Hollow viscus injury management

management on hollow viscus and retroperitoneal vascular injury

1. Hollow viscus and retroperitonial vascular injury management By Dr Mengistu.K (GSR III) Moderator: Dr eyuel (surgeon) 12/14/2020 1 HVI mgt By Mengistu GSR III

2. OUTLINE Objectives Introduction Mechanisms of injury Patient approach Specific organ injury management Summery Reference 12/14/2020 2 HVI mgt By Mengistu GSR III

3. Objective To have a brief and clear understanding on specific hollow viscus injuries 12/14/2020 3 HVI mgt By Mengistu GSR III

4. Introduction Abdomen is a diagnostic black box Variety of diagnostic adjuncts are used to identify abdominal injury Systematic approach is essential. Clinical examination  cornerstone in diagnosis of blunt abdominal trauma 12/14/2020 4 HVI mgt By Mengistu GSR III

5. Mechanisms of injury “Blunt” Vs“penetrating ” 3:1 in most urban trauma centers In rural centers, blunt abdominal injuries are generally seen in more than 90% of patients. Motor vehicle crashes  falls and bicycle accidents 12/14/2020 5 HVI mgt By Mengistu GSR III

6. Blunt injury Proposed mechanisms of intestine trauma Crush injury to the bowel itself-common mechanism of duodenal injury and more common in lean individuals and children Shearing forces of the bowel at fixed points of attachment Burst injury caused by increased intraluminal pressure 12/14/2020 6 HVI mgt By Mengistu GSR III

7. Penetrating injury Low velocity Vs high velocity injury Penetrating injuries  most common cause of HVI GSW that penetrate the peritoneal cavity -80% GI injury Stab wounds with fascial penetration- 50% needs laparotomy and 30% will have HVI Cavitation phenomenon?? ??????? 12/14/2020 7 HVI mgt By Mengistu GSR III

8. Laparotomy for gunshot or shotgun wounds that penetrate the peritoneal cavity Anterior abdominal stab wounds - explored under local anesthesia Blast injuries: four mechanisms Overpressure wave induced by the blast itself Projectiles from the explosion Generation of “blast winds” Fire and heat generated by the explosion 12/14/2020 8 HVI mgt By Mengistu GSR III

9. Patient approach ABCDE of life 28% sensitive in definitively diagnosing enteric injury . M ainstay of diagnosis to rule out enteric injury 12/14/2020 9 HVI mgt By Mengistu GSR III Hallmark of accurate diagnosis  “high level of suspicion”

10. 12/14/2020 10 HVI mgt By Mengistu GSR III

11. ABCDE of life Shock on admission is the most significant predictors of mortality in patients with enteric injuries 12/14/2020 11 HVI mgt By Mengistu GSR III

12. Specific organ injury management Peritoneal(HVI) Retroperitoneal injury 12/14/2020 12 HVI mgt By Mengistu GSR III

13. Gastric injury Easiest to diagnose and repair Occur in 20% of all abdominal penetrating trauma and 1% of blunt trauma Almost always consist of a single or a pair of perforations Most commonly affected sites :- Anterior wall (40%)  Greater curvature(23%)  lesser curvature (15%), and Posterior wall(15%) 12/14/2020 13 HVI mgt By Mengistu GSR III

14. Management Grades I and II intramural hematomas -  evacuate hematoma , secure hemostasis  repaired with interrupted 3-0 silk Grade I and II perforations  primary closure in one or two layers Grade III injuries near the greater curvature  primary closure in one or two layers or use of a GIA stapler Grade IV injuries  proximal or a distal gastrectomy , rarely total gastrectomy 12/14/2020 HVI mgt By Mengistu GSR III 14 A pyloric wound may be converted to a pyloroplasty to avoid possible stenosis

15. Small Bowel Injuries Most commonly injured intraabdominal organ in penetrating trauma Perforation from blunt injury is the common at the ligament of triez , ileocecal valve,mid jejunum or in the areas of adhesion. 12/14/2020 HVI mgt By Mengistu GSR III 15

16. Principle small bowel exploration: through midline laparotomy incision Pack all quadrants of the abdomen with abdominal pack. Eviscerate the bowel to the right side of the abdomen Control mesenteric bleeding by placement of clamps on the ends of the bleeding vessels followed by suture ligature Control perforations temporarily with whip-stitch sutures or Babcock clamps Carefully examine intestine and mesentery beginning at the ligament of Treitz 12/14/2020 HVI mgt By Mengistu GSR III 16

17. Management Grade I –repair by interrupted sutures Grade II –limited debridement and repair on one or two layers in transverse manner. Grade III –REEA or repaire primarily if luminal narrowing can be avoided Grade IV and V – resection and anastomosis 12/14/2020 HVI mgt By Mengistu GSR III 17 Resection and anastamosis Grade III injury and above Multiple injuries in small segment Devascularized or Mesentric boarder injuries ????

18. Duodenal injury The epitome of an organ poorly designed to withstand the ravages of trauma Relatively rare injuries with segnificant morbidity and mortality Associated with liver, pancreatic, IVC and Aortic injuries Penetrating injury –more common D2 is most commonly injured (35%) ,while other portions having an equal distribution of 10% to 15% 12/14/2020 HVI mgt By Mengistu GSR III 18

19. The incidence of injuries to nearby organs and vessels in patients with duodenal wounds 12/14/2020 HVI mgt By Mengistu GSR III 19

20. Diagnosis Requires a high index of suspicion More difficult to diagnose in blunt trauma than penetrating injuries No specific diagnostic test found to be accurate all of the time Abdominal X-rays UGS Endoscopy CT Scan 12/14/2020 HVI mgt By Mengistu GSR III 20 CT Findings Suggestive of duodenal Injuries

21. 12/14/2020 HVI mgt By Mengistu GSR III 21

22. Management Challenges in duodenal injury management The retroperitoneal location Proximity to important abdominal structures Marginal blood supply Biliary , pancreatic and gastro-intestinal secretions in it Delay in the diagnosis 12/14/2020 HVI mgt By Mengistu GSR III 22

23. Principles of management A long, midline exploratory laparotomy A thorough search for intraperitoneal injuries kochers & cattell - brasch Manoeuvres All 4 parts of duodenum are to be inspected. After a duodenal injury is identified, its extent should be defined. 12/14/2020 HVI mgt By Mengistu GSR III 23 Basic principles Restore intestinal continuity Decompress the duodenal lumen Provide external drainage Provide nutritional support

24. Predictors of outcome Mild injuries Severe injuries Stab wound Less than 75% duodenal wall injury Third or fourth portion of the duodenum injury Injury repair interval was less than 24 hours; and No associated injury occurred to the common bile duct Blunt trauma or a missile wound Greater than 75% duodenal wall injury Injury located in the first or second portion of the duodenum Injury repair interval was greater than 24 hours; and Associated injury occurred to the common bile duct 12/14/2020 24 HVI mgt By Mengistu GSR III

25. Grade I or II hematoma If detected pre operatively Observation Naso gastric aspiration TPN No improvement with in 3 wks  laparotomy If detected intra operatively Evacuation if luminal compromise more than 50% Distal feeding jejunostomy in the setting of luminal compromise up to 50% 12/14/2020 25 HVI mgt By Mengistu GSR III

26. Grade I or II laceration Primary closure in one or two layers Repair in the direction in which the injury is formed is generally recommended Pyloric exclusion only if there is associated pancreatic injury 12/14/2020 26 HVI mgt By Mengistu GSR III

27. Grade III injury Attempt primary closure as first option, as long as a tension-free repair possible with concomitant pyloric exclusion If its not feasible ,treat as follows Injury proximal to ampulla -perform antrectomy plus GJ and stump closure 12/14/2020 HVI mgt By Mengistu GSR III 27

28. Injury distal to ampulla -Roux-en-y duodenojejunostomy to proximal end of duodenal injury with oversewing of distal duodenum 12/14/2020 HVI mgt By Mengistu GSR III 28

29. Grade IV or V injuries Usually present either in shock or with concomitant severe injuries to other organs Patients are best served with a damage control strategy Management options are Pancreaticoduodenectomy Reconstruction with hepaticojejunostomies Reimplantation of distal CBD into roux-en-y jejunal limb 12/14/2020 HVI mgt By Mengistu GSR III 29

30. Pancreaticoduodenectomy Indications Massive and uncontrollable bleeding from the head of the pancreas, adjacent vascular structures, or both. Massive and unreconstructable ductal injury in the head of the pancreas. Combined unreconstructable injuries of the following: Duodenum and head of the pancreas Duodenum, head of the pancreas, and common bile duct 12/14/2020 HVI mgt By Mengistu GSR III 30

31. Duodenal Diversion In high risk duodenal injury Earliest technique – Tube decompression Stone & Garoni “triple ostomy ” Gastrostomy tube to decompress stomach Retrograde jejunostomy to decompress duodenum Antegrade jejunostomy for feeding Pyloric exclusion 12/14/2020 HVI mgt By Mengistu GSR III 31

32. Duodenal diverticulation The goal of excluding the duodenum from the passage of gastric contents Includes antrectomy , debridement, and closure of the duodenum, tube duodenostomy , vagotomy , biliary tract drainage, and a feeding jejunostomy 12/14/2020 HVI mgt By Mengistu GSR III 32

33. Complications Duodenal fistula Intra abdominal abscess Pancreatitis Duodenal obstruction Bile duct fistula 12/14/2020 HVI mgt By Mengistu GSR III 33

34. Colorectal injury Common following penetrating trauma Blunt trauma  presents special diagnostic problems and about a third will have full-thickness colon perforations. Colon : most commonly injured organ following posterior stab wounds and Third most commonly injured organ in anterior abdominal stab wounds 12/14/2020 HVI mgt By Mengistu GSR III 34

35. Right colon  most frequently injured after blunt force trauma Transverse colon  most commonly injured segment after gunshot wounds and Left colon  most commonly injured segment after stab wounds. 12/14/2020 HVI mgt By Mengistu GSR III 35

36. 12/14/2020 HVI mgt By Mengistu GSR III 36

37. Diagnosis Commonly made intraoperatively after laparotomy CT with IV contrast: if nonoperative management considered FAST, DPL or laparoscopy have little or no role 12/14/2020 HVI mgt By Mengistu GSR III 37

38. Principles of operative management Approaches Options of management Damage control approach Definitive treatment of injuries Primary repair Resection and anastomosis Proximal fecal diversion 12/14/2020 38 HVI mgt By Mengistu GSR III

39. Damage control approach Proposed criterias PH of 7.2 or less Intraoperative temperature less than 34 °C Blood replacement greater than 4 L, and Total intraoperative fluid replacement >10L 12/14/2020 HVI mgt By Mengistu GSR III 39

40. Components : Resuscitative surgery : control of hemorrhage and intestinal contamination  temporary abdominal wall closure Correction of lethal triads in the intensive care unit; and Reexploration for definitive management of injuries 12/14/2020 HVI mgt By Mengistu GSR III 40

41. 12/14/2020 HVI mgt By Mengistu GSR III 41

42. Definitive treatment of injuries Depends on: Mechanism of injury Delay between the injury and surgery Overall condition and stability of the patient Degree of peritoneal contamination, and Condition of the injured colon 12/14/2020 HVI mgt By Mengistu GSR III 42 Shock Injury to more than two other organs Mesenteric vascular damage, and Extensive fecal contamination Contraindications to primary repair of colonic injury

43. 12/14/2020 HVI mgt By Mengistu GSR III 43

44. Nondestructive colon injuries Injury involving less than 50% of the bowel wall and without devascularization primary repair unless contraindicated. Destructive colon injuries Injury with loss of more than 50% of the bowel wall circumference or with devascularization Require a segmental colonic resection and anastomosis unless contraindicated 12/14/2020 HVI mgt By Mengistu GSR III 44

45. Colon injury treatment algorithm 12/14/2020 HVI mgt By Mengistu GSR III 45

46. Management of Rectal Injuries Intraperitoneal injuries: manage as colonic injuries Extraperitoneal injuries Primary repair  Small, clean rectal injuries in stable patient Fecal diversion: majority of penetrating rectal injuries, proximal injury and significant contamination APR: extensive tissue loss with severe anal sphincter damage Distal washout and presacral drains are not routinely recommended 12/14/2020 HVI mgt By Mengistu GSR III 46

47. WOUND MANAGEMENT ANTIBIOTIC PROPHYLAXIS Primary wound closure doubled the risk of infection Fecal spillage  delayed primary closure of the skin 3–5 days Infection Colostomy complication Antibiotic regime covering both aerobes and anaerobes Duration has been a controversial issue 24-hour prophylaxis is at least as effective as prolonged prophylaxis for 3–5 days 12/14/2020 47 HVI mgt By Mengistu GSR III Complications

48. Timing of trauma ostomy closure Remains a debated issue Traditionally, a minimum of 3 months from the original operation More recent studies even recommended closure within 2 weeks of the colostomy creation 12/14/2020 HVI mgt By Mengistu GSR III 48

49. Specific organ injury management Peritoneal(HVI) Retroperitoneal injury 12/14/2020 HVI mgt By Mengistu GSR III 49

50. Abdominal vascular injuries Retroperitoneum : sites of major blood vessels of the abdomen Usually the injuries occur in association with other intra-abdominal organ injuries 90-95 % o due to penetrating trauma Results in massive bleeding & requires supraceliac aortic clamping for visualization 12/14/2020 HVI mgt By Mengistu GSR III 50

51. Diagnosis and presentations The diagnosis is almost always made during laparotomy . Frequently associated with significant ongoing blood loss & hemodynamic instability. Delineation of specific vascular injuries mostly requires exploration & exposition of retroperitoneum Location of hematomas guide surgical decision 12/14/2020 HVI mgt By Mengistu GSR III 51

52. The retroperitoneum conceptually divided in to three zones Zone 1: midline retroperitoneum Supramesocolic region Inframesocolic region Zone 2: upper lateral retroperitoneum Zone 3: pelvic retroperitoneum 12/14/2020 HVI mgt By Mengistu GSR III 52

53. Zone Vascular content Visceral content I(midline retroperitoneum) Supramesocolic area Suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery Pancreas, duodenum Inframesocolic area Infrarenal abdominal aorta or inferior vena cava. ------ II(upper lateral retroperitoneum) Renal arteries and renal veins Kidney, adrenal gland,renal pelvis and proximal uterers III(pelvic retroperitoneum) Iliac arteries and veins ----- 12/14/2020 HVI mgt By Mengistu GSR III 53

54. Principles of surgical management Zone 1 retroperitoneal hematomas Explore regardless of cause or size Zone 2 retroperitoneal hematomas 2 nd to penetrating injury  explore if encountered in the OR 2 nd to blunt injury  left alone if they are not expanding Zone 3 retroperitoneal hematomas Penetrating injuries  explore to exclude major vascular injuries 12/14/2020 HVI mgt By Mengistu GSR III 54 Expose Achieve proximal control Assess injury and Restore flow

55. Management of zone I injuries Supramesocolic region Supraceliac exposure Through the lesser omentum Important to control aortic emergency Less likely to be aneurysmal 12/14/2020 HVI mgt By Mengistu GSR III 55 1 2 3

56. Exposure to visceral Aorta Left medial visceral rotation Mattox maneuver 12/14/2020 HVI mgt By Mengistu GSR III 56 1 2

57. Modified Mattox maneuver 12/14/2020 HVI mgt By Mengistu GSR III 57 Performed by allowing the kidney to remain in gerota’s fascia and selecting a disection plane that include panceas and spleen Give excellent exposure of celiac trunk, superior mesentric artery and left renal pedicles

58. Right medial visceral rotation Kocher’s maneuver Identify deodenum Incise posterior peritonium immediate lateral Reflect the duodenum and pancreatic head from retroperitoneum Allow access to infrahepatic IVC, distal CBD,deodenum,pancreatic head and rt renal hilum . 12/14/2020 HVI mgt By Mengistu GSR III 58

59. Extended kocher maneuver Carry the classic kocher incision caudally along white line of Toldt Access to entire infrahepatic IVC, kidney hilum and Rt iliac vessels 12/14/2020 HVI mgt By Mengistu GSR III 59

60. CATTEL BRAASCH MANEUVER Extended Kocher +incise line of fusion of small bowel mesentery to posterior peritoneum Swing small bowel and Rt colon out of abdomen Expose entire inframesocolic retroperitonium , infrarenal aorta,IVC,Lt renal hilum and vessel,lt iliac vessels and superior mesentric vessels 12/14/2020 HVI mgt By Mengistu GSR III 60

61. ZONE II hematoma management Also known as lateral retroperitoneal hematoma or hemorrhage Operative interventions are required Expanding hematoma Active hemorrhage Time of ischemia & contralateral renal function dictates management of Renovascular injuries 12/14/2020 HVI mgt By Mengistu GSR III 61

62. ZONE III hematoma management Are due to injuries to iliac vessels Most of the time associated with pelvic fracture, especially open Injuries to common & external iliac arteries should be repaired or temporarily shunted Internal iliac artery injuries can be ligated safely in time of difficulty Common & external iliac vein injuries are best treated with either lateral repair or ligation. 12/14/2020 HVI mgt By Mengistu GSR III 62

63. 12/14/2020 HVI mgt By Mengistu GSR III 63

64. Summery Abdomen is a diagnostic black box Penetrating injuries are the most common cause of HVI Duodenum is epitome of an organ poorly designed to withstand the ravages of trauma Colorectal injury are diagnosed commonly after laparotomy Zone 1 retroperitoneal hematomas should be explore regardless of cause or size 12/14/2020 HVI mgt By Mengistu GSR III 64

65. Reference Shackelford's Surgery of the Alimentary Tract 2018 ed. Trauma Mattox 8th Edition Schwartz’s principles of Surgery 11 th ed. Sabiston textbook of Surgery 20 th ed Maingot’s Abdominal Operations 12 th ed. Greenf ield’s Scientific Principles & Practice surgery 6 th ed 12/14/2020 HVI mgt By Mengistu GSR III 65

66. Thank you 12/14/2020 HVI mgt By Mengistu GSR III 66