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SOLID ORGAN INJURIES

SOLID ORGAN INJURIES. SPLEEN , LIVER , PANCREAS 2013. Abdominal Injuries. 5 pillars Solid Organs: Bleed, shock Hollow Organs: Leak, peritonitis Retroperitoneum: pancreas, large vessels Urinary system Diaphragm. Mechanism of injuries. Blunt: spleen , liver, and small bowel

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SOLID ORGAN INJURIES

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  1. SOLID ORGAN INJURIES SPLEEN , LIVER , PANCREAS 2013

  2. Abdominal Injuries • 5 pillars • Solid Organs: Bleed, shock • Hollow Organs: Leak, peritonitis • Retroperitoneum: pancreas, large vessels • Urinary system • Diaphragm

  3. Mechanism of injuries • Blunt: • spleen, liver, and small bowel • Penetrating stab: • liver, small bowel, diaphragm, colon • Penetrating gun shot: • small bowel, liver, colon

  4. Splenic Function • Immunologic filter • Primary remover of non-opsonized bacteria • Produces tuftsin and properdin • Properdin vital component of alternate pathway of complement activation • Immunoglobulin production

  5. Splenic Anatomy • 100-250 grams • 200 cc/min blood flow • Splenic artery • 85%-extrasplenic bifurcation • 15%-extrasplenic trifurcation • Ligamentous attachments • stomach, kidney, diaphragm, colon

  6. Diagnosis of Splenic Injury • Physical examination - poor sensitivity • Ultrasound - nonspecific • DPL-too sensitive, ? role in nonoperative management • CT-most common in hemodynamically stable pts • Laparoscopy-has not found a universal role

  7. Management of Splenic InjuriesFactors Influencing Decision • Age of patient- >55yo splenectomy better • Success of non-operative management- 68-83% • Risk of missed injury • Risk of OPSI-0.026-1.0% over lifetime • Risk of blood transfusion-0.014% per unit • Risk of nontherapeutic laparotomy-0.01-6.0%

  8. Non-Operative Management • Proper patient selection • Bed rest 2-3 days • Serial physical exams, Hcts x 24-48 hours • Follow-up CT scan at 3-5 days • Overall hospitalization 5-10 days • Severe injuries-3 months no contact sports

  9. Non-operative management • Embolisation • Trans-arterial catheter  aorta  splenic artery • Partial or total splenic embolization • Splenic immunocompetence is preserved after splenic artery angio-embolisation

  10. Operative Management • Midline incision, pack, examine abdomen • Systematic splenic mobilization • Splenorrhaphy- Cautery, surgicell, pledgetted sutures, mesh wrapping • Splenectomy- life threatening bleeding • Autotransplantation-experimental • Vaccination-Pneumococcus, H. influenza, N. meningitidis

  11. Complications • Pneumonia most common • Subphrenic Abscess 3-13% • Recurrent bleeding - up to 45 days • 1% re-operative rate (for haematoma, or abscess drainage for example) • Acute gastric distention- kids usually • Thrombocytosis (very high platelets)

  12. OPSI • Nausea, vomiting, confusion, sepsis • Mortality 50-70% • Vaccine provides 60% protection • Best timing of vaccine unknown • Proper counseling a must • Sensitive to malaria

  13. HEPATIC INJURIES • ANATOMY • INJURY CLASSIFICATION • INITIAL PATIENT MANAGEMENT • OPERATIVE TECHNIQUES • SPECIAL TOPICS • JUXTAHEPATIC VENOUS INJURIES • SUBCAPSULAR / INTRAHEPATIC HEMATOMAS • EXTRAHEPATIC BILIARY TREE INJURIES • COMPLICATIONS • Most commonly injured in stab wounds and blunt injuries • Present as bleeding with hemodynamic instability

  14. ANATOMY • LIGAMENTOUS ATTACHMENTS • TRIANGULAR • CORONARY • FALCIFORM • COUINAUD CLASSIFICATION OF LOBAR / SEGMENTAL DIVISIONS

  15. DIAGNOSIS OF LIVER INJURY • ATLS primary / secondary surveys • Peritoneal signs - exploration • Hemodynamic instability - US or DPL • Stable – CT scan with contrast (embolization) • Non-operative management : hemodynamic stability, no other suspected injuries, alert patient*, ICU monitoring, accessible for re-examination, minimal transfusions

  16. LIVER -Penetrating Wounds • STAB WOUNDS • LOCAL WOUND EXPLORATION • ULTRASOUND • DPL • ? LAPAROSCOPY • GUNSHOT WOUNDS • EXPLORE • ? ROLE FOR ULTRASONOGRAPHY • ? ROLE FOR LAPAROSCOPY

  17. OPERATIVE TECHNIQUES • MANUAL COMPRESSION • EXPOSURE(INCISION + LIGAMENTS) • PRINGLE MANEUVER (32-75 MINUTES) • Portal vein; hepatic artery: block inflow of blood; find source of bleeding • TOPICAL HEMOSTATIC AGENTS • BOVIE / ARGON BEAM COAGULATOR • FIBRIN GLUE

  18. OPERATIVE TECHNIQUES • Tractotomy / individual vessel and duct ligation • Omental packing • Resectional debridement • Absorbable mesh wrapping

  19. OPERATIVE TECHNIQUES • Drainage (grade III or better) • Laparotomy pad packing - remove before 3 days if possible • *Deep sutures • *Hepatic artery ligation • *Anatomic lobectomy *avoid if possible

  20. OPERATIVE TECHNIQUES • HEAT CONSERVATION • BEGINS WITH INITIAL PATIENT CONTACT • LIMIT HEMORRHAGE • SPEED / EFFICIENCY COUNTS • EQUATES TO PROMPT DECISION-MAKING • DAMAGE CONTROL SURGERY: quick, manage bleeding and contamination; continue resus in ICU • PREVENT TRIAD OF ACIDOSIS, COAGULOPATHY AND HYPOTHERMIA (affects clotting mechanism)

  21. Control of Transhepatic Penetrating Wound

  22. Juxtahepatic Venous Injury • Early recognition • Big (chest) incisions (laparotomy and thoracotomy) • Atrial-caval shunt or caval balloon shunt • Direct attack with or without hepatic vascular isolation • Packing alone

  23. Atrial-Caval Shunt

  24. Subcapsular Hepatic Hematomas During non-operative treatment , operate for: • On-going hemorrhage • Progressive expansion by ct scan • Signs of infection • Deteriorating transaminase measurements Intra-operative, if not expanding: • Leave alone in stable patients

  25. Extrahepatic Biliary Tract Injury • Rare: 3-5% of all abdominal trauma • Gallbladder (most common) • cholecystectomy • CBD > RHD> LHD • <50% circumference - repair with or without T-tube; drain • >50% circumference - duct enterostomy; drain

  26. COMPLICATIONS • Recurrent bleeding - 2% to 7% • Fever - 65% to 75%, grade 3 or more • Abscess - 2% to 10% (increased by shock, transfusion, colon injury) • Biloma / biliary fistula - 5% to 28% • Hemobilia - extremely rare; 1/3 have jaundice, upper GI bleed, right upper quadrant pain • Arterial portal venous fistula

  27. Damage Control Considerations • Deep suturing • Packing • Omental packing • Drains • Antibiotics • Atrial-caval shunts • CT scan / non-operative management

  28. PANCREATIC INJURY • RETRO-PERITONEAL ORGAN • PENETRATING INJURY – IS THE DUCT INTACT ? • BLUNT INJURY – TRANSECTION OF GLAND OVER THE VERTEBRAL COLUMN

  29. PANCREATIC INJURY • DIAGNOSIS DIFFICULT • HIGH INDEX OF SUSPICION • CLINICAL EXAMINATION NOT HELPFUL • U/S, CT SCAN IF STABLE • SERUM AMYLASE (increased? Duct intact? >>) • do ERCP

  30. Diaphragmatic injury • Traumatic rupture (blunt trauma) • More common on left side (85%) • Tear posterolateral from hiatus • Herniation of stomach, colon, spleen into chest • Penetrating injury usually a small hole, on either side

  31. Diaphragmatic injury • Diagnosis: clinical difficult • Bowel sounds in chest on auscultation • CXR: high diaphragm on left side, or diaphragm invisible • Confirmation by passing a nasogastric tube, which can be seen in stomach in chest • Chronic: contrast studies (Ba meal or enema)

  32. Diaphragmatic injury • Laparoscopy (or thoracoscopy) for diagnosis • Repair: surgical, via laparotomy (or thoracotomy), or endoscopic technique • Pitfall: PPV (positive pressure ventilation) reduced the abdominal organs from chest

  33. Questions?

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