PENETRATING ABDOMINAL TRAUMA

PENETRATING ABDOMINAL TRAUMA

1. PENETRATING ABDOMINAL TRAUMA Done by : Rowaa Lahaseh Supervised by Dr Ibrahim Majjad

2. Back ground Penetrating abdominal trauma typically involves the violation of the abdominal cavity by a gunshot wound (GSW) or stab wound. The management of penetrating abdominal trauma has evolved greatly over the last century. Before World War I, penetrating trauma was managed expectantly and was nearly uniformly fatal. Laparotomy became the treatment of choice during World War I, but mortality remained high. By World War II, early laparotomy resulted in a survival rate close to 50%. The 1950s afforded availability of antimicrobials, better understanding of fluid replacement, and faster transport from the scene, which further increased survival rates. By the late 1950s, mandatory laparotomy was the rule for the management of patients with abdominal penetrating trauma. In 1960, Shaftan suggested selective management of patients with abdominal stab wounds after observing an increased rate of laparotomies without identifiable injuries. More recently, expectant management has also been used in the treatment of specific GSWs to the abdomen. The introduction and refinement of diagnostic procedures and imaging studies, including peritoneal lavage, laparoscopy, computed tomography (CT), and focused ultrasonography, have directed the evolution of penetrating abdominal trauma management. Damage control surgery (abbreviated laparotomy with physiologic resuscitation in the intensive care unit and staged abdominal reconstruction) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. Nevertheless , penetrating abdominal organ injury patterns and survival have plateaued over the past decade. Death from refractory hemorrhagic shock or exsanguination in the first 24 hours remains the most common cause of mortality. Damage control surgery is being used more frequently with improved early survival but with a concurrent increase in late morbidity

3. Anatomy In evaluating patients with penetrating abdominal trauma, the abdomen is classically divided as follows: Anterior abdomen - Anterior costal margins to inguinal creases, between the anterior axillary lines Intrathoracic abdomen or thoracoabdominal area - Fourth intercostal space anteriorly (nipple) and seventh intercostal space posteriorly (scapular tip) to inferior costal margins Flank - Scapular tip to iliac crest, between anterior and posterior axillary lines Back - Scapular tip to iliac crest, between posterior and axillary line This anatomic classification is important in guiding the clinician’s suspicion for specific organ injury. Intraperitoneal abdominal organs include the solid organs ( ie , spleen, liver) and the hollow viscus organs ( ie , stomach, ileum, jejunum, transverse colon).

4. Flank and back stab wounds  —  Identifying structures injured from penetrating wounds to the flank and back can be difficult. Stab wounds to these regions can injure both retroperitoneal and intraperitoneal structures. Several reports indicate that up to 40 percent of penetrating flank wounds result in significant internal injury . In the past, triple-contrast computed tomography (CT) was the study of choice for stable patients with such wounds, but with advanced, high-resolution, multidetector CT (MDCT) scanners, IV contrast is likely all that is needed to assess possible retroperitoneal injury from back or flank wounds Such advanced imaging often allows for safe nonoperative management. Ultrasound (US) and diagnostic peritoneal lavage (DPL) do not adequately assess retroperitoneal structures. Thoracoabdominal stab wounds  —  Thoracoabdominal wounds present a diagnostic challenge as movement of the diaphragm makes prediction of the stab wound tract difficult . If the wound is close to the lower chest, intrathoracic and diaphragmatic injuries must be considered and evaluated in addition to intra-abdominal injury. Pericardial tamponade is particularly important to consider in stab wounds near the xyphoid process. The risk of complications from a missed left-sided diaphragmatic injury is high (the liver generally prevents small bowel herniation on the right side). However , controversy continues about how best to evaluate possible diaphragm injuries. If diaphragmatic injury is a concern, diagnostic laparoscopy (DL) or thoracoscopy are the preferred tests because CT is relatively insensitive .

5. Right upper quadrant stab wound  —  Patients with a right upper quadrant stab wound who remain hemodynamically stable and free of abdominal tenderness, and who are reliable ( eg , not intoxicated and remain alert) may be managed without laparotomy . Most patients with injuries of this nature have sustained grade I or grade II hepatic injuries that do not require operative intervention. However , these patients should be admitted for a period of observation of at least 48 hours . Many centers perform CT scanning to confirm and determine the extent of any hepatic wounds and to assess for potential colonic injury. If the severity of liver injury cannot be determined with certainty by CT scan, most trauma surgeons perform diagnostic laparoscopy . The physical examination cannot be considered reliable in patients with a brain injury, spinal cord injury, or intoxication, or who require sedation or general anesthesia, and serial physical examination is not an appropriate means of evaluation in these circumstances.

6. Retroperitoneal area Retroperitoneal organs include the duodenum, pancreas, kidneys, ureters, urinary bladder, ascending and descending colon, major abdominal vessels, and rectum.

7. Zone 1 , or the central zone , is delimited by the diaphragm above and reaches the aortic bifurcation below. It includes the aorta, the origin of the large vessels, the duodenum and the pancreas. Blunt trauma to this region affects the duodenum and the pancreas to a greater extent, with vascular lesions being less frequent. Most of the series analyzed report a duodenal injury rate that does not exceed 12 %.  Pancreatic injuries have an incidence that ranges between 1% and 12% of penetrating trauma, and 5% of blunt trauma. Among the vascular lesions, inferior vena cava injury stands apart, representing 30%–40% of abdominal vascular injuries. Their overall mortality rate varies from 34% to 70%, and factors for morbidity and mortality include both the level of the injury and the existence of active bleeding or other associated lesions .  Abdominal aorta injuries are around 0.2 %,and its high immediate mortality rate is the second most common cause of death in blunt trauma injuries. It is estimated that 80% of patients die before hospital care, and between 50% and 78% do so after. Zones 2 or the lateral zones, are the areas between the diaphragm and the aortic bifurcation, delimited medially by the renal vessels and laterally with Toldt's fascia, so they therefore encompass the adrenal glands, kidneys, renal vessels, ureters, and a portion of ascending and descending colon. The incidence of renal injuries stands out in this anatomical region at approximately 1.2 %. adrenal injuries have a lower incidence, situated at around 0.4 %.  Renal vascular damage, on the other hand, occurs in less than 5% of blunt traumas Zone 3 the pelvic zone, is delimited by the aortic bifurcation above. It includes the iliac vessels, distal ureters, distal sigmoid colon and the rectum. The incidence of iliac vessel injuries is less than 1%. Specifically, they represent between 2% and 6.5% of vascular lesions .  The associated mortality ranges between 25% and 42%, although in some series this figure can reach 62%, presenting higher mortality rates in penetrating trauma injuries

8. Etiology : A GSW is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can involve an unpredictable pattern of injuries. Secondary missiles, such as bullet and bone fragments, can inflict additional damage. Military and hunting firearms have higher missile velocity than handguns, resulting in even higher energy transfer. In penetrating abdominal trauma due to gunshot wounds, the most commonly injured organs are as follows  [2]  : Small bowel (50%) Colon (40%) Liver (30%) Abdominal vascular structures (25 %) The severity of shotgun wounds depends on the distance of the victim from the weapon. The mass of a shot pellet is minimal, and thus its velocity decreases rapidly after the shell leaves the barrel of the gun. When the distance is less than 3 yd , the injury is considered high velocity; if the distance exceeds 7 yd , most of the buckshot penetrates only the subcutaneous tissue.

9. Etiology : Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked, resulting in devastating complications. In penetrating abdominal trauma due to stab wounds, the most commonly injured organs are as follows: Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%)

10. Diagnosis History: The history provides clues to the most likely injury patterns and potential management priorities. Emergency medical services (EMS) personnel are often essential in providing a history, especially in a critically ill patient or one with altered mental status. A common acronym describing important information to gather when taking the history is AMPLE, as follows: Allergies ,Medications ,Prior illnesses and operations ,Last meal ,Events and environment surrounding injury The anatomic location of injury and type of weapon ,the number of gunshots heard or the number of times the patient was stabbed, and the patient’s position at the time of injury help describe the trajectory and path of the injuring object. Blood loss at the scene should be quantified as accurately as possible from EMS personnel. The character of the bleeding ( eg , arterial pumping, venous flow) may assist in determining whether major vascular injury has occurred.  [10] The initial level of consciousness or, for moribund patients, the presence of any signs of life at the scene ( ie , pupillary response, respiratory efforts, heart rate or tones) is vital to determine the prognosis and to guide resuscitative efforts. Particularly important is the patient's response to therapy en route to the ED. Evidence of hypotension in the field should raise suspicion for intra-abdominal injury.

11. Physical Examination Per ATLS protocol , 1ry & 2ry survey Initial vital signs assist in determining injury severity and need for operative intervention. Hypotension, narrow pulse pressure, tachycardia, high or low respiratory rate, or signs of inadequate end organ perfusion in the setting of penetrating abdominal trauma provide evidence of significant intra-abdominal injury, especially vascular trauma, and warrant immediate surgical exploration. Examination of the abdomen in a patient who is awake may indicate peritoneal signs, such as pain and guarding and rebound tenderness. Hemodynamically stable patients with penetrating abdominal trauma and peritonitis can be assumed to have a hollow visceral perforation and may have significant intra-abdominal hemorrhage. Thus, peritonitis on physical examination is a trigger for emergent intervention regardless of vital signs .. Abdominal distention in an unresponsive patient may indicate active internal bleeding. In hypotensive patients, this may be an indication for immediate exploration. Rectal examination is performed on all patients with penetrating abdominal trauma, because blood per rectum and, in males, high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively. Notation of blood at the urethral meatus is also a sign of genitourinary tract injury.

12. Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds. Multiple wounds may represent either entrance or exit wounds and must not be labeled as such, since multiple missiles or foreign objects may be retained within the body. Wounds located on the anterior abdomen can be explored locally to determine whether they penetrate the peritoneum. On the flank area and back area, exploration is more difficult and less reliable. Therefore, flank and back wounds are not explored and are considered penetrating unless obviously superficial. When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing and diagnostic and imaging studies. Patients without recordable cardiac activity upon presentation should not be further resuscitated.

13. Approach The approach to patients with penetrating abdominal trauma depends on whether the injury is a gunshot wound (GSW) or a stab wound and the patient’s hemodynamic status. GSWs are associated with a high incidence of intra-abdominal injuries and nearly always mandate laparotomy. Stab wounds are associated with a significantly lower incidence of intra-abdominal injuries

14. Work up In case of need for emergent operation, all patients with penetrating abdominal trauma should undergo certain basic laboratory testing, as follows: Blood type and crossmatch Complete blood count (CBC) Electrolyte levels Blood urea nitrogen (BUN) and serum creatinine level Glucose level Prothrombin time (PT)/activated partial thromboplastin time ( aPTT ) Venous or arterial lactate level Arterial blood gas (ABG) Urinalysis Serum and urine toxicology screen

15. Imaging Plain Radiography A chest radiograph is obtained on all patients because penetration of the chest cavity cannot be ruled out, even with abdominal stab wounds or even-numbered GSWs ( ie , apparent entrance and exit wounds) outside the chest. Chest radiographs can reveal hemothorax or pneumothorax or irregularities of the cardiac silhouette, which can be a sign of cardiac injury or great vessel injury. Air under the diaphragm indicates peritoneal penetration. Chest radiography is relatively specific, although insensitive, for diagnosing diaphragmatic injury. Abdominal radiographs in 2 views ( ie , anterior-posterior [AP], lateral) are also obtained on all patients with GSWs to help determine missile trajectory and to account for retained missiles ( ie , bullets, shrapnel, and foreign bodies) in patients with odd-numbered GSWs. If all foreign bodies are not accounted for, consider the possibility that the foreign body is intraluminal or intravascular, and thus is a potential source of emboli distant from the site of entrance.

16. Ultrasound Ultrasonography has been widely used in the assessment of patients with blunt trauma, but it has only recently been used in the assessment of patients with penetrating injuries. In these cases, the study is performed using the focused assessment with sonography for trauma (FAST). FAST has gained acceptance in the evaluation of penetrating abdominal trauma because of its speed, noninvasiveness, and reproducibility in diagnosing intraperitoneal injury that requires laparotomy. FAST uses 4 views of the chest and the abdomen ( ie , pericardial, right upper quadrant, left upper quadrant, pelvis) to evaluate for pericardial fluid indicative of cardiac injury and for free peritoneal fluid. Free fluid in the abdomen can be a sign of hemorrhage secondary to liver or splenic laceration or, less commonly, of spillage secondary to hollow viscus injury. While FAST has been found to be 94-98% specific for abdominal injury in penetrating abdominal trauma, its sensitivity of 46-67% is not good.    That is, a positive FAST result in the setting of penetrating trauma is usually an indication for laparotomy due to the high positive predictive value for a therapeutic laparotomy. Unfortunately, a negative FAST result cannot rule out the need for laparotomy and cannot be relied on to exclude important intraperitoneal injury; these patients require further testing to rule out occult injury.  

17. CT scan CT scanning is used in the evaluation of patients with stab wounds to the flank and the back and in the evaluation of selected patients with abdominal stab wounds and penetrating, nontangential GSWs . Abdominal CT is the most sensitive and specific study in identifying and assessing the injury severity to the liver or spleen.   The presence of a contrast blush on CT or ongoing hemorrhage is an indication for laparotomy or angiography and embolization.   Triple-contrast CT has been found to be 97% accurate in the evaluation of penetrating flank and back wounds. Exploration of these wounds is more difficult, less reliable, and therefore not indicated.    One study of CT with IV contrast only found it useful for patients with GSW to the abdomen selected for nonoperative management.   Specific signs of peritoneal penetration on CT include the following: A wound tract outlined by hemorrhage, air, or bullet or bone fragments that clearly extend into the peritoneal cavity The presence of intraperitoneal free air, free fluid, or bullet fragments Obvious intraperitoneal organ injury

18. CT scan The diagnosis of significant penetrating injury should not be delayed by routinely obtaining CT scans of the abdomen and pelvis. Instead, patients with an appropriate history, physical examination or vital sign abnormalities, in particular with a positive FAST, should undergo expeditious exploration.    There is no place for CT scanning in hemodynamically unstable patients with penetrating abdominal injury. The primary limitation of CT is lack of sensitivity in diagnosing mesenteric, hollow visceral, and diaphragmatic injuries, all of which are common in penetrating trauma. Therefore, unless the wound is clearly superficial on CT scan, admission and serial observation is indicated, even with a negative CT result for injury.  [24] No absolute indications exist for CT in anterior penetrating trauma. Some centers use CT as a screening tool to complement physical examination, while others perform serial examination or diagnostic peritoneal lavage (DPL). Patient selection is extremely important when considering CT as a diagnostic adjunct in patients with penetrating abdominal trauma. The availability and quality of the CT scan and the experience of the examining radiologist are also key considerations.

19. Diagnostic Peritoneal Lavage In the hemodynamically stable patient with penetrating abdominal injury, DPL can be used to identify hollow viscus or diaphragmatic injury. While very sensitive and specific, DPL requires a fair amount of time to perform, and it has been supplanted in many institutions’ protocols by FAST, CT scan, and/or laparoscopy. The primary disadvantages are invasiveness, inability to evaluate the retroperitoneum , moderate specificity for therapeutic laparotomy, and a significant false-positive rate.  [29] DPL can be performed via either a closed or open method. The bladder and stomach must be decompressed. The closed method involves a small skin puncture with blind insertion of a catheter over a guidewire ( ie , Seldinger technique). The open method involves exposure of the peritoneum through a small infraumbilical incision and insertion of catheter under direct vision ( ie , mini-laparotomy).

20. Result : Aspiration of gross blood or food particles is positive for peritoneal penetration and organ injury . If aspiration is negative, 1 liter of warm normal saline or lactated Ringer solution (20 mL/kg for pediatric patients) is infused rapidly and allowed to return by placing the intravenous bag on the floor .   The fluid is then sent for analysis ( eg , cell count, differential, Gram stain, bilirubin, amylase, vegetable matter, fecal matter). A positive test result varies with the mechanism of injury. A red blood cell (RBC) count of greater than 100,000/mm 3  or white blood cell count of 100-500/mm 3  count may be considered positive in a stab wound. However , if a diaphragmatic injury is possible, some physicians lower the value of a positive test to an RBC threshold of 5000/mm 3 . Because of the more serious nature of gunshot wounds, clinicians often use a similarly lower value for a positive test when there is concern a projectile has entered the peritoneal cavity . The lower the threshold for positivity, the more sensitive the test, but the higher the nontherapeutic laparotomy rate ( ie , higher rate of false-positive result).

21. Local Wound Exploration In the trauma patient with an anterior stab wound, local wound exploration may be a valuable diagnostic aid, depending on the wound's mechanism and location. Stab wounds to the anterior abdomen are well suited for local wound exploration because many do not penetrate the fascia. Exploration requires aseptic technique, good overhead lighting, and local anesthesia. The wound is enlarged as necessary so that the posterior fascia may be evaluated. If exploration either confirms that penetration has occurred or is inconclusive, the wound is considered intraperitoneal and must be evaluated further by DPL or more invasive procedures. Gunshot wounds and those produced by thin instruments, such as an ice pick, are more difficult to explore and, accordingly, are generally considered intraperitoneal injuries. Once the area is surgically prepared, draped, and anesthetized, the wound may be widened with gentle retraction and gently probed with a hemostat to determine whether a tract exists. If the wound is small, extending it to aid visualization is accomplished with a No. 10 blade scalpel. The rectus fibers may be separated by spreading in their direction using a hemostat or Kelly clamp. The posterior rectus sheath is easily identifiable as a white layer directly underlying the rectus musculature. If yellow fat or omentum is identified, a fascial violation is established.

22. Laparoscopy Laparoscopy is a reasonably safe, effective procedure for the evaluation and treatment of hemodynamically stable patients with abdominal trauma, and it can reduce the number of nontherapeutic laparotomies performed. In thoracoabdominal stab wounds, laparoscopy aids in the diagnosis of diaphragmatic and other intra-abdominal injuries. Patients with stab wounds to the anterior abdomen or with uncertain peritoneal penetration are also candidates for diagnostic laparoscopy. Gunshot wounds to the anterior abdomen with questionable penetration may be assessed this way. Multiple studies have shown a reduction in unnecessary laparotomies in patients with a penetrating mechanism but no identifiable organ injury who underwent diagnostic laparoscopy. In one center with significant experience with diagnostic laparoscopy in penetrating abdominal trauma, laparoscopy was associated with decreased cost and length-of-stay when compared with open laparotomy (n=44).  [19] A retrospective study of 44 laparoscopies in patients with penetrating abdominal trauma found that half of were negative for penetration and resulted in avoidance of laparotomy.  [30]  A prospective study of 99 patients showed that diagnostic laparoscopy was negative in 62% of the patients with penetrating abdominal trauma, reducing the rate of unnecessary laparotomy from 78.9% to 16.9%.  [31] The successful incorporation of diagnostic laparoscopy into the management of patients with penetrating abdominal trauma depends on the selection of hemodynamically stable patients, the availability and ease of use of quality laparoscopic equipment, and the experience of the surgeon in using the technique for diagnostic purposes in traumatic injuries.

23. Emergency Department Thoracotomy Victims of penetrating abdominal trauma who lose vital signs or who present with exsanguinating hemorrhage that is not controllable with direct external pressure are candidates for an ED left anterolateral-left thoracotomy. The purpose of this procedure is to relieve cardiac tamponade , control cardiac bleeding, obtain proximal aortic control, and provide open cardiac massage to improve cardiopulmonary cerebral resuscitation efforts. This procedure is performed only in extremely selected circumstances, since survival from abdominal injury requiring a resuscitative ED thoracotomy is rare. It is much more effective if the arrest is due to cardiac injury with thoracoabdominal trauma. Patients who may be considered for thoracotomy are those who had vital signs on arrival or en route, with or without pulseless electrical activity (PEA) on the cardiac monitor. Thoracotomy is rarely successful in blunt trauma.

24. The surgical procedure is as follows: After rapidly preparing and draping the entire chest, make a curvilinear incision from the left sternal border of the fifth intercostal space to the table, paralleling the course of the underlying rib. Divide all tissues above the rib with the scalpel. Halt respirations. Using a finger or Kelly clamp, pierce the intercostal muscle bundle above the rib, then divide with a curved Mayo scissor for the length of the incision. Reinflate the lungs. Insert a rib spreader with a ratchet mechanism placed laterally. Open the pericardium longitudinally to avoid injury to the pericardiacophrenic vessels and the phrenic nerve. Subluxing the heart into the left chest allows for open massage. Retract the left lung superiorly using a moist laparotomy pad, and divide the inferior pulmonary ligament using Metzenbaum scissors.  [35] The tissues overlying and just lateral to the vertebral bodies contain the aorta, esophagus, thoracic duct, and countless nerves. Usually, blunt dissection frees the aorta enough to place a Satinsky or long, curved DeBakey clamp. In certain circumstances, the aorta is not identified easily, and the aorta and esophagus must be clamped en masse in a patient who is in extremis. Warm saline is essential to prevent cooling of the heart, and pressor support usually is needed as well.   [35]

25. Operative management The indications for operative intervention include the following: Development of hemodynamic instability Development of increasing pain, peritoneal findings ( eg , point tenderness, involuntary guarding, rebound tenderness) Diffuse and poorly localized pain that fails to resolve Impalement injury Evisceration Blood from a nasogastric tube or on rectal examination

26. Preoperative: Surgical intervention begins with preparation of the patient in the operating room, as follows: The patient is placed in the supine position with arms extended The entire chest, abdomen, and pelvis, including the upper thighs, are prepped and draped Fluids and blood products should be readily available (and administered via warm lines) Warming devices should be placed on the patient’s upper and/or lower extremities Entering the abdominal cavity can release tamponade , resulting in a precipitous drop in blood pressure, so the anesthesia team must be informed when the midline incision is made Intraoperative : Essential components to the trauma laparotomy include the following: Control of bleeding Identification of injuries Control of contamination Reconstruction (if possible)

27. Procedure Initial control of bleeding is accomplished with 4-quadrant packing using laparotomy pads The abdominal wall is retracted, the falciform ligament is taken down, and packs are placed above the liver and the spleen and in both sides of the pelvis after the bowel is swept cephalad Once anesthesia has been given time to catch up with fluid resuscitation, the packs are removed one quadrant at a time, starting away from the sites of apparent bleeding All areas are examined for injuries; each solid organ and the entire bowel are inspected Contamination is controlled with the use of clamps, staples, or suture closures Depending on the character of the defect(s), resection may be necessary If the patient is stable enough to continue the operation, reconstruction may then be performed Occasionally, patients with penetrating abdominal trauma develop such significant metabolic acidosis and coagulopathy that proceeding with the reconstruction phase of the laparotomy is not possible. In these cases, the operation is considered damage-control surgery, and the abdomen is closed rapidly. Often, a temporary closure with an intravenous fluid bag or mesh (occasionally with a vacuum dressing) is used, as the patient has undergone massive fluid resuscitation and the bowel has become quite edematous, precluding primary closure of the abdomen. The patient is then transported to the intensive care unit for continued resuscitation and warming. Reconstruction then takes place upon return to the operating room in 24-48 hours.

28. Colon injuries Primary repair of colonic injuries may be considered if the patient is hemodynamically stable and if the injury is fairly small with minimal fecal contamination. A diverting colostomy should be performed if the patient has any of the following: Multiple injuries Requirement for significant blood product resuscitation Acidosis, hypothermia, and coagulopathy A large defect (>50% of the circumference) and considerable fecal spillage

29. Other organ injuries Diaphragm - Lower-grade injuries may be repaired either via laparotomy or with laparoscopic or thoracoscopic techniques Liver - The key rules are gaining adequate exposure and obtaining hemostasis Spleen - On the basis of the patient's hemodynamic status, comorbidities, and operative access, the surgeon will plan for splenorrhaphy or splenectomy Kidney – If at all possible, the kidney is salvaged with renography , using pledgeted sutures and wrapping, and capsular reapproximation ; if nephrectomy is deemed necessary because of the severity of injury or instability of the patient, an intraoperative intravenous pyelogram is performed to confirm function of the contralateral kidney Stomach – Exposure and thorough inspection is necessary, facilitated by opening of the gastrocolic ligament; injuries extending into the lumen may be repaired quickly with a stapling device Diaphragm – For exploration, the Kocher maneuver is used to mobilize the duodenum, along with the pancreatic head and distal common bile duct; primary repair of injury is the goal, with protection of the repair using closed-suction drainage; diversion procedures are often used for protection Pancreas – Pancreatic duct status and injury location are determinants in the management; lacerations or contusions without ductal injury can be treated conservatively, while more severe injuries may require partial or complete pancreatectomy

30. Damage-control surgery Damage control surgery involves abbreviated laparotomy after control of surgical hemorrhage and enteric spill, with physiologic resuscitation in the intensive care unit and staged abdominal reconstruction.  [4] Damage-control techniques include the following: Perihepatic or intra-abdominal packing and towel clip closure of the abdomen Therapeutic decompressive celiotomy Prophylactically leaving open the abdominal fascia after laparotomy

31. Postoperative details Patients should be monitored closely in the surgical intensive care unit after trauma laparotomy. Many patients will remain intubated and require ventilatory support. Attention should be paid to the following: Warming the patient Continuing fluid and blood product resuscitation Replacing electrolytes Monitoring drain outputs Patients with evidence of ongoing bleeding may benefit from angiographic evaluation for possible embolization; some require reexploration for control of hemorrhage Patients who have undergone damage-control procedures or have temporary abdominal closures must return to the operating room within 24-48 hours for definitive repair

32. Complications: Deep vein thrombosis and pulmonary embolism Stress ulceration and bleeding Pressure ulcers Atelectasis Ventilator-associated pneumonia Catheter-related sepsis ICU psychosis Early postoperative complications include the following: Ongoing bleeding Coagulopathy Abdominal compartment syndrome Later complications include the following: Acute respiratory distress syndrome Pneumonia Sepsis Intra-abdominal fluid collections Wound infections Enterocutaneous fistulae Small bowel obstruction Incisional hernias

33. Medications Analgesics Morphine is the drug of choice for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Fentanyl is a potent narcotic analgesic with much shorter half-life than morphine sulfate. It is also an excellent choice for pain management and sedation, with short duration (30-60 min) and easy to titrate. Fentanyl is easily and quickly reversed by naloxone Anxiolytics

34. Antibiotics Antibiotic prophylaxis is proven to reduce postoperative surgical infections after penetrating abdominal trauma. The Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines recommended , in the absence of hollow viscus injury, administering a single dose of a broad-spectrum antimicrobial agent that provides both aerobic and anaerobic coverage. No specific agent is recommended, but it may be a single agent with beta-lactam coverage or combination therapy with an aminoglycoside and clindamycin or metronidazole. In patients with a hollow viscus injury, antimicrobial prophylaxis should be extended to 24 hours.  [37] .

35. ATS Penetrating abdominal trauma resulting in wounds contaminated with either dirt or debris or wounds caused by metallic objects carry a risk of  Clostridium tetani  infection. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.. Patients who may not have been immunized against  C tetani  products ( eg , immigrants) should receive tetanus immune globulin (Hyper- Tet ).

36. Thank you