Abdominal Trauma

jeffri_winardi_digestive@yahoo.co.id

Apa yang menarik????

 BLACK BOX
Impossible to know specific injury at initial
evaluation
The important key is how to identify any
abdominal injury

Gohil VD. Palekar HD. Ghoghari M. Diagnostic and therapeutic laparoscopy in

various blunt abdomen trauma. WJ o Lap Surg. 2009;2(2):42-7

ATLS!!!!
Primary Survey
ABCDE

Adjunct to primary Survey

CxR, Pelvic xR

Secondary Survey
Head to toe

Anatomy of the Abdomen

Thoracoabdominal area
Transverse nipple line to
costal margin

Anterior abdomen

Costal margin to groin

crease to anterior axillary
lines bilaterally

Flank area

Anterior axillary line to

posterior axillary line, costal
margin to iliac crests

Back

Medial to posterior axillary

lines, tip of scapula to iliac
crests

Torso

All the above

Anatomy of the Abdomen

Intraperitone
al contents
Retroperitone
al space
contents
Pelvic cavity
contents

 Mechanism of Injury???

Blunt Abdominal Trauma

Penetrating Abdominal
Trauma

 Blunt Abdomen Trauma

MVC
Seatbelt injury
Fall from height
Crash injury
Sport injury

Penetrating Abdomen Trauma

Seat Belt Sign Not Just the

Abdomen

 Blunt abdominal injuries carry a greater

risk of morbidity and mortality than
penetrating abdominal injuries.

What Are We Worried About?

Bleeding:

Liver
Spleen
Kidneys
Mesentery

Bowel:
Rupture Contamination

Bladder:
Intraperitoneal rupture

Diaphragm:
Rupture, mainly on the left side

 How to diagnose??
How to managed??

What is hemodynamic stability??

How to Investigate Blunt Abdominal

Trauma? BMJ 2008
Concealed or occult hemorrhage is the 2 nd
most common cause of death after trauma
Missed abdominal injuries are a frequent
cause of morbidity and mortality
Appropriate and expeditious investigations
are important
Non-operative management of solid organ
injury now more common

 Diagnostic tools???

Tools Available For Abdominal

Trauma

Physical exam
X-Rays
Ultrasound (FAST)
Computerized Tomography (CT)
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy
Exploratory laparotomy

Tools Available For Abdominal

Trauma
Physical exam bad for blunt, good for
penetrating (serial physical exams)
X-Rays
Ultrasound (FAST) helpful if positive
Computerized Tomography (CT) not for HVI
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy
Exploratory Laparotomy if needed

Physical Exam
Difficult to rule out internal bleeding
Excellent to watch for the development of
peritonitis (contamination)
Less than 24 hours, usually by 13 hours
A modality usually employed in penetrating
trauma

Very poor to detect bladder or

diaphragmatic injury

Focused Assessment With

Sonography in Trauma (FAST)
Free intra-abdominal fluid
Also pericardial fluid

Non-invasive, no radiation, repeatable

Highly Sn (79-100%) and Sp (96-100%)
Repeating FAST also increases Sn

May still need other imaging modalities with a

negative FAST
Can be performed with equal accuracy by
surgeons
Use controversial in penetrating trauma of the
abdomen
Only helpful if positive

FAST

Diagnostic Peritoneal Lavage

(DPL)
Described in 1965, standard of care
Open or closed (Seldinger) approach
Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%)
Lead to a non-therapeutic laparotomy rate of 36%

Laparotomy when:
10 cc gross blood
Enteric contents
1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3

High false positives with pelvic fractures

Do a supraumbilical approach

High Sn for hollow viscus injuries

Risk of visceral injury = 0.6%
Retroperitoneum cant be assessed

Diagnostic Peritoneal Lavage

In real life:
Good tool if FAST
equivocal in the HD
abnormal pt. in the
setting of a pelvic
fracture
FAST unavailable, pt. is
HD abnormal

Computerized Tomography
Imaging modality of choice only in HD normal patients
Pts crumping in CT a performance indicator in trauma
centres

Sn = 92-97%, Sp = 99% for bleeding

Active arterial contrast extravasation, blush or
pseudoaneurysm

Only modality to directly detect retroperitoneal injury

Less accurate for HVI
Still need serial physical exams
If pelvic fluid is present in absence of solid organ injury
exploratory laparotomy is mandated, especially if moderate
or large amounts of free fluid Chen, 2009
3% males may have pelvic fluid 2dary to resuscitation

Poor test to diagnose diaphragmatic injury

Hypovolemic Shock Complex

How to DIAGNOSE hollow viscus

injury, WHAT TOOLS???
CT scan?? Sensitivity 53,5% and Specificity
92,06%
CT alone cant screen hollow viscus injury, the
decision to operate has to be based on MOI and
clinical findings together with radiological
evidence

Predicting hollow viscus injury in BAT with CT. Bhagvan S, Turai M, Holden
A, Ng A and Civil I. World J Surg.2013;37:123-6

Indications for Laparotomy

Blunt Abdominal Trauma
Absolute Indications:
1.
2.
3.
4.
5.

Shock
Peritonitis
Blood out of NG tube or on rectal exam
Intraperitoneal bladder rupture
Diaphragmatic rupture

Laparoscopic??

Not widely used, but useful in selected patients with BAT, who have
equivocal findings on clinical exam and imaging investigations in order to
clarify the lesional diagnosis, thus avoiding unnecessary laparotomies.

Laparoscopy is safe, feasible, effective procedure and it can reduce

nontherapeutic laparotomies.

Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma?Chirurgia

2011;106(1):59-66
Choi YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc
2003;17:421-7

Laparoscopic??

Not widely used, but useful in selected patients with BAT, who have
equivocal findings on clinical exam and imaging investigations in order to
clarify the lesional diagnosis, thus avoiding unnecessary laparotomies.

Laparoscopy is safe, feasible, effective procedure and it can reduce

nontherapeutic laparotomies.

Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma?Chirurgia

2011;106(1):59-66
Choi YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc
2003;17:421-7

Diagnostic accuracy of laparoscopy

Gohil VD. Palekar HD. Ghoghari M. Diagnostic and therapeutic laparoscopy in

various blunt abdomen trauma. WJ o Lap Surg. 2009;2(2):42-7

Incidence of negative laparotomy

Gohil VD. Palekar HD. Ghoghari M. Diagnostic and therapeutic laparoscopy in

various blunt abdomen trauma. WJ o Lap Surg. 2009;2(2):42-7

Role of Laparoscopy in PAT

2569 patients underwent DL for PAT, 1129 (43.95 %) were
positive for injury. 13.8 % of those with injury had a therapeutic
laparoscopy.
33.8 % were converted ,16 % of which were non-therapeutic and
11.5 % of them were negative.
1497 patients were spared a non-therapeutic laparotomy.
Overall, 72 patients suffered complications, there were 3
mortalities and 83 missed injuries.
Sensitivity ranged from 66.7-100 %, specificity from 33.3-100 %
and accuracy from 50-100

OMalley E, Boyle E, OCallaghan A, Coffey JC, Walsh SR. Role of laparoscopy in

penetrating abdominal trauma: a systematic review. WoJ Surg. 2013;37(1):113-22

Thank you for your attention