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Abdominal injuries

Abdominal injuries. Yoram Klein MD. Introduction. Suture repair of bowel - the 15th century. Routine exploration not employed until WW I. – mortality 70-75%. WW II – mortality 50%. Introduction. Diagnostic challenge. Importance of prompt management (?!).

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Abdominal injuries

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  1. Abdominal injuries Yoram Klein MD

  2. Introduction • Suture repair of bowel - the 15th century. • Routine exploration not employed until WW I. – mortality 70-75%. • WW II – mortality 50%.

  3. Introduction • Diagnostic challenge. • Importance of prompt management (?!). • Evolution in surgical management: Damage control. Staged repair. Colo-rectal repair. Duodenal repair.

  4. Decisions • What is the systemic condition? • Is there an abdominal injury? • Can the systemic condition be related to the abdominal injury?

  5. What is the systemic condition? • Oxygenation. • Hemodynamic stability. • Neurological status.

  6. Is there an abdominal injury? • Mechanism of injury. • Physical examination. • FAST. • Plain X-ray. • CT. • DPL.

  7. Blunt Hemodynamic status. Abdominal wall hematoma. Seat-belt sign. Peritoneal irritation. GI bleeding. Confounding factors. Penetrating Hemodynamic status. Location of the wound. Evisceration. Peritoneal irritation. GI bleeding. Confounding factors. Physical examination

  8. Advantages Free fluid in the peritoneal or pericardial cavity? Quick. Bedside. Repeatable. Disadvantages False sense of security. Retoperitoneum. Hollow viscous injury Penetrating trauma. User dependant. FASTFocused Assessment Sonography for Trauma

  9. Blunt CXR. Pelvic. Penetrating CXR. KUB in GSW. Plain X-ray

  10. Blunt The gold standard. Hemodynamic stability. Normal FAST? Penetrating RUQ low-energy missiles. Triple-contrast for flank and back wounds. CT

  11. Blunt Free fluid with no organ injury in the CT. Patient’s examination unreliable. Discrepancy between FAST and physical finding. Penetrating Violation of the anterior abdominal fascia --- stab wounds. DPL

  12. Emergency laparotomy • Hemodynamic instability and abdominal injury. • Hemodynamic instability and positive FAST. • Diffuse peritoneal irritation. • Significant evisceration. • Imaging study suggesting hollow viscous injury. • GI bleeding.

  13. Management of penetrating injuryGSW • 85% need surgical repair. • Low energy RUQ. • Tangential wounds.

  14. Management of penetrating injurystab wounds Anterior abdomen • local wound exploration. • Violation of anterior fascia – DPL. Flank and back • Triple contrast CT. Left thoraco-abdominal • Surgical evaluation of the diaphragm. Right thoraco-abdominal • CT.

  15. Management of blunt injury • CT. • Free fluid with no organ injury in the CT. Patient’s examination unreliable --- DPL. • If signs of arterial bleeding - angiogram?

  16. Hollow viscous injuries • Diagnostic challenge. • Importance of prompt management (?!). • Evolution in surgical management: Damage control. Staged repair. Colo-rectal repair. Duodenal repair.

  17. Evolution in surgical management • Non-operative management. • Damage control. • Staged repair. • Colo-rectal repair. • Duodenal repair.

  18. Non-operative treatment • No indication for emergency surgery. • Spleen – OPSI in pediatric surgery. • Liver – non bleeding CT diagnosed injuries. • Penetrating injuries – good outcome with stable patients and unavailable OR.

  19. Damage control

  20. Physiological failure On-going coagulopathy acidosis hypothermia

  21. Damage control • Bleeding control. • Contamination control. • Temporary abdominal closure.

  22. Damage control • Bleeding control. • Contamination control. • Temporary abdominal closure.

  23. Damage control • Bleeding control. • Contamination control. • Temporary abdominal closure.

  24. Surgical approach • Hemorrhage control. • Primary exploration and temporary control of spillage. • Thorough exploration and definitive spillage control. • Irrigation. ------------------------------------------ • Reconstitute continuity. • Definitive abdominal closure.

  25. ???

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