Penetrating abdominal injury

1. Penetrating abdominal injury Chao-Wen Chen M.D. Hon-Man Chen M.D. Division of Traumatology Department of Emergency Medicine Kaohsiung Medical University Hospital

2. Preface • Penetrating abdominal injury is usually caused by gunshot wound or stab wound. • More common in area of high level of poverty, low level of education and high alcohol consumption.

3. Mechanism • Gunshot wound • Low velocity: <2000ft/s (<609m/s) • Damage due to direct injury to vital structures • High velocity: >2000ft/s (>609 m/s) • Wide debridement necessary • Organ injury generally requires more complex techniques • Stab wound • Knives are most prevalent

4. Priorities • Hemodynamic status • Area of injury • Specific consideration based on injury area

5. Gunshot wound

6. Stab wound

7. Immediate laparotomy • Shock • Peritonsim • Evisceration

8. Evisceration

9. Categories of hemodynamics • Dying patients • Emergent laparotomy is indicated • Unstable groups • Emergent laparotomy may be needed , if ABCs are well performed with poor response • Stable groups • Decision according to clinical presentation or trauma mechanism

10. Initial Management of the Hemoclynamically Stable Patient • Assess ABC's • Apply oxygen • Oxygen saturation/ECG Monitoring • At least two large-bore IV catheters • Expose patient • All patients: hematocrit, urinalysis, type and screen • As indicated: coagulation studies, platelet count, elec-trolytes, renal function studies, amylase, ethanol/toxicologyscreening, pregnancy screening • Nasogastric tube/Foley catheter, as indicated • Notify trauma surgeon, anesthesiologist, operating room, asindicated • Complete physical exam with special attention to abdominalexam, rectal exam and neurovascular exam of the lowerextremities • Antibiotics, tetanus prophylaxis

11. Pitfalls • Abdominal exam is frequently unreliable • Physical findings have been reported to be lacking in 23-36% of patients with intraperitoneal injuries*1 • Whereas l4-28% of patients without intraperitoneal penetration will have false-positive physical findings*2 *1 Thai ER. Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 1977;17: 642-648 *2 Moore EE, Marx JA. Penetrating abdominal wounds: Rationale for exploratory laparotomy. JAMA 1985;252:2705-2708.

12. Surgical management • Local wound exploration • Damage control surgery • gradually accepted • Definite surgery • based on area of abdomen injured • Consider the possible nontherapeutic laparotomies

13. Management based on area of abdomen injured • Upper abdominal injuries • Spleen • Liver • Stomach • Duodenum • Pancreas • Middle abdominal injuries • Small bowel and mesentery • Colon • Renal • Lower abdominal injuries • Rectal • Perineal • Bladder • Vascular injuries

14. Most Frequently Injured Organs from Anterior Abdominal Stab Wounds LiverSmall bowel/mesenteryStomachColonSpleenKidneyPancreasDuodenumBiliary tract

15. Guidelines for management of anterior abdominal injuries(EMST) • Laparotomy for all penetrating abdominal injuries with: • Hypotension • Peritonitis • Evisceration • GSW • 99% risk of significant injury • Therefore, explore ALL patients • Some evidence to contrary (after imaging) (Saadia R, Degiannis E. 2000) • If the injury is tangential, and the patient is stable, consider laparoscopy • Stab wounds • Local exploration of wound • Observe if no signs on examination. Perform serial examinations or DPL

16. Flank and back injuries • The thickness of the flank and back muscles is protective (skin to peritoneum: 10-20cm) • Investigation of potential colon ,renal and ureteral injuries • Wounds are more frequently tangential • Serial physical examinations are very accurate in detecting retroperitoneal or intraperitoneal injuries to flanks or back • Contrast CT scans are useful

17. Specific management - spleen • In recent years there has been an appreciable shift from operative management toward nonoperative management (Corson & Williamson, 2001)

18. AAST Splenic injury grading system

19. Non-operative management - spleen • Can avoid post-splenectomy sepsis • Only applicable when operating theatre is available at short notice • Failure rates of conservative management: • Grades I,II,III  5% • Grades IV,V  18% (Davis et al 1998) • Probably more dependent of amount of haemoperitoneum. Attempts have been made to classify this by CT • Note delayed rupture occurs between 1 and 9 days (mean 3.5 days) • Beware splenic artery false aneurysms (causing contrast blush)  62% failure rate

20. Operative management - Spleen • Splenorrhaphy • Uncommon – if the patient needs a laparotomy, splenectomy is usually indicated • Use of superficial haemostatic agents (electrocautery, argon beam, topical thrombin, oxidised cellulose, absorbable gelatin sponge) • Pledgeted repair • Resectional debridement • Mesh wrap • Splenectomy

21. Specific management - Liver • Non-operative management is increasing • Significantly lower transfusion requirements (where injuries were matched for severity)(Croce MA et al 1995) • Most hepatic bleeding is venous, most splenic bleeding is arterial Maybe 80% of hepatic injury can be managed conservatively • Unstable patients require emergency laparotomy • Discrete contrast blush or frank contrast extravasation probably mandates embolization or laparotomy

22. Operative management - liver • Gauze packing • may have infective complications (Ivatury RR et al 1986) • Omental packing • Resectional debridement • Mass liver suture • Hepatic artery ligation • Total hepatic isolation - good for retrohepatic venous injuries • Atriocaval shunt

23. Specific management – Duodenum • Relatively uncommon 80% due to penetrating trauma (Corson & Williamson 1999) • Difficult diagnosis • Mortality 5%-30% • Three times more likely to die if operation delayed > 24 hours (Lucas CE, Ledgerwood AM. 1985) • Early death – exsanguination due to associated vascular injury • Late death – sepsis

24. Operative management – Duodenum • Most duodenal wounds can be closed primarily by duodenorrhaphy • Debride devitalized tissue • One or two layer closure • Pyloric exclusion for more difficult injuries (Vauhgn GD et al 19987) • Primary repair, followed bySide-to-side gastrojejunostomy

25. Specific management – Pancreas • Associated injuries in penetrating trauma • 75% have injury to one of: (JurkovichGJ, Carrico CJ. 1990) • Aorta • Portal vein • Inferior vena cava • Mortality rate: 10% – 30% • Manage haemorrhage and contamination first

26. AAST pancreatic injury grade

27. Operative management - Pancreas • Minor injuries (grades I and II) • No ductal injury • External drainage alone • Closed systems superior to sump systems (Fabian TC et al 1990) • Grade III • Distal pancreatectomy (up to 80% of gland is well tolerated) • Spleen can be preserved in 50% • Grade IV • Most result in death • Wide external drainage is becoming more common • Distal resection (up to 95% of gland) • Grade V • Most die. Diversion procedures or pancreatoduodenectomy

28. Specific management – Colon • Management recommendations depend on whether destruction is such that resection is required • Strong evidence supporting primary repair of nondestructive wounds in the absence of peritonitis • Anastomoses: • No difference between single/double layer, stapled/hand-sewn; absorbable/nonabsorble

29. Specific management – Colon • Destructive wounds requiring resection, can undergo primary anastomosis if: • Hemodynamically stable • No severe underlying disease • Minimal associated injuries • Do not have peritonitis

30. Current trend : Why and How? • Emergent department discharge or not? • FAST or not? • Laparotomy or laparoscopy? • Out of control? Damage control? • Open or close?

31. ED discharge or not? • 236 patients were enrolled, 69 had selective ED work-up • ED work-up including radiologic and invasive diagnostic procedures, ED disposition, complications and follow-up. • Selective management include hospital admission for observation, triple contrast CT, and local wound exploration. • Patients having a (-) selective ED work-up can be safely discharged… *Selective Management Of Penetrating Truncal Injuries: Is Emergency Department Discharge A Reasonable Goal? J. H. Patton, Jr.M. F. Conrad et al. Am Surg 2001

32. ED discharge or not? • 650 asymptomatic patients with abdominal stab wounds were admitted and underwent serial examination, over a 5 year period. • 582 had no abdominal surgical intervention, while 68 patients had abdominal surgery. • No patients were identified as requiring surgery, more than 12 hours after presentation… • Asymptomatic patients with abdominal stab wounds can be safely discharged after 12 hours of observation. *WHEN IS IT SAFE TO DISCHARGE ASYMPTOMATIC PATIENTS WITH ABDOMINAL STABWOUNDS? 2003 Annual Meeting Heythern Alzamel MD, Stephen Cohn MD

33. FAST or not? • 100 victims of penetrating torso trauma assessed by our trauma teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound.. • The overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity of 96%. The positive predictive value was 86% and negative predictive value was 87%... • The US examination lacks sensitivity to be used alone in determining operative intervention…Rarely does US information contribute to the management of patients with penetrating abdominal injuries *A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003

34. FAST or not? • 149 patients with suspicion for abdominal trauma were evaluated…leaving 134 patients for analysis. • There were 111 true negative FAST exams, 5 true positives, 17 false negatives, and 2 false positives. • Chi-square analysis showed significant discordance between FAST and CT (p<0.001). • Utilization of FAST as a screening tool for BAI in hemodynamically stable trauma patients results in under-diagnosis of intraabdominal injury… • Patients with suspected abdominal trauma should undergo routine CT scanning. *Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002

35. Laparotomy or laparoscopy? • Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. • Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. • Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoraco-abdominal injury. Laparoscopy in the evaluation of penetrating thoracoabdominal trauma McQuay N Jr, Britt LD et al.Am Surg. 2003 Sep

36. Laparotomy or laparoscopy? • Forty-eight patients underwent LS (62 per cent male); average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8. • 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). • No injuries were missed. No patients required reoperation. • LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. The value of laparoscopy in management of abdominal traumaChelly MR, Major K, Am Surg. 2003 Nov

37. Laparoscopy vs. laparotomy • Avoid nontherapeutic celiotomies • Missed injury • Difficulty to view all small bowel with laparoscopy • Difficult to see right-sided diaphragmatic injury • May impair heart/lung function • May cause tension pneumothorax

38. (adapted from Ferrada R, Birolini D. 1999)

39. Control or not? • Damage control surgery: an alternative approach for the management of critically injured patientsKouraklis G, Spirakos S, Glinavou A Surg Today. 2002;32(3):195-202 …These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery • Coagulopathy, hypothermia and acidosis in trauma patients: the rationale for damage control surgeryDe Waele JJ, Vermassen FE. Acta Chir Belg. 2002 Oct;102(5):313-6. Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands…

40. Damage control • Definite surgery is time-consuming and may be not executed • Surgical insult may waste functional reserve • Aims: • Damage control operation • Resuscitation in SICU • Planned reoperation in 24-48 hours

41. Timing for damage control • Bleeding caused by coagulopathy • Severe metabolic acidosis (pH <7.3) • Hypothermia during operation (T° <34°) • Inability to control the haemorrhage (hepatic, retroperitoneal, pelvic, thoracic or cervical) • Inability to formally close the abdomen because of intestinal edema

42. Technique for damage control • Hemorrhage control • Packing ± angiographic embolisation • Ligation of vessels instead of repair • Balloon catheter tamponade for deep or hepatic wounds • Contamination control • Hollow viscus ligation instead of repair • External tube drainage of biliary and pancreatic injury instead of pancreatoduodenectomy • Avoidance of formal colostomy

43. Open or close? • Recent studies demonstrate that ACS is an independent predictor of MOF and that the prevention of ACS decreases the incidence of MOF.. Abdominal Compartment Syndrome: The Cause or Effect of Postinjury Multiple Organ Failure. Balogh Z, McKinley BA et al. Shock. 2003 Dec

44. Open or close? Abdominal compartment syndrome • Intraabdominal pressure rise to: • 10 mmHg  decreased venous return & CO • 25 mmHg  increased airway pressures • How does it occur? • Capillary leak  gastrointestinal oedema • Ongoing bleeding • Definite organ injury  exacerbate general condition • Decompressive laparotomy

45. ACS (Abdominal compartment syndrome) • Pathophysiological effects include release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate. • These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome. Pathophysiology and management of abdominal compartment syndrome. Walker J, Criddle LM et al. Am J Crit Care. 2003 Jul

46. Decompressive laparotomy • Performe in the presence of Intraabdominal hypertension with definite organ failure • Explore total abdomen, control bleeders, hemastasis, temporary abdominal closure or bridging wound gap • TAC: Bogota bag or skin closure?

47. Temporary Abdominal Closure • In contrast to patients with skin closure, Bogota bag patients had no cases of ACS and less morbidity, while achieving similar rates of eventual fascial reapproximation. • the use of a Bogota bag is superior to skin closure in achieving TAC when primary fascial closure is deemed unwise. Temporary Abdominal Closure (TAC): Bogota Bag Is Superior To Skin Closure JJ Morken MD, SG Muehlstedt MD Hernia. 2002 Dec

48. Summary • Organ injury patterns and survival from penetrating abdominal injury have remained similar over the last decade • Death from refractory hemorrhage in the first 24 hours remain the common cause of mortality. • DCS and use of open abdomen are being used more frequently with imporved survival, but result in more morbidity. • Evidence-based analysis will be the ultimate guideline to determine the optimal management.

49. Thank you for your attention!