CERTIFICATE BY GUIDE

This is to certify that this Dissertation on "ABDOMINAL TRAUMA- A CLINICAL PROFILE " has been carried out by Dr. KUMBHA NAGA SUNEETHA, M.B.,B.S., who is a post graduate student working under my direction, guidance and supervision, in partial fulfillment of the rules and regulations laid down by N.T.R University of Health ciences, !i"ayawada, to appear for #. $%eneral urgery&

Degree '(amination to be held in )*R+,-./01.

Date2 *lace2 !+ )3H)*)TN)#.

Dr. G.ARJUNA, M.S. *R45' 4R 45 %'N'R), UR%'R6

D'*)RT#'NT 45 %'N'R), UR%'R6 )NDHR) #'D+7), 74,,'%' 3+N% %'4R%' H4 *+T), !+ )3H)*)TN)#

CERTIFICATE BY HOD

This is to certify that the Dissertation on ABDOMINAL TRAUMA- A CLINICAL PROFILE" is the bonafide work carried 4ut in )ndhra #edical 7ollege 8 3ing %eorge Hospital. !isakhapatnam by Dr.KUMBHA NAGA SUNEETHA, M.B.,B.S., who is a *ost %raduate student working under my direction, guidance and supervision, in the partial fulfillment of rules and regulations laid down by N.T.R. University of Health ciences, !i"ayawada, to appear for #. . (%eneral urgery& degree e(amination to be held in )pril ./01

P !"# $ !isakhapatnam

D!%#

Dr.N.SUBBARAO ,M.S. Pr&'#((&r ) HOD &' %*# +#,!r%-#.% D#,!r%-#.% &' /#.#r! (0r/#ry K1./ G#&r/# *&(,1%! 21(!3*!,!%.!-

ABDOMINAL TRAUMA- A CLINICAL PROFILE

) Dissertation

ubmitted to the

Dr. N.T.R. UN+!'R +T6 45 H'),TH 7+'N7' , !+9)6):)D)

In partial fulfillment of the Rules and Regulations for #. . ;%eneral urgery< D'%R'' '=)#+N)T+4N To be held in )*R+,- ./01.

D r . K U M B H A N A G A S U N E E T H A , M.B.B.S.,

U n d e r the Direction and Guidance of Dr.G.ARJUNA M.S.

*R45'

4R 45 %'N'R), UR%'R6

D'*)RT#'NT 45 %'N'R), UR%'R6 )NDHR) #'D+7), 74,,'%' 3+N% %'4R%' H4 *+T), !+ )3H)*)TN)# $).*&

ACKNO4LEDGEMENTS + e(press my sincere thanks and deep sense of gratitude to Dr.N.SUBBARAO M.S. *rofessor of %eneral urgery, )ndhra #edical 7ollege,!isakhapatnam, :ho has taken keen interest and rendered his most valuable guidance and supervision in each and every step of my effort in preparing this dissertation. + sincerely acknowledge my heartful thanks to my respected professors Dr.N.Dwarakanadh#. .#ch., Dr. .!.3umar.#. ., Dr.7h. waminaidu.#. ., Dr.)r"una.#. ., Dr.T.Narayanarao.#. ., Dr. ivakumar.#. ., Department of general surgery, )ndhramedical college, !isakhapatnam for their valuable guidance. + am thankful for their encouragement and advice. +t is my great privilege to honestly thank my associate professors Dr.Ra"agopal.#. ., Dr.!.#anmadharao.#. ., Dr.R.>havanirao.#. ., and assistant professors Dr.*.).Ramani.#. ., Dr.3.9anardhanrao.D.N.>., Dr.>.7haitanyababu.#. ., Dr. .Ratnakishore.#. ., for their valuable guidance, encouragement and advice. + also thank *rincipal )ndhra #edical 7ollege, !isakhapatnam, faculty of Department of Radiology for permitting me to carry out this work. + am thankful to all my colleagues for their co-operation and help throughout the present study. ,ast, but not the least + am grateful to the patients who have submitted themselves for this study and for their remarkable co- operation.

(Dr.RAJESH MUPPANA5

LIST OF ABBRE2IATIONS 0. .. ?. 1. @. A. B. C. D. 0/. 00. 0.. 0?. 01. 0@. 0A. 0B. 0C. 0D. ./. .0. ... %7 T+ )+ + )*)7H' D*, R>7 :>7 +U8, +!U 7T 5) T #R+ )>% 4T %+ 'R7* 7>D +!* +!7 %' U % %lgasgow 7oma cale Therapeutic +ntervention core ystem )bbreviated +n"ury cale +n"ury everity core )cute *hysiological and 7hronic Health Diagnostic *eritoneal ,avage Red >lood 7ell :hite >lood 7ell +nternational Units *er ,iter +ntravenous Urography 7omputeriEed Tomography 5ocused )ssessment onography in Trauma #agnetic Resonance +maging )rterial >lood %as 4peration Theatre %astro-intestinal 'ndoscopic Retrograde 7holangio *ancreaticography 7ommon >ile Duct +ntravenous *yelogram +nferior !enecava %astro-esophageal Ultrasonography

74NT'NT *age No. *)RT - + 0 . +NTR4DU7T+4N R'!+': 45 ,+T'R)TUR'

*)RT - ++ 0. )+# )ND 4>9'7T+!' .. #)T'R+), )ND #'TH4D ?. 7) ' H''T 1. 4> 'R!)T+4N )ND R' U,T @. D+ 7U +4N

A. 74N7,U +4N B. >+>,+4%R)*H6 C.#) T'R 7H)RT

INTRODUCTION +n"ury is the leading cause of death and disability in the first four decades of life and is the third most common cause of death overall. +n +ndia communicable diseases continue to take the ma"or share even now, still in"ury is responsible for BF of all deaths. )bout 0 in 1/,/// individuals die in +ndia every year, whereas appro(imately double the number is disabled and this number is increasing. >y convention, in"ury is classified into several categories - *enetrating, >lunt or Nonpenetrating, >last overpressure, Thermal, 7hemical and others including crush and barotrauma. +n blunt in"uries, the damage may be caused by acceleration, deceleration, rotational or shearing forces. Trunkey has pointed out that deaths due to trauma fall broadly into three groups, giving a distinct trimodal pattern. 0. +mmediate deaths $@/F& .. 'arly deaths $?/F& ?. ,ate deaths $./F& +t is among those cases represented by second and third peaks that potentially preventable deaths occur. 4f one fourth to one third of the deaths from trauma could be prevented by more effective initial care. The primary aids like airway management, restoration of circulation, care of cervical spine, cardiopulmonary resuscitation is carried out in the initial stages. Roughly 0/F have life threatening in"uries and speed in diagnosis and therapy is crucial to their survival.

coring systems have been developed to facilitate triage, research and Guality assurance. #ore recently their ability to predict morbidity and mortality particularly septic complications have been studied. )bdominal trauma is one of those sub"ects where the skills of the surgeon is "udged, both in correct diagnosis of the associated visceral in"uries and in treating them, promptly and skillfully, since the morbidity and mortality is very high if not treated adeGuately. :ith the increase in the number of motor vehicle accidents, there is rising incidence of abdominal trauma. The abdomen is the third most commonly in"ured body region, with in"uries reGuiring operation in about ./F of civilian trauma victims. )bdominal in"uries can be particularly challenging because it is often difficult to assess the intra abdominal pathology in the multiple in"ured victim. There is also masking of abdominal in"uries by associated conditions like head in"uries, fractures, alcoholism, drug abuse, shock etc. +nitial clinical assessment of the abdomen in blunt trauma is accurate in only B/-C/F of cases. ,aparotomy should be done when in doubt in a patient with multiple in"uries where all clinical and other investigations have failed to e(clude the abdomen as a source of shock syndrome he displays. )s more and more improvements in the diagnostic modalities for abdominal trauma are forthcoming a therapeutic approach towards conservation with decreased operative intervention has been increasing especially for solid organ in"uries. The ob"ect behind my study is to present a comprehensive picture of the recent concepts in assessment and management of abdominal in"uries in our setup and to highlight upon the diagnostic difficulty it poses and the distressing high mortality it carries. The dissertation has review of literature on the sub"ect and report on the nature of in"ury, type of viscera in"ured,

treatment offered for abdominal in"ury patients, admitted to 3ing %eorge Hospital, !isakhapatnam during the period of #ay ./00 to 4ctober ./0?.

RE2IE4 OF LITERATURE HISTORICAL RE2IE4 )ristotle was the first person to describe about visceral in"uries due to blunt trauma. ,ater on Hippocrates and %alen have given description about this condition. 4ne of the most interesting early practitioners of trauma care was %alen $0?/-.// ).D&. %alenHs book became the primary source for treatment of wounds throughout the middle ages. +ndiaHs system of trauma care has rivaled the Romans. During the reign of )shoka $.AD.?. >.7&, the )rthashastra was written. This book documented that army had an ambulance service with well eGuipped surgeons. )t appro(imately the same time a very famous surgeon ushrutha lived and treated patients in >enaras. )mbroise *are $0@0/-0@D/ ).D& ma"or contribution in treating in"uries include his treatment of gunshot wounds, use of ligature instead of cautery and use of nutrition during post in"ury period Traverse $0C.B& has reported fracture of body of pancreas caused by blunt trauma. 4wen in 0C1C gave a graphic description of a case of closed abdominal in"ury and fatal hypovolemic shock due to liver rupture following a fall. 9ance $0C@A& described a fatal isolated pancreatic in"ury due to a kick. !on Reclinghausen $0CA0& described renal artery thrombosis occurring as a result of blunt in"ury. +n 0CB/ >urn was the first one to resect the liver successfully and >urkhart in 0CCA controlled acute traumatic liver haemorrhage by suturing.1 ,ongrat $0CB@& was the first person to study the pathogenesis of rupture of bowel. +n 0CC., #arion imms began to emphasiEe the need for laparotomy in the case of abdominal trauma. +n 0CCA, Riolti successfully repaired a torn left dome of diaphragm caused by fall from a tree. 3een $0CDD& e(cised left lobe of liver using cautery.

%rant #ussay $0D.?& wrote that -Hin closed abdominal in"uries, early diagnosis is almost impossible and must be guided by general consideration of clinical picture than presence or absence of any particular signH. )inheim in 0D?1 described abdominal paracentesis as a diagnostic procedure. Root in 0DA@ popularised the techniGue of peritoneal lavage, though it was first suggested by olomon in 0D/A. during the 5irst :orld :ar, the treatment of abdominal in"uries was mainly conservative with a mortality around BBF. Hence, in :orld :ar ++, e(ploration was done for all, thus bringing down the mortality to .@F. ANATOMY OF ABDOMEN M0(" #( &' Ab+&-#. #uscles of abdomen can be divided into anterolateral and posterior groups. )NT'R4,)T'R), #U 7,' 45 )>D4#'N 7onsists of four large flat muscular sheets. 0. .. ?. 1. '(ternal obliGue. +nternal obliGue. Transversus abdominis. Rectus abdominis.

*4 T'R+4R #U 7,' 45 )>D4#'N2 There are four muscles forming posterior wall of abdomen. 0. *soas ma"or. .. *soas mr. ?. +liacus. 1. Iuadratus lumborum. FASCIA 5asciae in relation to abdominal wall can be divided into2 0. Those in relation to anterior abdominal wall.

.. Those in relation to posterior abdominal wall. 5) 7+) +N R',)T+4N T4 )NT'R+4R )>D4#+N), :),,2 0. uperficial fascia which is divided into superficial fatty layer 7amper and deep membranous layer carpa .. Rectus sheath. ?. Transversalis fascia. 5) 7+) +N R',)T+4N T4 *4 T'R+4R )>D4#+N), :),,2 TH4R)74,U#>)R 5) 7+). +t has three layers. *osterior layer,middle layer and anterior layer.

NEURO2ASCULAR PLANE The abdominal wall is supplied by all the lower si( thoracic nerves via intercostal nerves and the first lumbar nerve via iliohypogastric and ilio-inguinal nerves. The nerves and vessels run in the plane between transverse abdominis and internal obliGue musles. LYMPHATIC DRAINAGE )bove the umbilicus drain into *ectoral group of a(illary nodes. >elow the umbilicus go to the uperficial inguinal lymph nodes. PERITONEUM *eritoneum is a fibrous membrane lined by mesothelium. That part of peritoenoum which lines linea alba, the anterior and posterior abdominal walls is the parietal peritoneum. *arietal peritoneum is supplied by nerves supplying abdominal muscles. That part of peritoneum investing the viscera is known as visceral peritoneum and is devoid of nerve supply and hence pain insensitive. *'R+T4N'), 7)!+T6

The potential space between these two layers containing a few ml, of tissue fluid is known as peritoneal cavity. This poritoneal cavity is divided into greater sac and lesser sac communicating through foramen of :inslow or epiploic foramen lying between the first part of duodenum and the undersurface of liver. +t is limited anteriorly free edge of lesser omentum and posteriorly inferior venecava. %R')T'R )7 +t is divided into supracolic compartment and infracolic compartment by the transverse mesocolon. upracolic compartment is further divided into right half and left half by falciform ligament. upracolic compartment is continuous with right paracolic gutter whereas the left paracolic gutter is separated by phrenico-colic ligament. +nfracolic compartment is divided into right and left halves by attachment of mesentry e(tending from duodenal-"e"unal "unction to right iliac fossa. ,' 'R )7

+t is also called as omental bursa and lies behind the stomach. OMENTUM These are peritoneal folds. There are . omenta2 %reater and lesser omentum, %R')T'R 4#'NTU# This is the largest peritoneal fold. +t consists of a double sheet folded on itself so that it is made up of four layers. The two layers which descend from the stomach and 0 st part of duodenum pass downwards infront of small intestines for a variable distance then turn upon themselves and ascend as far with upper layer of transverse mesocolon. That part of greater omentum e(tending from greater curvature to diaphragm is called gastrophrenic ligament. The part e(tending from greater curvature to spleen is known as

gastrosplenic ligament. That part between spleen and left kidney is le-renal ligament and the part between greater curvature and transverse colon is gastrocolic ligament. ,' 'R 4#'NTU#2

+t e(tends form lesser curvature of stomach and commencement of duodenum to the undersurface of liver. Hepatic attachment is 9 shaped, horiEontal limb corresponding to the margin of porta hepatis.

2ISCERA !iscera of supra colic compartment are liver, spleen, and stomach, and that of infracolic compartment - small intestine and large intestine. LI2ER ,iver is the largest organ in the body situated in right hypochondrium and epigastric region . +t has 1 lobes and 1 surfaces2 54UR ,4>' 0.Right lobe, ..,eft lobe,?.7audate lobe and 1.Iuadrate lobe. 54UR UR5)7' 0. uperior surface,..*osterior surface ,?.Right surface and 1.+nterior surface '%#'NT), )N)T4#6 The line drawn from bed of gall bladder to inferior vena cava divides the ,iver into right lobe and left lobe. Right lobe is divided into anterior and posterior segments. ,eft lobe is divided into medial and lateral segments. )ll these segments are divided into superior and inferior segments. *'R+T4N'), 74NN'7T+4N 45 ,+!'R

0. 5alciform ligament,..Right triangular ligament,?.,eft triangular ligament,1.7oronary ligament and @.,esser omentum. SPLEEN *rincipally situated in the left hypochondrium. +ts long a(is lies in line of 0/th rib. +t has diaphragmatic and visceral surfaces. Upper and lower border and anterior and posterior e(tremities. The diaphragmatic surface is conve(, smooth and faces upwards and to left. The visceral surface is directed towards the abdominal cavity and has gastric, renal, pancreatic and colic impressions. %astrosplenic ligament e(tends form greater curvature of stomach to spleen. ,e renal ligament-is the peritoneal fold $ part of greater omentum& e(tending from spleen to left kidney. STOMACH tomach has . openings - cardia and pylorus , . curvatures Jgreater curvature and lesser curvature , . surfaces J antero superior and postero inferior and ? parts J fundus ,body and antrum. )NT'R4 U*'R+4R UR5)7' 5undic part is in relation to the diaphragm. Upper and left part of this surface is in contact with the gastric surface of spleen. The right half is in relation to the inferior surface of liver and anterior abdominal wall. *4 T'R4+N5'R+4R UR5)7' This is related to diaphragm, left superarenal gland, upper part of left kidney, splenic artery and anterior surface of pancreas, left colic fle(ure and upper layer of transverse mesocolon. These structures from the stomach bed but the stomach is separable from them and can slide over them due to the intervening omental bursa.

STRUCTURES OF INFRACOLIC COMPARTMENT 6. SMALL INTESTINE 2 '(tends from pylorus to ileocaecal "unction. +t is A-B meters in length. 4f this .8@ th is "e"unum and ?8@th is ileum. +t covered by peritoneum e(cept over duodenum and is attached to posterior abdominal wall by mesentry. DUODENUM$ .@cm long and is the most fi(ed part of small intestine. C&.(1(% &' 7 ,!r%($ 0. 0st uperior, .. .nd Descending, ?.?rd HoriEontal and 1.1th )scending. R',)T+4N 0- S0,#r1&r ,!r%$ related anteriorly to Guadrate lobe and posteriorly to gastro-duodenal )rtery, bile duct and portal vein. .- S#"&.+ ,!r%$ related anteriorly to duodenal impression on right lobe of liver, tranverse colon and transverse mesocolon. *osteriorly to right kidney. )mpulla of vater open into the middle of this part on postero medial aspect. ?. T*1r+ ,!r%$ related anteriorly to superior mesenteric artery and the root of mesentry. *osteriorly to right ureter, +nferior vena cava and aorta $origin of inferior mesenteric artery&. 1. F&0r%* ,!r%$ related anteriorly to the transverse colon and transverse mesocolon, posteriorly to the left kidney and ureter. JEJUNUM AND ILEUM 0. Diameter of "e"unum is $1cm& more than ileum $?.@cm&. .. !ascular arcades are less in "e"unum one as compared to ileum two or more. ?. 9e"unum is double layered $because the mucosa is folded to produce valves&, while ileum is single layered. 1. #esenteric fat encroaches on to "e"unal wall but not in case of ileum. COLON 0. 7olon is 0.@ meters long has a greater diameter.

+t is distinguished by taenia coli formed by longitudinal muscle fibres, the presence of )ppendices epipoicae and presence of haustrations.

RECTUM +t is 0. -0C cm. ,ong, e(tending from ?rd piece of sacrum to "ust below the tip of coccy(. The longitudinal muscle spreads to encircle whole circumference. +t has no appendices epiploicae and haustrations. 5) 7+) 0. 5ascia of :aldeyer2 avascular dense connective tissue between sacrum and rectum. .. ,ateral ligament of rectum, e(tending from lateral wall of pelvis to rectum containing middle rectal vessels. ?. 5ascia of Denonvillier is the loose areolar tissue between rectum posteriorly and seminal vesicles and prostrate anteriorly.

STRUCTURES OF RETROPERITONEUM$ 6. PANCREAS *ancreas is situated transversely behind the stomach from the duodenum to the spleen. +t has head, neck, body and tail. 0. H')D$ lies in the curve of duodenum and is related to inferior vena cava. .. N'73$ related anteriorly to gastroduodenal artery and its branches, *osteriorly. ?. >4D6$ related anteriorly to omental bursa and posteriorly to aorta and origin of superior mesenteric artery, left supra renal artery and left kidney. 1. T)+,$ contained in the . layers of lerenal ligament and intimately related to hilum of spleen. KIDNEY

'(tends from upper border of 0.th thoracic vertebra to the lower border of ? rd lumbar vertebra. Right kidney is at a lower level than the left kidney. R+%HT 3+DN'6 + R',)T'D )NT'R+4R,6 Nearer superior pole to suprarenal gland and a large area below this to hepatic area. #edial border is in contact with descending part of duodenum. +nferiorly kidney is related to right colic fle(ure. *osteriorly it is related above to diaphragm and below $from medial to lateral& Guadratus

lumborum and

transverses tendon.

,'5T 3+DN'6 + R',)T'D )NT'R+4R,6 4n superior aspect to suprarenal gland, lateral half to spleen, medial area to stomach, middle area to pancreas and below the pancreatic area laterally to colon and medially to coils of "e"unum. %R')T !' ', 45 )>D4#'N

0,)>D4#+N), )4RT) >ranches 0. !entral -7eliac trunk - uperior mesenteric artery -+nferior mesenteric artery .. ,ateral -inferior phrenic artery -middle suprarenal artery -renal artery -artery to testis8 ovary ?. Dorsal -lumbar artery -middle sacral artery

1.Terminal Jcommon iliac artery .. +N5'R+4R !'N)7)!) 5ormed by union of two common iliac veins, on right side of the body of ,@ vertebra, ascends in front of vertebral column on the right side of aorta. GENERAL FEATURES OF ABDOMINAL INJURIES T*# 8!r1&0( C!0(#( !r# !( '& &9($ Road traffic accidents +ndustrial accidents 5all from height )ssault Run over by vehicles ports in"ury

M#"*!.1(- &' 1.:0ry$ >lunt in"uries are thought to result from a combination of 0& crushing .& deforming ?& stretching and 1& shearing forces. The magnitude of these forces is directly related to the mass of the ob"ects involved, the rate of the acceleration or deceleration and the relative direction on impact. +n"ury results when the sum of these forces e(ceeds the cohesive strength of the tissue and organs involved. *enetrating abdominal trauma whereby the abdominal cavity communicates with the e(terior. The causes are multiple and include gunshots, high velocity missiles and knives. The e(tent of intra-abdominal in"uries may be difficult to predict. However, a high inde( of suspicion must be maintained to avoid missing occult in"uries.0AThe increased use of 7T scan in patients with penetrating abdominal in"uries has reduced the rate of negative and unnecessary laparotomies. +n one study of .0 patients with penetrating abdominal in"ury who underwent 7T,

@ had laparotomies and all were positive laparotomies. The remaining 0A were managed conservatively and all had uncomplicated recovery.

H&(% C*!r!"%#r1(%1"( )bdominal in"uries associated with rapid deceleration at points of ma(imum fi(ation include tears of the "e"unum at the ligament of TreitE, the terminal ileum and other points of adhesion. 4ther host related factors thought to influence the response to trauma include age and pre-e(isting disease. *atients more than B/ years of age e(perience a mortality rate appro(imately five times than that of younger adults, due to diminished physiologic reserve and more fragile tissue. )cute ethanol into(ication reduces the physiologic response to stress. #otor vehicle accidents accounts for B@F of cases of blunt abdominal trauma. ome series list the liver rather than spleen as the most commonly in"ured intra abdominal organL this difference probably reflects the means of diagnosis. mall liver in"uries are often detected in patients who undergo 7T scan of the abdomen, whereas splenic in"uries in adults are more likely to be clinically significant and reGuire surgical intervention.

TRIAGE AND INJURY SE2ERITY SCORES This is based on patient stability, mechanism of in"ury and site of in"ury, as well as diagnostic and therapeutic maneuvers. The term triage, which is 5rench, was adopted in to the 'nglish language during :orld :ar +. +t is defined as a process of sorting and classifying sick and in"ured patients, taking into consideration the nature of in"ury, the resources available, the time to definite care and the prognosis of the in"uries. Triage is based on the concept that survival will be optimiEed if the patientHs needs can be matched with medical resources in a timely way. INJURY SE2ERITY SCORING P*y(1& &/1"! S"&r#($

0. .. ?. 1. @. A. A.!%&-1"! S"&r#($ 0. )bbreviated +n"ury cale $)+ &. .. +n"ury everity core $+ &.

%lasgow 7oma cale $%7 &. Trauma core. Revised Trauma core. *ediatric Trauma core. Therapeutic +ntervention core ystem $T+ )pache +, ++, +++ &

GLASGO4 COMA SCALE(GCS5 This widely used scale relates specifically to the head in"ury component of the in"ured patient. The three aspects of the coma which are specifically assessed are - eye opening ,verbal response and motor respnse . >y adding the scores of the three components, the total %lasgow coma scale is determined. The higher the scores the better the prognosis. RE2ISED TRAUMA SCORE 7hampion in 0DCD revised his own trauma score to incorporate the %7 . The Trauma core and Revised Trauma core differ only in that the latter does not include capillary refill or chest e(pansion. T!b # 6$ R#81(#+ Tr!0-! S"&r#

G !(/&9 "&-! ("! # 6;-6<

Sy(%& 1" b &&+ ,r#((0r# MCD

R#(,1r!%&ry r!%# 6=-6>

P&1.%( 7

>-6? A-B 7-< ;

BA-CD @/-B@ 0-1D /

@?> A-> 6-< =

; ? 6 =

!ariables on three organ systems that are vital to survival are thus combined into a single score. High scoring eGuates with better prognosis.

THERAPEUTIC INTER2ENTION SCORE SYSTEM (TISS5 Devised by 7hampion and introduced in 0DB1, this is a method of Gualifying nursing, medical and technological support activity and calculated for cost. 7urrently it consists of BA procedures. )ssigned a point score of 0 to 1. +t is a non specific score. ACUTE PHYSIOLOGICAL AND CHRONIC HEALTH E2ALUATION (APACHE5 SCORE Devised by 3naus in 0DC@. initially it had ?1 variables selected and weighed by clinical consensus. +t proved unyielding. +n its second version, mandatory physiological variables were reduced to 0.. The score is computed after .1 hours of +7U care, using the worst values recorded for each of the 0. variables. This reflects risk of death with CAF accuracy. This is used all over the world. ABBRE2IATED INJURY SCORE (AIS5 The first anatomic scoring system, )+ was

published in 0DB0 as a scoring system for blunt trauma as a result of motor vehicle accidents. 0C ubseGuently there have been si( revisions. The most recent revision in 0DD/, classified more than 0?// in"uries into si( levels of in"ury severity. 0D The scores were originally based on four criteria2 threat to life, permanent impairment, treatment period and energy dissipation. The in"uries were further categoriEed into si( different regions. The )+ allows comparisons only among patients with similar in"uries.

HISTORY AND PHYSICAL ECAMINATION )s with any surgical disease or emergency, obtaining a careful history and performing a physical e(amination are of utmost importance in the case of trauma victim. H1(%&ry$ The history taking should never delay providing appropriate care for the e(sanguinating patient. ) Guick pertinent history of the in"ury should be obtained from the patient or from family members, bystanders, police and paramedics, important facts include the time of in"ury, the type and siEe of the wounding agent, the initial vital signs, and the amount of blood loss at the scene. pecific details of the in"ury mechanism are critical. :hat was the position of the victim in the vehicleN :hat was the type of accidentN 5rontal impact, side impact, side swipe, rear impact and rollover have their own uniGue patterns of in"ury. :hat was the siEe and shape of
the weapon, severity of impact forcesN

4ther important information such as allergies, bleeding tendencies, current medications, past or present illness, tetanus immuniEation status and the time of the last meal must be determined. )ll women of childbearing age should be Guestioned about their last menstrual period and then asked whether they are pregnant. The severity of mechanism is related to the force and duration of impact as well as the mass of patient contact area. )ll details regarding pain abdomen, vomiting, retention of urine, constipation, distention of abdomen etc. should be obtained. P*y(1"! ED!-1.!%1&.$ The physical e(amination has always been the most important part. !ital data and signs of peritoneal irritation are most helpful. )s the most freGuent signs of intra abdominal in"uries due to blunt trauma are hypotension or peritonitis, which can occur simultaneously. They might have blood in one of the four areas viE. the pleural cavities, the peritoneal cavity, the retro peritoneum or e(ternally . 4n inspection of the abdomen it is important to note contusion of skin, particularly in the areas of lower ribs on either side. 'cchymosis in the flanks, indicating retroperitoneal haemorrhage should be noted but it may not occur until late. 4n a patient with right sided

contusions over the lower chest or upper abdominal wall or fractures in the lower si( ribs, in"ury to the liver should be suspected. +f the same findings are present in the left lower chest or left upper Guadrant, in"ury to the spleen should be suspected. There is a ./F chance of splenic in"ury and a 0/F chance of hepatic in"ury, with fractures of left and right lower si( ribs, respectively.
+nspection in penetrating in"ury will reveal entry and e(it wounds, lacerations, abdominal distension evisceration, impaled ob"ects and sometimes bullet lodged in subcutaneous tissue.

4n palpation, the overt signs of peritonitis may be elicited. Tenderness from abdominal wall in"ury and intraabdominal in"ury can sometimes be distinguished, if a cooperative patient can raise his legs several inches off the e(amining table. +f tenderness disappears, in"ury is intraabdominal. +f tenderness is increased, in"ury is to the abdominal wall. +f the tenderness is diminished, in"ury to both is present. igns of overt peritonitis may be masked by shock, head in"ury, spinal in"ury, alcohol or drug ingestion. )ppro(imately B@F of all penetrating in"uries to abdomen occur in upper Guadrant. #a"ority are in the left upper Guadrant reflecting the fact that, when two assailants face each other, the right handed opponent is most likely to inflict left upper Guadrant in"ury. ,ocation of wound will help surgeon to gain a rough idea preoperatively of the e(tent of abdominal in"ury. )bdomen is percussed for the evidence of obliteration or e(tension of liver and spleen dullness. 5lanks are percussed for the evidence of free fluid in the peritoneal cavity. The absence of bowel sounds does not necessarily indicate significant intraabdominal in"ury since shock and trauma to other areas can cause ileus. The progression from the active bowel sound to diminished and then absent is a more reliable indication. )lso the presence of bowel sounds does not rule out the possibility of intraabdominal in"ury. +n stable patients, there is a need for repeated abdominal e(amination, as they may develop peritoneal signs at a later stage The back, perineum, rectum and vagina should always be e(amined for wounds of entrance and e(it. ) rectal e(amination is done for blood, crepitus or high floating prostate and to know the sphincter tone and integrity of the rectal wall. *resence of blood provides evidence

of colorectal in"ury whereas a flaccid bladder is indicative of spinal cord in"ury in penetrating trauma. ) valuable sign of continuing intraabdominal haemorrhage is transient elevation of blood pressure to normal for a few minutes followed by return to hypotensive levels, with rapid infusion of @//-0///ml of Ringer ,actate. *atients who are hypotensive due to minimal blood loss or neurogenic shock do not behave in this manner. )bdominal e(amination should be completed by inserting nasogastric tube and foleys catheter. L&"! 4&0.+ ED, &r!%1&. 2 +n the stable patient without obvious signs $eg2 peritonitis&, local wound e(ploration remains a viable screening option. ,ocal wound e(ploration is a well-defined procedure done under local anaesthesia to assess whether peritoneal tear is present. imultaneous wound debridement is done by e(tending the wound as necessary to follow its track. ,ocal wound e(ploration is difficult in stab wounds between nipple and costal margin, which may lead to pneumothora( and stab in back region because of bulky musculature. +f wound e(ploration is positive or eGuivocal the incidence of negative laparotomy is still @/F. S&-# 1-,&r%!.% (1/.( !r# A5 S#!% b# % (1/.$ 'cchymosis over the lower abdomen, where a lap seat belt has been compressed against the iliac crest and lower abdomen, indicates that severe force was applied against the abdominal viscera, especially a distended caecum. B5 L&.+&.E( (1/.$ The presence of pattern bruising of the skin, like an imprint of the clothing, indicates that a crushing force has been applied sufficient to rupture the bowel against the vertebral column. This sign is a strong indication for laparotomy. C5 P&1.%1./ %#(%$

+t is a sign of great value in ruptured intestine. The sign may locate accurately the site of perforation. D5 Gr#y T0r.#rE( (1/.$ Discoloration of flanks from retroperitoneal haemorrhage which is noted a few hours after in"ury. E5 C0 #.E( (1/.$ >luish discoloration around the umbilicus. F5 K#*rE( (1/.$ *ain is referred to the left shoulder due to irritation of the left half of the diaphragm by splenic blood indicating in"ury to the spleen. G5 G1b(&.E( (1/.$ )n e(tremely scaphoid abdomen following blunt trauma to the abdomen, due to diaphragmatic in"ury. H5 H!r+#E( (1/.$ aggital compression of sternum causes sharp pain below the left costal arch, positive in splenic in"ury. I5 B! !."#E( (1/.$ *ersistent dullness on the left side of the abdomen due to early coagulation of splenic blood and shifting dullness on the right side indicates in"ury to the spleen. J5 S.&9 B! (1/.$ ,arge amount of blood coagulated in the *ouch of Douglas causes a bulge which retains the finger mark like a snow ball. K5 S!#//#((#rE( (, #.1" ,&1.%$

*ressure with finger tip on the phrenic nerve above the clavicle between the stemomastoid and the scalenus medius on the left side causes violent pain, positive in splenic rupture. L5 F&DE( (1/.$ >luish discoloration below the inguinal ligament indicates retroperitoneal haemorrhage. DIAGNOSTIC MODALITIES +nvestigations are essential in the evaluation of abdominal trauma to make accurate assessment. +n the multiple in"ured patient additional diagnostic modalities may be of significant benefit. LABORATORY STUDIES$ >lood studies of value in the initial evaluation include the hematocrit and serum amylase or lipase. a& H!#-!%&"r1% 8! 0#$ reflects a balance of acute blood loss, endogenous plasma refill and administration of crystalloid. b& L#03&"y%# "&0.%$ leucocytosis following blunt in"ury abdomen is common but non-specific. c& S#r0- A-y !(#$ elevation is indicative of bowel in"ury or pancreatic in"ury but lacks sensitivity and specificity for intraabdominal in"ury. d& H#-&/ &b1. #8# $ erial estimation of hemoglobin percentage should be done to assess the amount of haemorrhage. e& P !(-! A-%r!.('#r!(# #8# $ may be of some value in the diagnosis of liver in"ury particularly in children. f& Ar%#r1! b &&+ /!( !.! y(1($ is warranted in intubated patients or those who are at risk for subseGuent pulmonary decompensation. Ur1.! y(1($ detects presence of microscopic hematuria suggestive of asymptomatic urologic trauma.

BEDSIDE IN2ESTIGATIONS$ )& Ry #E( %0b# !(,1r!%1&. 2 aspirated stomach contents are e(amined for the presence of blood >& Ab+&-1.! P!r!"#.%#(1(2 5our-Guadrant tap was populariEed by Neuhof and 7ohen in 0D.A and refined by 5itEgerald and ider in 0DA/ to detect intraperitoneal haemorrhage. +t is simple and Guick procedure with relatively few complications. T#"*.1F0#$ The abdomen is painted with antiseptic solution. )n 0C% short level spinal needle is attached to a syringe $preferably 0/ml& and inserted through the abdominal wall, after prior infiltration of local anaesthetic. uction is applied to the syringe as the needle is slowly advanced into the abdomen at various sites. Return of a minimum of /.0ml of non-clotting blood is considered as positive tap. Pr#"!0%1&.($ 0. *uncture of rectus sheath should be avoided, for the risk of causing hematoma of rectus sheath from rupture of epigastric vessels. .. )reas of abdominal scars or other points of bowel fi(ations to the wall should be avoided. ?. Direction of needle inside the abdominal cavity should be changed only by withdrawing the needle "ust superficial to peritoneum and then reintroducing. +t should be avoided in the presence of marked bowel distension because of danger of leak due to increased intraluminal pressure. DIAGNOSTIC PERITONEAL LA2AGE (DPL5 Root et al described the techniGue of peritoneal lavage in 0DA@ and it was further refined by 4lsen et al in 0DB. with the addition of Gualitative analysis of the lavage effluent. This is a rapid, ine(pensive, accurate, relatively safe and reliable procedure for evaluating patients with blunt in"ury abdomen.

T#"*.1"! !(,#"%($ the term peritoneal lavage implies washing of peritoneal contentsL one litre of normal saline is instilled by catheter into peritoneal cavity, recovered by gravity and analyEed. *receding this is peritoneal aspiration in which an attempt is made to retrieve free intraperitoneal blood. This finding indicates intraperitoneal organ in"ury and precludes the need for subseGuent lavage. The techniGue consists of inserting a standard peritoneal dialysis catheter into the peritoneal cavity, infra umbilically in midline. 7riteria in whom diagnostic peritoneal lavage should be considered are as follows2 - 'Guivocal physical e(amination - Une(plained shock or hypotension - )ltered sensorium $closed head in"ury, drugs, etc& - %eneral anaesthesia for e(tra abdominal procedures - 7ord in"ury The contraindications are 2 - 7lear indication for e(ploratory laparatomy Relative contraindications2 - *revious e(ploratory laparotomy - *regnancy - #orbid obesity - 7oagulopathy - ignificant haematomas of abdominal wall related to pelvic fracture There are three methods of introducing the D*, catheter into the peritoneal cavity2 65 C &(#+ %#"*.1F0# $,aEarus Nelson& +t consists of inserting the catheter in a blind percutaneous fashion. +t has been replaced by the much safer but eGually simple eldinger method. ?5 O,#. %#"*.1F0# $*arryHs method& The open procedure, traversing the abdominal wall under direct visualiEation, is safer but more time consuming and introduces air into the peritoneal cavity.

;5 S#-1 &,#. %#"*.1F0# +t is Guick, easy and reliable. >efore lavage, the stomach and bladder are decompressed. The tap is considered positive if greater than 0/ml of blood is aspirated. ) minimum of B@F lavage effluent is reGuired for the test to be considered valid. The fluid is sent for laboratory analysis of red and white blood cell counts, amylase and alkaline phosphatase levels and e(amination for the presence of bile. C&-, 1"!%1&.($ 0. :ound complications include dehiscence, infection and hematoma have been cited up to AF, but occurred in only /.?F in two large series..@ .. +atrogenic intraperitoneal in"ury can be inflicted by the catheter, trocar or wire. *erforation of small and large bowel has been reported most commonly, and bladder and vascular punctures have occurred. ?. 5inally, large diaphragmatic rents typical of blunt pathophysiology permit flow of lavage fluid into the thoracic cavity. I.%#r,r#%!%1&. &' DPL$ ,avage markers can be categoriEed as2 0. 7ellular - gross blood, R>7, :>7 ..'nEymatic - amylase, alkaline phosphatase ?.#iscellaneous - gram stain, bile, vegetable fibers and protein. T!b # ?$ T*# "r1%#r1! '&r ,&(1%18# DPL '& &91./ b 0.% 1.:0ry !b+&-#.. I.+#D )spirate >lood 5luid lavage P&(1%18# M0/ml 'nteric contents EF018&"! M@ ml

R>7s :>7s 'nEyme

M0,//,/// 8mm? M@// 8 mm? $ confirmed by repeat D*,& )mylase M./+U8, )lkaline phosphatase M ? +U 8 ,

M @/,/// 8 mm? M .// 8 mm?

>ile

7onfirmed biochemically

D*, sensitivity range from @D - ADF, specificity from CC - DBF and accuracy BC - DCF RADIOLOGICAL STUDIES$ 65 P !1. F1 -($ )nteroposterior chest radiographs provide clues to associated thoracic and diaphragmatic in"ury. mall amount of free intraperitoneal or retroperitoneal air may be detectable in patients with gastric, duodenal, small bowel or colonic perforations. ) search should be made for rib, pelvic, vertebral body and transverse spus process fractures as these warrant special consideration for nearby visceral damage. '(amination of soft tissue shadows may give information concerning alternations of siEe, shape or position of many viscera. +ndirect evidence of solid visceral rupture with secondary hemorrhage may be presumed by an increase in density in the region, by displacement of neighboring viscera or by accumulation of fluid between the gas filled bowel loops. The appearance of pneumoperitoneum may be facilitated by in"ecting B@/-0///ml, of air into the nasogastric tube. )t least C// ml of intraperitoneal blood is reGuired to be evident on plain abdominal radiograph. 4bliteration of psoas shadow may indicate retroperitoneal hemorrhage. )ppearance of gas bubbles around duodenal area may indicate its retroperitoneal rupture. The following findings may be observed2 0. O5lank-stripe signO - fluid dense Eone separating the ascending or descending colon from a distinctly outlined lateral peritoneal wall, and the colon is displaced medially.

.. ODog-ear signO - results from accumulation of blood that gravitates between the pelvic viscera and side walls on each side of the bladder. ?. OHepatic angle signO - loss of definition of the usually distinct inferior and right lateral borders of the liver as accumulates between the hepatic angle and the right peritoneal wall. 1. O%round glass appearanceO - with e(tensive hemoperitoneum, small bowel may float towards the center of the abdomen with the production of Oground glass appearanceO. There may also be loss of psoas shadow or renal shadow in cases of retroperitoneal hemorrhage. @. The in"ured spleen may cause displacement of gastric bubble or indentation of the splenic fle(ure of the colon. A. +n chest =-rays loops of bowel can occasionally be identified in the chest which is suggestive of diaphragmatic in"uries. B. 5ree air under diaphragmn may have entered through the stab wound and may not be Pbowel airQ. Therefore abdominal films contribute little to evaluation of stab wound of abdomen ?5 G!(%r&/r!''1. C&.%r!(% S%0+1#($ +t is indicated in case of in"ury to stomach, duodenum and small bowel. +t is a simple, safe screening test for high risk patient. The procedure consists of instilling .@/ ml. of %astrograffin via. the nasogastric tube then rolling the patient into the right lateral decubitus position. Radiological sign of duodenal hematoma include defects in the normal contour of the duodenal loop and obstruction to contrast flow. ;5 I.%r!8#.&0( Ur&/r!,*y$ +ndications for +!U in the initial evaluation of blunt trauma remain unsettled. The intravenous urogram is a test of function and its main purpose is to identify irreparable parenchymal disruption as well as renovascular occlusion. %ross hematuria clearly reGuires an early pyelogram. +!U should be followed by 7T scanning or arteriography for better definition of poor renal function. 75 R#%r&/r!+# Cy(%&/r!-$

+t is useful in patients with suspected urinary bladder in"uries. +t is performed by instilling radio opaGue fluid $A/ml of ?@F hypaGue or conray with 0./ml of sterile isotonic saline& into the bladder through a catheter. <5U %r!(&0.+ Ab+&-#. This has been used more freGuently in recent years. The ob"ective of ultrasound evaluation is to search for free intra peritoneal fluid. +t can be done e(peditiously and is as accurate as diagnostic peritoneal lavage. *ortable machines can be used in resuscitation area or in the emergency department in a haemodynamically unstable patient without delaying the resuscitation. The advantages and disadvantages of ultrasound are 2 )dvantages2 - Non invasive - Does not reGuire radiation - Useful in resuscitation room or emergency department - 7an be repeated - Used during initial evaluation - ,ow cost - 7an be used repeatedly to follow up a patientH clinical course. Disadvantages 2 - '(aminer dependant - 4besity - %as interposition - ,ower sensitivity for free fluid R @// ml - 5alse negatives 2 retroperitoneal and hollow viscus perforation The accuracy rate for detecting haemorrhage with an ultrasonography ranges from D0 J DBF
547U 'D )>D4#+N), 4N4%R)# 54R TR)U#) $5) T&

5) T evaluation of the abdomen consists of visualiEation of the pericardium from a sub(iphoid view, the splenorenal and the hepatorenal spaces $#orisonHs pouch&, the paracolic gutters and the *ouch of Douglas in the pelvic. #orisonHs pouch view has been shown to be the most sensitive, regardless of the etiology of the fluid. 5ree fluid, generally assumed to be blood in the setting of abdominal trauma, appears as a black stripe. 5ree fluid in a hemodynamically unstable patient should prompt e(igent laparotomyL however, the stable patient with free fluid may be further evaluated by 7T scan. ensitivity and specificity of these studies range from C@-D@F.

+ND+7)T+4N 54R U G IN PATIENTS WITH BLUNT TRAUMAABDOMEN

+ndications are the same as for D*,. )dditionally it includes2 0. intra-parenchymal haemorrhage. .. with indeterminate peritoneal lavage. ?. 1. +n patients in whom D*, is contraindicated *atients in whom a diagnosis has been such as patients with multiple previous abdominal operations or pregnancy. established by other means $surgicallyL radiologically as 7T scan, radionuclide scanning, angiography&, for freGuent monitoring and follow up. There is no absolute contraindication for ultrasound. +maging may be sub- optional in cases with gross obesity, and acoustic window may not be available in patients with fracture ribs and associated subcutaneous emphysema. Use of lower freGuency probes may be useful in obese patients because of greater penetration
A5 CT-S"!. !b+&-#.

+n stable patients, as an initial method of

scanning, ultrasound may be used to detect a small amount of free intra-peritoneal blood or +n patients with eGuivocal clinical findings or

7T scan was added to the surgeonHs diagnostic armamentarium for blunt abdominal trauma in the early 0DC/Hs. )lthough initially widely criticiEed for its lack of sensitivity, the accuracy of 7T scans in abdominal tauma has improved with e(perience and a better understanding of what constitutes abnormal findings. 7T scan has been e(tensively used in recent years for evaluation of abdominal trauma. +ts usefulness lies chiefly in hemodynamically stable, co-operative patients, especially if conservative management is planned, and for evaluation of retroperitoneum. The high cost of eGuipment, time reGuired, radiation e(posure, need for administration of oral and i.v. contrast, and persistent availability of radiologists having necessary e(pertise in interpretation of scan are its main drawbacks. *atientHs co-operation is reGuired. ) small but significant number of false negative scans has been reported. +t has proved e(tremely valuable in assessing the retroperitoneum, an anatomic area of in"ury for which D*, is not helpful. 7T should not be performed in unstable patients, who are best evaluated by e(ploratory laparotomy or D*,. *eitEman and colleagues have listed five indications for abdominal 7T scans in trauma victims2 0. a hemodynamically stable patient with an eGuivocal abdominal e(aminationL .. a patient with close head in"uryL ?. a patient with spinal cord in"uryL 1. hematuria in the stable patientL and @. patients with pelvic fractures and significant bleeding. :ith these indications and a patient who is truly hemodynamically stable, the time reGuired to perform 7T does not delay surgical procedures and e(pensed personnel are available for immediate interpretation of the results. The accuracy of 7T ranges from D. - DCF with low false positive and false negative results. G5 L!,!r&("&,y (P#r1%&.#&("&,y5$ herwood et al in 0DC/ modified the techniGue for the trauma patients using eGuipment that is portable and readily available for use in the emergency room. The procedure is performed under local anesthesia and employs a miniature laparoscope with an e(ternal diameter of @mm.'mergency laparoscopy is very useful in blunt abdominal in"uries and is e(tremely helpful

in avoiding unnecessary abdominal e(ploration. This is a relatively Guick and reliable investigation and can be done by the surgeon with relatively few complications B5 A./1&/r!,*y$ +t is useful in splenic hematoma, kidney and liver in"ures, retroperitoneal hemorrhage, )! fistula and pseudo aneurysms. Therapeutic selective hepatic artery emboliEation is useful in controlling hemorrhage from hepatic in"ury. elective infusion of vasoconstrictive drugs can be used to control gastrointestinal hemorrhages. Haemostatic agents as well as autologous clot may be used to selectively emboliEe the bleeding vessels. )ngiography is now a time honored instrument in managing arterial hemorrhage from blunt and penetrating trauma. >5 I(&%&,# S"!..1./$ +t is applicable to liver and splenic in"uries. +t provides an evidence for a lesion or a reassurance of its absence. The radionuclide most freGuently used is technetium DD sulphur colloid and can be performed within 0/-0@ minutes. 6=5 M!/.#%1" R#(&.!."# I-!/1./ (MRI5$ +t is an e(cellent non-invasive diagnostic aid e(tremely accurate in anatomic definition of structural in"ury, though costlier to patients.

MANAGEMENT OF ABDOMINAL TRAUMA PATIENTS #anagement of )bdominal trauma in multiple in"ured patients should take place in the priority schemes of primary and secondary surveys of patient. +n primary survey, abdomen should be considered as the site of blood loss in hypotensive patients after attention to airway, breathing, circulation and e(ternal bleeding. +n secondary survey, abdomen should be thoroughly e(amined. #anagement starts in emergency department and includes airway management $if needed&, insertion of large bore intravenous catheter, and administration of intravenous antibiotics and tetanus to(oid prophyla(is. '(tent of resuscitation depends on haemodynamic stability of the patients. Those with haemodynamic instability, peritoneal signs, evisceration, %+T bleed and gunshot wounds with obvious peritoneal penetration should undergo emergency laparotomy.

+f no indication for immediate laparotomy are present, a more deliberate approach is indicated and further diagnostic approaches performed. table patients with stab wounds to anterior abdomen can be managed in different ways. ,ocal wound e(ploration is done to rule out peritoneal penetration and patients can be discharged home after .1 J 1C hours of observation. +f there is peritoneal penetration, peritoneal tap is performed and is positive, e(ploratory laparotomy is performed. 4therwise patient is safely observed. ,aparoscopy is particularly useful in stab wounds to lower chest or upper abdomen as none of other investigations are reliable. Those with evidence of peritoneal penetration and bleeding solid organ can be safely observed. +n patient with stab wound to back or flank, management by serial observation or by triple contrast 7T can be done and D*, is unreliable. )ll unstable patients and those with peritoneal penetration following gun shot in"uries should undergo e(ploratory laparotomy. #anagement of penetrating abdominal trauma in presence of shock or physical finding of peritoneal irritation should be, immediate laparotomy. Nearly one third of stab wounds do not penetrate peritoneal cavity and appro(imately @/F that penetrate, cause no significant in"ury and hence selective conservatism for stab wounds to anterior abdomen is shown to be safe and effective. ) policy of selective conservatism is advocated patients with no signs or eGuivocal abdominal findings and haemodynamically stable. #andatory laparotomy, irrespective of clinical signs is recommended for gunshot wounds INJURIES TO THE DIAPHRAGM )ppro(imately ?F of patients with trauma to torso have a diaphragmatic in"ury identified, with appro(imately two thirds of them secondary to penetrating trauma. +t occurs from massive increase in the intraabdominal pressure resulting in lacerations that radiate laterally from the central tendon. B@F of them are left sided because liver protects the right dome. #ost common cause of blunt diaphragmatic in"ury is by steering wheel, other causes like industrial accidents, penetrating in"uries, sports account for only .@F of cases. S1/.( &' +1!,*r!/-!%1" 1.:0ry (Br0+#91"*E(5$

a. )bsence of respiratory sounds over affected hemi thora(. b. ) change in position of heart with its displacement to right or left of midline. c. )bnormal gurgling sounds over affected hemi thora(. d. ) tympanic note on percussion over affected hemi thora(. e. Reduced movement over the affected hemi thora(. f. caphoid abdomen $%ibsonHs sign& T!b # ;$ Or/!. I.:0ry S"! # - +1!,*r!/Gr!+# I II III I2 2 D1!/.&(1($ 7hest =-ray with in"ection of water soluble contrast medium through nasogastric tube may confirm the diagnosis. The best radiographic signs of a diaphragmatic defect occur when herniation is present and include elevation of a hemidiaphragm, contra lateral shift of the mediastinum, an intrathoracic air bubble or the presence of mass above the diaphragm. Ultrasonography may demonstrate the right hemidiaphragm as an echogenic curvilinear structure superior to the liver. ) break in the continuity of this line may signify an in"ury. 7T scan may be able to visualiEe a diaphragmatic defect if it contains herniated abdominal viscera. I.:0ry D#("r1,%1&. 7ontusion ,aceration R .cm ,aceration . - 0/ cm ,aceration M 0/cm, with tissue loss R .@ sG.cm ,aceration with tissue loss M .@ sG.cm )+ . ? ? ? ?

Diagnostic peritoneal lavage is probably the best non-operative method of diagnosing a diaphragmatic in"ury. There is almost certainly an in"ury to the diaphragm if lavage fluid e(its through a thoracostomy tube. Thoracoscopy and ,aparoscopy2 4chsner et al found thoracoscopy to be 0//F diagnostic. M!.!/#-#.%$ During e(ploratory laparotomy, the entire diaphragmatic surface should be e(posed and directly visualiEed. ,inear laceration can be repaired with a simple running suture or interrupted horiEontal mattress sutures using non absorbable material, whereas larger lacerations and tissue deficits occasionally reGuire repair with prosthetic material. 7are must be taken to avoid iatrogenic in"ury to the pericardium, heart or lungs. +f diaphragmatic in"uries are detected more than four weeks after in"ury, they should be approached through a thoracotomy, so that adhesions to the lung and pleura can be lysed. Diaphragmatic dysfunction is commoner after repair of large blunt in"uries and may reGuire prolonged ventilatory support. 4ccasionally the diaphragm with a large chronic defect has atrophied and retracted and primary repair is not possible. +n such cases, a prosthetic material such as marle( or prolene mesh may be necessary to close the defect. INJURIES TO THE ABDOMINAL 4ALL The abdominal wall contracts when it receives a force thus protecting the viscera inside but the muscle, fascia and skin take the whole brunt. +n"ury to the abdominal wall without intraperitoneal in"ury is difficult to diagnose. Types of in"uries of abdominal wall are2 )brasions, contusions, lacerations and hematomas. #uscular guarding and rigidity are freGuently present. )bdominal breathing is diminished over the part. 7orresponding to the site of rupture a bulge of considerable siEe appears. Tenderness increases on leg raising test if it is a parietal wall in"ury but decreases in case of intraabdominal in"ury. Hematomas are usually due to rupture of rectus abdominis or

epigastric arteries. To distinguish this mass from intraabdominal mass, leg raising test should be carried out. +f owing to the lesion of posterior rectus sheath, the bowel is pushed forward between the edges of the torn rectus, the palpatory finding is slightly reminiscent of chronic hernia of the abdominal wall. The most important aspect of differential diagnosis is to e(clude the lesions of abdominal cavity. +n purely parietal lesions, the general condition of the patient does not deteriorate. '(ception is the rupture of epigastric artery. *arietal wall in"ury is never associated with paralytic ileus. ,acerations and abrasions need wound debridement, suturing and dressing. ,arge hematoma needs evacuation and ligation of bleeders. Rupture of muscle reGuires immediate operative intervention. INJURY TO SOLID ORGANS SPLEEN +t is the most commonly in"ured intraabdominal organ in blunt trauma. plenic in"ury following penetrating trauma is less. +n"ury is suspected whenever there is a blow, fall or sports in"ury to the left chest $with or without fractures of left lower ribs&, flanks or left upper abdomen. 4nce regarded as Omysterii pleni organonO, the spleen is now considered an important immunologic factory as well as reticuloendothelial filter. Routine splenectomy remained the treatment of choice for splenic in"ury. :ith increase in recognition of the haEards of asplenic state, a more conservative approach to splenic in"ury is now preferred. Diseased spleen as in infectious mononucleosis, malaria, leukemia, hemolytic anemia, congestive splenomegaly and polycythemia vera may rupture due to a trivial trauma. D#,#.+1./ 0,&. %*# " 1.1"! -!.1'#(%!%1&. r0,%0r# &' (, ##. 1( " !((1'1#+ !( '& &9($ a& A"0%# r0,%0r#$ The patient succumbs rapidly, never recovering from the initial shock. Tearing of the splenic vessels and complete avulsion of the spleen from its pedicle gives rise to rapid blood loss which can be fatal within minutes.

b& S0b !"0%# r0,%0r#$ +nitial shock, recovery from shock, signs of a ruptured spleen is the usual type of presentation. )fter the initial shock has passed off, there are signs which point to intraabdominal bleeding. c& D# !y#+ %y,#$ )fter the initial signs have passed off, the symptoms of a serious intraabdominal catastrophe are postponed for a variable period of up to two weeks or more. The delayed type of splenic rupture was described by >audet in 0D/. and the asymptomatic interval between in"ury and rupture is known as Othe latent period of >audetO. The cause of delayed hemorrhage is local vasoconstriction with or without the formation of blood clot which seals the tear. The causes of hemorrhage are those of reactionary or secondary hemorrhage. C 1.1"! F#!%0r#($ +f the patient complains of pain associated with respiration, suspicion of splenic rupture is heightened. ) ruptured spleen seems even more likely if the left 0/ or 00 th rib is fractured, a diagnosis best made during physical e(amination by gentle, careful palpation along the course of the ribs. plenic in"ury is always suspected if any penetrating in"ury to left upper Guadrant or left flank. *enetrating in"ury to spleen cause significant bleeding. The history and physical e(amination continue to be the basis from which splenic in"ury is diagnosed. *hysical e(amination has an accuracy of A?F. There is an increasing pallor, a rising pulse rate, sighing respiration and restlessness. )bdomen may be distendedL tenderness and guarding may be generaliEed or localiEed to left upper Guadrant. ,eft lower ribs may be fractured. ,ocal bruising may be present in left upper Guadrant. 3ehrHs sign, pain at the tip of the shoulder, may be elicited by pressure in the left upper Guadrant by placing the patient in the Trendelenburg position. >allanceHs sign, fi(ed dullness to percussion in the left upper Guadrant may be appreciated. Tenderness may be elicited at the aeggesserHs splenic point i.e. on phrenic nerve above the clavicle between the sternomastoid and the scalenus medius on the left side.

hifting dullness may be present at the flanks. Rectal e(amination freGuently reveals tenderness and sometimes a soft swelling due to blood or clots in the rectovesical pouch i.e. the O now >all signO. I.8#(%1/!%1&.($ 0& ,aboratory evaluation can demonstrate a wide variability in the hematocrit, increase in the leukocyte count. ) base deficit R ? meG8, obtained from )>% analysis suggests significant hemorrhage. ..*lain =-ray abdomen2 radiological signs of splenic rupture are 'levation of the left hemidiaphragm, obliteration of the splenic shadow,obliteration of psoas shadow,enlargement of splenic shadow, medial displacement of the gastric bubble because of the accumulation of clot in the gastrosplenic ligament, widening of the space between the splenic fle(ure and preperitoneal pad of fat, fracture of one or more ribs on the left side $present in .BF of cases& ?& Ultrasonography2 The spleen can usually be visualiEed and a surrounding hematoma may suggest rupture. erial e(amination by showing a change in splenic siEe can identify an enlarging sub capsular hematoma. 1& 7T scan2 especially essential if non-operative therapy is planned. plenic lacerations appear as irregular intrasplenic low density regions. The paracolic gutters, subhepatic space and cul-desac should be e(amined for the presence of free intraperitoneal blood. @& Radionuclide scans2 using technetium sulfur colloid, collections of blood within the splenic parenchyma will compress the surrounding tissues and produce focal areas of decreased uptake. A& )rteriography2 Direct signs include e(travasation or pooling of contrast material in the parenchyma, arteriovenous shunting or pseudo aneurysm formation. *eritoneal ,avage2 This is a rapid, ine(pensive, accurate, relatively safe and reliable procedure to detect hemoperitoneum. +t has an accuracy rate of D@-DCF. T!b # 7$ Or/!. I.:0ry S"! # - S, ##.$

Gr!+# I Haematoma ,aceration II Haematoma

I.:0ry D#("r1,%1&. ub capsular, non-e(panding R0/F surface area 7apsular tear, Rlcm parenchymal depth ub capsular, 0/-@/F surface area, intraparenchymal, R@cm diameter.

,aceration III Haematoma

0-? cm parenchymal depth which does not involve a trabecular vessel. ub capsular M@/F of surface area or e(panding, ruptured sub capsular hematoma with active bleeding. +ntraparenchymal hematoma M@cm or e(panding.

,aceration I2 Haematoma ,aceration

M?cm parenchymal depth or involving trabecular vessels. Ruptured intraparenchymal hematoma +nvolving segmental or hilar vessels producing ma"or devascularisation $M.@F spleen&

,aceration !ascular

7ompletely shattered spleen Hilar vascular in"ury which devascularises spleen.

M!.!/#-#.%$ Non-operative #anagement2 7lass +, ++ or +++ splenic in"uries may be candidates for non-operative management if there is2 0& No hemodynamic instability after initial fluid resuscitation .& No serious associated intra-abdominal in"ury.

?& .1 hour availability of emergency 7T scan, 4.T. and surgeon round the clock. These patients are managed in the surgical intensive care unit on complete bed Rest with close monitoring by repeated physical e(amination and serial hematocrits. )n empiric 1-A weeks of convalescence with reduced activity for ? months has been recommended. 4perative #anagement2 The principle goal of operation for splenic in"ury is to control bleeding. ) midline incision provides rapid and e(cellent access to the management of splenic in"ury. 7omplete mobiliEation of the spleen is the key to adeGuate assessment of in"ury and safe repair. The lerenal and phrenicoleinal ligaments are avascular and can be incised away from lateral margin of the spleen. !essels in lecolic ligament are ligated and divided. pleen is rotated into the wound by bluntly dissecting the plane posterior to the pancreas and anterior to the %erotaHs fascia. Then short gastric vessels in the gastroleinal ligament should be divided. )fter adeGuate mobiliEation, clots over spleen are removed by gentle irrigation or grasping with forceps. )fter adeGuate mobiliEation and clot removal, severity of in"ury is assessed. 5urther operative management depends on the assessment of degree of in"ury to the spleen. 0& %rade + in"ury2 generally reGuire little treatment $Tamponade, topical hemostat& or no treatment. %rade ++ in"ury2 can be treated with haemostatic agents $including microfibrillar collagen, gelfoam soaked in topical thrombin or surgicel& with tamponade to control bleeding. ?& %rade +++ in"ury2 various techniGues have been described. The principles are removal of clot and devitaliEed tissue, complete reappro(imation of parenchymal edges to the depth of the wound to avoid leaving dead space and suture placement within the fibrous capsule well away from the wound margin to prevent tearing. '(panding sub capsular hematoma should be opened, the clot evacuated and a diligent search made for parenchymal arterial bleeding, which can be controlled with suture ligature.

1& %rade +! in"ury2 often reGuires partial splenectomy. Hemostasis is attained by selected ligation of the appropriate segment artery. Debridement is accomplished by finger fracture or sharp resection at the line of demarcation. The resected splenic surface is treated with a combination of through and through capsular suture and haemostatic agents. )n omental pedicle may be used to seal raw surface. Use of an absorbable mesh wrap has been described. Topical and intraparenchymal in"ections of fibrin glue $a mi(ture of fibrgen thrombin, aprotinin and calcium chloride& have produced hemostasis in cases with deep splenic in"ury and coagulopathy. @& %rade ! in"ury2 splenectomy should be performed.other indications of abdominal in"uries with hypotension. Routine drainage of the splenic bed is not used for either splenectomy or splenorrhaphy. +f there is associated in"ury to tail of pancreas, closed suction drainage is employed. *olyvalent pneumococcal vaccine should be administered immediately after splenectomy, to prevent the risk of overwhelming pneumococcal sepsis. C&-, 1"!%1&.(2 0. Hemorrhage - *rimary and reactionary .. ,eft lower lobe atelectasis, pneumonia $especially left lower lobe& left pleural effusions. ?. %astric complications - gastric dilatation and fistula, gastric necrosis when the short gastric vessels are ligated ad"acent to the stomach. 1. Haematemesis, @. ubphrenic abscess,
A. Thrombocytosis. plenectomy increase the platelet count by ?/F

plenectomy 0. +f

splenorrhaphy is unsuccessful in other grades, ..rupture of diseased spleen and ?.multiple intra

B. *ancreatitis - The overall incidence is .F following splenectomy C. +nfection - 'arly infection occurs in appro(imately .@F of patients. :ound infection occurs in @F of patients who have had splenectomy for trauma. O8#r9*# -1./ P&(% S, #.#"%&-y I.'#"%1&. (OPSI5 has been defined by Diamond as a fulminant bacterial illness that usually progresses to death within .1 hours of recognition and does not always e(hibit the usual prodromal signs of infection. 5ollowing splenectomy, young children are particularly at high risk to develop fulminant infections due to treptococcus

pneumoniae, H. influenEa and Neisseria meningitides. )ll patients of splenectomy should be given polyvalent pneumococcal vaccine. 7hildren should also receive the H. influenEa type > !accine. #ortality 2 4verall mortality following splenic in"ury is 0/F. #orbidity correlates with degree of associated in"ury.

LI2ER >ecause of its siEe and location in the abdominal cavity, the liver is freGuently in"ured in penetrating in"ury and is the second most commonly in"ured organ following blunt trauma. +n pregnancy, sickle cell anemia, primary hepatocellular carcma and hepatic adenoma, the liver may be fragile and fractured by a mr blow. +t may result from direct blows, compression between the lower ribs on the right and spine or shearing at fi(ed points secondary to deceleration. fractures of the lower ribs on the right freGuently accompany blunt trauma to the liver. C 1.1"! F#!%0r#($ )ll lower chest stabs on the right side and upper abdominal stab wounds should be suspect, especially if considerable blood volume replacement has been reGuested. imilarly crush in"ury to right lower chest or upper abdomen, often combine rib fracture, haemothora( and damage to liver. ) subcutaneous emphysema or ecchymosis on abdominal skin should greatly arouse suspicion of blunt trauma. *atient can present with profound hypotension, temporarily responsive to the infusion of blood and fluids. *atient can have abdominal distension, guarding, rigidity and tenderness in the right hypochondrium. The area of liver dullness may be enlarged. 7ompression of the lower end of the sternum elicits tenderness over the lower coastal arch. There may be hemothora( on right side. I.8#(%1/!%1&.($

0. *lain =-ray of abdomen - may reveal fracture of vertebrae and right lower ribs, hemothora( on right side, elevation of right dome of diaphragm, increased liver shadow, obscured psoas shadow and concomitant in"uries with free or retroperitoneal air. .. U % of abdomen - Useful in tracking of parenchymal or sub capsular hematoma and appro(imate loss of blood into the peritoneal cavity. ?. D*, - 5or hemoperitoneum, accurate in D/F of cases 1. +sotope scanning - The radionuclide most freGuently used is Technetium DD sulphur colloid. @. 7T scan - +t is highly sensitive and specific in defining the presence of an intra-hepatic hematoma or hepatic laceration and the appro(imate volume of blood loss into the peritoneal cavity. A. )ngiography - 5or diagnostic purpose and therapeutic purpose of hepatic artery emboliEation. T!b # <$ Or/!. I.:0ry S"! # - L18#r (6>>7 R#81(1&.5

Gr!+# I.:0ry I Hematoma ,aceration II Hematoma

D#("r1,%1&. ub capsular, R0/F surface area 7apsular tear, Rlcm parenchymal depth ub capsular, 0/-@/F surface area, intraparenchymal, R0/cm diameter.

,aceration III Hematoma

7apsular tear, 0-? cm parenchymal depth. ub capsular M@/F of surface area, ruptured sub capsular hematoma or parenchymal hematoma, +ntraparenchymal hematoma M0/cm or e(panding. M?cm parenchymal depth

,aceration

I2

,aceration

*arenchymal disruption involving .@-B@F hepatic lobe or 0-? 7ouinaud segments

,aceration

*arenchymal disruption involving MB@F of hepatic lobe or M? 7ouinaud segments within a single lobe

!ascular 2I !ascular

9u(tahepatic venous in"uries $i.e., retrohepatic venecava 8 central ma"or hepatic veins& Hepatic avulsion

M!.!/#-#.% Non operative management criteria2 Hemodynamic stability )bsence of peritoneal signs Neurological integrity 7T can delineation of in"ury )bsence of associated intra abdominal in"uries Need for not more than . hepatic related blood transfusions 7T scan documented improvement or stabiliEation with time

4perative #anagement +ndications2 0. .. tab or gunshot wounds that have penetrated the abdomen igns of peritonitis during observation. 1. )ssociated other intraabdominal in"uries. The abdomen should be rapidly opened and a Guick appraisal of bleeding sites made. )ll blood clots and debris should be removed rapidly by scooping them out. Temporary control of bleeding sites may be obtained by placement of packs and the use of manual compression. ) Guick

?. *atients with une(plained shock, uncontrolled heamorrhage or clinical deterioration

e(ploration should be carried out of the liver, spleen and ma"or vessels. +f ma"or bleeding from the liver is noted, compression of the portal triad between the thumb and inde( finger to include the hepatic artery and portal vein $*ringle maneuvre& may be useful ad"unct to packs and manual compression. )n atraumatic clamp may be placed across the hepatoduodenal ligament. +f these fail, a simple hepatic tourniGuet may be constructed by using a large De >akey aortic clamp and a penrose drain. The aorta is to be temporarily occluded "ust below the diaphragm using manual compression with an aortic compressor of the hand of an assistant, when persistent hemorrhage is found and continues in spite of the use of packing and the *ringleHs maneuvre, in"ury to hepatic vein or retro hepatic venecava is likely. +n this situation, control of infra and supra hepatic venacava must be obtained. They may then be temporarily occluded. This is a last resort temporiEing maneuver, since occlusion of inferior venacava impedes A/F of the blood return to the right atrium and may lead to further deterioration of the patient. Recently, the use of various intracaval shunts has alleviated this problem. The method is that described by 6ellis, consisting of a number C endotracheal tube with multiple side holes cut into it and inserted through a purse string suture in the right atrial appendage@1. 65 Dr!1.!/# %rades + and ++ in"uries make up C@F of all liver in"uries. +n the past most surgeons agreed that all liver in"uries should drained, however this has recently been challenged. ?5 S0%0r1./ Hemorrhage from grade ++ liver in"uries can usually be halted by the placement of heavy mattress sutures $0-/ or .-/& of an absorbable material on a blunt tipped liver needle. +f buttressing is necessary, the use of omentum is preferred. ;5 L1/!%0r# &' B ##+1./ P&1.%( Directly ligate the bleeding points with suture or surgical hot clips. 'lectrocautery may be useful in obtaining hemostasis in the diffuse ooEe. )lternatively application of one of the topical haemostatic agents like o(idiEed cellulose $surgicel& and 75 D#br1+#-#.% gelatin sponge $%elfoam&.

)nother important aspect of treatment is the debridement of the non viable parenchyma. This does not imply a formal resection, but rather it is carried out along the planes of in"ury <5 S# #"%18# *#,!%1" !r%#ry 1/!%1&. +f the bleeding continues in spite of above measures and appears to be arterial, the right or left hepatic arteries may be ligated selectively. However it should be avoided in patients with cirrhosis@AH@B. A5 4#+/# R#(#"%1&. +f the bleeding continues and the tract is near the periphery of the liver, a wedge resection with individual ligation of bleeding points may be performed. G5 P!"31./ +n an effort to achieve hemostasis and avoid resection in hepatic in"uries, the placement of multiple packs has been used e(tensively. The wounds are tamponaded with gauEe packs and the patient stabiliEed while clotting parameters corrected. 4nce the patientHs condition improves, they are taken back to the 4.T., a second look operation, during which the packs are removed, area of devitaliEed tissue debrided and drains placed. B5 O-#.%! ,#+1" # ' !, )n omental vascular pedicle is developed using right gastroepiploic vessels. The omentum is then packed into the depths of liver fracture and the edges of the hepatic defect, appro(imated under mild tension with a continuous large polypropylene suture, sump drains were then placed to avoid accumulation of blood. >5 R#(#"%1&. Resection or Resectional debridement may be carried out whenever there is a ragged wound with nonviable tissue. )ll nonviable tissue should be removed and the individual vessels and bile ducts are suture ligated. Hepatic lobectomy in liver trauma has been advocated e(tensively in the past. >ecause of high mortality, it should be considered only when other methods fail to control the bleeding or if

there is e(tensive damage isolated to one lobe of the liver . The techniGue of resection is similar to that used in elective resection. The use of cell-saver device may limit the need for transfusion and the recently developed ultrasonic aspirator $7U )& described by Hodgson may be helpful. %rade ! in"uries are rare. These in"uries can often be managed by primary repair and an intracaval shunt is necessary only in the e(treme situation. C&-, 1"!%1&.($ 0.Hemorrhage,..Respiratory insufficiency, ?..7oagulopathy, 1..Hypoglycemia ,@.>iliary fistula or other bile duct in"ury, A.Hemobilia,B. ub diaphragmatic or intraparenchymal abscess formation ,C.Hypoalbuminemia,D.Transient hyperbilirubinemia, PANCREATIC TRAUMA The *ancreas, because of its close pro(imity to lumbar vertebrae, is more susceptible to crushing in"uries due to direct blow or seat belt in"uries. +ncidence of in"uries to this organ is 0/0.F of all abdominal in"uries. >ecause of its retroperitoneal location, symptoms are usually delayed. *enetrating in"uries to pancreas is associated with mortality rate of ?-.?F. *ancreas is rarely in"ured in isolation and occur in .F patients, because of its location. Therefore, ma"ority of its associated mortality is due to haemorrhage and other associated in"uries The site of in"ury is prognostically important because damage to the pancreatic head has a mortality rate double that of either body or tail in"ury. C 1.1"! F#!%0r#($ oft tissue contusion in the upper abdomen away from bony prominences indicates that a significant force has been dissipated in this areaL epigastric pain out of proportion to the abdominal e(amination is often due to a retroperitoneal in"ury. I.8#(%1/!%1&.($ 0. erum )mylase - neither sensitive nor very specific for pancreatic in"ury.

.. D*, - estimation of amylase in peritoneal fluid. ?. Radiography i. *lain =-ray abdomen may reveal obliteration of psoas shadow, retroperitoneal air along psoas margin or upper pole of right kidney or pleural effusion and elevated diaphragm, especially with in"ury to tail of pancreas. +n later stages, there may be ground glass appearance. ii. Upper %.+. studies with water soluble contrast media may show, widening of 7-loop of duodenum, abnormal displacement of stomach and colon and sometimes leakage of contrast medium. 1. )ngiography - may reveal splenic vein thrombosis and portal hypertension. @. Ultrasound - not helpful in the acute phase, helpful during follow-up for the development of pseudocyst or abscess formation. A. 'ndoscopic retrograde cholangio pancreaticography $'R7*& - for ductal disruption. B. 7T scan - will reveal early pseudocysts, mild traumatic pancreatitis, pancreatic contusions, lacerations and fractures with high degree of accuracy. C !((1'1"!%1&.$ ,ucas developed the following classification for pancreatic in"ury 2 7lass +2 7ontusions or abrasions to the pancreas but not involving the main ducts. 7lass ++2 evere distal pancreatic laceration or disruption with suspected ductal in"ury. 7lass +++2 7lass ++ type of in"ury only to pro(imal rather than distal pancreas. 7lass +!2 evere combined pancreaticoduodenal in"ury. M!.!/#-#.%$ The following are the key principles for the management of pancreatic in"ury. 0. 7ontrol hemorrhage and control bacterial contamination. .. Debride devitaliEed pancreatic tissue.

?. *reserve at least ./-@/F of functional pancreatic tissue whenever possible 1. *rovide adeGuate internal or e(ternal drainage of pancreatic in"uries or resections. 7lass +2 '(ternal drainage, infreGuent distal pancreatectomy. 7lass ++2 Distal pancreatectomy 7lass +++2 Distal pancreatectomy or Rou(-en-6 pancreatico"e"unostomy 7lass +!2 Repair 8 e(clude duodenum, treat pancreas as 7lass +, ++, and +++. *ancreaticoduodenectomy. C&-, 1"!%1&.($ 0. .. ?. with in"ury. 1. non-operative management. +n most series, there is up to .@F mortality rate that occurs early, as a result of associated vascular in"uries. ECTRAHEPATIC BILLARY TRACT +n"uries to gall bladder and e(trahepatic biliary tract are rare with incidence of 0.1F. %all bladder is commonly in"ured part and attributed to its superficial location and larger siEe. #ortality rate for e(trahepatic biliary tract varies between 1F - 00F and depends on associated in"ury. #ortality rate can be @/F when biliary in"ury is associated with vascular in"ury. C 1.1"! Pr#(#.%!%1&.$ *seudocyst - about ..@F, more common after 5istula - in @ to .DF of patients econdary Hemorrhage - @-0/F *ancreatitis - occurs in less than @F of patients

*atient may present with shock due to chemical peritonitis caused by bile which leads to outpouring of fluids into peritoneal cavity. )bsorption of bile salts may cause cholaemia, bradycardia is a valuable diagnostic sign. I.8#(%1/!%1&.($ Diagnosis of in"uries to the e(trahepatic biliary tract is rarely made preoperatively. +t is usually made intra operatively. 0. *eritoneal tap 8 D*, positive for bile salt or pigments. .. Radionuclide hepatobiliary imaging with Technetium DDm.

T!b # A $ED%r!*#,!%1" B1 1!ry Tr!"% 1.:0ry S"! # $

Gr!+# I

D#("r1,%1&. %all >ladder contusion8Haematoma. *ortal triad contusion8Haematoma.

II

*ortal %all >ladder avulsion from liver bedL cystic duct intact, laceration or perforation of %all bladder.

III

7omplete gall bladder avulsion from liver bed, cystic duct laceration

I2

*artial or complete right hepatic duct laceration. *artial or complete left hepatic duct laceration.

*artial common hepatic duct laceration $R @/F&. *artial common hepatic duct laceration $M @/F&. M @/F transection of common hepatic duct. M @/F transection of common bile duct.

M!.!/#-#.%$ The treatment depends on general condition of the patient and on the e(tent of damage to gall bladder. (A5 I.:0r1#( %& /! b !++#r !.+ "y(%1" +0"%$ 0. imple suture 8 cholecvstorrhaphv2 This can be employed for mr in"uries. +t is not

recommended now days because of the risk of bile leakage. 7holecystectomy2 +s indicated if the general condition of the patient is satisfactory and there is avulsion of gall bladder from liver bedL e(tensive laceration or in"ury to pathological gall bladder, for in"ury to cystic duct or if right hepatic artery is ligated for haemorrhage control and in gunshot in"uries 7holecystostomy 2 +ndications are $a& :hen general condition is not satisfactory $b& There are severe associated in"uries $c& :hen anatomy of biliary tree is obscured by in"ury. (B5 I.:0r1#( %& b1 # +0"%( $ 0. *artial bile duct in"uries2 mall lacerations can probably be closed without a T-tube . +n"uries with less than @/F tissue loss along the medial or posterior aspect of the duct can be repaired primarily using @-/ vicryl. .. in"uries to left and right hepatic duct2 +n unstable patient, ligation of either duct can be performed. +f the patient is stable, then a Rou(-en-6 ?. +n"uries to common hepatic duct2 The standard approach is hepatico"e"unostomy. 1. +n"uries to common bile duct2 +n"ury to the supra and retro duodenal portions of the 7>D can be managed by cholecysto"e"unostomy, choledochoduodenostomy can be used for more distal in"uries of the common bile duct. +f there is significant destruction to the surrounding tissues including the duodenum, then a pancreaticoduodenectomy is advised.

C&-, 1"!%1&.($ 0. >iliary fistula incidence varies from /-AAF ,..+ntra abdominal

abscess,?.Hemobilia,1.4bstruction of the duct,@.:altman - :alters syndrome due to accumulation of bile in right subphrenic and sub hepatic space and A. tricture formation. INJURY TO HOLLO4 ORGANS (GASTROINTESTINAL INJURIES5 STOMACH >lunt gastric trauma is rare and is estimated to occur in /.1 to 0.BF of blunt abdominal in"uries. )ny penetrating in"ury to abdomen, particularly in the upper part of abdomen, should be suspected of causing in"ury to stomach. The large area of stomach accounts for more number of in"uries to this organ. *enetrating gastric in"uries are more likely to produce peritoneal signs at early stage due to acid. #ost common mechanism of in"ury is a sudden increase in intraluminal pressure resulting from a direct blow to a full stomach. This results in rupture of stomach along anterior surface of the stomach or greater curvature. 7ompression of stomach against vertebral column may be responsible for complete or partial transection of the stomach. hearing of the stomach wall at points of fi(ation due to rapid deceleration result in in"uries near gastro esophageal "unction, pylorus or at sites of perigastric adhesions. C 1.1"! F#!%0r#($ !omiting and Haematemesis and shallow respiration are common after in"ury to stomach. There may be diffuse board like rigidity. There may be obliteration of liver dullness and absence of bowel sounds. ,ocation of stab wound and passage of blood in nasogastric tube helps in penetrating in"ury along with signs of peritonitis. I.8#(%1/!%1&.($ 0. *lain =-ray abdomen in erect posture demonstrates free gas under the domes of diaphragm. .. RyleHs tube aspirate may be blood stained

?. )bdominal tap 8 D*, - may be positive 1. 5le(ible esophagogastroduodenoscopy Or/!. #(1&. " !((1'1"!%1&.$ %rade +2 uperficial hematoma, partial thickness laceration %rade ++2 ,aceration R 0cm %rade +++2 ,aceration l-@cm %rade +!2 ,aceration @-0/cm M!.!/#-#.%$ >leeding and enteric spill can be temporarily controlled by figure of eight sutures or >abcock forceps placed across the wound. )bdomen is e(plored for associated in"uries like splenic, thoracic, orthopedic and hepatic in"uries. :ounds are most likely to be missed in four areas2 0. The gastro esophageal "unction .. The greater curvature, at the omental and splenic attachments ?. The lesser curvature, at the gastro hepatic ligament 1. The posterior wall of stomach #ost in"uries can be managed by debridement and simple closure. *artial or complete transection of the stomach and devasculariEing in"uries are rare but may reGuire resection. Repair of stomach is usually accomplished with a two layer inverting closure. The inner layer is performed with continuous absorbable suture to obtain hemostasis of the gastric wall and the outer layer is performed with an interrupted, non absorbable suture. 7are should be taken not to narrow the gastric lumen when repairing wounds near %' "unction and pylorus. 7onsideration should be given for pyloroplasty in wounds involving the pylorus. ) gastric drainage procedure should be performed for in"uries along the lesser curvature when damage to vagal nerves has occurred. +f there is e(tensive in"ury to stomach J total gastrectomy is done. C&-, 1"!%1&.$

0.

+ntra abdominal abscess,..Disruption of the

gastric repair,?.5istula formation,1.#issed in"uries,@.Hemorrhage and A.4bstruction DUODENUM +n"ury to the duodenum from blunt abdominal trauma is rare. +ncidence of duodenal in"ury following penetrating abdominal in"ury range from ? J @F. +n part, this is because of its location. The duodenum lies in the upper retroperitoneum, protected anteriorly and laterally by the coastal margin of the ribs and posteriorly by the spine and muscles of the back. *ancreatic in"ury is commonly associated with duodenal in"ury.

C 1.1"! F#!%0r#($ +n the early stages, there may be pain around the epigastrium and umbilical region radiating towards the back. ,ater on the patient may go into shock. Radiation of pain into testicles $>utter 7arlson& due to irritation of nerve ple(us in the retroperitoneum is a valuable diagnostic aid. *atient may vomit altered blood. ,ater on local signs of peritonitis may appear which spreads to whole abdomen. +ntramural hematoma may present as upper gastrointestinal obstruction. I.8#(%1/!%1&.($ 0. erum amylase is elevated in appro(imately @/F of patients.

.. Needle paracentesis 8 D*, - may be positive for blood, bile or bowel contents. ?. Upright chest and abdominal =-ray may show 2 a. +ntraperitoneal air, retroperitoneal air or air in the biliary tree. b. 4bliteration of the psoas shadow. c. Retroperitoneal air around the kidney in more than D/F of patients. d. )ir in front of first lumbar vertebra on a lateral =-ray film of abdomen.

1. folds. @. material.

7ontrast study of upper %+T showing O7oiled

springO or O tacked coinO appearance of duodenum secondary to stacking of its mucosal

7omputed tomography with or without contrast

may demonstrate small amount of retroperitoneal gas and e(travasated intestinal contrast

C !((1'1"!%1&.$ T!b # G$ Or/!. I.:0ry S"! # - D0&+#.0Gr!+# I.:0ry I Hematoma ,aceration II Hematoma ,aceration III ,aceration D#("r1,%1&. +nvolving single portion of duodenum *artial thickness, no perforation +nvolving more than one portion Disruption R@/F of circumference Disruption @/-B@F circumference of D., Disruption of @/-0//F circumference of Di, D?, D1.

I2

,aceration

Disruption MB@F circumference of D. involving ampulla or distal common bile duct.

,aceration !ascular

#assive disruption of duodeno pancreatic system DevasculariEation of duodenum.

M!.!/#-#.%$

urgical prophyla(is is begun by early administration of broad spectrum

antibiotic, even before the abdominal incision. )ppro(imately B@ to C@F of all duodenal

in"uries can be repaired safely using simple techniGues. #any surgical techniGues for treating duodenal in"uries have been described in the literature.. 0. Duodenorrhaphy with drainage. .. Duodenorrhaphy with tube duodenostomy a. *rimary $through duodenum& b. )nte grade $through pylorus& c. Retrograde $through "e"unum& ?. 9e"unal serosal 8 mucosal patch. 1. Triple ostomy techniGue $gastrostomy and ante grade and retrograde "e"unostomies&. @. *edicle grafts ileum, "e"unum and stomach $gastric island&. A. Duodenal resection followed by a.Duodenoduodenostomy b.Duodeno"e"unostomy B. Duodenal diverticuliEation C. *yloric e(clusion with gastro"e"unostomy D. *ancreaticoduodenectomy $:hippleHs procedure&. Total mobilisation should be accomplished by kocherSs manoeuvre or cattell and >raasch manoeuvre. 3ocherSs manoeuvre is performed by incising lateral peritoneal attachments of duodenum and sweeping both second and third portions medially by combination of sharp and blunt dissection. 7attell and >raasch manoeuvre allows inspection of third part of duodenum, reGuires mobiliEation of hepatic fle(ure of colon. The retroperitoneal attachment of small bowel are incised sharpely e(tending from right lower Guadrant to duodeno"e"unal "unction with reflection of small bowel, cephalad of abdominal cavity. Duodenum J third part can be visualiEed by e(tending kocherSs manoeuvre, coupled with transection of ligament of TrietE. )ny finding as haematoma, edema, or crepitation, however minimal or insignificant it may appear, reGuires a thorough e(ploration of duodenum

C&-, 1"!%1&.($)re high $?/ -0//F& with the calculated mortality rates purely ascribed to duodenal in"ury ranging from A.@F to 0..@F. 7omplications include anastamosis leak or, biliary peritonitis, enterocutaneous fistula, post op pancreatitis and abscess SMALL INTESTINE mall intestinal in"uries occur in @-0@F of cases of blunt abdominal trauma. The "e"unoileum is freely suspended from the posterior abdominal wall by fan shaped mesentery, this affords considerable mobility to the small intestine, allowing it to escape serious in"ury from most e(ternally applied blunt forces. +n"ury to mesentery of small intestine secondary to blunt trauma is uncommon. The small bowel is the most freGuently in"ured organ following penetrating in"uries and accounts for 1D J A/F of all in"uries. C 1.1"! F#!%0r#($ The speed and severity of the development of peritonitis depends to some e(tent on the site of trauma. Rupture of lower ileal loops owing to their more infectious contents is followed by diffuse peritonitis earlier than rupture of "e"unum. 4ther signs include guarding and rigidity, absence of bowel sounds, obliteration of liver dullness and tenderness in rectovesical or recto uterine pouch on per rectal e(amination. =-ray abdomen erect view reveal gas under diaphragm. M!.!/#-#.%$ The peritoneal cavity is opened through a long midline incision. The priorities at laparotomy are to secure hemostasis, control contamination, identify in"uries and repair tissues. 4nce hemostasis is secured, enteric contamination is controlled by application of non crushing bowel clamps. Hematomas and serosal lacerations can be Hturned inH using ,embert sutures placed in a transverse fashion. mall perforations should be closed transversely following debridement of the wound edges. )d"acent perforations should be repaired by dividing the connective tissue bridge and closing the defect transversely, to preserve lumen diameter. >owel resection and primary

enteroenterostomy is indicated if the length of an enterorrhaphy e(ceeds one half of the bowel diameter, multiple in"uries occur in pro(imity or if a segment of bowel is devascularised. #esenteric hematomas and lacerations reGuire accurate assessment. Hematomas that are greater than .cm, e(panding, uncontained or near the root of the mesentery reGuire e(ploration. *ro(imal control must be obtained prior to e(ploring a mesenteric hematoma. +n large distal mesentery, it is easily accomplished by digital compression. +n large hematomas at root of mesentery, pro(imal control of superior mesenteric artery is reGuired, which is achieved by #atto( maneuvre. >y reflecting the left colon, spleen and pancreas medially, the suprarenal aorta, celiac a(is, renal arteries and pro(imal superior mesenteric artery are identified. 5ollowing vascular control, the mesenteric hematoma is evacuated and meticulous hemostasis is achieved by individually ligating all bleeding points. Repair of the pro(imal superior mesenteric artery is reGuired to prevent ischaemic loss of the entire small bowel, after which a second look operation should be considered within .1 hours, in order to assess bowel perfusion and irreversible transmural necrosis and its seGuelae. C&-, 1"!%1&.($ The rate is higher in older patients, those with previous pathological conditions and delay in surgical treatment. 0.+ntraabdominal abscess and sepsis, ..)nastomotic leakage, ?.:ound infection, 1.'nteric fistula, @.+ntestinal obstruction, A. hort bowel syndrome and B.Hemorrhage COLONIC INJURIES >lunt trauma accounts for appro(imately @F of colonic in"uries. 7olon is the second freGuently in"ured organ after gunshot wounds and third after stab wounds to abdomen. #orbidity rates after colon in"uries vary from ./ - ?@F and mortality rates from ? - 0@F. Repair of colonic in"ury within . hours dramatically reduce the incidence of infectious complications )cute in"uries can be due to penetrating wounds by stab in"ury. +t may also be result of industrial accident wounds. )utomobile accident and other forms of penetrating in"ury may produce acute in"ury to colon. +n blunt trauma colon is compressed against the vertebral column

or the pelvis.

hear in"uries can occur at sites where the fi(ed retroperitoneal portions of colon

assume an intraperitoneal position and are suspended from a mesentery. udden compression of a fluid filled segment of colon that is at least partially occluded at either end may account for in"ury to that segment. C 1.1"! F#!%0r#($ igns of peritonitis may occur when transverse and sigmoid colon are in"ured. The volume of free intra abdominal gas is often so great that both liver and splenic dullness may be obliterated. Rectal e(amination may indicate intraluminal bleeding. I.8#(%1/!%1&.($ 0. *lain =-ray abdomen in erect posture .. 7olonoscopy ?. %astrograffin enema 1. 7T scanning R1(3 '!"%&r( 1. "& &. 1.:0ry -!.!/#-#.%$ 0. )ge .. #echanism of in"ury ?. hock - >urch and associates observed that the mortality rate was significantly increased in the presence of sustained hypotension pre and intraoperatively. 1. Duration from in"ury to operative control @. 5ecal contamination - an increase in the rate of abscess and septic deaths in patients with ma"or fecal contamination. A. )ssociated in"uries

B. >lood transfusion - the number of units of blood transfused has been shown to be an independent risk factor for post operative morbidity by several authors. C. )natomic location of in"ury

T!b # G$C& &. 1.:0ry (#8#r1%y ("&r#$ +n"ury severity based on )bdominal Trauma +nde( %rade +%rade ++%rade +++ %rade +! %rade ! erosal in"ury only ingle wall in"ury ,ess than .@F of wall in"ured #ore than .@F of wall in"ured 7olon wall and blood supply in"ured

M!.!/#-#.%$ +.Definitive methods2 0.*rimary repair ..Resection of in"ured segment with restoration of bowel continuity. ?.Repair of lacerated colon and e(terioriEation of repair for e(tra-corporeal observation for a period of B to D days and subseGuent interioriEation of healed colon ++.7olostomy2 0.,oop colostomy ..'(terioriEation of colon laceration as a colostomy or repair the laceration and pro(imal colostomy. 'nd colostomy with mucous fistula or HartmannHs type of resection.

*ostoperative complications include abscess formation, anastomotic leak, peristomal hernia and the morbidity and mortality associated with closure of colostomy. The incidence of postoperative intraabdominal sepsis is significantly higher in repair group. tomal complications like stomal obstruction, peritoneal abscess, multiorgan failure add to the morbidity. 7olostomy reGuires subseGuent surgery for closure. 'arly mortality is due to associated ma"or vascular in"uries and range from @.C to BF. #orbidity secondary to sepsis and multiorgan failure with or without anastomatic leak, ranges from 0 J BF. ANORECTAL TRAUMA +n"ury by blunt forces to that part of the large intestine below the peritoneal reflection is unusual, because of protection offered by the bony pelvis. The e(tensive network of arteries and veins that course along the pelvic side walls cause massive retroperitoneal hemorrhage to freGuently accompany this in"ury. *enetrating in"uries to anorectum are also uncommon. #ost result from gunshot wounds. 4ther causes are foreign body impalement, pelvic fractures, bullgore in"ury and iatrogenic $after proctosigmoidoscopy& should be considered. Transpelvic gunshot wounds as well as any penetrating in"ury to lower part of abdomen and buttocks, should raise suspicion for a rectal in"uries. Rectal in"ury can be e(traperitoneal or intraperitoneal. Rectal e(amination may reveal blood or an in"ury may be palpable. :orkup of anorectal in"uries include anoscopy, rigid proctosigmoidoscopy, 7T or at laparotomy. T!b # B$ Or/!. I.:0ry S"! # - R#"%0-$ Gr!+# I.:0ry I II III Hematoma ,aceration ,aceration D#("r1,%1&. 7ontusion or hematoma without revasculariEation *artial thickness laceration R @/F of circumference

I2 2

,aceration ,aceration

5ull thickness with e(tension into the perineum Devascularised segment

M!.!/#-#.%$ +n intra peritoneal rupture of rectum, the perforation is closed with sutures. +f blood is present beneath the pelvic peritoneum, it is necessary to mobiliEe the recto sigmoid, which allows the rectum to be drawn upwards. )fter closing the laparotomy wound, a defunctioning colostomy is done in the left iliac fossa. +f the rectal in"ury is below the pelvic floor, wide drainage from below is indicated. Drainage of the retro-rectal area is established by making a curvilinear incision in the posterior perianal area incising the ano-coccygeal ligament and bluntly dissecting into presacral space. 7are must be taken to preserve the sphincter function during the debridement of the perineal wounds. ) HprotectiveH colostomy is advisable. C&-, 1"!%1&.($ *elvic abscesses, rectal or urinary fistula, rectal incontinence, rectal stricture, urinary incontinence and loss of se(ual function are known complications. GENITOURINARY TRAUMA RENAL TRAUMA >lunt renal trauma accounts for D/F of renal in"uries. 3idneys are protected by thoracic cage, posterior abdominal wall and pad of fat around it. )bout D/F of all blunt renal in"uries are treated nonoperatively. %unshot and knife wounds cause most penetrating in"uries to the kidney and any such wound in the flank area should be regarded as a cause of renal in"ury unless proved otherwise. )ssociated visceral in"uries are present in C/F of renal penetrating wounds

+n"uries to the kidney result most often from either a blow or fall on loin or a crushing in"ury. Rib fracture may cause laceration. 3idneys that are ectopic, malrotated or fused are even more vulnerable for blunt trauma. *athological conditions of kidneys like cysts, tumors and hydronephrosis render the organ more susceptible for in"ury. C 1.1"! F#!%0r#($ There may be superficial bruising, or entry wound, local pain and tenderness. Hematuria is a cardinal sign of a damaged kidney, but it may not be present until some hours after the accident. +f the hemorrhage is profuse, it may be followed by clot colic. udden profuse hematuria can occur between the ?rd day and the ?rd week after the accident in a patient who appears to be progressing favourably. +t is due to the clot getting dislodged. +n many cases of renal in"ury, abdominal distension is seen about .1 to 1C hours after the accident. +n all probability, it is caused by a retroperitoneal hematoma implicating splanchnic nerves. ) perinephric hematoma should be suspected if there is even a slight flattening of the normal contour of the loin, provided there is no scoliosis. I.8#(%1/!%1&.($ 0- *lain =-ray2 may reveal the fracture of the ribs or upper lumbar vertebraL enlargement of kidney shadow indicates sub capsular hematomaL ground glass appearance suggests hematomaL obliteration of psoas shadow is another sign. .. +ntravenous pyelogram $+!*&2 high dose +!* with nephrotomography forms the cornerstone

for the evaluation of renal trauma. +t helps in determining the state of the in"ured kidney, as well as e(tent of damage to the in"ured kidney. ?. 1. @. A. 7ystoscopy2 cylindrical clots in bladder are diagnostic of renal bleeding. Retrograde *yelography2 used if avulsion or in"ury to ureter is suspected. Ultrasound of abdomen2 easily available and can be done bedside. 7T scan2 the precise anatomic and functional renal information obtained is superior to that

from any other imaging techniGue.

B.

Renal angiography2 non visualiEation in +!U may reGuire an angiogram to rule out pedicle

in"ury, that demands emergency surgery. C. Renal isotope scan2 in"ured areas show decreased concentration of isotope.

T!b # >$ Or/!. I.:0ry S"&r# - K1+.#y$ Gr!+# I I.:0ry 7ontusion D#("r1,%1&. #icroscopic or gross hematuria, urologic studies normal

Hematoma II Hematoma ,aceration III ,aceration

ub capsular, non e(panding, no parenchymal laceration Non e(panding perirenal hematoma confined to renal retro peritoneum R 0cm parenchymal depth of renal corte(, without urinary e(travasation M 0cm depth of renal corte(, without collecting system rupture or urinary e(travasation

I2

,aceration

*arenchymal laceration e(tending through the renal corte(, medulla and collecting system

!ascular 2 ,aceration !ascular

#ain renal artery or vein in"ury with contained hemorrhage 7ompletely shattered kidney )vulsion of renal hilum which devascularises kidney

)dvance one grade for multiple in"uries upto %rade - +++ M!.!/#-#.%$

#ost blunt in"uries to the kidneys can be treated nonoperatively. #r in"uries are treated with bed rest, freGuent e(aminations, serial hemoglobin determinations and urine specimens and analgesics. Those patients with ma"or in"uries with unstable vital signs, e(panding flank masses and falling hemoglobin levels reGuire surgical intervention. *enetrating wounds causing small parenchymal in"uries are generally treated by debridement, primary repair and drainage. #ore e(tensive wounds may reGuire partial or total nephrectomy. +n"uries involving the hilum are seldom repaired primarily and in most circumstances total nephrectomy is necessary. #ore that C/F of patients sustaining penetrating renal in"ury have other intraabdominal in"uries. +ndications for emergency surgery2 Unstable vital signs, e(panding flank mass, severe rupture. +ndications for early surgery $.-@ days&2 +nfection, unstable vital signs, e(panding flank mass, continued bleeding and +nitially unrecogniEed severe in"ury. +ndications for delayed surgery2 Hypertension, hydronephrosis and unresolved collections. )bdomen is opened by midline transperitoneal route. ,arge sub capsular or intrarenal hematomas are evacuated and adeGuate debridement of nonviable tissue is carried out. The renal artery may be occluded temporarily if e(cessive bleeding occurs. +ndividual bleeders are controlled with figure of eight 1-/ chromic suture. +n"uries to the collecting system are repaired with 1-/ absorbable sutures. +n"uries to the polar regions that cannot be repaired are best managed with partial nephrectomy. 4mental pedicle grafts or retroperitoneal fat may be used for covering parenchymal defects to aid in hemostasis and wound healing. evere bleeding, pedicle in"ury and

Renal *edicle +n"uries2 ,eft renal vein is the most commonly in"ured vessel and may be ligated if necessary. Repair of the right renal vein may be difficult because of its short length and pro(imity to the +!7. egmental arteries are difficult to repair and are best ligated with accompanying partial nephrectomy, if the infarcted segment is more than 0@F. Renal artery occlusion due to an intimal tear occurs secondary to

acceleration8deceleration in"ury. Repair includes primary anastomosis with e(cision of the damaged segment, interposition grafts $vein or synthetic& or splenorenal or hepatorenal anastomosis. C&-, 1"!%1&.($ 'arly complications2 delayed bleeding, urma or abscess formation, urinary e(travasation and fistula formation. ,ate complications2 )rteriovenous fistulas, hydronephrosis, stone formation, chronic pyelonephritis, pain, hypertension and aneurysm of renal artery. URETERAL INJURIES Ureteral in"uries from e(ternal trauma constitute less than 0F of all genitourinary in"uries. The ureterHs mobility and anatomic characteristics protect it from trauma. Rupture of ureter can occur as a result of an accident causing hypere(tension of the spine. +n"ury is suspected preoperatively by location of entrance site of penetrating in"ury C 1.1"! F#!%0r#($ The early diagnosis is primarily based on suspicion. Hematuria is an unreliable indicator and can be absent in more than ?/F of the cases. 5reGuently traumatic in"ury to the ureter is unrecogniEed at the time of presentation. Delayed manifestations arise from urinary leakage and include fever, flank pain and fistula. I.8#(%1/!%1&.($

0. +ntravenous pvelogram $0!*&2 may demonstrate e(travasation of contrast, delayed function or mild ureteral dilatation pro(imal to the in"ury. .. Retrograde pyelogram2 provides most accurate imaging information. The ma"ority of ureteral in"uries are diagnosed by direct visual inspection during laparotomy. +ntraoperative recognition may be facilitated by intravenous or intraureteral in"ection of indigo carmine or methylene blue. C !((1'1"!%1&.$ Ureteral in"uries can be classified according to their location2 0. Upper2 from ureteropelvic "unction to the iliac crest. .. #iddle2 the ureteral segment overlying the pelvic brim. ?. ,ower2 the segment lying below the pelvic brim, ending in the bladder T!b # 6=$Ur#%#r I.:0ry S"! # $ Gr!+# + ++ +++ +! ! D#("r1,%1&. Haematoma 7ontusion or haematoma without devascularisation ,aceration R @/F transection. ,aceration M @/F transection ,aceration 7omplete transection with R . cms devascularisation ,aceration )vulsion with M . cms devascularisation

)dvance one grade for multiple in"uries upto %rade J +++ M!.!/#-#.%$ +n"uries to the upper and middle third of the ureter are best managed by ureteroureterostomy. Downward mobiliEation of the kidney can decrease the length of defect by @-B cm, facilitating the ureteral appro(imation. +n"uries to the lower third of the ureter are best managed by sub mucosal bladder implantation. This can be done with a combined intra and e(travesical approach, bringing the

ureter through the posterior bladder wall "ust medial to its original hiatus. ) sub mucosal tunnel is created, based on the standard ?20 ratio of tunnel length to ureteral diameter, the distal ureter is then brought through the tunnel and secured to the bladder wall with interrupted 1-/ absorbable sutures. ,ong segmental ureteral in"uries can be managed by transureteroureterostomy. ) 0.@ cm longitudinal ureterostomy is made on the medial side of the recipient normal ureter of opposite side and an end to side, tension free anastomosis is created with running 1-/ chromic sutures. +n severe ureteral in"uries with e(tensive defects, auto transplantation or rarely ileal interposition can be used for renal salvage. >oth internal and e(ternal drains should be used for all ureteral reconstructions. BLADDER #ost bladder in"uries occur as a result of blunt trauma. +t is associated with pelvic fractures in B/F of the patients with bladder rupture. This could be intra peritoneal ./F or e(tra peritoneal C/F. +ntra peritoneal rupture may be secondary to a blow, kick or fall on a fully distended bladder. '(tra peritoneal rupture is caused by ad"acent bony fragments and resembles rupture of membranous urethra. C 1.1"! F#!%0r#($ +ntra peritoneal rupture2 There is a sudden, agoniEing pain in the hypogastrium, often accompanied by severe shock and sometimes syncope. The patient has no desire to micturate. 4n e(amination, varying degree of abdominal rigidity and abdominal distension are present. +n spite of the fact that patient has not passed urine since the accident, there is no dullness above the pubis corresponding to the distended bladder. Usually there is tenderness in the hypogastrium. +f the amount of urine in the peritoneal cavity is considerable, shifting dullness can be elicited. Rectal e(amination often reveals a bulging of the rectovesical pouch, when the urine is sterile, symptoms and signs of peritonitis are delayed for hours.

+f catheteriEation is done in supine position, only a few drops of bloody turbid urine are obtained as the bladder is empty. uddenly the patient is made to sit up, when profuse discharge of bloody urine starts i.e., #orleHs sign. '(tra peritoneal rupture2 There is some suprapubic tenderness and dullness to percussion. There will be blood in the urine often with clots. I.8#(%1/!%1&.($ 0,7ystography2 most accurate method. )fter completely distending the bladder with ?@/ ml of water soluble contrast material, anteroposterior filling and drainage films must be obtained. The drainage study is important because 0?F of the e(tra peritoneal rupture are detected solely with this film. ..7T scan ?.*eritoneal tap 1.+ntravenous urography may confirm a leak from the bladder.

B !++#r I.:0ry S"! # $ Gr!+# + Ty,# Haematoma ,aceration ++ +++ +! ,aceration ,aceration ,aceration D#("r1,%1&. 7ontusion, intramural haematoma. *artial thickness. '(tra peritoneal bladder wall laceration R .cms. '(tra peritoneal $M. cms& or intra peritoneal $R . cms& bladder wall laceration. +ntraperitoneal bladder wall laceration M . cms.

,aceration

+ntraperitoneal or e(traperitoneal bladder wall laceration e(tending into the bladder neck or ureteral orifice.$trigone&

- )dvance one grade for multiple in"uries upto %rade - +++ M!.!/#-#.%$ 7ontusions can be treated by transurethral catheter drainage alone, maintained until hematuria subsides completely. >oth e(tra and intra peritoneal ruptures should be managed by surgical e(ploration and primary repair. )lthough e(tra peritoneal ruptures from blunt trauma can be successfully managed nonoperatively, e(perience is limited with conservative treatment for penetrating bladder in"uries. '(tra peritoneal lacerations are repaired from within the bladder lumen, in one or two layers, with absorbable suture material, for lacerations e(tending into the bladder neck, the internal sphincteric mechanism must be carefully reconstructed to decrease the post traumatic incontinence or contracture. +ntra peritoneal ruptures are closed in multiple layers, incorporating the peritoneum and bladder muscle in one layer and the bladder mucosa in another. ) large suprapubic tube is used to drain the bladder, and anterior cystostomy is closed in two layers. ) urethral catheter is maintained until hematuria grossly clears. The suprapubic tube is left in place for B to 0/ days and a cystogram is performed before its removal. C&-, 1"!%1&.($ 'arly complications of bladder in"ury include infection and persistent bleeding. ,ong term seGuelae are rare, but include incontinence and persistent bladder instability from detrusor in"ury. URETHRAL INJURIES $ Urethral in"uries are rare in women. 4ccur mostly in men, freGuently after either pelvic fractures or straddle type falls. Urethral in"uries should be suspected on the basis of mechanism of in"ury and associated pelvic fracture.

4n clinical e(amination perineal haematoma or perineal in"uries, blood at the urethral meatus and displacement of the prostate gland are seen. ) retrograde urethrogram is essential for diagnosis. T!b # 66$Ur#%*r! I.:0ry S"! # $ Gr!+# + ++ +++ I.:0ry Ty,# 7ontusion tretch +n"ury *artial disruption D#("r1,%1&. >lood at urethral meatus, urethrography normal. 'longation of urethra without e(travasation on urethrography. '(travasation of urethrography contrast at in"ury site with contrast visualiEed in the bladder. +! 7omplete disruption '(travasation of urethrography contrast at in"ury site without contrast visualiEation in ! 7omplete disruption bladderL R . cm of urethral separation. 7omplete transection with M . cms urethral separation, or e(tension in to the prostate or vagina.

)dvance one grade for multiple in"uries upto %rade J +++. M!.!/#-#.% $ *atients sustaining urethral in"uries should be managed initially by bladder decompression via., suprapubic cystostomy and delayed urethroplasty. 7omplications of urethral in"uries include stricture, urinary incontinence and impotence, with disruption of the urethra. RETROPERITONEAL HEMATOMA The incidence of retroperitoneal hematoma in patients who have suffered blunt abdominal trauma is 0@F. +n most of the cases, a pelvic fracture is present and is the likely cause. M#"*!.1(- &' I.:0ry$

Disruption of multiple arteries that are often distal branches of abdominal aorta and small branches of inferior venecava cause retroperitoneal hematoma, rather than avulsion of ma"or branches of these vessels. +n patients with perirenal hematoma, the source of blood is usually from in"uries to the kidney. Retroperitoneal hematoma can usually form in following positions2 midline suprarenal, midline infrarenal, lateral perirenal, lateral pelvic and portal. C 1.1"! F#!%0r#($ )bdominal pain, tenderness and back pain may be present. Hypovolemic shock is a constant finding. ometimes a tender mass is palpable. There may be positive %rey TurnerHs sign, 7ullenHs sign or 5o(Hs sign. Dullness in the flanks is non shifting. Rectal e(amination reveals a boggy mass anterior or posterior to the rectum. I.8#(%1/!%1&.($ 0. =-ray abdomen and pelvis2 shows fracture pelvic bone and obliteration of psoas shadow .. +!U, retrograde cystogram and angiography2 if patient condition is stable. ?. 7Tscan M!.!/#-#.%$ Retroperitoneal hematoma is usually due to pelvic fracture, for which application of an e(ternal fi(ation device is reGuired. +f the patient develops multiple episodes of hypotension before fi(ation of pelvic fractures, then selective emboliEation of internal iliac arteries can be done to prevent e(travasation from deep pelvic arteries. +n other cases, laparotomy is indicated. )nother option is to in"ect a sludge of autologous clot, microfibrillar collagen and calcium chloride into the ipsilateral internal iliac artery. 4n rare occasion, it may be necessary to pack pelvis with non opaGue gauEe for .1-1C hours for precise localiEation of the bleeding site. 0.#idline2 a& b& upramesocolic2 open the hematoma +nframesocolic2 open the hematoma

..,ateral2 *erirenal2 do not open if preoperative +!* or 7T scan reveals intact kidney. *elvic2 do not open if there is fracture pelvis with slow rate of e(pansion. *ortal2 open the hematoma

. part

nd

AIMS AND OBJECTI2ES 0. To know the incidence of blunt and penetrating abdominal in"uries and the etiology of abdominal trauma. .. ?. 1. @. To find out the age and se( incidence. To study the mode of presentation of various types of abdomen trauma. To assess the importance of the various investigations. To study the nature and incidence of in"ury to different intra-abdominal organs.

A. B. C. D. 0/.

To find out the incidence and nature of associated in"uries. To study the mode of treatment offered. To study the post operative complications. To study the cause of death and evolve better management. To analyEe the results and compare them with the results reported by other authors

MATERIALS AND METHODS S&0r"# &' +!%! !.+ ,#r1&+ &' (%0+y$ The present study OA ABDOMINAL TRAUMA- A CLINICAL PROFILE O comprises of patients admitted to and operated in various surgical units in the Department of urgery at 3ing %eorge Hospital, attached to )ndhra #edical 7ollege !isakhapatnam, from #ay ./00 to 4ctober ./0?. C& #"%1&. &' +!%!, (!-, # (1H# !.+ -&+# &' (# #"%1&.$ A@ patients with blunt abdominal in"uries and penetrating trauma admitted in surgical wards included in the study. *atients were methodically enGuired according to the proforma

approved by the guide. ) detailed history as to the mode of in"ury, thorough clinical e(amination and necessary investigations like routine investigations, special investigations including ultrasound and ct scan were done. I." 0(1&. Cr1%#r1!$

)ll patients with blunt and penetrating, abdominal in"ury with intra abdominal in"uries $1/& were included in the study. ED" 0(1&. Cr1%#r1!$ Those patients admitted with in"ury to e(ternal genitalia and those without any intra abdominal in"uries without gaining admission into the department of surgery were e(cluded from the study. *atients who died before confirmation of definitive diagnosis were also e(cluded from this study. M#%*&+ $ The management was individualiEed and each case was assessed on its own. +n patients where laparotomy was performed after resuscitation, the details regarding the viscera in"ured and nature of surgery performed were recorded. 'ach case was carefully followed up to evaluate the progress of patient and to note the development of complications, if any and its management. The details of all cases are summariEed in the master chart and results of the study have been analyEed in detail.

CASE SHEET-6 Name 2>ri"ilal Netam )ge8 e( 2 1/8m 4ccupation 2 daily labour Duration 20 day #ode of +n"ury 2RT) History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 upper abdomen Radiation 2No .. !omiting 2 present two episodes 5reGuency 2 Duration 2 0 day 7haracter 2Dull aching Referral 2 No +* No2 ./CA? Unit2s1 Urban 8 Rural D4) 2 018A800 D4 2018A800 D4D2.A8A800

PRESENTING COMPLAINTS$ *ain )bdomen

7haracter of vomiting2 contain food particles ?. Distension of )bdomen Duration 2 Diffuse 8 ,ocaliEed2 +f localiEed J site 1. >owels History of passage of flatus and stools after the incident 26es8No +f yes 5reGuency and Guantity 20 episode 7haracter of stools 2Normal @. #icturition 2 Desire to pass urine 2 6es 8 No >leeding per Rectum2 nil 0 day diffuse ,eft Hypochondrium

Retention 2No A. )ny other complaints 2No B. )ny associated in"uries 2No *) T H+ T4R62 Nil significant

Haematuria 2No

*'R 4N), H+ T4R6 2 moking 8 )lcoholic 2No ECAMINATION $ %eneral condition 25air *ulse rate )naemia 2No Hydration2 *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 mild distension present !isible in"uries2 abrasions over anterior abdominal wall present '(ternal genitalia2 Normal #ovement with Respiration 2 *resent *eristalsis 2 PALPATION Distention 2 *resent Tenderness 2 )bdominal girth2 Rigidity 2present Hernial orifices 2Normal plenic dullness 2 TT 5luid thrill 2 present *uddleSs sign 2 TT *8R2Normal *8!2Normal *resent #uscular %uarding2 *resent #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 2 4bliterated Dullness over mass 2 TT hifting dullness2 present AUSCULTATION $ >owel sounds 2absent ) 47+)T'D +N9UR+' No *ulsations2 No %ood 2C.8min 7onsciousness2 conscious Respiratory rate 2 ./8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 00/8B/mm of Hg

Head and neck2Normal pine2Normal '(tremities 2Normal *R4!+ +4N), D+)%N4 + 2 >lunt +n"ury )bdomen +N!' T+%)T+4N 2 0& >lood 2 erial HbF20/gmF TR>7 21lakhs8cmm %rouping 2)U!' .& Urine 7olour2 normal ugar 2TT ,5T 2 erum >ilirubin 2TT %4T %*T )lkaline phosphatase 1& =-Rays T7

Thora(2Normal *elvis 2Normal

*7!21/F D7 )lbumin 2TT #icrobiology 2TT

?& erum )mylase 8 erum electrolytes 2Na-0?1meGL3-1.0meG

)bdomen *neumoperitoneum present 4thers +!U )mylase2 TT #icroscopy2 TT

)bdominal paracentesis 7olour 2bilious fluid Iuality 2 TT B& 7'7T )bdomen 2 TR')T#'NT 2 Resuscitation 2Done 4perative treatment 2 Time lag from in"ury 2 less than .1 hrs Nature of operation 2 ,aparotomy ,avage V primary closure of perforation )naesthesia 2%) +notropics used 2 Dopamine >lood 8 >lood products transfused 20 points whole blood

A& Ultrasound canning 2moderate free fluid in peritoneal cavity

*reoperative findings 2 "e"una perforation and e(udative fluid in peritoneal cavity *ost operative course 2 :ound infection 2superficial surgical site infection >urst 2TT )nastamotic leak 2TT Name 2%. konda )ge8 e( 2 1.8# 4ccupation 2 ,abourer Duration 2 one day #ode of +n"ury 2RT) History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 peri umbilical Radiation 2No .. !omiting 2 ---5reGuency 2. 'pisodes 7haracter of vomiting 2>ilious ?. Distension of )bdomen Duration 2 Diffuse 8 ,ocaliEed +f localiEed J site 1. >owels History of passage of flatus and stools after the incident 26es8No +f yes 5reGuency and Guantity 2 7haracter of stools 2 @. #icturition 2 Desire to pass urine 2 6es 8 No >leeding per Rectum2 0 day localiEed ,eft Hypochondrium Duration 2 0 day 7haracter 2 diffuse Referral 2 No 4thers 2TT CASE SHEET-? +* No2 .@?1. Unit2s1 Urban 8 Rural D4) 2 ./8.800 D4 2./8.800 D4D2?8?800 Respiratory complications2TT Re-laparotomy 2TT

PRESENTING COMPLAINTS$ *ain )bdomen

Retention 2No A. )ny other complaints 2No B. )ny associated in"uries 2No *) T H+ T4R62Nil significant

Haematuria 2No

*'R 4N), H+ T4R6 2 moking 8 )lcoholic 2 )lcoholic #'N TRU), H+ T4R6 2 TT ECAMINATION $ %eneral condition 25air *ulse rate )naemia 2No Hydration2 *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 distended !isible in"uries2No #ovement with Respiration 2 restricted *eristalsis 2 PALPATION Distention 2 *resent Tenderness 2 )bdominal girth2 Rigidity 2present Hernial orifices 2Normal plenic dullness 2 TT 5luid thrill 2 present *uddleSs sign 2 TT *8R2Normal *resent #uscular %uarding2 *resent #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 2Not 4bliterated Dullness over mass 2 TT hifting dullness2 present AUSCULTATION $ >owel sounds 2absent ) 47+)T'D +N9UR+' No *ulsations2No '(ternal genitalia2Normal %ood 2C.8min 7onsciousness2 conscious Respiratory rate 2 ./8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 00/8B/mm of Hg

Head and neck2Normal pine2Normal '(tremities 2 Normal *R4!+ +4N), D+)%N4 + 2 >lunt +n"ury )bdomen +N!' T+%)T+4N 2 0& >lood 2 erial HbF201gmF TR>7 21lakhs8cmm %rouping 2>U!' .& Urine 7olour2 high coloured ugar 2TT ,5T 2 erum >ilirubin 2TT %4T %*T )lkaline phosphatase 1& =-Rays T7

Thora(2Normal *elvis 2Normal

*7!21/F D7 )lbumin 2TT #icrobiology 2TT

?& erum )mylase 8 erum electrolytes 2Na-0?1meGL3-1.0meG

)bdomen 2 pneumoperitoneum present 4thers +!U )mylase2 TT #icroscopy2 TT

)bdominal paracentesis 7olour 2Red Iuality 2 TT TR')T#'NT 2 Resuscitation 2Done 4perative treatment 2 Time lag from in"ury 2 more than .1 hrs Nature of operation 2 ,aparotomy and "e"uno "e"unal anastomosis. )naesthesia 2%) *reoperative findings 2Haemoperitoneum, large perforation "e"unum and mesenteric tear. +notropics used 2 Dopamine >lood 8 >lood products transfused 2. packet whole blood

A& Ultrasound canning 2 Haemoperitoneum

*ost operative course 2 %ood :ound infection 2TT >urst 2TT )nastamotic leak 2TT 4thers 2TT CASE SHEET-; Name 2* rinu )ge8 e( 2 4ccupation 2 5armer Duration 2 0 day #ode of +n"ury 2RT) History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 ,eft hypochondrium Radiation 2left shoulder .. !omiting 2 5reGuency 2 no 7haracter of vomiting ?. Distension of )bdomen Duration 2 Diffuse 8 ,ocaliEed +f localiEed J site 1. >owels History of passage of flatus and stools after the incident 26es8No +f yes 5reGuency and Guantity 2 7haracter of stools 2 @. #icturition 2 Desire to pass urine 2 6es 8 No >leeding per Rectum2 diffuse 0 day Duration 2 0 day 7haracter 2Dull aching Referral 2 No +* No2 ?/1C@ ./ yrs8# Urban 8 Rural Unit2s1 D4) 2 .@8C80. D4 2 .A8C80. D4D2 A8D80. Respiratory complications2TT Re-laparotomy 2TT

PRESENTING COMPLAINTS $ *ain )bdomen

Retention 2No A. )ny other complaints 2No B. )ny associated in"uries 2No *) T H+ T4R62Nil significant

Haematuria 2No

*'R 4N), H+ T4R6 2 moking 8 )lcoholic 2 )lcoholic #'N TRU), H+ T4R6 2 ECAMINATION $ %eneral condition 25air *ulse rate 2C.8min 7onsciousness2 conscious Respiratory rate 2 ./8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 00/8B/mm of Hg *allor 2 present Hydration2 *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 distended !isible in"uries2No #ovement with Respiration 2 *resent *eristalsis 2 PALPATION Distention 2 *resent Tenderness 2 )bdominal girth2 Rigidity 2No Hernial orifices 2Normal plenic dullness 2 TT 5luid thrill 2 TTT *uddleSs sign 2 TT *8R2Normal *resent #uscular %uarding2 *resent #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 2Not 4bliterated Dullness over mass 2 TT hifting dullness2 TT AUSCULTATION $ >owel sounds 2absent ) 47+)T'D +N9UR+' No *ulsations2No '(ternal genitalia2Normal dehydrated

Head and neck2Normal pine2Normal '(tremities 2Normal *R4!+ +4N), D+)%N4 + 2 >lunt +n"ury )bdomen +N!' T+%)T+4N 2 0& >lood 2 erial HbF2C..gmF TR>7 21lakhs8cmm %rouping 2 4Uve .& Urine 7olour2 normal ugar 2TT ,5T 2 erum >ilirubin 2TT %4T %*T )lkaline phosphatase 1& =-Ray2 chest2 no bony in"ury )bdominal paracentesis 7olour 2Red Iuality 2 TT )mylase2 TT #icroscopy2 TT

Thora(2Normal *elvis 2Normal

*7!2?CF T7 D7 )lbumin 2TT #icrobiology 2TT

?& erum )mylase 8 erum electrolytes 2Na-011meGL3-1.0meG

)bdomen2 no *neumoperitoneum

A& Ultrasound canning 2 Haemoperitoneum, plenic Haemotoma B&7'7T abdomen 2gread +++ splenic laceration with heamatoma TR')T#'NT 2 Resuscitation 2Done 4perative treatment 2 Time lag from in"ury 2.1 hrs Nature of operation 2 ,aparotomy ,avage V pleenectomy )naesthesia 2%) *reoperative findings 2Haemoperitoneum V spleenic laceration and haemotoma +notropics used 2 Dopamine >lood 8 >lood products transfused 2. points whole blood

*ost operative course 2 good :ound infection 2TT >urst 2TT )nastamotic leak 2TT 4thers 2TT CASE SHEET-7 Name 2 >ibo +* No2 ..CB1 )ge8 e( 2 1/yrs8m Urban 8 Rural Unit2s1 4ccupation 2 daily labour Duration 20 day #ode of +n"ury 2 bullet in"ury History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 rt lumbar region and loin right side Radiation 2No .. !omiting 2 no 5reGuency 2 Referral 2 No Duration 2 0 day 7haracter 2Dull aching D4) 2 B8B80. D4 2C8B80. D4D20C8B80. Respiratory complications2 left side pleural effusion Re-laparotomy 2TT

PRESENTING COMPLAINTS $ *ain )bdomen and pain in loin

7haracter of vomiting 2 ?. Distension of )bdomen Duration 2 no Diffuse 8 ,ocaliEed +f localiEed J site 1. >owels History of passage of flatus and stools after the incident 26es8No +f yes 5reGuency and Guantity 20 episode 7haracter of stools 2Normal @. #icturition 2 Desire to pass urine 2 6es 8 No >leeding per Rectum2nil

Retention 2No A. )ny other complaints 2No B. )ny associated in"uries 2No *) T H+ T4R62Nil significant

Haematuria 2No

*'R 4N), H+ T4R6 2 moking 8 )lcoholic 2yes #'N TRU), H+ T4R6 2 ECAMINATION $ %eneral condition 25air *ulse rate )naemia 2No Hydration2 *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 Normal #ovement with Respiration 2 *resent *eristalsis 2 PALPATION Distention 2 Tenderness 2 )bdominal girth2 Rigidity 2 Hernial orifices 2Normal plenic dullness 2 TT 5luid thrill 2 TTT *uddleSs sign 2 TT *8R2Normal *8!2Normal *resent #uscular %uarding2 *resent #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 2Not 4bliterated Dullness over mass 2 TT hifting dullness2 TT AUSCULTATION $ >owel sounds 2 ) 47+)T'D +N9UR+' No *ulsations2No '(ternal genitalia2 Normal !isible in"uries2 entry wound is seen in right upper back %ood 2D/8min 7onsciousness2 conscious Respiratory rate 2 ./8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 0./8B/mm of Hg

Head and neck2Normal pine2Normal '(tremities 2Normal

Thora(2Normal *elvis 2Normal

*R4!+ +4N), D+)%N4 + 2 *'N'TR)T+N% +N9UR6 $>U,,'T& +N!' T+%)T+4N 2 0& >lood 2 erial HbF20..AgmF TR>7 21lakhs8cmm %rouping 2>U!' .& Urine 7olour2 normal ugar 2TT ,5T 2 erum >ilirubin 2TT %4T %*T )lkaline phosphatase 1& =-Rays )bdomen foreign body seen in lumbar region right side 4thers )bdominal paracentesis 7olour 2 Iuality 2 TT )mylase2 TT #icroscopy2 TT +!U )lbumin 2TT #icrobiology 2TT *7!21?F T7 D7

?& erum )mylase 8 erum electrolytes 2Na-011meGL3-1.0meG

A& Ultrasound canning 2no free fluid +n peritoneal cavity and no solid organ in"ury B& 7'7T )bdomen 2 foreign body is seen near right kidney with peri nephric collection TR')T#'NT 2 Resuscitation 2Done 4perative treatment 2 Time lag from in"ury 2 more than .1 hrs Nature of operation 2 ,aparotomy ,avage V debridement )naesthesia 2%) +notropics used 2 Dopamine >lood 8 >lood products transfused 2

*reoperative findings 2 foreign body found close to gerotas fascia, no kidney in"ury, *ost operative course 2 %ood :ound infection 2 surgical site infection >urst 2TT )nastamotic leak 2TT Name 23 atyavathi )ge8 e( 2 1/8f 4ccupation 2 house wife Duration 20 day #ode of +n"ury 2RT) History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 ,eft hypochondrium Radiation 2No .. !omiting 2 . episodes 5reGuency 2 ?. Distension of )bdomen Duration 2 Diffuse 8 ,ocaliEed +f localiEed J site 1. >owels History of passage of flatus and stools after the incident 2 6es8No +f yes 5reGuency and Guantity 2 0 episode 7haracter of stools 2 Normal @. #icturition 2 Desire to pass urine 2 6es 8 No >leeding per Rectum2 nil 0 day localiEed ,eft Hypochondrium Duration 2 0 day 7haracter 2Dull aching Referral 2 No 4thers 2TT CASE SHEET-< +* No2 .?C.? Unit2s1 Urban 8 Rural D4) 2 018B80. D4 2018B80. D4D2.@8B80. Respiratory complications2TT Re-laparotomy 2TT

PRESENTING COMPLAINTS $ *ain )bdomen

7haracter of vomiting2

Retention 2No A. )ny other complaints 2No

Haematuria 2 No

B. )ny associated in"uries 2 fracture @th Ath Bth ribs on left side *) T H+ T4R62 Nil significant *'R 4N), H+ T4R6 2 moking 8 )lcoholic 2No #'N TRU), H+ T4R6 2 Regular cycles ECAMINATION $ %eneral condition 25air *ulse rate 2D/8min 7onsciousness2 conscious Respiratory rate 2 ..8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 0?/8D/mm of Hg *allor 2 present Hydration2 %ood *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 distended #ovement with Respiration 2 *resent *eristalsis 2 PALPATION Distention 2 *resent Tenderness 2 *resent )bdominal girth2 Rigidity 2No Hernial orifices 2Normal plenic dullness 2 5luid thrill 2 present *uddleSs sign 2 TT *8R2Normal *8!2Normal #uscular %uarding2 *resent #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 2Not 4bliterated Dullness over mass 2 TT hifting dullness2 present AUSCULTATION $ >owel sounds 2absent ) 47+)T'D +N9UR+' No *ulsations2No !isible in"uries2 multiple abrasions on lower chest left side '(ternal genitalia2Normal

Head and neck2Normal pine2Normal '(tremities 2Normal

Thora(2 @th Ath Bth rib fractures *elvis 2Normal

*R4!+ +4N), D+)%N4 + 2 >lunt +n"ury )bdomen +N!' T+%)T+4N 2 0& >lood 2 erial HbF2C.AgmF TR>7 21.@lakhs8cmm %rouping 2)U!' .& Urine 7olour2 normal ugar 2TT ,5T 2 erum >ilirubin 2TT %4T %*T )lkaline phosphatase 1& =-Rays )bdomen 4thers )bdominal paracentesis 7olour 2Red Iuality 2 TT )mylase2 TT #icroscopy2 TT plenic ,aceration plenic ,aceration $%rade-1& +notropics used2 Dopamine +!U )lbumin 2TT #icrobiology 2TT T7 D7 *7!21.F

?& erum )mylase 8 erum electrolytes 2Na-0?1meGL3-1.0meG

A& Ultrasound canning 2Haemoperitoneum, B& 7'7T )bdomen 2 Haemoperitoneum, TR')T#'NT 2 Resuscitation 2Done O,#r!%18# %r#!%-#.%2 Time lag from in"ury2 .1 hrs -

>lood 8 >lood products transfused2 . points whole blood

Nature of operation2 ,aparotomy, ,avage V plenectomy )naesthesia2 %)

*reoperative findings 2 Haemoperitoneum V spleenic laceration *ost operative course 2 %ood :ound infection 2TT >urst 2TT )nastamotic leak 2TT Name 2 .%anni Ra"u )ge8 e( 2 1@yrs8# Urban 8 Rural 4ccupation 2 ,abourer Duration 20 day #ode of +n"ury 2 RT) History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 ,eft hypochondrium Radiation 2No .. !omiting 2 . episodes 5reGuency 2 Duration 2 0 day 7haracter 2Dull aching Referral 2 No Respiratory complications2 left pleural effusion Re-laparotomy 2TT 4thers 2TT CASE SHEET-A +* No2 0D.B0 Unit2s1 D4) 2 0/8A800 D4 20/8A800 D4D20?8A800$e(pired&

PRESENTING COMPLAINTS$*ain )bdomen

7haracter of vomiting2 >ilious ?. Distension of )bdomen Duration 2 Diffuse 8 ,ocaliEed +f localiEed J site 1. >owels History of passage of flatus and stools after the incident 26es8No +f yes 5reGuency and Guantity 2 7haracter of stools 2 @. #icturition 2 Desire to pass urine 2 6es 8 No >leeding per Rectum2 0 day diffuse

Retention 2No A. )ny other complaints 2No B. )ny associated in"uries 2No *) T H+ T4R62Nil significant

Haematuria 2No

*'R 4N), H+ T4R6 2 moking 8 )lcoholic 2No #'N TRU), H+ T4R6 2 ECAMINATION $ %eneral condition 25air *ulse rate )naemia 2No Hydration2 *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 distended !isible in"uries2 No #ovement with Respiration 2 *resent *eristalsis 2 PALPATION Distention 2 *resent Tenderness 2 *resent #uscular %uarding2 *resent #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 24bliterated Dullness over mass 2 TT hifting dullness2 TT AUSCULTATION $ >owel sounds 2absent ) 47+)T'D +N9UR+' *8R2Normal plenic dullness 2 TT 5luid thrill 2 TTT *uddleSs sign 2 TT )bdominal girth2 Rigidity 2 present Hernial orifices 2Normal No *ulsations2 No '(ternal genitalia2 Normal %ood 20//8min 7onsciousness2 conscious Respiratory rate 2 ./8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 0./8C/mm of Hg

Head and neck2 Normal pine2 Normal '(tremities 2 Normal

Thora(2 Normal *elvis 2Normal

*R4!+ +4N), D+)%N4 + 2 >lunt +n"ury )bdomen with hollow viscus perforation +N!' T+%)T+4N 2 0& >lood 2 erial HbF201gmF TR>7 2@lakhs8cmm .& Urine 7olour2 normal ugar 2TT ,5T2 erum >ilirubin2 T %4T %*T )lkaline phosphatase 1& =-Rays2 )bdomen2 *neumoperitoneum present @& )bdominal paracentesis 7olour2 Red Iuality2 TT B& 7'7T )bdomen2 Not done TR')T#'NT2 Resuscitation2 Done 4perative treatment2 Time lag from in"ury2 .1 hrs Nature of operation2 ,aparotomy, transection of small bowel and end to end anastomosis. )naesthesia2 %) *reoperative findings2 Haemoperitoneum V "e"unal perforation +notropics used2 Dopamine >lood 8 >lood products transfused2 . points whole blood )mylase2 TT #icroscopy2 TT )lbumin 2TT #icrobiology 2TT *7!21/F %rouping 2)U!'

?& erum )mylase 8 erum electrolytes 2Na-0?1meGL3-1.0meG

A& Ultrasound canning2 5luid collection with internal echoes in peritoneal cavity

*ostoperative course2 '(pired :ound infection2 TT >urst2 TT )nastamotic leak2 TT Respiratory complications2 TT Re-laparotomy2 TT 4thers2 TT

CASE SHEET-G Name2 !enkateswara Rao )ge8 e(2 .Ayrs8# 4ccupation2 5armer Duration2 0 day #ode of +n"ury2 Homicidal assault with bow and arrow History of presenting illness 0. *ain )bdomen 4nset2 sudden ite2 Right lower abdomen Radiation2 No .. !omiting2 5reGuency2 7haracter of vomiting2 ?. Distension of )bdomen2 Duration2 Diffuse 8 ,ocaliEed2 +f localiEed J site2 1. >owels2 History of passage of flatus and stools after the incident2 6es8No +f yes 5reGuency and Guantity2 7haracter of stools2 @. #icturition2 >leeding per Rectum2 Duration2 0 day 7haracter2 Dull aching increases with movement Referral2 No +* No2 .?011 Unit2s1 Urban 8 Rural D4)2 /@8/?80? D4 2 /A8/?80? D4D2 0B8/?80?

PRESENTING COMPLAINTS$ *ain in the )bdomen

Desire to pass urine2 6es 8 No Retention2 No A. )ny other complaints2 No B. )ny associated in"uries2 )rrow head is in situ in right iliac fossa with evisceration of omentum *) T H+ T4R62 Nil significant *'R 4N), H+ T4R62 moking 8 )lcoholic2 6es ECAMINATION$ %eneral condition2 5air *ulse rate2 C.8min >*2 00/8B/mm of Hg )naemia2 No Hydration2 %ood *upils2 N R, ,ocal '(amination of )bdomen2 INSPECTION hape2 Normal #ovement with Respiration2 *resent *eristalsis2 No PALPATION Distention2 #ild distension #uscular %uarding2 *resent #ass per abdomen2 No '(ternal genitalia2 Normal PERCUSSION ,iver dullness2 Not 4bliterated Dullness over mass2 TT hifting dullness2 TT AUSCULTATION$ >owel sounds2 )bsent ) 47+)T'D +N9UR+' *8R2 Normal *8!2 Normal plenic dullness2 TT 5luid thrill2 TTT *uddleSs sign2 TT Tenderness2 *resent )bdominal girth2 Rigidity2 No Hernial orifices2 Normal *ulsations2 No '(ternal %enitalia2 Normal !isible in"uries2 *enetrating in"ury in right iliac fossa 7onsciousness2 7onscious Respiratory rate2 ./8min Temperature2 Normal 7yanosis2 No Decubitus Haematuria2 No

Head and Neck2 Normal pine2 Normal '(tremities2 Normal

Thora(2 Normal *elvis2 Normal

*R4!+ +4N), D+)%N4 + 2 *enetrating abdomen in"ury with hallow viscus perforation +N!' T+%)T+4N 2 0& >lood2 erial HbF2 01gmF TR>72 1lakhs8cmm %rouping2 )U!' .& Urine 7olour2 Normal ugar2 TT ,5T2 erum >ilirubin2 TT %4T %*T )lkaline phosphatase 1& =-Rays )bdomen *neumoperitoneum 4thers +!U @& )bdominal paracentesis 7olour2 Red Iuality2 TT localiEed collection. B& 7'7T )bdomen2 5oreign body is seen in descending colon and retroperitoneal haematoma TR')T#'NT2 Resuscitation2 Done >lood 8 >lood products transfused2 Nil +notropics used2 )mylase2 TT #icroscopy2 TT )lbumin2 TT #icrobiology2 TT *7!2 1/F T7 D7

?& erum )mylase 8 erum electrolytes2 Na-0?1meGL 3-1.0meG

A& Ultrasound canning2 #inimal free fluid in peritoneal cavity, foreign body is seen with

4perative treatment2 Time lag from in"ury2 .1 hrs Nature of operation2 ,aparotomy and primary closure of cecal perforation and primary closure of small ileal tear. )naesthesia2 %) *reoperative findings2 7ecal perforation and ileal perforation and retroperitoneal heamatoma *ostoperative course2 :ound infection2 *resent >urst2 TT )nastamotic leak2 TT Respiratory complications2 TT Re-laparotomy2 TT 4thers2 TT

CASE SHEET-B Name2 %. Narayana #urthy )ge8 e(2 ?@8# 4ccupation2 ,abourer Duration2 0 day #ode of +n"ury2 )ccidental penetration in"ury of abdomen with a sharp ob"ect History of presenting illness 0. *ain in the )bdomen 4nset2 sudden ite2 Umbilical region Radiation2 No .. !omiting2 5reGuency2 7haracter of vomiting2 ?. Distension of )bdomen2 Duration2 #ild distension Diffuse 8 ,ocaliEed2 ,ocaliEed +f localiEed J site2 Umbilical Duration2 0 day 7haracter2 Dull aching Referral2 No +* No2 .BBDA Unit2s? Urban 8 Rural D4)2 ?/8/C80? D4 2 ?/8/C80? D4D2 018/C80?

PRESENTING COMPLAINTS$ *ain in the )bdomen

1. >owels History of passage of flatus and stools after the incident2 6es8No +f yes2 5reGuency and Guantity2 0 episode 7haracter of stools2 Normal @. #icturition2 Desire to pass urine2 6es 8 No Retention2 No A. )ny other complaints2 No B. )ny associated in"uries2 No *) T H+ T4R62 Nil significant *'R 4N), H+ T4R62 moking 8 )lcoholic2 6es ECAMINATION$ %eneral condition2 5air *ulse rate2 C.8min >*2 00/8B/mm of Hg )naemia2 No Hydration2 %ood *upils2 N R, ,ocal '(amination of )bdomen INSPECTION hape2 Normal '(ternal genitalia2 Normal #ovement with Respiration2 *resent *eristalsis2 No PALPATION Distention2 *resent #uscular %uarding2 *resent #ass per abdomen2 No '(ternal genitalia2 Normal Tenderness2 *resent )bdominal girth2 Rigidity2 No Hernial orifices2 Normal *ulsations2 No !isible in"uries2 #ultiple penetrating in"uries in the umbilical region 7onsciousness2 7onscious Respiratory rate2 0C8min Temperature2 Normal 7yanosis2 No Decubitus Haematuria2 No >leeding per Rectum2 Nil

PERCUSSION ,iver dullness2 Not 4bliterated Dullness over mass2 TT hifting dullness2 TT AUSCULTATION >owel sounds2 luggish ) 47+)T'D +N9UR+' Thora(2 Normal *elvis2 Normal Head and Neck2 Normal pine2 Normal '(tremities2 Normal *R4!+ +4N), D+)%N4 + 2 *enetrating in"ury abdomen +N!' T+%)T+4N 2 0& >lood2 erial HbF2 0.gmF TR>72 1lakhs8cmm %rouping2 )U!' .& Urine2 7olour2 Normal ugar2 TT ,5T2 erum >ilirubin2 TT %4T %*T )lkaline phosphatase 1& =-Rays2 )bdomen No pneumoperitoneum 4thers +!U @& )bdominal paracentesis 7olour2 Red Iuality2 TT B& 7'7T )bdomen2 )mylase2 TT #icroscopy2 TT )lbumin2 TT #icrobiology2 TT *7!2 1/F T7 D7 *8R2 Normal plenic dullness2 TT 5luid thrill2 TT *uddleSs sign2 TT

?& erum )mylase 8 erum electrolytes2 Na-0?1meGL 3-1.0meG

A& Ultrasound canning2 #inimal Haemoperitoneum

TR')T#'NT2 Resuscitation2 Done >lood 8 >lood products transfused 4perative treatment2 Time lag from in"ury2 .1 hrs Nature of operation2 ,aparotomy ,avage )naesthesia2 %) *reoperative findings2 #inimal Haemoperitoneum V mesenteric tear *ostoperative course2 :ound infection2 uperficial surgical site infection, >urst2 TT )nastamotic leak2 TT Respiratory complications2 *resent Re-laparotomy2 TT 4thers2 TT CASE SHEET-> Name2 !. 7hiran"eevi )ge8 e(2 1/8# 4ccupation2 ,abourer Duration2 0 day #ode of +n"ury2 RT) History of presenting illness 0. *ain in the )bdomen 4nset2 udden ite2 Right Hypochondrium Radiation2 No .. !omiting2 ---5reGuency2 7haracter of vomiting2 ?. Distension of )bdomen2 Duration2 0 day Duration2 0 day 7haracter2 Dull aching Referral2 No +* No2 ??/0D Unit2s1 Urban 8 Rural D4)2 018/D800 D4 2018/D800 D4D2.18/D800 tropics used2 Dopamine

PRESENTING COMPLAINTS$ *ain in the )bdomen

Diffuse 8 ,ocaliEed2 ,ocaliEed +f localiEed J site 1. >owels History of passage of flatus and stools after the incident2 6es8No +f yes 5reGuency and Guantity2 0 episode 7haracter of stools2 Normal @. #icturition2 Desire to pass urine2 6es 8 No Retention2 No A. )ny other complaints2 No B. )ny associated in"uries2 No *) T H+ T4R62 Nil significant *'R 4N), H+ T4R62 moking 8 )lcoholic2 No ECAMINATION$ %eneral condition2 5air *ulse rate2 DC8min >*2 00/8B/mm of Hg )naemia2 No Hydration2 %ood *upils2 N R, ,ocal '(amination of )bdomen INSPECTION hape2 Normal !isible in"uries2 No #ovement with Respiration2 *resent *eristalsis2 No PALPATION Distention2 *resent #uscular %uarding2 *resent #ass per abdomen2 No Tenderness2 *resent )bdominal girth2 Rigidity2 No *ulsations2 No '(ternal genitalia2 Normal 7onsciousness2 7onscious Respiratory rate2 ./8min Temperature2 Normal 7yanosis2 No Decubitus Haematuria2 No >leeding per rectum2 Nil Right Hypochondrium

'(ternal %enitalia2 Normal PERCUSSION ,iver dullness2 Not 4bliterated Dullness over mass2 TT hifting dullness2 TT AUSCULTATION >owel sounds2 *resent ) 47+)T'D +N9UR+' Head and Neck2 Normal pine2 Normal '(tremities2 Normal

Hernial orifices2 Normal plenic dullness2 TT 5luid thrill2 TT *uddleSs sign2 TT *8R2 Normal Thora(2 Normal *elvis2 Normal

*R4!+ +4N), D+)%N4 + 2 >lunt +n"ury in the )bdomen +N!' T+%)T+4N 2 0& >lood2 erial HbF2 0?.CgmF TR>72 1lakhs8cmm %rouping2 )>U!' .& Urine2 7olour2 Normal ugar2 TT ,5T2 erum >ilirubin2 TT %4T %*T )lkaline phosphatase 1& =-Rays )bdomen 4thers +!U @& )bdominal paracentesis 7olour2 Red Iuality2 TT )mylase2 TT #icroscopy2 TT )lbumin2 TT #icrobiology2 TT *7!2 1/F T7 D7

?& erum )mylase 8 erum electrolytes2 Na-0?1meGL 3-1.0meG

A& Ultrasound canning2 Haemoperitoneum with contusion of right lobe of liver

B& 7'7T )bdomen2 Haemoperitoneum with contusion of right lobe of liver TR')T#'NT2 Resuscitation2 Done 4perative treatment2 Time lag from in"ury2 0. hrs Nature of operation2 ,aparotomy V ,avage. )naesthesia2 %) *reoperative findings2 .ltrs of blood in peritoneum *ostoperative course2 %ood :ound +nfection2 TT Respiratory complications2 TT >urst2 TT )nastamotic leak2 TT Re-laparotomy2 TT 4thers2 TT CASE SHEET-6= Name2 >. *arvatamma )ge8 e(2 1/85 4ccupation2 Housewife Duration20 day #ode of +n"ury2 Homicidal assault History of presenting illness 0. *ain in the )bdomen 4nset2 udden ite2 :hole abdomen Radiation2 No .. !omiting2 5reGuency2 . episodes 7haracter of vomiting2 >ilious Duration2 0 day 7haracter2 Dull aching Referral2 No +* No2 000?A Unit2 s1 Urban 8 Rural D4)2 /18/1800 D4 2 /18/1800 D4D2 018/1800 +notropics used2 Dopamine >lood 8 >lood products transfused2 . points whole blood

PRESENTING COMPLAINTS$ *ain in the )bdomen

?. Distension of )bdomen2 Duration2 0 day Diffuse 8 ,ocaliEed2 Diffuse +f localiEed J site 1. >owels History of passage of flatus and stools after the incident2 6es8No +f yes 5reGuency and Guantity2 7haracter of stools2 Normal @. #icturition2 Desire to pass urine2 6es 8 No Retention2 No A. )ny other complaints2 No B. )ny associated in"uries2 No *) T H+ T4R62 Nil significant *'R 4N), H+ T4R62 moking 8 )lcoholic2 No #'N TRU), H+ T4R62 Regular cycles ECAMINATION$ %eneral condition2 5air *ulse rate2 DC8min >*2 0?/8D/mm of Hg )naemia2 No Hydration2 %ood *upils2 N R, ,ocal '(amination of )bdomen INSPECTION hape2 Normal '(ternal %enitalia2 Normal #ovement with Respiration2 )bsent *eristalsis2 No *ulsations2 No !isible in"uries2 #ultiple stab wounds all over anterior abdominal wall 7onsciousness2 7onscious Respiratory rate2 ./8min Temperature2 Normal 7yanosis2 No Decubitus Haematuria2 No >leeding per rectum2 Nil

PALPATION Distention2 *resent #uscular %uarding2 *resent #ass per abdomen2 No '(ternal genitalia2 Normal PERCUSSION ,iver dullness2 4bliterated Dullness over mass2 TT hifting dullness2 TT AUSCULTATION$ >owel sounds2 )bsent ) 47+)T'D +N9UR+' Thora(2 Normal *elvis2 Normal Head and Neck2 Normal pine2 Normal '(tremities2 Normal *R4!+ +4N), D+)%N4 + 2 *enetrating in"ury abdomen +N!' T+%)T+4N 2 0& >lood2 erial HbF2 D.AgmF TR>72 1lakhs8cmm %rouping2 )U!' .& Urine 7olour2 Normal ugar2 TT ,5T2 erum >ilirubin2 TT %4T %*T )lkaline phosphatase 1& =-Rays )bdomen *neumoperitoneum present 4thers +!U )lbumin2 TT #icrobiology2 TT *7!2 1.F T7 D7 *8R2 Normal *8!2 Normal plenic dullness2 TT 5luid thrill2 TT *uddleSs sign2 TT Tenderness2 *resent )bdominal girth2 Rigidity2 *resent Hernial orifices2 Normal

?& erum )mylase 8 erum electrolytes2 Na-0?1meGL 3-1.0meG

@& )bdominal paracentesis 7olour2 >ilious Iuality2 TT B& 7'7T )bdomen2 TR')T#'NT2 Resuscitation2 Done 4perative treatment2 Time lag from in"ury2 0. hrs Nature of operation2 ,aparotomy V ,avage, end to end "e"unal anastomosis )naesthesia2 %) *reoperative findings2 #ultiple "e"unal perforations involving a segment *ost operative course2 %ood :ound infection2 >urst2 TT )nastamotic leak2 TT + Respiratory complications2 TT Re-laparotomy2 TT 4thers2 TT CASE SHEET-66 Name2 #. Ra"a Rao )ge8 e(2 ?Cyrs8# 4ccupation2 ,abourer Duration2 0 day #ode of +n"ury2 >ull gore in"ury History of presenting illness 0. *ain )bdomen 4nset2 udden ite2 ,eft lumbar region and back Radiation2 No Duration2 0 day 7haracter2 Dull aching Referral2 No +* No2 .DBB@ Unit2 s1 Urban 8 Rural D4)2 /A8/A800 D4 2 /B8/A800 D4D2 .C8/A800 +notropics used2 Dopamine >lood 8 >lood products transfused2 . points whole blood )mylase2 TT #icroscopy2 TT

A& Ultrasound canning2 #inimal free fluid in peritoneal cavity

PRESENTING COMPLAINTS$ *ain in the )bdomen

.. !omiting2 ---5reGuency2 7haracter of vomiting2 ?. Distension of )bdomen2 Duration2 0 day Diffuse 8 ,ocaliEed2 ,ocaliEed +f localiEed J site2 ,eft lumbar region and hypochondrium 1. >owels History of passage of flatus and stools after the incident2 6es8No +f yes 5reGuency and Guantity2 7haracter of stools2 Normal @. #icturition2 Desire to pass urine2 6es 8 No Retention2 No A. )ny other complaints2 No B. )ny associated in"uries2 *enetrating in"ury back on left side *) T H+ T4R62 Nil significant *'R 4N), H+ T4R62 moking 8 )lcoholic 2 )lcoholic ECAMINATION$ %eneral condition2 5air *ulse rate2 C.8min >*2 00/8C/mm of Hg )naemia2 No Hydration2 %ood *upils2 N R, ,ocal '(amination of )bdomen INSPECTION hape2 Normal #ovement with Respiration2 *resent *ulsations2 No !isible in"uries2 *enetrating in"ury on back left side '(ternal genitalia2 Normal 7onsciousness2 7onscious Respiratory rate2 ./8min Temperature2 Normal 7yanosis2 No Decubitus Haematuria2 No >leeding per rectum2 Nil

*eristalsis2 No PALPATION Distention2 *resent #uscular %uarding2 *resent #ass per abdomen2 No '(ternal genitalia2 Normal PERCUSSION ,iver dullness2 Not 4bliterated Dullness over mass2 TT hifting dullness2 TT AUSCULTATION$ >owel sounds2 )bsent ) 47+)T'D +N9UR+' Thora(2 Normal *elvis2 Normal Head and Neck2 Normal pine2 Normal '(tremities2 Normal *R4!+ +4N), D+)%N4 + 2 >ull gore in"ury +N!' T+%)T+4N 2 0& >lood2 erial HbF2 0...gmF TR>72 1lakhs8cmm %rouping2 )U!' .& Urine2 7olour2 Normal ugar2 TT ,5T2 erum >ilirubin2 TT %4T %*T )lkaline phosphatase 1& =-Rays )bdomen no *neumoperitoneum )lbumin2 TT #icrobiology2 TT *7!2 1/F T7 D7 *8R2 Normal *8!2 plenic dullness2 TT 5luid thrill2 TT *uddleSs sign2 TT Tenderness2 *resent )bdominal girth2 Rigidity2 No Hernial orifices2 Normal

?& erum )mylase 8 erum electrolytes2 Na-0?1meGL 3-1.0meG

4thers @& )bdominal paracentesis 7olour2 Red Iuality2 TT B& 7'7T )bdomen2 TR')T#'NT2 Resuscitation2 Done 4perative treatment2 Time lag from in"ury2 .1 hrs

+!U )mylase2 T #icroscopy2 TT

A& Ultrasound canning2 No free fluid in peritoneal cavity

+notropics used2 Dopamine

>lood 8 >lood products transfused2 0 points whole blood

Nature of operation2 ,aparotomy primary closure of colon perforation )naesthesia2 %) *reoperative findings2 *erforation of siEe 1(. cm in descending colon with surrounding necrosis *ostoperative course2 :ound infection2 urgical site infection >urst2 TT )nastamotic leak2 TT Respiratory complications2 TT Re-laparotomy2 TT 4thers2 'nterocutaneous fistula CASE SHEET-6? Name 2!.venkatarao )ge8 e( 2 .1yrs8# 4ccupation 2 student Duration 2 0 day #ode of +n"ury 2 5all 5rom Tree History of presenting illness 0. *ain )bdomen 4nset 2 sudden ite 2 lower abdomen and perenium Duration 2 0 day 7haracter 2Dull aching +* No2 ?1?DD Unit2s1 Urban 8 Rural D4) 2 .?8D800 D4 2.?8D800 D4D2.80/800

PRESENTING COMPLAINTS$ *ain )bdomen

Radiation 2No .. !omiting 2 5reGuency 2 7haracter of vomiting 2 ?. Distension of )bdomen Duration 2 Diffuse 8 ,ocaliEed +f localiEed J site 1. >owels

Referral 2 No

History of passage of flatus and stools after the incident 26es8No +f yes 5reGuency and Guantity 2 . episodes 7haracter of stools 2 stools mi(ed with blood @. #icturition 2 Desire to pass urine 2 Retention 2 no A. )ny other complaints 6es 8 No Haematuria 2 no 2 pain in right leg, inability to move right leg >leeding per Rectum2 present

B. )ny associated in"uries 2 fracture right tibia, fracture pelvis *) T H+ T4R62Nil significant *'R 4N), H+ T4R6 2 moking 8 )lcoholic 2No ECAMINATION $ %eneral condition 25air *ulse rate )neamia 2 no Hydration2 normal *upils 2 N R, ,ocal '(amination of )bdomen INSPECTION hape 2 normal *ulsations2No !isible in"uries 2 laceration of siEe A(. in perenium left side, '(ternal genitalia2 Normal 20/.8min 7onsciousness2 conscious Respiratory rate 2 0C8min Temperature 2 Normal 7yanosis 2No Decubitus >*2 0./8B/mm of Hg

#ovement with Respiration 2 *resent *eristalsis 2 PALPATION Distention 2 no Tenderness 2 no )bdominal girth2 Rigidity 2 no Hernial orifices 2Normal plenic dullness 2 TT 5luid thrill 2 TTT *uddleSs sign 2 TT *8R2Normal Thora(2 rib fractures Bth Cth Dth right side *elvis 2 fracture pelvis present #uscular %uarding2 no #ass per abdomen 2 No '(ternal genitalia 2 Normal PERCUSSION ,iver dullness 2Not 4bliterated Dullness over mass 2 TT hifting dullness2 TTT AUSCULTATION $ >owel sounds 2 present ) 47+)T'D +N9UR+' Head and neck2 Normal pine2Normal '(tremities 2 fracture tibia present *R4!+ +4N), D+)%N4 + 2 penetrating in"ury abdomen +N!' T+%)T+4N 2 0& >lood 2 erial HbF20?.CgmF TR>7 21lakhs8cmm %rouping 2)>U!' .& Urine 7olour2 normal ugar 2TT ,5T 2 erum >ilirubin 2TT %4T %*T )lkaline phosphatase )lbumin 2TT #icrobiology 2TT *7!21/F T7 D7 No

?& erum )mylase 8 erum electrolytes 2Na-0?1meGL3-1.0meG

1& =-Rays

)bdomen 4thers +!U )mylase2 TT #icroscopy2 TT

)bdominal paracentesis 7olour 2 Iuality 2 TT

A& Ultrasound canning 2 no free fluid in peritoneal cavity , no solid organ in"ury B& 7'7T )bdomen 2 penetrating in"ury rectum which communicates e(ternally through pereneal wound TR')T#'NT 2 Resuscitation 2Done 4perative treatment 2 Time lag from in"ury 2 .1 hrs Nature of operation 2 ,aparotomy V loop sigmoid colostomy. )naesthesia 2%) *reoperative findings 2 no haemoperitoneum , *ost operative course 2 good :ound infection 2 surgical site infection >urst 2TT )nastamotic leak 2TT 4thers 2TT Respiratory complications2TT Re-laparotomy 2TT +notropics used 2 Dopamine >lood 8 >lood products transfused 2. points whole blood

Ob(#r8!%1&.( !.+ R#(0 %( A((&"1!%1&. 91%* 1.%r! !b+&-1.! 1.:0ry >lunt in"ury abdomen cases associated with intra abdominal in"ury cases without intra abdominal in"ury Total number of cases ?/$0@.?F& .@ @@ Penetratin g injury abdo en $%&'()*+, %
$%

Tota! '% *(-

"er#ent ($)-+ ./)-+

$%%+

A/# 1."1+#."# A/# 1. Y#!r( N&. &' b 0.% N& &' 1.:0ry ,#.#%r!%1./ P!%1#.%( 1.:0ry ,%( ? > 1 B @ 0 ; ? . 0 T&%! P#r"#.%!/# (I5 0/./ ;=.= 0B.@ ...@ 0@

0?-0D ?=-?> ?/-?D 1/-1D @/-@D

1 6? B D A

MA/

A.A

(#D 1."1+#."# e( male female >lunt in"ury .. C *enetrating in"ury D 0 Total No. of patients ?0 D *ercentage BB.@F ...@F

+n this study ma"ority were male.

T1-# &' ,r#(#.%!%1&. Time of presentation :ithin .1hours #ore than .1hours >lunt in"ury ./ 0/ *enetrating in"ury C . Total No. of patients .C 0. percentage B/F ?/F

.C out of 1/ patients were presented to emergency department within .1hours M#"*!.1(- &' 1.:0ry M#"*!.1(- &' 1.:0ry Road traffic accident >ullgore in"ury 5all form height tab in"ury >ullet in"ury >last in"ury B 0.% .A P#.#%r!%1./ 1.:0ry / N&. &' P!%1#.%( .A P#r"#.%!/# (I5 A@F

/ 1 / / /

0 . ? 0 /

0 A ? 0 /

..@F 0@F B.@F ..@F -

Homicidal assault +ndustrial in"ury

/ /

0 0

0 0

..@F ..@F

30 25 20 15 10 5 0 R TA stab injury no of cases

#ost common mechanism of in"ury is road traffic accident followed by fall from height I(& !%#+ &r/!. 1.:0ry

4rgan in"ured

No of blunt patients 0/ A 1 1 ? -

*ercentage of blunt trauma pts ??.?F ./F 0?.?F 0?.?F 0/F -

No. of penetrating trauma patients 0 0 0 . . 1 . 0

spleen liver mall intestine #esentery Retroperitoneal hematoma 7olon and rectum 3idney and ureter stomach

*ercentage of penetrating trauma patients 0/F 0/F 0/F ./F ./F 1/F ./F 0/F

I2o!ated organ injury

$% 1 / 0 ( ' . * $ %

' $ $ $ * * * no) o3 "enetrating trau a "t2 No o3 b!unt trau a"atient2

#ost commonly in"ured organ was spleen followed by liver in blunt abdominal trauma, in penetrating trauma colon is the most commonly in"ured organ in my study

M0 %1, # &r/!. 1.:0r1#( #ultiple organ in"uries mall bowel in"ury with mesenteric tear mall bowel in"ury with urinary bladder in"ury mall bowel in"ury with stomach mall bowel in"ury with large intestine mall bowel in"ury with large intestine and ureter 0 0 0 No. of *atients . 0

A((&"1!%#+ 1.:0r1#( )ssociated in"uries :ith chest in"ury and fracture ribs :ith pelvic fracture '(tremities fractures ? ? . No. of *atients percentage B.@F B.@F @F

A22o#iated injurie2

'% .% *% $% %

.* . . *

M!.!/#-#.% #anagement >lunt trauma pts urgical 7onservative .@ @ *enetrating Total trauma pts No. of *atients 0/ / ?@ @ *ercentage $F& CB.@ 0D.@

?@ cases were managed by surgery and only @ cases were managed conservatively of which 1cases are blunt trauma liver and one case of spleen trauma.

S, #.1" 1.:0ry -!.!/#-#.% #anagem >lunt in"ury ent plenecto D my 7onservat 0 ive *enetrating in"ury 0 / Total No. of *atients 0/ 0 *ercentage $F& D/.D D.0

S plenicinjury m anag em ent

$%

2"!ene#to y #on2er4ati4e

plenic in"ury was most common, 00 of which only 0 case was managed conservatively

L18#r 1.:0ry -!.!/#-#.% #anagement urgical 7onservative >lunt in"ury . 1 *enetrating in"ury 0 / No. of *atients ? 1

Li4er injury anage ent

'

@BF of the liver in"ury patients were managed conservatively.

B&9# 1.:0ry -!.!/#-#.% Ty,# &' B&9# 1.:0ry 7losure of perforation Resection and anastomosis B 0.% 1.:0ry P#.#%r!%1./ 1.:0ry A 0 @ 0 T&%! N&. &' ,!%1#.%( 00 . P#r"#.%!/#(I5 C1.AF 0@.?CF

C&-, 1"!%1&.( Ty,# &' "&-, 1"!%1&. :ound +nfection Respiratory +nfection +ntra abdominal abscess epticemia :ound dehiscence Reactionary hemorrhage 'nterocutaneous fistula B 0.% 1.:0ry 1 ? . . 0 0 0 P#.#%r!%1./ 1.:0ry ? . / / 0 / 0 T&%! N&. &' P!%1#.%( B @ . . . 0 . P#r"#.%!/# 0B.@F 0..@F @F @F @F ..@F @F

:ound infection was the common complication followed by respiratory infection.

D0r!%1&. &' (%!y 1. *&(,1%! Duration in days /-B C-01 0@-.D M?/ B 0.% 1.:0ry @ 0A ? . P#.#%r!%1./ 1.:0ry . @ . 0 T&%! N&. &' P!%1#.%((.J;A5 B .0 @ ?

Duration o3 2tay in 7o2"ita!

**% $$% % %50day2 /5$'day2 $-5*1day2 6 .%day2

@/F of patients were discharged .weeks from their admission

M&r%! 1%y 7ause of death Respiratory +nfection epticemia Reactionary hemorrhage No of patients 0 . 0

+n my study . deaths were due to septicemia , 0 due to respiratory infection and one due to reactionary hemorrhage.

DISCUSSION +n this study A@ cases of abdominal trauma who were admitted at 3ing %erorge, !isakhapatnam during #ay ./00 to 4ctober ./0?, were included and studied 1@ cases. *resently available literature on abdominal in"uries is reviewed and the results of our study are compared with those of well known authors. The following observations were made in the present study. !arious results of the study have been analysed in detail.

6. A/# I."1+#."# +n our study, the age of the patient varied from 0? to B/ years. The ma(imum incidence of abdominal trauma was observed in the age group of ./ to .D years $?/F& followed by the age group of 1/ to 1D years $.?.@F& 0@F belonged to the age group of @/-@D years. 0B.@F belonged to the age group of ?/-?D years and 0/F belonged to the age group of 0?-0D. 4nly . case was found in the age group of more than A/ years $A.AF&. ?. S#D 1."1+#."# +n our study ?0$BB.@F& were males and D$.BF& were femalesL male to female ratio was ?.11F which depicts male predominance. ;. C!0(# &' 1.:0ry +n our study it was found that the most common mechanism of blunt in"ury abdomen was road traffic accidents A@.@F followed by fall from height 0/F and most common cause of penetrating in"ury was stab in"ury$B.@F& followed by fall from hight$@F&. 7.Sy-,%&-( The commonest symptom was pain abdomn present in all patients $0//F& followed by vomiting $1/F&. 4ther modes of presentation were abdominal distension $?@F&, retention of urine $./F&, chest pain $0/F&, hematuria $B.@F&, hematemesis $@F& and loss of consciousness $@F&.

<. P*y(1"! S1/.( +n our study, generaliEed tenderness was present in BB.@F of patients, guarding or rigidity in AB.@F, distension of abdomen in @..@F, absent bowel sounds in ?B.@F and localiEe tenderness in ...@F.

A. I.:0ry !.+ !+-1((1&. %1-# 1.%#r8! +n our study B/F of patients were bought to the hospital within .1 hours after in"ury, ?/F were brought .1-1C hours. The delay in reaching the hospital by ma"ority of the patients may be because of difficulty in transport, poor socio- economic status of the people and lack of proper guidance. +nadeGuacies in the organiEation of trauma care, paucity of means of communication and lack of well eGuipped ambulance facilities also add to the problem. G. I.8#(%1/!%1&.( Routine investigations like hemoglobin F, bleeding time, clotting time, blood grouping and Rh typing, and urine e(amination were done in all cases. ,iver function test, serum amylase, serum electrolytes and chest =- ray were done whenever warranted. *lain =- ray erect abdomen was done in all patients which helped in diagnosing hollow visucs in"ury by showing gas under the diaphragm. Diagnostic paracentesis was done in .. patientsL in 0D cases it was true positive, true negative in 0 case and false negative in . cases. Hence accuracy rat of diagnostic paracentesis in our study was D/.DF. Ultrasound of abdomen was done in all patients. +n one case, ultrasound failed to show splenic in"ury which was found at laparotomy. Hence, accuracy rate of ultrasound abdomen in blunt in"ury abdomen in our study was DA.0@F. Retrograde cystourethrogram was done in a case of suspected blader in"ury, where it helped to diagnose the same. 7hest an a(ial skeleton =-ray were done in case of associated chest in"ury and e(tremities in"ury. 7'7T abdomen was done in stable patients. B. Or/!.( I.8& 8#+

+n our study, commonest organ involved was spleen $??F& followed by liver $./F& mesentery $0?F&, small intestine $0?F& in blunt abdominal trauma and colon and rectum $1/F& was the most common organ involved in penetrating trauma. pleen is most commonly involved in blunt in"ury abdomen because of its mobility, its attachment to many of the structures in the left upper Guadrant and its position and intimate contract with Dth ,0/th and 00th ribs. 4rgans involved in blunt in"ury abdomen in various studies are shown in the following table $comparative study& >. M0 %1, # &r/!. 1.:0ry +n our study A patients showed multiple intra abdominal visceral in"uries +nvolvement of small bowel along with mesentery was seen in . patients and small bowel in"ury along with urinary bladder in"ury in patient, small bowel in"ury with stomach in one case, small and large bowel in"ury with ureter in"ury in one case. 6=. A((&"1!%#+ I.:0r1#( +n our study, C/F of the patients had only isolated abdominal in"uriesL ./F cases had associated in"uries like chest in"ury, rib fractures, long bone fractures and pelvic fracture. 66. M!.!/#-#.% 4ut of ?/ cases of blunt trauma .@ patients were managed surgically and @ patients were managed conservatively. %uidelines for conservative treatment were2 0. Hemodynamic tability of the patient .. #inimal intra *eritoneal collection ?. 7lass + +n"ury of olid organs. #ost of the blunt abdominal patients managed conservatively are those with low grade splenic in"ury. 4ne patient had combined grade + spleen and grade + liver in"ury. urgical

management decisions were taken based on the results of physical e(amination, ultrasound abdomen and diagnostic paracentesis. )ll the penetrating abdominal trauma patients cases were managed surgically. 6?. A+-1((1&. !.+ S0r/#ry (I.%#r8! I. *&0r(5 +n our study, A?F $0D& of the patients managed surgically were operated upon within 0? to .1 hrs after admissionL ?/F$0/& were operated upon B to 0. hours after admissionL most of the patients B/F were operated upon with in 0? to .1 hours after admission. This denotes the time delay in the necessary investigations causing loss of precious time. 6;. S, #.1" I.:0ry M!.!/#-#.% +n our study, plenectomy was done in 0/ $D/.DF& patients $D blunt trauma, 0 penetrating trauma&, conservative #anagement was done in 0 $D.0F& patient, the patient which managed conservatively was hemodynamically stable and presented with pain and tenderness. Ultrasonography of the abdomen and pelvis showed minimal collections. The siEe of the laceration was less than 0 cm. 67. L18#r 1.:0ry M!.!/#-#.% +n our study, 1..DF $. blunt in"ury, 0 penetrating &cases of liver laceration were managed surgically, conservative management was done in @B.0F $1 blunt trauma &of liver in"ury patients. 6<. B&9# I.:0ry M!.!/#-#.% ,arge and small bowel in"uries were 00 $D blunt, 0 penetrating & perforations which were closed primarily. 4ne case of blunt trauma with ileal perforation, mesenteric involvement with compromised blood supply due to which the segment had become gangrenous was managed by resection with end to end anastomosis. 4ne case of penetrating trauma with multiple pro(imal "e"unal perforations was managed by resection with end to end anastamosis.

6A. B !++#r I.:0ry +n our study, we had 0 case of e(tra peritonela rupture of bladder which were managed by closure of rent in two layers with suprapubic bladder drainage. 6G. R#%r&,#%1%&.# ! *#-!%&-! :e had @ cases of retroperitoneal hematoma all cases were without ma"or vascular in"ury. 6B. C&-, 1"!%1&.( +n our study, postoperative wound infection was the commonest complication 0B.@F and most infections were associated with bowel in"ury with peritonitis and in those cases that were brought to the hospital late. Three cases 0..@F developed respiratory infection which subsided with antibiotics and chest physiotherapy. Two cases $@F& developed septicemia, all of whom e(pired as a result of multiple organ failure. Two case $@F& developed intra abdominal abascess and two cases $@F& developed wound dehiscenceL two case developed intestinal fistula and one casev developed reactionary hemorrhage all of which were managed conservatively. 4ne of the patient with wound dehiscence reGuired secondary suturing. 6>.M&r%! 1%y$ :e had a mortality of 0/F, 1 out of 1/ patients, ? deaths were in the late postoperative period, one case e(pired in the early postoperative period whom e(pired as a result of reactionary hemorrhage. The mortality was highL reason might be patient reaching the hospital late, delay in diagnosis and surgery and high incidence of postoperative wound infections.

)bdominal 4rgans involved and complications encountered in blunt in"ury abdomen in various studies are shown in the following table$comparative study& *resent study$nW?/& halu
M&*!-#+ AA#% alD,'ugypt

guptaetalB,+ndia common age group e( plenic in"ury ,iver in"ury mall intestine in"ury #esenteric tear Urinary bladder in"ury 7omplications #ortality ./-.Dyrs #ale$B?F& $0/cases&??.?F $Acases&./F $1cases&0?F $1cases&0?F $0case&?.?F $01cases&1A.BF $1cases&0?.?F B $nWA?& .0-?/yrs #ale$C@F& $Acases&D.@F $0.cases&0DF $00cases&0B.1F $.cases&?..F $Acases&D.@F $@cases&B.DF

$nWD1&

.@-?@yrs #ale$B@F& A0.BF 1B.DF ---.B.CF

$Bcases&00.0F ?C.?F

7ommon age group in our study was ./-.Dyrs, this was similar to halu gupta etal B and #ohamed)) etalD.+n our study male were commonly involved similar to the above studies. o age and se( distribution in our study was comparable. 7ommonly in"ured !isceral organ was spleen similar to #ohamed)) etal study, but liver in"ury was common in shalu gupta etal study. 7omplications were more compared to shalu gupta and #ohamed etal . This was probably because of poor pre operative general condition of the patient. #ortality was similar to shalu gupta etal study, but less :hen compared to #ohamed)) etal study.

CONCLUSIONS DD #a"ority of the victims involved in blunt in"ury abdomen are young males involved in

outdoor work. Road traffic accident is the commonest cause of in"ury. The delay in patients of trauma reaching the hospital may be because of lack of an efficient emergency trauma service.

Thorough clinical e(amination, diagnostic paracentesis, plain =-ray erect abdomen and ultrasound proved to be very helpful in the diagnosis of intra abdominal in"uries. pleen is the commonest organ involved in blunt trauma and colon is the commonly in"ured organ in penetrating abdominal trauma, many patients have associated e(tremity and a(ial skeleton in"uries. :ith advances in diagnosis and intensive care technologies, most patients of solid visceral in"uries with hemodynamic stability can be managed conservatively. :ound infection is the most common complication following surgery. The mortality is highL reason might be patient reaching the hospital late, delay in diagnosis and surgery and high incidence of postoperative wound infection.

SUMMARY 0. #a(imum numbers of cases were in the age group of ./ to ?D years. .. BB.@F of in"ured were males.

?. Road traffic accident was the commonest mode of in"ury in blunt in"ury abdomen accounting for A@FF of the cases, stab in"ury was the commonest mode of in"ury in penetrating trauma accounting for B.@F 1. *ain abdomen was the commonest symptom $0//F& followed by vomiting in 1/F of cases and distension of abdomen in ?@F of cases. @. %eneraliEed tenderness was the commonest physical sign present in BB.@/F of cases followed by guarding8rigidity present in ?BF of cases. A. B/F of cases came to the hospital within .1 hours of the in"ury. B. )ccuracy rate of plain =- ray erect abdomen was CC.DF and ultrasound abdomen was DA.0@F C. pleen was the commonest organ involved in blunt abdominal in"ury $??F& followed by liver $./F&. 7olon and rectum was commonest organ involved in penetrating trauma$1/F& D. B.@F had associated chest in"ury with fracture ribs. 0/. #a"ority of intestinal in"uries were perforations. 00. CB.@F of the cases were managed surgically 0D.@F conservatively. 0.. A?F of the patients managed surgically were operated upon within 0? to .1 hrs after admission and ?/F were operated uponB to 0. hours after admission. 0?. B/F of patients stayed for a period of C to 01 days in the hospital. 01. D.0F of splenic in"ury cases were managed conservatively. 0@. @B.0F of liver in"ury cases were managed conservatively 0A. #ost of bowel in"ury cased managed by closure of perforation, . cases resection V end to end anastomosis was done. 0B. 0 cases of e(tra peritoneal rupture of bladder were managed by closure of rent in two layer with suprapubic bladder drainage. 0C. A cases of retroperitoneal hematoma, all of them managed conservatively. 0D. :ound infection was the commonest complication 0B.@F followed by respiratory infection 0..@F. ./. 4verall mortality rate in our study was 0/ F. >+>,+4%R)*H6

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0) http288www.indian"medsci.org8article.aspNissnW//0D-

1) http288www.ncbi.nlm.nih.gov8pubmed8.//A.CDC,source2Department of %eneral

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