaths occur in 48-72 hrs ( due to hypovolemic shock)

30. Liver Trauma Blunt trauma due to direct injury Solid organ compressive forces burst Compressed b/w impacting object and ribcage/vertebral column. Penetrating inujry  e.g gun shot (damage due to shock wave) Vascular component to be seen in imaging

31. Liver trauma

32. GRADE 1,2,3  USUALLY stable- conservative GRADE 4,5 Explore patient Push/bimanual compression Pringle’s manuovre Plug: using silicone tube / Sengstaken Blakemore tube Packing

33. Management

34. Mesentric injury Mc : seatbelt syndrome Longitudinal tear: no bowel ischemia as adjacent branches will be supplying. Rx: repair of tear. Transverse tear: entire supply is cut and segment goes for necrosis. Rx: Resection & anastomosis .

35. Pancreatic injury MC due to blunt trauma Amylase/lipase insensitive Most important prognostic factor: Injury to main pancreatic duct ( poor prignosis )

36. Duodenal injury Usually ass with pancreatic injury Retroperitoneal ,Usually hidden Mc due to penetrating/ gun shot Ioc : CT with oral contrast (if stable) Duodenal hematoma: bowel rest (NPO) Perforation: omental patch repair (Grahams patch repair)

37. Injury to colon and rectum Colonic & rectal trauma: Destructive Penetrating injury:Wounds more than 50% of colonic circumference, complete transection , devascularised segments Blunt injury: tears more than 50% circumference, full thickness perforation, mesentric devascularisation Destructive rectal > 25% circumference Non destructive

38. Suspected injury : Stable: triple phase CT: ORAL, IV, RECTAL Unstable/ peritonitis Colon injury – if viable, little contamination: wound repair --if doubtful viability, defunctioning colostomy Rectal injury: - intraperitoneal #: same as colon - extraperitoneal #: primary wound repair -extensive tissue loss: diverting end colostomy & distal end closure ( hartmann procedure) / loop colostomy PRESACRAL DRAINAGE IS NO LONGER USED

39. Renal and Urological tract injury Stable  IOC : CECT For assessment of bladder injury : cystogram (min 300ml of contrast into bladder) Renal injury generally managed non-operatively Ureter injury: rare, mcc : penetrating injury Repaired/diverted/ ligated

40. INTRAPERITONEAL RUPTURE OF BLADDER (BLUNT TRAUMA) REQ. SURGICAL REPAIR EXTRAPERITONEAL REPAIR ( ASS WITH PELVC #) -- Heal with adequate urine drainage via transurethral route (if not possible, Supra pubic drainage )

41. Injury to Retroperitoneum Difficult to diagnose Ioc : CT ( STABLE)

42. Zone 1 (central): always be explored Zone 2 (lateral): explored only if expanding or pulsatile / penetrating injury . USUALLY RENAL IN ORIGIN  NON-OPERATIVELY, some may req angioembolisation . Zone 3 (pelvic): explored only if expanding or pulsatile /penetrating injury. Pelvic hematomas:difficult to contral  should not be opened. Best controlled with compression or extraperitoneal packing. If bleeding arterial in origin angioembolisation .

43. Hematomas of infrarenal vasculature / right renal hilum : Right medial visceral mobilisation : CATTEL-BRAASCH manueuver . Wide KOCHER Maneuver : peritoneal dissection inferiorly  mobilise right colon Continue around cecum & superiorly up to mesenteric root.

44. Injuries to suprarenal great vessels/ left renal hilum : Left medial visceral mobilisation – MATTOX Maneuver Diving peritoneum along left side, above the spleen to distal left colon. Plane posterior to colonic mesentry and pancreas developed, viscera retracted to right.

45. Damage control surgery Carried out when :terrible triad of trauma: HYPOTHERMIA ACIDOSIS COAGULOPATHY

46. INDICATIONS: ANATOMICAL Inability to achieve haemostasis : complex abdominal injury e.g , liver , pancreas Combined vascular, solid, hollow organ injury, e.g , aortic or caval injury Inaccessible major venous injury e.g , retrohepatic venacava Non operative control of other injuries: fractured pelvis Time-consuming procedure

47. PHYSIOLOGICAL TEMPERATURE <34 C PH <7.2 Lactate >5 mmol /l PT >16 s APTT> 60 s >10 units blood transfussed SBP < 90 MMHG for > 60 min

48. Environmental Operating time >60min ( core temp. loss 2 C/HR) Inability to approximate abdominal incision Reassess to intra-abdominal contents

49. Phases Phase 0 identification of patient in ER

50. PHASE 1 Emergency laparotomy in ot aim: to stop bleeding to prevent contamination Temporary closure of abdomen

51. Phase 2 IN ICU AIM: To correct physiology (terrible triad)

52. Phase 3 After 24-48 hrs, Re-exploration in OT Aim: to correct anatomy

53. Stages of damage control surgery: Patient selection Control of hemorrhage, contamination ICU care Definitive surgery Abdominal closure

54. Abdominal compartment syndrome Sustained elevation of IAP >/=20MMHG with new organ dysfunction Seen in: Massive burns (distension of bowel) Bowel obstruction Massive ascitis

55. Intra abdominal hypertension Sustained or repeated pathologic elevation of IAP >12MMHG GRADE 1 : 12-15 MMHG GRADE 2 :16-20 MMHG GRADE 3 : 21-25 MMHG GRADE 4 : >25 MMHG

56. EFFECTS OF RAISED IAP RENAL INCREASE IN RENAL VASCULAR RESISTANCE REDUCTION IN GFR IMPAIRED RENAL FUNCTION

57. CARDIOVASCULAR DECREASE IN VENOUS RETURN DECREASE CARDIAC OUTPUT ( REDUCED PRE LOAD AND AFTER LOAD)

58. RESPIRATORY INCREASED VENTILATION PRESSURE DECREASE LUNG COMPLIANCE INCREASED AIRWAY PRESSURES

59. VISCERAL PERFUSION Reduction in visceral perfusion

60. Intracranial effects: SEVERE RISE IN ICP

61. MANAGEMENT SUPPORTIVE MEDICAL Mx - Neuromuscular relaxants, paracentesis of ascitis , etc ADEQUATE IV FLUIDS- fresh whole blood/ balanced transfusion of plasma, platelets, PRBCs > crystalloids DECOMPRESSIVE LAPAROTOMY