pent.trauma

7/23/2019 pent.trauma

1/74

Emergency Abdominal Surgery For

Penetrating Injury

BY

PROF/ GOUDA EABBA!

EGYP"


2/74

Penetrating abdominal trauma

# $ore common in area% o&'( )ig* le+el% o& ,o+erty

( o- le+el% o& education( )ig* alco*ol con%um,tion

( arger ,o,ulation%


3/74

$ec*ani%m%

# Gun%*ot -ound% .GS0

# Stab -ound%


4/74

Firearm%

# o- +elocity' 12333&t/% .1435m/%0

# )ig* +elocity' 62333&t/% .6435 m/%0

# $o%t *and gun% are lo- +elocity

# )ig* +elocity -ea,on% areincrea%ing in a+ailability


5/74

ounding ca,ability

# 7E 8 9 m+2

( Double t*e bullet %i:e 2; t*e energy

( Double t*e mu::le +elocity


6/74

S*otgun -ound%

# o- mu::le +elocity .u%ually 43 m/%0

# $ulti,le %,*erical ,ellet%

# Pellet% lo%e energy +ery uic@ly

# =lo%e range .3C3C5m0

( $a%%i+e contaminated -ound%( Similar to *ig* +elocity GS

# ong range .6C2m0( $inimal tor%o injury


7/74

Stab -ound% .nonballi%tic

,enetrating trauma0# $o%t occur in u,,er uadrant%

# Injurie% de,endent on'

( In%trument u%ed( Patient motion

# Parietal ,eritoneum ,enetrated in 3H( Only 3H o& t*e%e .H total0 cau%e +i%ceral

injury


8/74

DiJerent management

# o- +elocity GS / %tab -ound%( Damage due to direct injury to +ital

%tructure%

# )ig* +elocity GS( ide debridement nece%%ary

( Organ injury generally reuire% more com,le;tec*niue%


9/74

$anagement ,rioritie% o&

,enetrating abdominal trauma


10/74

$anagement ba%ed on

*aemodynamic criteria

C


11/74

"*ree *aemodynamic grou,%

# $oribund ,atient%( !o %,ontaneou% +entilatory eJortK no &emoral ,ul%e and

no re%,on%e to ,ain&ul %timuli#

a,arotomy# Some recommend t*oracic aorta occlu%ion ,rior tola,arotomy to ,re+ent cardiac arre%t &rom %udden relea%eo& abdominal -all tam,onade .edger-ood et al 540

# Un%table ,atient%( Any +ital %ign .BPK )RK RR0 i% altered

# AB= ( i& Luid% do not *el,K or only *el, tem,orarilyKla,arotomy i% reuired

# Stable ,atient%# Deci%ion ba%ed on mec*ani%m o& injury and ,*y%ical

e;amination


12/74

"*e idea o& >damage control?

# In t*e ,a%tK deMniti+e re,air o& mo%t le%ion% -a%attem,ted initially

# $ulti+i%ceral injurie% and e;%anguinated ,atient% arebad candidate% &or major re%ection% and

timecon%uming recon%truction%# "*e combination o& trauma ,lu% t*e %urgical in%ult

e;ceed% t*e ,*y%iological re%er+e% o& many ,atient%

# Aim%'

C Initial damage control o,eration2C Re%u%citation in t*e %urgical I=U

C Planned reo,eration a&ter 2<


13/74

Indication% &or damage control

# Bleeding cau%ed by coagulo,at*y

# Se+ere metabolic acido%i% .,) 1C0

# Se+ere ba%e deMcit .,) 630# )y,ot*ermia during o,eration ."N 1


14/74

"ec*niue% o& damage control

# )aemorr*age control( Pac@ing angiogra,*ic emboli%ation( igation o& +e%%el% in%tead o& re,air

( Balloon cat*eter tam,onade &or dee, or*e,atic -ound%

# =ontamination control( )ollo- +i%cu% ligation in%tead o& re,air

( E;ternal tube drainage o& biliary and ,ancreaticinjury in%tead o& ,ancreatoduodenectomy

( A+oidance o& &ormal colo%tomy


15/74

Abdominal *y,erten%ion

# Intraabdominal ,re%%ure ri%e to'( 3 mm)g decrea%ed +enou% return =O( 2 mm)g increa%ed air-ay ,re%%ure%

# )o- doe% it occurQ( =a,illary lea@ ga%trointe%tinal oedema( Ongoing bleeding

# Bogot bag.actually de+elo,ed at Uni+er%ity )o%,italK =ali0

( =lot* :i,,ered me%* -it*iC+C ,la%tic Luid bag underneat*

( Allo-% reduction inintraabdominal ,re%%ure%


16/74

Ot*er a%,ect% o& care

# Early enteral nutrition .e+en a&ter bo-elana%tomo%i%0 i% better t*an ,arenteralK

e%,ecially in t*e mo%t %e+ere trauma# Antibiotic%' day i% a% good a% or day% .7irton O= et al 23330

# Abdominal %e,%i% occur% 23H .Rotondo $FK onie% D)550


17/74

$anagement ba%ed on area o&

abdomen injured

2C


18/74

U,,er abdomen.t*oracoabdominal area0

# bet-een dia,*ragm and lo-er co%tal margin( In%ertion o& dia,*ragm

#Ti,*oid ,roce%% anteriorly#5t*I=S mida;illary line

#t*

%,ace ,o%teriorly( Remember t*at dia,*ragm mo+e% &rom "3 at end

in%,iration to " at ende;,iration

# =ontain%'( i+er( S,leen

( Stomac*( Pancrea%( Great +e%%el%( i%ceral arterial branc*e%


19/74

"*oracoabdominal ,enetratinginjurie%

# E;,lore A ,atient% due to ri%@ o& dia,*ragmaticinjury

( Occur% in H o& %tab -ound%K


20/74

Dia,*ragmatic ru,ture


21/74

(adapted from Ferrada R, Birolini D. 1999)


22/74

$iddle abdomen

# Bet-een lo-er co%tal margin and ASIS( Bo-el ( Small bo-el and colon

( 7idney%( Aorta

( I=


23/74

o-er abdomen

# Fal%e ,el+i% ( -it*in t*e iliac bone% to%acral ,romontory .S0

#"rue ,el+i% ( belo- %acral ,romontory( Small bo-el

( Recto%igmoid colon

( Rectum

( Genitourinary %y%tem( Iliac +a%culature


24/74

Antero,o%terior di+i%ion o& t*e

abdomen# Anterior .bet-een anterior a;illary

line%0

# Flan@% .bet-een anterior and,o%terior a;illary line%0

# Bac@ .bet-een ,o%terior a;illary

line%0


25/74

E$S" guideline% &or managemento& anterior abdominal injurie%

( a,arotomy &or all ,enetrating abdominal injurie% -it*'#)y,oten%ion#Peritoniti%#E+i%ceration

( GS#55H ri%@ o& %igniMcant injury#"*ere&oreK e;,lore A ,atient%

( Some e+idence to contrary .a&ter imaging0 .Saadia RK Degianni% EC 23330

# I& t*e injury i% tangentialK and t*e ,atient i% %tableK con%iderla,aro%co,y

( Stab -ound%#ocal e;,loration o& -ound#Ob%er+e i& no %ign% on e;aminationC Per&orm %erial e;amination%

or DP


26/74

Flan@ and bac@ injurie%

#"*e t*ic@ne%% o& t*e Lan@ and bac@mu%cle% i% ,rotecti+e .%@in to ,eritoneum'323cm0

# ound% are more &reuently tangential# Serial ,*y%ical e;amination% are +ery

accurate in detecting retro,eritoneal

or intra,eritoneal injurie% to Lan@% orbac@ .E$S" %tudent manual0# =ontra%t =" %can% are u%e&ul too


27/74

$anagement ba%ed on anatomical

%tructure injured

C


28/74

Outline

# U,,er abdominal injurie%( S,leen( i+er( Stomac*

( Duodenum( Pancrea%

# $iddle abdominal injurie%( Small bo-el and me%entery( =olon( Renal

# o-er abdominal injurie%( Rectal( Perineal( Bladder

# a%cular injurie%


29/74

S,lenic injurie%


30/74

S,lenic injury

# In recent year% t*ere *a% been ana,,reciable %*i&t &rom o,erati+e

management to-ard nono,erati+emanagement.=or%on illiam%onK 2330


31/74

AAS" S,lenic injury grading %y%tem


32/74

!ono,erati+e management# =an a+oid ,o%t%,lenectomy %e,%i%

# Only a,,licable -*en o,erating t*eatre i% a+ailable at%*ort notice

# Failure rate% o& con%er+ati+e management'( Grade% IKIIKIII H( Grade% IK H .Da+i% et al 550

# Probably more de,endent o& amount o& *aemo,eritoneumCAttem,t% *a+e been made to cla%%i&y t*i% by ="

# !ote delayed ru,ture occur% bet-een and 5 day% .mean C day%0

# Be-are %,lenic artery &al%eaneury%m% .cau%ing contra%t blu%*0

42H &ailure rate


33/74

O,erati+e management

# S,lenorr*a,*y( Uncommon ( i& t*e ,atient need% a

la,arotomyK %,lenectomy i% u%ually indicated#U%e o& %u,erMcial *aemo%tatic agent%

.electrocauteryK argon beamK to,ical t*rombinKo;idi%ed cellulo%eK ab%orbable gelatin %,onge0

#Pledgeted re,air

#Re%ectional debridement#$e%* -ra,

# S,lenectomy


34/74

i+er injurie%


35/74

i+er injury

# !ono,erati+e management i% increa%ing( SigniMcantly lo-er tran%&u%ion reuirement% .-*ere

injurie% -ere matc*ed &or %e+erity0.=roce $A et al 550

# $o%t *e,atic bleeding i% +enou%K mo%t %,lenicbleeding i% arterial$aybe 3H o& *e,atic injury can be managed

con%er+ati+ely

# Un%table ,atient% reuire emergency la,arotomy# Di%crete contra%t blu%* or &ran@ contra%t

e;tra+a%ation ,robably mandate% emboli%ation orla,arotomy


36/74

O,erati+e management o& li+er

injury# Gau:e ,ac@ing

( may *a+e in&ecti+e com,lication% .I+atury RR et al 540

# Omental ,ac@ing# Re%ectional debridement

# $a%% li+er %uture

# )e,atic artery ligation

#"otal *e,atic i%olation good &or retro*e,atic +enou% injurie%

# Atrioca+al %*unt

- risk of injury to large vessels and ile du!ts

- poor effi!a!y of produ!ing "aemostasis


37/74

Stomac* injurie%


38/74

Stomac* injurie%

# Xuite common a&ter ,enetrating traumaCery rare a&ter blunt trauma

# Diagno%i%( At la,arotomy &or GS to anterior abdomen( )aemateme%i% or gro%%ly bloody na%oga%tric

a%,irate a&ter UX %tab -ound

# Remember' t*e %tomac* i% mobile andcan be injured e+en &rom a %tab -ound tot*e lo-er abdomen


39/74

$anagement o& %tomac*

trauma#"*oroug* intrao,erati+e e;amination

( Di+ide t*e ga%tro*e,atic or ga%trocolicligament% i& reuired

# I& t*ere i% an injury to t*e anterior -allKa%%ume an injury to t*e ,o%terior -all( Di+ide ga%trocolic ligament and enter le%%er

%ac# Debride and clo%e all injurie%

# =om,lication% mainly in&ecti+e


40/74

Duodenal injurie%


41/74

Duodenal injurie%

# Relati+ely uncommonC 3H due to,enetrating trauma .=or%on /illiam%on0

# Retro,eritoneal organ ( diagno%i% o& injurydiWcult

# $ortality H3H("*ree time% more li@ely to die i& o,eration

delayed 6 2< *our% .uca% =EK edger-ood A$C 5G0

( Early deat* ( e;%anguination due to a%%ociated+a%cular injury

( ate deat* ( %e,%i%


42/74

Diagno%i% o& duodenal injurie%

# DiWcult

# ATR c*ange% .in 3H0 Air'

( Outlining t*e rig*t @idney( Along t*e ,%oa% mu%cle

# ater%oluble contra%t .Ga%trograWnY0&ollo-t*roug* e;amination

# =" -it* iC+C and oral contra%t


43/74

Re,air o& t*e duodenum

# $o%t duodenal -ound% can be clo%ed,rimarily by duodenorr*a,*y

# Debride de+itali%ed ti%%ue# One or t-o layer clo%ure

# Pyloric e;clu%ion &or more diWcult injurie%.au*gn GD et al 50

( Primary re,airK &ollo-ed by( Sideto%ide ga%trojejuno%tomy

along t*e greater cur+ature


44/74


45/74

Pancreatic injurie%


46/74

Pancreatic injury

# A%%ociated injurie% in ,enetrating trauma( H *a+e injury to one o&' .Vur@o+ic*GVK =arrico =VC 5530

#Aorta

#Portal +ein

# In&erior +ena ca+a

# $ortality rate' 3H ( 3H

#$anage *aemorr*age and contaminationMr%t


47/74

E;,o%ure o& ,ancrea%

All ,enetrating injurie% in t*e +icinity o&t*e ,ancrea% mandate e;,o%ure andin%,ection o& t*e -*ole gland

# Enter t*e le%%er %ac by inci%ing t*e ga%trocolic ligament# Retract %tomac* %u,eriorly# Retract tran%+er%e colon in&eriorly# $obili%e *e,atic Le;ure# 7oc*erZ% manoeu+er# Remember to +i%uali%e

,o%terior ,art o& gland


48/74

Sign% o& injury

# Parenc*ymal injury( =entral retro,eritoneal *aematoma( Oedema around t*e gland and in t*e le%%er %ac

( Bile %taining o& t*e retro,eritoneum# Ductal injury

( Direct +i%uali%ation o& a ductal injury( =om,lete tran%ection o& t*e gland

( aceration o& more t*an one *al& o& t*e gland( =entral ,er&oration( Se+ere maceration


49/74

AAS" ,ancreatic injury grade

Grade Description of injury

# $inor !ontusion % superfi!ial la!eration &it"out du!tinjury

## $ajor !ontusion % major la!eration &it"out du!tinjury or tissue loss

### Distal transe!tion or paren!"ymal injury &it" du!talinjury

#' roimal transe!tion (to rig"t of *$') orparen!"ymal injury involving ampulla

V Massive disruption of pancreatic head

+dvan!e one grade for multiple injuries to t"e same organ


50/74

O,erati+e management

# $inor injurie% .grade% I and II0( !o ductal injury( E;ternal drainage alone

# =lo%ed %y%tem% %u,erior to %um, %y%tem% .Fabian "= et al 5530

# Grade III( Di%tal ,ancreatectomy .u, to 3H o& gland i% -ell tolerated0

# S,leen can be ,re%er+ed in 3H

# Grade I( $o%t re%ult in deat*( ide e;ternal drainage i% becoming more common

( Di%tal re%ection .u, to 5H o& gland0# Grade

( $o%t dieC Di+er%ion ,rocedure% or ,ancreatoduodenectomy


51/74

=olonic injurie%


52/74

=olon injury

# 23H o& GS cau%e colonic injury

# $anagement recommendation%

.EAS"0de,end on -*et*er de%tructioni% %uc* t*at re%ection i% reuired

Very strong evidence (RCT) supportingprimary repair of nondestructivewounds in the absence of peritonitis(EAST)


53/74


54/74


55/74

Rectal injurie%


56/74

Rectal injury

# ac@ o& adeuate e+idence

# Rectum i% diJerent &rom re%t o& colon no%ero%a o+er u,,er 2/ ,o%teriorly and lo-er /

circum&erentially# Sero%a i% im,ortant &or %ecure %uturing

# $aybeQ'( Primary re,air i% a,,ro,riate

( Di%tal rectal -a%*out not im,ortant( Po%te;,lorationK lo-er -ound% do not need retrorectal

drainage


57/74

Renal injurie%


58/74

Surgical management o& renal

injurie%# Only a %mall ,ro,ortion due to ,enetrating injury

# Be%t management i% unclear( A grading %y%tem e;i%t% to %ugge%t indication% &or

con%er+ati+e management# i&et*reatening injurie% do not attem,t renal

%al+age .unle%% t*ere i% only one @idney0

# Debride de+itali%ed %egment% ,artialne,*rectomy

# Obtain *aemo%ta%i% -it* a *ori:ontal mattre%% anda ,iece o& omentum

# $ajor laceration -ra, @idney in ab%orbable me%*


59/74

Perineal injurie%


60/74


61/74

$anagement o& ,erineal injury

# Broad%,ectrum antibiotic%

# a,arotomy

# Di+er%ion o& &aecal %tream to ,re+ent%e,%i%

# a%*out o& di%tal rectum

# Feeding jejuno%tomy

# O&ten *a+e diWcult to manage -ound%( Freuent debridement and la+age

( Gra&t% or La,%


62/74

Bladder injury

# *en due to ,enetrating trauma it i%u%ually identiMed at la,arotomy

# *en identiMed'

( E;,lore bladder t*roug* cy%to%tomy on domeo& bladder( E;tra,eritoneal injury Foley cat*eter

drainage alone( Intra,eritoneal injury'

#Re,air in t*ree layer% -it* ab%orbable %uture%#Some %ay t*at %u,ra,ubic cat*eter %*ould be

in%erted


63/74

Abdominal a%cular Injurie%


64/74

Incidence o& abdominal +a%culartrauma

# 2H H o& all +a%cular trauma i%intraabdominal

#Incidence o& abdominal +a%cular injurie%i% ri%ing


65/74

$ec*ani%m% o& injury to abdominal+a%culature

# Penetrating injurie% mo%t common( 53H to 5H o& all abdominal +a%cular injurie%

# O& ,atient% undergoing la,arotomy &orabdominal GS( 2H *a+e abdominal +a%cular injurie%

( .com,ared to 3H &or %tab -ound la,arotomie%0

#U%ually a%%ociated -it* multi,le ot*erinjurie%

# $ulti,le +e%%el% occa%ionally in+ol+ed


66/74

ED management

# Follo-% u%ual E$S" ,rotocol%

T

# RE$E$BERK do not ,lace iC+C cannulae in&emoral +ein%# =ro%%clam,ing o& de%cending t*oracic

aorta

( Sto,% intraabdominal *aemorr*age( Im,ro+e% ,er&u%ion o& carotid and coronaryarterie%

( Ri%@ o& di%tal i%c*aemia and re,er&u%ion injury


67/74

Intrao,erati+e management

# Pre,are %@in &rom nec@ to midt*ig* .in ca%e anautogenou% %a,*enou% +ein gra&t i% reuired0

# $idline inci%ion

# I& la,arotomy *a% commencedK and t*e ,atient

decom,en%ate% *aemodynamicallyK cro%%clam,t*e aortaC "*e dia,*ragmatic crura may reuiretran%ection


68/74

one # aorti!

"iatus to sa!ral

promontory, over

verterae

suprameso!oli! and

inframeso!oli! parts

one ## eri!oli!

gutters

one ### sa!ral

promontory to pelvis


69/74

one I %u,rame%ocolic .A%en%io VA et alC 23320

# =oeliac a;i% ligation

# S$A .%t 2nd,art%0 re,airligation i% t*eoretically ,o%%ible

gra&t% and tem,orary %*unt% *a+e beenu%ed

# In&ra*e,atic %u,rarenal I= ,rimarily

re,air &rom -it*in t*e +e%%el-*ere t*ere *a% been ma%%i+e de%truction ligate .H %ur+i+al0K or u%e ,ro%t*etic gra&t


70/74

one I in&rame%ocolic

# S$A .rd


71/74

one II

# Renal arterie%( ,rimarily re,air

OR( re%ect and re,lace -it* gra&t .,ro%t*etic or

autogenou%0

# Renal +ein% ( re,air or ligate( Rig*t renal +ein ligation reuire% rig*t ne,*rectomy( e&t renal +ein ligation i% better tolerated due to

collateral% &rom le&t gonadal +ein and renolumbar +ein%


72/74

one III

# O&ten a%%ociated colonic and genitourinaryinjurie% -it* %igniMcant contamination

# =ommon iliac arterie% re,aircan u%e autogenou% or ,ro%t*etic gra&t%

# Internal iliac arterie% ligation

# E;ternal iliac arterie% re,air

# Ilio&emoral gra&t can be ,er&ormed# Iliac +ein% ligation i% -ell tolerated


73/74

Re&erence%# edger-ood A$K 7a:mer% $K uca% =EC "*e role o& t*oracic aortic occlu%ion &or ma%%i+e *emo,eritoneumC V "rauma 54[4'43# =or%on VD illiam%on R=! .ed%0 Surgery 233 $o%by ondon


74/74

=or%on VDK illiam%on R=! .ed%0C SurgeryC 233C $o%byC ondon# FerradaK Birolini DC !e- conce,t% in t*e management o& ,atient% -it* ,enetrating abdominal -ound%C Surg =lin !ort* Am 555 4[4'4# Reynold% $AK Ric*ard%on VDC =*e%t -all and dia,*ragmatic injurie%C In' $aul 7IK Rodrigue: AK ile% =E III .ed%0C =om,lication% in trauma and critical careC

P*iladel,*ia' B Saunder%[ 554'2# i%e K =onnor% VK )-ang Y) et alC "raumatic injurie% to t*e dia,*ragmC V "rauma 5['5

pent.trauma

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