TRAUMA HOLLOW

ORGAN ABDOMEN
Oleh:
dr. Hans Marpaung, SpB, FICS.
1
External Anatomy of Abdomen
 Mechanism of Injury: Blunt
Compression, crush, or sheer
injury to abdominal viscera:
deformation of solid or hollow
organs, rupture (e.g. small
bowel, gravid uterus)

Deceleration injuries:
differential movements of fixed
and non-fixed structures (e.g.
liver and spleen laceration at
sites of supporting ligaments)
 Pattern of Injury in Blunt Abdominal Trauma

Spleen 40.6% Colorectal 3.5%

Liver 18.9% Diaphragm 3.1%

Retroperitoneum 9.3% Pancreas 1.6%

Small Bowel 7.2% Duodenum 1.4%

Kidneys 6.3% Stomach 1.3%

Bladder 5.7% Biliary Tract 1.1%

* Rosen: Emergency Medicine (1998)

 Mechanism of Injury: Penetrating

Stab
Low energy, lacerations

Gunshot
Kinetic energy transfer
Cavitation, tumble
Fragments
 Assessment: Physical Exam
Inspection, auscultation, percussion,
palpation
Inspection: abrasions, contusions,
lacerations, deformity
Grey-Turner, Kehr, Balance, Cullen
Auscultation: careful exam advised
by ATLS. (Controversial utility in
trauma setting.)
Percussion: subtle signs of
peritonitis; tympany in gastric
dilatation or free air; dullness with
hemoperitoneum
Palpation: elicit superficial, deep, or
rebound tenderness; involuntary
muscle guarding
 Abdominal Injury
Factors that Compromise the Exam
Alcohol and other drugs
Injury to brain, spinal cord
Injury to ribs, spine, pelvis

Caution
A missed abdominal
injury can cause a
preventable death.
Focused Abdominal Sonography for Trauma (FAST)
Demonstrate presence of free intraperitoneal fluid

Evaluate solid organ hematomas

Advantages
No risk from contrast media or radiation
Rapid results, portability, non-invasive, ability to repeat exams.

Disadvantages
Cannot assess hollow visceral perforation
Operator dependent
Retroperitoneal structures are not visualized
Ultrasound (FAST)
1 2 3 4
 FAST
Four View Technique:
Morrisons pouch (hepatorenal)
Douglas pouch (retropelvic)
Left upper quadrant (splenic view)
Epigastric (View pericardium)
 Diagnostic Peritoneal Lavage
Introduced by Root (1965)
Indications for DPL in blunt trauma:
1. Hypotension with evidence of abdominal
injury

2. Multiple injuries and unexplained shock

3. Potential abdominal injury in patients who

are unconscious, intoxicated, or paraplegic

4. Equivocal physical findings in patients who

have sustained high-energy forces to the
torso

5. Potential abdominal injury in patients who

will undergo prolonged general anesthesia
for another injury, making continued
 Contraindications of DPL
Absolute :
Peritonitis
Injured diaphragm
Extraluminal air by x-ray
Significant intraabdominal injury by CT scan
Intraperitoneal perforation of the bladder by cystography

Relative :
Previous abdominal operations (because of adhesions)
Morbid obesity
Gravid Uterus
Advanced cirrhosis (because of portal hypertension and the risk of
bleeding)
Preexisting coagulopathy
DPL: Procedure
 Evaluation of DPL
Fluid is sent for: cell count, amylase, alk phos, presence of bile

Index Positive value

Aspirate Blood >10 mL
Fluid Enteric content
Lavage RBC > 100,000/mL
WBC > 500/mL
Amylase >175 U/dL
Alk Phos > 3 IU
Bile Confirmed
Negative RBC < 50,000/mL
WBC < 100/mL
Amylase < 75 U/dL
 Diagnostic Peritoneal Lavage
RBC Count Incidence of visceral damage
>100,000 95%
20,000-100,000 15-25% Warrant further investigation
<20,000 < 5%

Complications of DPL: Perforation of small bowel,

mesentery, bladder and retroperitoneal vascular structures.

Limitation: offers no information about status of

retroperitoneal organs nor allow determination of which
organ has been injured.
Indications for Laparotomy Blunt Trauma

Hemodynamically abnormal with suspected

abdominal injury (DPL / FAST)

Free air

Diaphragmatic rupture

Peritonitis

Positive CT
 Decision Making
Airway
Breathing
Circulation
SHOCK

Hemodynamically
Transient Hemodynamically
Stable
Responder Unstable

How are you going to assess?

 Gaster
Gastorrhapy ( Simple interrupted )

Occult Gastric perforation

Resection
( Billroth 1 or 2)
 DOUDENUM

Sulit dalam mendiagnosa karena :

- Retroperitoneal
- Jumlah bakteri
- Ph netral .. No chemical peritonitis
Abdominal X ray:
- air bubble didepan Th. L 1 (Lateral foto)
- hilangnya gambaran garis Psoas
- scoliosis lumbar spine
- retroperitoneal air
Mekanisme cedera perhatikan
Hyperamylasemia
 Diagnostic:

Foto Thorax

Free Air (+)

Abdominal X Ray
Plain films:
fractures nearby visceral
damage
free intraperitoneal air
Foreign bodies and missiles

CT scan contras
 Treatment
Non surgical
- Intramural hematom

Surgical
- Simple closure
- Rouex-en-Y doudenojejunostomy
- Triple tube
- Whipple prosedur
 SMALL INTESTINE INJURY

- Mechanism: Rapid deceleration with compression, shearing

- Often at points of fixation: Treitz, ileocaecal valve, prior
adhesions, or on mesentery.
- Chance fracture ( transverse fracture of lower thoracic/lumbar
vertebral body) raises index of suspicion for small bowel injury
- DX: DPL (+).
- Clinical sign may be absent until 6 12 hours post injury
- Delayed perforation: due to direct injury, transmural
contusion, ischemia from mesenteric vascular injury ; usually
presents within 1-2 next days.
 Penetrative objects
should not be removed
except where definitive treatment can
be provided.
stab wound
small intestine clearly protrudes
 Small Instestine

Simple closure

Resection
 Colon Injuries
History
World War I
Primary repair
Mortality : 60 %
World War II
Colostomy
Mortality : 53 %
1970 : exteriorized repair
Stone (1979) :
Prospective randomized study
excluded (risk factor) :
Hypotension
Multiple associated injuries
Delayed operation
Concluded :
Primary repair fewer complication than colostomy
 Epidemiology
Penetrating injuries
Majority
American urban center
Gunshot wound :
27 % of cases undergoing laparotomy
Anterior abdominal stab wound
18 % of cases undergoing laparotomy
Posterior abdominal stab wound
25 % of cases undergoing laparotomy
 Epidemiology
Blunt trauma
Uncommon : 0.5 % of all major trauma
10.5 % of cases undergoing laparotomy
Most common : motor vehicle trauma
Direct compression : create a close loop intraluminal
pressure - blow out
Shearing force : splenic flexure, rectosigmoid junction
Deceleration injuries : mesocolic avulsion
Seat belt injuries
 Diagnosis
Clinical examination (unreliable)
Repeat clinical examination
Retroperitoneal colon injuries : delayed clinical sign
DRE
Blood (distal colon & rectal injuries)
Abdominal & chest film
Free air
CTScan
Free air
Thickened bowel wall
Extravasation (water soluble contrast enema)
Laparoscopic
Not procedure of choice
Intraoperative diagnosis
Almost always in colon injury
Attention : hematoma, discolorization, contusion of colon or mesocolon
Small perforation temporary selaed leak later
 Traumatic Colon Injury
Assessment:
Physical exam
Peritoneal signs
Rectal exam blood is
fairly sensitive
DPL
X-ray, CT
GSW mandates
operation
Colon Injury Scale (AAST)

V a) Transection of the colon with segmental tissue loss

b) Devascularized segmen
Therapeutic options
Two stage
Repair and protective-ostomy
Resection and stoma formation proximally
Distal Hartmanns or mucous fistula
Exteriorization of repaired bowel uncommon
now
One stage
Simple suture repair
Resection and primary anastamosis
Hopital course
 Rectal Injuries
History
World war I : mortality 67 %
Today : 0 10 %
Vietnam war : morbidity 72 %
Today : + 10 %
Controversies
Fecal diversion
Distal rectal wash out
Presacral drainage
Debridement & closure
 RECTAL INJURY
1. Intraperitoneal wounds
2. Extraperitoneal wounds

Diagnostic :
Proctoscopy
Sigmoidoscopy
 Diagnosis
Intraperitoneal rectal injuries = colonic injuries
High index suspicion with blunt or penetrating
mechanism
Extraperitoneal injuries
DRE + Rigid proctoscopy
Water soluble contrast enema
 TERIMA KASIH
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cc: file dr.Hans Marpaung, SpB