Closed Abdominal Injuries

1. Closed Abdominal Injuries

2. Classification of Abdominal trauma
 Penetrating trauma
solid viscera injury
 Blunt trauma
hollow viscera injury
Injuries from blunt trauma are more
common and more difficult to assess

3. Mechanism of closed abdominal injury
Deceleration forces from motor vehicle accidents
or falls may tear organs from their points of
fixation
e.g. liver, bladder, gut
A steering wheel or other solid object striking the
abdomen may disrupt any of the organs that cross
the vertebral column
e.g. pancreas, duodenum, vena cava

4. Characteristic features of different organ injuries
Parenchymal organ injury hollow organ injury
liver, spleen, kidney stomach, intestine, gallbladder
internal hemorrhage acute peritonitis
pulses BP abdominal tenderness
abdomen soft rigidity
tenderness not clearly rebound tenderness
rebound tenderness obvious diminishing of liver dullness
presence of shifting dullness

5. Diagnosis—whether there is viscus damage
Repeated frequent examination is essential
Get the history of injuries
symptoms:abdominal pain, vomiting, nausea,
blood stained stool, hematuria,
management after injury

6. Physical examination
BP, pulses, temperature, abdominal tenderness,
rigidity, rebound tenderness, diminishing of liver
dullness, presence of shifting dullness and alter-
nation of bowel sound, P.R examination
Laboratory findings
intraabdominal bleeding: RBC Hb
WBC
pancreatic injury: amylase in urine and blood

7. The early symptoms of abdominal injury
Shock, especially hemorrhagic shock.
Severe constant abdominal pain, nausea, vomiting
and signs of acute peritonitis.
Shifting dullness present and diminished liver
dullness
Vomiting of blood, passing bloody stool or urine
PR examination: tenderness, pulsating swelling
may be detected and there maybe blood on gloves

8. X-ray examination of the chest and abdomen
Abdominal puncture
valuable in difficult cases
Diagnostic Peritoneal lavage(DPL)
more reliable technique , accurately reflects the
presence of significant visceral damage in about
95% of cases
Additional diagnostic modalities

9. Ultrasonography
noninvasive, can detect hemoperitoneum and
solid organ injury
CT scan --- highly accurate diagnostic modality
Hemodynamically stable patient with an equivocal
abdominal examination
Patient with closed head injury
Patient with spinal cord injury
Hematuria in the stable patient
Patient with pelvic fractures and significant bleeding

10. • Observation
If the patient still can not be diagnosed with
the above methods, the patient must be kept in
hospital under strict observation until the
diagnosis can be made clearly.

11. The rules of management during observation
Absolute rest
Restricting of diet and intravenous infusion
Don’t use morphe or any sedatives
Measuring BP, pulse rate, respiratory rate and
temperature at definite intervals
repeat abdominal examination and blood count
If there is any doubt of gastric perforation, gastric
suction and antibiotics should be used

12. • Performing exploratory laparotomy if necessary
Indication:
Increased tenderness or rigidity or distension
Evidence of continuing blood loss that can not
be clearly explained by extraabdominal source
Evidence of developing peritonitis
The presence of free air on X-ray

13. Enlarging of intraabdominal mass
Demonstration of blood, bile, intestinal
contents in abdominal puncture
High amylase level in abdominal fluid
In the presence of shock with increasing
abdominal rigidity and an inadequate
response to fluid replacement

14. Treatment principle
Keep the airway free
Circulatory resuscitation
laparotomy
Control of hemorrhage, in extreme cases
thoracotomy required
Contamination from lacerations of the gut should
be stopped as quickly as possible

15. spleen injury
Spleen is the most commonly injured intra-
abdominal organ
Splenic injury must be suspected in any patient
with blunt abdominal trauma, especially with left
lower rib fracture
Diagnosis is suspected on physical examination,
and confirmed by abdominal CT scan or
explora-
tory laparotomy for hemoperitoneum

16. Treatment
Splenorrhaphy or partial resection
Total splenectomy
hilar vascular injury
massive subcapsular hematoma
extensive fragmentation
total avulsion
severe associated injuries
continuing bleeding after attempted splenic repair

17. Nonoperative management
delayed spleen rupture must be considered
due to enlarging subcapsular hematoma
rupture of a traumatic
pseudoaneurysm
recurrent or ongoing hemorrhage

18. Liver and Biliary Tree
The second most commonly injured
organ following blunt trauma
Injury is ofen minor and can be easily
managed by direct suture ligation or by
using hemostatic agents

19. Seven basic techniques in operation
Suture
Inflow occlusion
Packing
Hepatic artery ligation
Resection
Mesh hepatorrhaphy
Atrial-caval shunting

20. Common bile duct injury
Completely transection or >50% injured
biliary-enteric anastomosis
Perforated or <50% injured
primary repair and place a T-tube
Cholecystostomy
cholecystectomy
Gallbladder injury

21. Stomach injury
Gastric rupture secondary to blunt
trauma is rare
 Iatrogenic gastric rupture
vigorous ventilation with an endotracheal
tube misplaced in the esophagus

22. If vomitus or gastric aspirate is
bloody, stomach injury should be
suspected
At laparotomy, gastrocolic omentum
must be widely opened for complete
inspection

23. Treatment
Debridement and closure
Gastric diversion or resection is
rarely necessary

24. Small intestion injury
Incidence 5% -- 15%
Mechanism
Crush injury between the vertebrae
and anterior abdominal wall
Sudden increase of intraluminal
pressure
Tear at the junction of a mobile and a
fixed segment of bower

25. Treatment
Simple laceration --- suture, avoid excessive
narrowing of the bowel
Extensive damage or multiple tears situated
fairly close --- resection of the involved
segment

26. Colon injury
Most colon injuries can only be definitively
recognized at laparotomy.
Early diagnosis and treatment dramatically
reduce infection complications.

27. Four tecniques in the management
Primary repair
Resection and primary anastomosis
Exteriorization of repair
colostomy

28. Guidelines of repair instead of colostomy
Operation within 4 to 6 hours
Less than 6 units of blood transfusion
No evidence of prolonged shock or
hemodynamic instability
Minimal soilage of peritoneal cavity
Injury limited to one aspect of the colon
No associated colonic vascular injury
No loss of abdominal wall

29. Rectum injury
Abdominal x-ray films are obtained for
the determination of retroperitoneal air
Proctosigmoidoscopy performed for
either direct visualization of the injury
or for the evidence of hemorrhage
Transpelvic gunshot wounds should
undergo celiotomy

30. Treatment
Full thickness rectal wounds above the
dentate line --- primary closure
combined with a diverting colostomy
Wounds below the dentate line ---
debridement accompanied by drainage

31. Wounds above the levators with
penetration of the pelvirectal space
Closure, if possible
Proximal diverting colostomy
Presacral (retrorectal) drainage
Irrigation of the rectal stump