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136
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Arrange fluids, blood, catheters, ventilator, etc.
Further definitive therapy depending on severity and site of
injury.
CONCEPTS
B
x Primary management using ABCDEF; assessment of patient as
stable or unstable with defined parameters
x One should follow ATLS or other guidelines
x “Timeline principle/concept” in which clinician should act within
the ‘critical time window’ in the compensatory stage only patient
should be addressed properly to prevent the patient from going
to decompensatory stage. We have to look everywhere and
focused exclusion of specified anatomical regions; check for
SRB's Manual of Surgery
hidden injuries
x Patient should be taken up for Damage Control Surgery (DCS) with
following criteria—hypothermia <34°C; pH <7.2; serum lactate >4
mmol/L; coagulopathy; blood pressure <70 mmHg or MAP <65
mmHg; transfusion of blood of 15 units; ISS >36%.
x “Early Total Care” (ETC) approach is done if patient is stable with
definitive procedures. Criteria for ETC are—stable haemodynamically; no inotropics; no hypoxemia; no hypercarbia; normothermia; serum lactate <2 mmol/ L; urine output >1 m
L/hour/kg.
A
Damage Control Surgery
Resuscitation and early therapy in operation theatre itself.
Minimum but essential surgery to control bleeding and
prevent contamination.
Secondary definitive surgery at a later period to have final
control.
Damagecontrolsurgery is done when there is inability to
control bleeding, complex abdominal injuries like of liver or
pancreas, major vascular injuries with or without bowel injuries, retrohepatic IVC injury which is not accessible; decline in
physiological reserve like temperature, pH, prothrombin time,
serum lactate, systolic blood pressure less than 90 mmHg
for 60 minutes; if operating time expected is more than one
hour, inability to close the wound or whenever reopening the
cavity is needed.
Principles of damage control surgery apply to injuries of the
abdomen, thorax and extremities equally.
Fig. 1.241: Hand injury involving all fingers.
B
Figs. 1.242A and B: A person has bitten this patient during a fight and
removed the central part of lower lip. It was repaired primarily by Y
repair. Rememberhumanbitesaremostdangerous.
SPINAL INJURY
Assess the type, extent and severity of the injury.
Careful first aid and transfer to prevent further damage to
the spinal cord.
Assess the sensory loss or motor loss properly.
Assess fractures clinically, by X-ray, CT scan (for fracture)
and MRI (for spinal cord injuries).
Central cord syndrome is common and is due to hyperflexion
or hyperextension of the neck in an injured patient causing
ischaemia of spinal column due to interfering of spinal artery
blood flow.
Brown-Sequard syndrome: It is due to partial transec tion of
the cord causing ipsilateral motor function loss and contralateral sensory function loss.
High dose of steroid is very useful to prevent further damage.
Rest, traction to neck.
Decompression of spinal canal surgically by removing bone,
disc, haematoma is useful.
Spinal stabilisation.
NECK INJURIES
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Neck is divided into zones for managing neck injuries:
x Zone I: From clavicle to cricoid cartilage
x Zone II: From cricoid cartilage to angle of the mandible
x Zone III: Above the angle of the mandible
Fig. 1.243: Neck trauma zones.
Indicationsfor neck exploration ininjuries: Expanding
haematoma; Uncontrolled external haemorrhage; Decreased
carotid pulse; Stridor, hoarseness, dysphonia, haemoptysis;
Severe dysphagia, odynophagia; Blood in oropharynx.
Treatment:
¾
The neck is explored with adequate incision under general
anaesthesia.
¾
The injured structure like vessels, oeso phagus, trachea,
muscles are sutured.
¾
Antibiotics started;
Blood transfusion is given as required;
Ryle’s tube kept for 5–7 days.
¾
Other injuries like head, thorax, abdomen, maxillofacial
area are discussed in respective chapters.
BULLET INJURIES
Bullet injury has wound of entry and wound of exit. Extent of
damage is not related to the external wounds. It is related to
the travel of bullet inside and extent of blast or cavitation effect
inside caused by the bullet. It causes burn damage.
It can damage vessels, organs like liver, spleen, kidneys,
bowel, lungs, heart, cranial structures, soft tissues, bones and
joints.
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CHAPTER 1J General Surgery: Trauma
Fig. 1.244: Multiple pellets over elbow region after gunshot.
All foreign bodies are removed.
Tendon repair should not be done primarily.
Wound should not be closed. It should be left open.
Adequate blood transfusion and antibiotics cover age should
be given.
Major artery or vein are sutured. Vein graft can be used. But
synthetic graft should never be used.
Thorough inspection, irrigation and debridement of injured
joints is done.
Immobilisation is done.
Tetanus toxoid, antitetanus globulin (3000 units IM), antigas
gangrene serum is given.
Second look surgeries at a later period is done once patient
has been stabilised.
Delayed primary closure in 4–7 days or secondary closure
in 14 days is done.
Depending on extent of defect, skin grafting or flaps are used.
Laparotomy, thoracotomy, craniotomy are done depending
on the site of the injury.
Management
The wounds are explored properly under general anaesthesia.
All dead tissues and dead muscles are excised.
Skin is generously and adequately incised.
Injured nerves are cleaned and silk marker stitches are placed
to identify for later secondary suturing (Nerve should not be
sutured primarily in bullet injury).
During an injury, unsuspected lesions of the spinal cord may cause the most excruciating abdominal pain.—Theodore Schrire
BLAST INJURIES
Here extent of damage is much more than bullet injuries. It
creates complex blast wave which contains blast pres-
sure wave and mass movement of air. This explosion
pressure wave is more than 1000 pounds per square inch.
This pressure wave has got incident pressure and reflected
pressure. Both will cause severe damage.
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SRB's Manual of Surgery
Fig. 1.247: Penetrating injury (sharp rod) into the
skull across brain.
Fig. 1.245: Degloving injury buttock. It needs colostomy to protect
the wound from sepsis. Later once skin coverage is done colostomy
is closed.
A B
Figs 1.246A and B: Crush injury foot with retained skin from plantar
aspect was rotated forward (Courtesy: Dr Mayur Rai, orthopaedician,
KMC, Mangaluru).
FACTORS CAUSING THE DAMAGE
B
x High pressure wave
x Mechanical injury
x Chemical injury
x Thermal injury
x Inhalation of toxic gases and smoke
Organs affected: Ear drums, lungs; GIT, brain; Skeletal
system.
Note:
Individual becomes deaf after blast and so rescue work may be delayed.
Management
¾
Critical trauma care; Ventilator support; Antibiotics.
¾
Management of shock and triage primary management.
¾
Urgent surgeries like laparotomy, thoracotomy, craniotomy.
¾
Massive blood transfusion.
¾
Management of specific organs like eye, ear.
Fig. 1.248: Penetrating injury. Pole missed all the major vessels.
Miraculously the patient survived, after a marathon surgery to tell her
tale to her children.
Fig. 1.249: Stab wound on the back communicating into the thoracic
cavity. Wound was explored and sutured, with an ICT inserted into the
thoracic cavity.
It is life-threatening and immediate surgical intervention is the
only treatment. Patient requires adequate amount of blood
transfusion, antibiotics, shock management.
ABDOMINAL TRAUMA
PENETRATING INJURIES
It can occur in abdomen, thorax, cranial cavity.
It causes haemorrhage, damage to internal organs like liver,
bowel vessels, lung, pericardium and heart, brain.
It can be: Blunt trauma; Stab injury; Abdominal wall injury
Abdominal trauma is a major surgical emergency which most
surgeons face. It is often associated with head injuries, chest,
pelvic and bone injuries. Often patient is unconscious causing
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difficulty in diagnosing the condition. Often more importance
is given to other system injuries like of head, thorax and bones
whereas abdominal injury is not addressed properly causing
life-threatening consequences. When patient is conscious,
history related to abdominal trauma is useful. Abrasion over
the abdominal skin suggests the possibility of internal injury
(London’s sign). Distension, tenderness, rebound tenderness,
fullness and dullness in the flank when present one should
presume internal injury. Tachycardia, hypotension, shock may
be evident when there is significant haemoperitoneum. Injuries
may be organ injury like of liver, spleen, kidney, pancreas, etc.
or bowel injury or retroperitoneal injury which is often under
diagnosed or missed. Major vessel injury like of inferior vena
cava, mesenteric vessels can cause real threat to life unless it
is identified and managed early. 25% of entire trauma patients
need surgical exploration of the abdomen.
Abdominal trauma can be blunt
orstab/penetratingor
abdominalwallinjuries. Spleen is the most common organ
involved in blunt trauma. Often in blunt trauma first part of the
jejunum or ileocaecal junction gives way (blow out effect) due
to traction often causing complete transection of bowel horizontally close to the junction. It is due to force of the mobile part of
the bowel over the fixed part. Liver is the most common organ
involved in penetrating injuries.
Injuries of the abdomen may be closed injuries, compression
injuries and penetrating injuries. Penetrating injuries may be
low velocity injury like stab injuries or high velocity injury like
gunshot injuries.
Penetration of blunt weapon causes less deep
trauma than sharp weapon (sickle, knife). In sickle injury, tip and
sharp edge moves in curved pattern and so it is often difficult to
predict the depth, track and organs injured.
Routinely followed indications for exploration in abdominal
trauma are—hypotension without any other cause; bleeding
through wound; continuous bleeding in nasogastric tube; evisceration of abdominal content through the open wound except
in case of protruded omentum without any hypotension and
features of peritoneal irritation; air under diaphragm in blunt
abdominal injury (not in penetrating injury as external air gets
sucked into the peritoneal cavity through the wound).
TYPES
B
x Liver injury
x Spleen injury
x Gastric/small bowel/colonic injuries
x Duodenal injuries
x Pancreatic injuries
x Injuries to kidney/bladder/urethra
x Mesenteric injury
x Vascular injuries
x Associated injuries like of diaphragm, lungs
x Abdominal compartment syndrome
x Gunshot or blast injuries
General Clinical Features
Features of shock—pallor, tachycardia, hypo tension, cold
periphery, sweating, oliguria.
Abdominal distension.
Pain, tenderness, rebound tenderness, guarding and rigidity,
dullness in the flank on percussion.
Respiratory distress, cyanosis depending on the amount of
blood loss.
Bruising over the skin of the abdominal wall.
Features specific of individual organ injuries.
Investigations
1. Ultrasound abdomen. FAST is Focused Abdominal Sonar
Trauma: It is rapid, noninvasive, portable bedside method
of investigation focusing on pericardium, splenic, hepatic
and pelvic areas. Blood more than 100 mL in cavities can be
identified. It is not reliable for bowel or penetrating injuries.
It often needs to be repeated.
2. Diagnostic peritoneal lavage (DPL): It is done in case of
blunt injury abdomen. Through a subumbilical lavage catheter
one litre of normal s aline/Ringer’s lactate is infused into the
peritoneal cavity. Patient is changed to different positions and
side-to-side. Fluid content is aspirated from the abdomen for
assessment. It has got 98% accuracy rate.
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CHAPTER 1J General Surgery: Trauma
Fig. 1.250: Traumatic haemoperitoneum.
ONE OF THE CRITERIAS SIGNIFIES POSITIVE LAVAGE
B
x 10 mL or more of gross blood
x RBC count more than 1,00,000/cumm
x WBC count more than 500/cumm
x Amylase level in the fluid more than 175 IU/dL
x Presence of bile, bacteria, food particles or foreign body
It is the procedure of choice in physiologically unstable patient
with blunt abdominal injury (like with spinal injury, unconscious
patient).
Remember what you do not know. It differs you from others.
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SRB's Manual of Surgery
A B
Figs. 1.255A to C: Stab injury to LIF by an angry husband to his wife causing left common iliac artery transection injury with aortic partial
injury. In spite saphenous vein graft reconstruction patient could not survive (Courtesy: Professor Yogishkumar, MS, KMC, Mangaluru).
C
CONTRAINDICATIONS FOR DPL
B
x When laparotomy is definitely indicated
x Previous laparotomy
x Pregnancy
x Obesity
3. CT scan is indicated in assessing retroperitoneum, solid organ
injuries. It is noninvasive and highly specific.
4. Diagnostic laparoscopy (DL) is valuable method in stable
abdominal trauma patient.
Treatment
Emergency laparotomy.
INDICATIONS FOR LAPAROTOMY
B
x Frank haemoperitoneum
x Significant diagnostic peritoneal lavage
x Haemodynamically unstable patient
x Ultrasound or CT scan shows significant intra- abdominal injuries
A B
Figs. 1.252 and B: Diagnostic peritoneal lavage—incision and technique. 10 French polyvinyl catheter is used. Urinary bladder is emptied by
passing a catheter. After injecting xylocaine local anaesthesia into subumbilical region, 2–3 cm vertical subumbilical midline incision is made.
Skin, linea alba is incised. Local anaesthesia is infiltrated into the peritoneum again. Peritoneum is held with two haemostats and a purse string
suture is placed using polyglactic acid absorbable suture material. Peritoneum is incised for 3 mm length. Catheter (standard peritoneal dialysis
catheter) is introduced into the peritoneal cavity. If blood enters the catheter immediately, it means early laparotomy is needed and carried out
without continuing the peritoneal lavage. Otherwise, one litre of normal saline is infused into the peritoneal cavity rapidly in few minutes through
the catheter using a drip set with elevation of the fluid bottle/bag. Patient is moved well to mix the fluid in all four quadrants. Now bag is lowered
below so that fluid from the peritoneal cavity reenters/siphoned into the bag. Collected fluid is analysed for red cells, leukocytes, etc. DPL may not
be useful in bowel injury, retroperitoneal injury, diaphragmatic injury, organ haematoma (subcapsular splenic haematoma). If patient is decided
for observation catheter can be left in situ for repeat DPL after 6 hours. One has to remember that DPL is not a substitute for clinical assessment
and monitoring. In Lazarus-Nelson approach Teflon catheter with a guide wire is used.
BLUNT TRAUMA OF ABDOMEN
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It is common in accidents. It is often missed or lately diagnosed.
Ultrasound/CT abdomen or diagnostic peritoneal lavage (DPL)
is useful. In many cases on clinical grounds direct exploratory
laparotomy is done. Plain X-ray abdomen may show gas under
diaphragm.
Difficulty arises in deciding about the need for laparotomy in
abdominal trauma in unconscious patients. If severity of external
injury is out of proportion to the existing severe shock then
exploratory laparotomy is indicated in an unconscious patient.
It is also often difficult to diagnose bowel injury in such patients.
If it is suspected laparotomy should be undertaken in such
patients. Associated spinal injury masks the abdominal findings.
Injuries may be of liver, spleen, GIT, pancreas, mesentery,
vascular or diaphragm. Associated chest, pelvis, skeletal and
head injuries should be remembered.
Features of Blunt Trauma
Features of profound shock, progressive distension of
abdomen, pain, tenderness, guarding, rigidity, rebound
tenderness, dull flank.
Features specific of individual organ injury like obliteration
liver dullness in bowel injury.
Bruising of skin over the abdomen—London’s sign.
Respiratory distress, cyanosis.
Repeated clinical examination is a must in blunt trauma.
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CHAPTER 1J General Surgery: Trauma
A
B
Evaluation
Ultrasound Abdomen
Itis very useful, simpler, noninvasive method of evaluating
the abdomen. Negative ultrasound means no immediate
further intervention is needed and also conservative treatment
can be undertaken.
Advantages of ultrasound: There is no danger of radiation;
it can be done bedside; it can be repeated many times; it
C
Figs. 1.254A to C: Traumatic blunt injury abdomen causing small
bowel injury which is sutured using interrupted horizontal silk sutures.
is cost-effective. Its sensitivity is 90%; specificity is 98%.
Focused abdominal sonar (ultrasound) for trauma (FAST) is
very useful method.
Disadvantages: It is less useful in obesity, with interposition
of gas, when fluid is less than 500 mL; retroperitoneal injuries
and bowel injuries.
Focused abdominal sonar trauma (FAST): It is rapid, nonin-
vasive, portable bedside method of investigation focusing on
pericardium, splenic, hepatic and pelvic areas. Blood more
than 100 mL in cavities can be identified. It is not reliable for
bowel or penetrating injuries. It often needs to be repeated.
Fig. 1.253: Blunt injury abdomen. Note the bruising over abdominal
skin—London’s sign.
Diagnostic Peritoneal Lavage (DPL) (by Perry)
It is useful in blunt injury abdomen. It is not very useful in penetrating injury, bowel injury, retroperitoneal and pelvic injuries.
Well done is better than well said.
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CT Scan of Abdomen
It is most commonly used and better investigation for abdominal
trauma. It is useful in blunt/penetrating trauma, suspected
pancreas, spleen, liver, duodenal, retroperitoneal injuries.
Smaller injuries, early haemoperitoneum are better detected. It
is noninvasive, highly specific, highly accurate (96%), with low
false-positive/low false-negative, noninvasive.
Other Investigations
a. Abdominal diagnostic paracentesis (Drapanas and
McDonald): Here 18 G short bevel spinal needle is inserted
SRB's Manual of Surgery
into the peritoneal cavity after injecting local anaesthetic
agent into the abdominal wall. With continuous suctioning
through syringe, needle is passed at various sites. Positive
tap means return of minimum of 0.1 mL of nonclotted blood.
False-positive result occasionally can occur due to needle
puncture of abdominal wall vessels. Needle should not be
inserted close to previous abdominal scar as bowel may be
adherent underneath the scar. Change of direction of needle
is done by withdrawing the needle tip outer to peritoneum
and again puncturing the peritoneum. Puncture by 18 G
needle of nondistended bowel will seal without any leakage.
Peritoneal tap should be avoided if bowel is distended.
Bilateral flank tap/four quadrant tap is also done with similar
result. Rectus sheath haematoma and false-negative results
are the problems.
b. Diagnostic laparoscopy is very useful. It can be done under
local anaesthesia. Haemoperitoneum, solid organ and
diaphragmatic injuries are well assessed. But bowel and
retroperitoneal injuries are more likely to be missed.
c. Arteriography through Seldinger technique is useful in
suspected cases of renal arterial injury (thrombosis/
spasm); intimal tears, traumatic aneurysm and aortic
occlusion (after seat-belt injury) are well diagnosed with
arteriography. Often it can be therapeutic also. Pelvic bleed
extending into retroperitoneum is not uncommon which can
be assessed by arteriography and also the bleeding vessel
can be identified. But venous bleed cannot be assessed by
this.
d.
Doppler assessment of major vessels may be beneficial
especially for IVC, aorta, iliac vessels, and portal system; but
with haemoperitoneum visualisation window may be poor and
vessels can be better identified by contrast CT scan.
Management Concepts in Abdominal Trauma
Evaluation of extent of the injury; number of organs injured
and severity of injury; haematocrit assessment (haemoglobin
drop up to 6 g% is tolerated well with adequate tissue
oxygenation. Rapid drop of haemoglobin needs adequate
number of blood to be kept ready for transfusion, like 5/10/
bottles or more); central line for volume replacement; urinary
catheterisation; administration of systemic antibiotics.
Autotransfusion of blood is very useful as a life-saving proce-
dure in such situation. Blood from the cavity is sucked out into
a sterile bottle which contains 150 m
L of 3.8% sodium citrate
dextrose solution. This blood is strained/filtered through
gauze and re-transfused. If there is colonic and small bowel
injuries auto transfusion is not possible for fear of sepsis
due to contamination.
Upper midline incision extending down across the left of the
umbilicus is the preferred incision. But surgeon should not be
hesitant to extend the incision into the thorax or do horizontal
T or extend as needed depending on the internal organ injury.
First priority after opening the abdomen is immediate control
of profuse bleeding using finger compression or mop or
pressure. Later once the field is clean; area is assessed for
the extent of injury without releasing the compressed finger
on the bleeding site. A vascular clamp or bulldog clamp is
helpful in such situation. Once it is applied over the site of
bleeding, compressing finger can be removed. Vascular
suturing using 4-zero or 6-zero polypropylene/resection of
the tissue; reconstruction of the area; persistent pressure
mop in situ with closure of the abdominal wall with an option
of second look surgery in 48 hours are the different options.
Individual organs are assessed and graded for injuries and
managed accordingly.
During laparotomy, entire abdomen should be inspected/
palpated carefully for any additional missed injuries. Lesser
sac, retroperitoneum, duodenum, pancreas and diaphragm
should be checked. Often peritoneum on the margin of the
duodenum and right side colon is incised, duodenum and
colon is reflected medially to visualise the retroperitoneum.
Pelvic structures need special attention. Rectum, urinary
bladder injuries are likely to be missed if proper attention is
not given. On catheterisation, if urine is clear it means urinary
system is normal. Portal venous system should be assessed.
Resection or repair should be decided later once haemostasis
is maintained. Whether the injury is to the bowel or organs
(liver/spleen/kidney, etc.) resection or repair approach is
decided depending on the severity of individual organ injury
(based on scale or grade).
Mesenteric tear may be the cause for haemoperitoneum.
Tear may be perpendicular or parallel to the bowel. If it is
perpendicular, haemostasis and approximation of the mesentery is sufficient; if it is parallel tear, then blood supply to
corresponding bowel may be compromised and resection of
that part of the bowel is indicated. Mesenteric haematoma is
left alone if small and nonprogressive. Whether there is any
colour changes in the adjacent bowel should be observed. If
haematoma is large; if it is progressive; if it causes compromised blood supply to the adjacent bowel, then it should be
gently evacuated. Mesenteric leaf is opened using curved
scissor; clot is evacuated using gentle finger dissection;
bleeder is identified and ligated. If there is compromised
bowel function, it should be resected. Bleeding from the
major vein like superior mesenteric vein is disastrous as tear
may not be localised but may be extensive; and even gentle
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dissection may cause more tear. It is carefully mobilised;
vascular clamps are applied and repaired using 5-zero polypropylene sutures.
Aortic clamping: Catastrophic bleeding found after opening
the abdomen which cannot be controlled and bleeding
with profound hypotension are the indications for aortic
clamping. Profuse intraperitoneal bleed comes under
control temporarily by tamponade effect of tense abdominal
wall and it itself temporarily helps the patient. The moment
abdomen is opened; tamponade effect is released causing
further rapid bleed leading into critical catastrophe. If such
event is expected prior to opening the abdomen very quick
rapid thoracotomy (prelaparotomy thoracotomy) through
left 5th intercostal space is done; left lung is deflated and
displaced; pleura over the thoracic aorta is incised; aorta
is dissected using finger; vascular clamp or soft intestinal
occlusion clamp is applied to occlude the thoracic aorta.
Later laparotomy is performed to go ahead with management of the bleeding. If profound bleeding is observed after
laparotomy necessitating the aortic clamping, it is done
by applying the clamp in infradiaphragmatic part of the
aorta. Peritoneum is incised on the right of the abdominal
oesophagus in infradiaphragmatic area; aorta is dissected
using finger high up close to diaphragm to avoid injury to
celiac plexus; clamp is applied across (infradiaphragmatic
aortic occlusion).
Usually drainage using tube drains on either side of the
abdomen is used even though it is controversial. ICT should
be placed if thoracotomy is also undertaken.
Jejunostomy for enteral nutrition is ideal in all major
abdominal injuries. Often gastrostomy is also done along
with jejunostomy in case of duodenal and pancreatic
injuries.
Management of individual organs after grading its severity of
the injury—duodenum, pancreas, liver, spleen, bowel, kidney,
etc. (Pleasereferindividualchaptersfordetail—highlights
ofindividualorganinjuryisgivenbelow).
Management as critical care (ICU with intensivist); multiple
blood transfusions; management of sepsis, maintenance of
respiration, management of electrolyte changes, treatment
of renal failure, provision of nutrition, prevention of DVT,
management of DIC are very essential part of postoperative
treatment.
DUODENAL INJURY
CT scan is more relevant investigation.
Associated other injuries should be managed accordingly.
Haematoma without extension is managed conser vatively
with nasogastric aspiration, antibiotics and IV fluids.
Lacerations are sutured surgically with a stenting or often
with bypass like gastrojejunostomy.
ERCP stenting or CBD bypass is also often required.
Grading of duodenal injury
T
Grade I – Haematoma
– Laceration
Grade II – Haematoma
– Laceration
Grade III – Laceration Disruption of 50–75% of the circumference
Grade IV – Laceration Disruption more than 75% of 2nd part of the
Grade V – Laceration
– Vascular
COMPLICATIONS
B
x Infection, duodenal leak.
x Peritonitis, haemorrhage.
Involving single portion of the duodenum.
Partial thickness injury without perforation.
Involving more than one portion.
Disruption less than 50% circumference.
of 2nd part of the duodenum; disruption
50–100% of the 1st, 3rd or 4th part of the
duodenum.
duodenum and involving the ampulla or distal
common bile duct.
Severe disruption of duodenopancreatic
complex.
Duodenal devascularisation.
SMALL BOWEL INJURY
It can be blunt injury or stab injury.
Blunt injury causes disruption of either duodenojejunal region
or at ileocaecal region.
Presentation is like haemoperitoneum or features of peri-
tonitis.
Monks localising zones in the abdomen signify the location
of the small bowel injury.
Presence of pattern bruising over the abdominal wall signifies
the small bowel injury and its site. It is called as London’s
sign.
Plain X-ray abdomen shows gas under abdomen with ground-
glass appearance.
Ultrasound abdomen is useful.
Laparotomy and closure of the perforation if it is small.
In presence of extensive bowel injury or multiple injuries,
resection and anastomosis is done.
Any associated injuries should be dealt with accordingly.
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CHAPTER 1J General Surgery: Trauma
Its severity depends on the type and extent of the injury.
It can be haematoma or lacerations.
Lacerations can cause duodenal disruption, may be < 50%
or >50% or 75% or more.
Laceration may extend into the ampulla, distal CBD, pancreas
or with duodenal devascularisation.
COLONIC INJURY
Left sided injury is treated with proximal colo stomy with
closure of the wound if it is small, or resection and anastomosis if it is wider area. Closure of colostomy is done at later
stages after 3–6 months.
Only bed of thorns can give crown of roses.
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A
SRB's Manual of Surgery
B
Figs. 1.255A and B: Assault causing stab injury abdomen. On opening
the abdomen, multiple perforations were found in the small bowel and
was sutured. Patient recovered well.
Small wound over right-sided colon can be sutured primarily.
Ileostomy alone or ileostomy with ileo-transverse anasto-
mosis or right hemicolectomy with ileostomy is indicated in
following situations:
¾
Extensive peritoneal contamination.
¾
Colonic vascular injuries.
¾
Haemodynamically unstable patients.
¾
Long-term hypotension after trauma.
Note:
For injuries of liver, spleen, pancreas, kidney, urinary bladder and urethra
refer respective chapters.
ABDOMINAL COMPARTMENT SYNDROME
Abdominal compartment syndrome (ACS; Richards and Krons,
1984) is organ dysfunction caused by increased intra-abdominal
pressure more than 12 mmHg (intra-abdominal hypertension/
IAH); organ dysfunction is usually respiratory, cardiovascular
and renal but can be any organ; normal intra-abdominal pressure
is being considered as 2–7 mmHg.
Abdominal perfusion pressure (APP) is the pressure which
maintains adequate abdominal blood flow. It is measured by
subtracting the intra-abdominal pressure (IAP) from mean arterial pressure (MAP). APP in ACS is usually less than 60 mmHg
but should be maintained as more than 60 mmHg.
Effects
Cardiovascular system: It is often sudden, rapidly progres-
sive, decreasing the venous return (due to IVC compression)
to heart and increasing peripheral resistance, with decreased
right atrial pressure and decreased cardiac output.
Respiratory system: Intrapleural pressure is increased
proportionately to the abdominal pressure. Upward displacement of the diaphragm, increased peak inspiratory pressure,
hypoxia, hypercapnia, acidosis, respiratory failure, ARDS are
other problems. It also causes restrictive lung disease.
Renal system: Decreased renal blood flow and glomerular
filtration causes oliguria, renal failure.
Gastrointestinal system: Mesenteric venous hypertension;
bowel wall oedema and ischaemia.
Central nervous system: Cerebral oedema and hypoxia,
unconsciousness.
Causes
Major abdominal trauma, postoperative haemorrhages, after
damage control surgery with abdominal packings, are the
common causes; ruptured aortic aneurysm.
Closure of the abdomen under tension; forcible reduction of
the massive hernia.
Bowel wall oedema, mesenteric congestion, acute ascites;
profound hypothermia and coagulopathy.
Acute gastric dilatation, paralytic ileus, gastroparesis, colonic
pseudo-obstruction.
Retroperitoneal haemorrhages, pancreatitis.
Laparoscopic procedures.
Morbid obesity, pregnancy, major burns, continuous ambula-
tory peritoneal dialysis are precipitating causes.
Features and Diagnosis
Tensely distended abdomen, progressive oliguria, airway
obstruction, occult blood loss.
Measurement of urinary bladder pressure: Transducer and
manometer methods are available. Bladder acts as a passive
reservoir at volume less than 100 mL (now 25 mL saline is
used to measure) and it can transmit IAP without imparting
any additional pressure from its bladder musculature. Measurement of bladder pressure reflects the IAP pressure. IAP
is measured using a urinary catheter in the urinary bladder.
Pressure is graded (Burch) as: I—10–15 cm of H2O (will not
require decompression); II—16–25 cm of H
monitoring); III—26–35 cm H
IV—more than 36 cm H
O (most need decompression);
2
O (all need decompression other-
2
wise will die of cardiac arrest in few hours). Beyond grade III
immediate decompression is needed. Initial volume preload is
essential otherwise sudden decompression may cause cardiac
arrest in asystole due to reduced preload, sudden influx of
high potassium, acid and other metabolic by products into
the heart. Grade III and IV becomes a surgical emergency.
O (needs close
2
Chest X-ray, ECG monitoring, ICU care, electrolytes, haema-
https://t.me/medicina_free
tocrit and serum creatinine estimation, USG abdomen should
be done.
Mortality for ACS is 40%.
Intraabdominal
pressure
grading
I 10–15 cm of H
II 15–25 cm of H
III 25–35 cm of H
IV >35 ≥25
Abdominalcompartmentsyndrome(ACS)
Causes
• Multiple
• Postoperative
• Acute abdomen
• Acute gastric
• Laparoscopic
• Intestinal
• Major burns
trauma and
ICU patients—
common
ileus
dilatation
procedures
obstruction
gradingin
Burch
cmofwater
Features
• Hypoxia,
hypercarbia
• Decreased urine
output – anuric
renal failure in
severe cases
• Tense
abdomen—
distended
• Decreased
venous return
• Refractory
hypoxaemia in
severe cases
• Bowel ischaemia
• Cardiac arrest
Society
World
of
theACSinmmof
Hg(Muckartetal.,and
Malbrainetal.)
O 12–15 mmHg
2
O 16–20
2
O 21–25
2
Management
• Bladder pressure
assessment
• Ryle’s tube
aspiration
• Hypotension
• Resuscitation
• ICU care
• Surgical
decompression
Treatment
Abdominal decompression is the only ideal treatment for
ACS; technique and timings are decided based on the clinical
situation.
Temperature and coagulation profile should be made as
possible as normal prior to decompression.
Silastic sheet created chimneys sutured to fascia around
is often used. Pressure free abdominal closure should be
the target. Bogota bag, first described by Londoni, chief
resident in Bogota, Columbia is cost effective; here irrigation bags are sutured to each other as necessary to get a
proper size and is sutured to fascia around using 1-zero
nylon suture. Several litres of serosanguineous or ascitic
fluid are let out through a plastic stoma bag attached to
a closed drainage system. Once patient is haemodynamically stable, definitive closure is performed after 48 hours.
Abdominal fascia is closed using nonabsorbable sutures;
subcutaneous tissue and skin are closed at a later period.
Fluid and electrolyte management, antibiotics, adequate
blood or blood product transfusions should be used as
needed.
Other methods of closure: Towel clips, temporary mesh
placement; PTFE mesh repair; vacuum assisted closure are
all temporary closure methods. Definitive closure methods—
primary closure of fascia; closure using synthetic mesh if no
sepsis in the wound; biological mesh closure; component
separation technique; closure using skin graft or flaps.
SEAT-BELT INJURIES
In an individual with seat-belt, during impact, violent decel-
eration of human body occurs. Seat-belt impinges heavily on
its point of contact with trunk and viscera continue to move
forward. It leads into severe contusion of abdominal contents;
detachment of bowel from its mesentery due to free forward
rapid mobility of the bowel over a relatively fixed mesentery.
Solid organ injury occurs only occasionally.
Two point anchorages causes’ solid organ injuries like of
liver/spleen. Lap-belt causes contusion and bowel injury
commonly.
It is often difficult to identify the injuries due to presence of
more obvious other injuries. CT chest and abdomen, diagnostic peritoneal lavage (DPL) are very useful.
Petechiae around iliac crest or costal margin are signs
wherein one can suspect seat-belt injuries.
Distraction fracture of lumbar spine (chance fracture) with
hyperaesthesia of T12 and L1 level is often associated. 10%
of such fractures are associated with intra-abdominal injuries.
Treatment is immediate laparotomy and proceed—bowel
suturing/resection/suturing of the organ injuries/splenorrhaphy/splenectomy.
145
CHAPTER 1J General Surgery: Trauma
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