ABDOMINAL

TRAUMA

POLITRAUMA
Frequency
Degree

of intensity

Classification
- closed injuries (blunt trauma)
- open injuries (penetrating)
Frequency
10% isolated injuries
90% politrauma
2/3 parenchimatous organs
1/3 hollow organs

DEGREE OF EMERGENCY
1. Acute cardiac failure
2. Acute respiratory failure
3. Injury of large vessels
4. Injury of parenchimatous organs
5. Craniocerebral trauma
6. Hollow viscus trauma
7. Other

CLINICAL EXAMINATIONANAMNESIS
How long from the accident?
Hematemesis?
Melena?
Hematuria?
Position during impact?
Any preexisting disease? (cirrhosis, cysts,
splenomegaly)

CLINICAL EXAMINATION
Skin lesions - indicate maximum impact
zone
Abdominal tenderness peritonitis
False abdominal tenderness muscular
ruptures, medullar lesions
Digital rectal examination

PARACLINIC EXAMINATIONS
1. Plain films of the abdomen
2. Chest X-Ray
3. Ultrasonography
4. Diagnostic aspiration of peritoneal fluid
5. CT-scan

PLAIN FILMS OF THE ABDOMEN

ASPECTS
Pneumoperitoneum gas under the diaphragm
Loss of the psoas shadow retroperitoneal
effusion
Hydroaeric images
Projectiles

CLINICAL PRESENTATION
Primary shock
- Reflex
- May hide the evolution of
existent
lesions
- May lead to unnecessary
laparotomy

CLINICAL PRESENTATION IN
EVOLUTION
A. POSTTRAUMATIC INTERNAL BLEEDING
- Acute anemia
- Pallor
- Blood pressure decreasing
- Pulse increasing
B. POSTTRAUMATIC PERITONITIS
- Abdominal tenderness
- Gas under the diaphragm

PARTICULAR CASES
Two step rupture

Two step peritonitis

Mesentery rupture followed by internal

hernia

RUPTURE OF THE LIVER

Depends of the intensity of the trauma:
- Low velocity missile may merely split the
capsule
(slight peritoneal irritation)
- High-velocity missile
- Severe crash injury

Wide area laceration

RUPTURE OF THE LIVER

OPERATIONS
From minor remal of devitalized liver
to wedge excision of liver or even
hepatic lobectomy
Injury of the hepatic veins and vena
cava

Liver
Trauma
Image
Injury:
Argon
beam
repair of
lacerated
liver

Injury: Blunt
injury to
right lobe of
liver

Liver Trauma
Image
Liver - gunshot
wound
-Entry wound

Exit
woun
d

Gunsho
t wound

Gunshot
wound

Gunshot
wound

Liver
laceration

Omental
patch
Liver
laceratio
n
Patch
oversew
n

Grade V
liver
laceration
with
laceration
of
retrohepati
c vena cava
and right
hepatic
vein.

Sutured
Vena Cava

Sutured
Right
Hepatic
Vein

PANCREATIC INJURY
- Isolated
- With rupture of the duodenum
Serum Amylase level
May be normal due to asymptomatic time
frame (72 h)
Operations
1. Drainage
2. Jejunal loop in case of fistula

Pancreas Trauma
Image
History: 17 year old
boy kicked in abdomen
while playing football.
Initial physical exam ternder in upper
abdomen. CT scan,
amylase normal.
Worsening pain, and
temperature spike on
day 3 with rise in
serum amylase
prompted repeat CT
scan.

Pancreas
Trauma Image
History: 14 year
old boy, fell off
bicycle and then
abdomen run
over by a car. By
the next morning
had abdominal
pain and
vomiting.
Amylase and
WBC slightly
increased.

pancrea
s
ERCP

Pancreas
Operativ
e view of
Injury

Distal
pancreatect
omy (spleen
preserving)

Pancreatic &
Duodenal
transection. Stab
wound

SPLENIC TRAUMA

Minor ruptures

Avulsion

Subcapsular haematoma

DELAYED RUPTURE

Historical diagnosis of trauma

Palpable tender spleen

Unexplained anemia

Shoulder tip pain

OPERATIVE DECISION
Is splenectomy always
necessary?
- Partially resection
- Suture
- Packing

8cm
splenic
laceratio
n

placement
of
absorbabl
e sutures

completed
repair with
omental
pedicle

Spleen
without
capsule

Mesh
wrap
repair

Ruptured
subcapsul
ar
haemato
ma

post
splenectom
y

Splenic
laceration
CT scan

CONCLUSIONS
When is laparotomy really necessary?
- Hypotension without other cause
- Continued bleeding
- Evisceration
- Unequivocal signs of peritoneal irritation
- Pneumoperitoneum

Injury: Small
bowel injury
(blunt trauma)

Small bowel
injury (blunt
trauma 2 days
post injury)

Injury: Blunt
abdominal
trauma.
Mesenteric
laceration
leading to
small bowel
necrosis.

Rectal injury

Rectal injury

Necrotizing fasciitis from a missed rectal injury (Identified at 48

hours). Initial injury was a stab wound to the buttock. Patient died in
the operating room.

SW to the epigastrium. Blood in NG tube.

Anterior & posterior wall of stomach.
Anterior only is shown.Classification:

Anterior & posterior wall of

stomach.
Anterior only is shown.

Right diaphragm laceration

A 28 yr old motorist crashed with his bike and was admitted
with severe abdominal trauma. Although most diaphragm
ruptures appear (or are diagnosed) on the left side, this is an
illustration that in high energy trauma a right sided diapraghm
rupture can occur as well and underlines the severity of the
impact. Chest X-ray

Operative View

Left diaphragm rupture (blunt) with

stomach & spleen herniation

Operative - showing band

constriction marks on stomach

Operative repair

Diaphragmatic Herniation

Diaphragmatic Herniation