Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1348 - файл.pdf
Diagnostic peritoneal lavage is the most useful diagnostic procedure
for suspected intra-abdominal visceral injury.
Diagnostic peritoneal lavage is contraindicated in certain circumstances
when intra-abdominal injury is obvious and mandatory laparotomy is
indicated.
Indications for DPL:
1. Head injury or impaired level of consciousness when abdominal
injury cannot be excluded.
2. Unexplained hypotension, particularly in association with head
injuries.
3. Suspicion of abdominal trauma, e.g. bruising pattern, guarding,
tenderness, no bowel sounds.
4. Wounds that penetrate the peritoneum (except gunshot Wounds)
Complications of DPL:
1. Instillation of fluid into extraperitoneal tissues.
2. Bowel perforation.
3. Trauma to the iliac vessels.
4. Bladder perforation.
* CT scanning:
Computed tomography should be performed when abdominal trauma
is suspected in an unconscious patient undergoing CT
evaluation of head injury. Injuries to solid viscera are easily seen in
the abdominal CT, whereas ruptures of hollow viscus is easily missed.
Patients undergoing CT scan must be haemodynamically stable.
Contrast enhanced CT scan gives useful anatomical and functional
information about several organs.
140
Ultrasonography:
Ultrasound can detect free fluid and injuries of solid organs,especially
liver, kidneys, spleen and associated haematomas. It could also help
detecting rupture of the hemidiaphragm.
FAST (focused abdominal sonography for trauma)
a. To identify if the abdomen is the source of haemorrhage in unstable
trauma patients.
b. To evaluate those with no major risk factors for abdominal trauma.
FAST - Results
Reliability
· Accuracy 86 - 97 %
· Sensitivity 88 - 91.7 %
· Specificity 94.7 - 99 %
· Can detect 70 ml fluid
Surgical intervention in abdominal trauma:
The principles of management should be to stop the bleeding, debride
devitalized tissues, repair wounds to the bowel by suture or resection
and eliminate all foreign bodies, haematomas and intestinal contents
to reduce postoperative complications (infections or others) It is very
important to identify the full extent of the intra-abdominal injury and
to plan the operative strategy.
Injury of diaphragm.
These rare injuries are more common following penetrating trauma
than blunt trauma, but could result from a high speed blunt trauma also.
The sudden rise in intra-abdominal pressure breaches the weakest part
of the abdominal wall, namely the diaphragm. 90% of the diaphragmatic
141
injuries are on the left hemidiaphragm. The right side is protected by
the liver. The diaphragmatic rupture must be repaired at laparotomy to
avoid late complication of diaphragmatic hernia. Colon and stomach
may herniate into the thorax, displacing the lung. Bowel sounds could
be heard in the chest and the chest radiograph may reveal bowel gas in
the lung fields.
A contrast study would confirm the diagnosis. Sometimes cases presented
acutely are treated by thoracotomy or thoracolaparotomy to achieve
proper and accurate exploration.
Injury left diaphragm with colon in left chest cavity.
Spleenic injury
In the majority of cases injury of spleen is a solitary lesion but injury
to adjacent structure such as diaphragm, pancreas, kidney and stomach
is not uncommon finding..
142
Diseased spleen (enlarged) is more likely to rupture than a normal one.
* Pathological features:
Avulsion from the pedicle.
Enlarged spleen usually split on its outer aspect to produce either a
tear or a subcapsular haematoma.
Small tear in the anterior aspect of the hilum which may produce quite
sever bleeding and yet be difficult to detect.
And the importance of determining the degree of the injury may help
for the proper therapeutic steps:
It may permit non operative management.
Could alert the surgeon to the possibility of the spleenic repair at operation
** Clinical presentation:
Spleenic rupture cases are divided into 3 groups:
I. The patient die rapidly, never rallying from the initial shock due to
tear of speenic vessel and complete avulsion of the spleen from its
pedicle that give rise to rapid blood loss which can be fatal in few
min.
II- Initial shock recovery from shock condition with signs of ruptured
spleen, it represents the commonest type of spleenic injury with
75% of cases.
III- Delayed type ; after initial signs have passed off, the symptoms of
serious intra-abdominal catastrophe are post pond for a variable
period up to 15 days or more. The cause of delayed haemorrhage
is local vasoconstriction and blood clot formation that seal the
tear.
143
* General signs of internal haemorrhage:
1. Pallor. 2. Increase of pulse rate.
3. Low blood pressure. 4. Restlessness
** Local signs:
1- Absence of bowel sound
2- Abdominal rigidity (in 50% of cases on upper abdomen)
3- Local bruising and tenderness on upper abdomen.
4- Abdominal distension due to peritonism and ileus.
5- Kehrs sign: pain referred to left shoulder, also can be Demonstrated
15 min after elevation of the bed foot (it is due to contact of blood
to the undersurface of diaphragm).
6 - Positive shifting dullness.
7- Balances sign: (in 25% of cases): there is dull note in both flanks,
but on right side can be shifted, where on left side it is constant
because blood around ruptured spleen is coagulated.
8- Rectal examination (PR): tenderness and soft swelling, due to blood
or clot in recto-vesical pouch.
*** Radiographic signs:
1- Elevation of left hemidiaphragm.
2 - Indentation of left side of gastric air bubble.
3- Obliteration of splenic outline.
4- Fractures of one or more of lower ribs of left side.
5- Transverse colon displaced downward.
6- Fluid b/w the coils of intestine.
7- Obliteration of psoas shadow
144
This CT shows a splenic injury
Management of splenic rupture:
1. Non-Operative Approach
· Stable
· Identified on Scan (USS/CT Scan)
· Exclusion of other injuries
Bed rest for 48 hours
Restrict activity for 6 weeks or longer.
Avoidance of any sports for 6months.
Risks:
· Missed injuries to other viscera
· Delayed rupture of spleen
145
Surgical intervention is indicated (> 30%) when:
· Haemodynamic instability
· Signs of peritonism
· Transfusion requirement >2 units/day
Ruptured spleen
This splenic injury above had stopped bleeding at laparotomy, and no
further treatment was required. Observations such as this led to the
current cautious philosophy of selective non-operative management
Operative approach in splenic injury:
Left paramedian incision is more popular nevertheless in an emergency
situation and supraumbilical midline incision could offer certain
advantages.
146
Ones the spleen is diseased and grossly enlarged a transversal or left
subcostal incision is better and proper, then it gives a good access to
the pedicle and could be extended to a thoracolapratomy incision if
spleen is difficult to handle by the abdominal approach alone.
The intraoperative strategy is according to the condition of the spleen.
Due to the importance of the spleen for the immunology of the organism
the operative strategy is to preserve the spleen.
A. If the spleen is not so much damaged a try to preserve the spleen
should be done (60% of spleens previously resected could be
preserved)
B. Hemisected spleen can be partially resected. C. Small laceration
may be sutured by heavy suture of polydioxanone.
D. Large laceration can be packed with omentum and is secured in
place with the same heavy sutures.
E. If the spleen is severely damaged and bleeding cannot be controlled
splenectomy is indicated.
Complications of splenectomy:
1- Serrous effusion in the splenic bed mimic subphrenic abscess.
2- Thrombocytosis.
3- Late infection which can be prevented by:
Penicillin V for 1 up to for life.
Pneumococcal vaccine.
Liver injury
The liver is the second common injured abdominal organ following
blunt trauma and the most injured after penetrating trauma. Liver trauma
147
may range from simple capsular avulsion or tear to sever retro-hepatic
caval injury. The most important feature is the extent of disruption of
liver parenchyma,in addition to bleeding from capsular tear there is
haemorrhage and necrosis in the liver substance. The mass of clot and
dead tissues that results may cause 2nd bleeding (local fibrinolysis),
infection, rupture to biliary system and spreading inflammatory process
in the liver that resemble cholangitic hepatitis.
There is much similarity between the presentation of rupture of liver
and rupture of spleen.
1. Early death in spite of attempts at resuscitation.
2. Gradualy development of signs of intra-abdominal disaster.
3. Delayed rupture (traumatic haemobilia)
Management.
The basic principles in the management of hepatic trauma are the control
of haemorrhage, removal of devitalized tissues and perihepatic drainage.
I. Non-Operative Approach:
a. Blunt trauma, Stable and is identified on CT Scan.
Exclusion of other injuries • Observe in specialist centre
Possible risks of non-operative way are:
1. Missed injuries to other viscera
2. Delayed rupture of liver (rare)
3. Biliary leaks (ERCP or Percutaneous)
When to stop non-operative approach? (2-11%)
1. If hemodynamic instability
2. Non-hepatic injuries were not previously identified.
3. Transfusion requirement >2 units/day
148
II. Operative approach:
On entering the abdomen haemorrhage can be encountered by 2
manoeuvres:
1. Pringles manoeuvre (compression of hepatic artery and hepatic
vein) -a large gauze pack should be tightly inserted into the laceration.
2. In case of small liver tear, suturing is indicated and possible.,but if
there is a large liver tear packing with planned reoperation within
the next 12-18 hours, and definitive haemorrhage control is sometimes
the only right choice.
Most major complications following hepatic trauma:
1. Postoperative haemorrhage.
2. Abcess formation.
3. Biliary fistula
Pancreatic injury
The usual lesion is transection and this frequently takes place through
the body of the pancreas along the vertical line of the inferior mesenteric
vein. Pancreatic injury is difficult to diagnose and most of cases are
discovered only at surgical exploration.
1. Only mild initial pain being experienced.
2. Over a few hours epigastric and back pain set in and vomiting is
profuse.
3. Then an intractable ileus and progressive circulatory failure develops.
Diagnosis:
1- Serum amylase level may be helpful (if they are markedly raised,
significant injury to pancreas, but also normal value don't exclude
sever damage.
149