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L. Lam and K. Inaba

• REBOA is a viable option for proximal control after chest radiograph to rule out thoracic vascular injury. Consider arterial sheath placement in the ED for easy placement of catheter of needed.

• Recognize when the patient is or will become physiologically impaired—these patients need damage control.

• Lateral repair is preferable but only if there is minimal to no stenosis.

• Shunt common and external iliac and SMA.Repair the aorta.

• Ligate celiac and internal iliac.

• Compress the supraceliac aorta for global control of the abdomen.

• Transection of the pancreas to access the SMA is okay.

• Keep SMA anastomosis away from the pancreas with omental covering.

• Nephrectomy is acceptable to save a life.

Suggested Reading

Asensio JA, Chahwan S, Hanpeter D, etal. Operative management

and outcome of 302 abdominal vascular injuries. Am J Surg. 2000;180:528–33; discussion 533–4.

Asensio JA, Britt LD, Borzotta A, etal. Multiinstitutional experience

with the management of superior mesenteric artery injuries. J Am Coll Surg. 2001;193:354–65; discussion 365–6.

Asensio JA, Petrone P, Roldan G, et al. Analysis of 185 iliac ves-

sel injuries: risk factors and predictors of outcome. Arch Surg. 2003;138:1187–93; discussion 1193–4.

Asensio JA, Petrone P, Kimbrell B, etal. Lessons learned in the manage-

ment of thirteen celiac axis injuries. South Med J. 2005;98:462–6.

Deree J, Shenvi E, Fortlage D, etal. Patient factors and operating room

resuscitation predict mortality in traumatic abdominal aortic injury: a 20-year analysis. J Vasc Surg. 2007;45:493–7.

Tyburski JG, Wilson RF, Dente C, et al. Factors affecting mortal-

ity rates in patients with abdominal vascular injuries. J Trauma. 2001;50:1020–6.

Spleen

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RagavanNarayanan andHeenaP.Santry

In the modern era, while the majority of patients presenting with splenic injury are victims of blunt trauma, up to 14% are victims of penetrating trauma. Conversely, for victims of penetrating trauma, the spleen has been reported to be one of the most infrequently injured organs, ranging from 7% to 9%.

In recent years, due to an increase in nonoperative man-

agement of splenic injuries through a combination of observation and endovascular approaches, fewer patients have been brought to the operating room (OR) for splenic injury. Once in the OR, fewer splenectomies overall have been performed due to concerns regarding the infectious risks of asplenia, new modes of splenorrhaphy with topical hemostatic agents and articial mesh, and advances in techniques of partial splenectomy.

Meanwhile, there has been a trend toward selective non-

operative management of penetrating abdominal trauma which involves carefully selecting patients who present without signs of peritonitis, exsanguinating hemorrhage, or hemodynamic instability and can be reliably serially examined (e.g., no evidence of intoxication, no concomitant head injury with altered mental status). Up to 40% of anterior abdominal stab wounds and 33% of gunshot wounds can be managed nonoperatively using these criteria. Abdominopelvic computerized tomography (CT) scans with intravenous (IV) contrast are often used as adjuncts in nonoperative management (NOM) for penetrating abdominal trauma. A series of gunshot wounds managed nonoperatively with the addition of computerized tomography found that 6/8 splenic injuries did not require laparotomy, while another with mixed penetrating mechanisms found that 24/225 were successfully managed without operation. Laparoscopy has also been used by some, in particular when there is concomitant concern for associated diaphragmatic injury without need for urgent

splenectomy. A 2019 systematic review including 5 published studies with a total of 608 cases of penetrating splenic injury where 20% of patients were managed nonoperatively reported an 18% failure rate with no mortality in NOM group vs. 11% mortality in the operatively managed group where the latter had hemorrhagic shock, concomitant intraabdominal injuries, and/or peritonitis on presentation.

Still, severe penetrating injuries to the spleen can result in uncontrolled bleeding and death if not rapidly addressed with splenectomy, and more than 80% of penetrating splenic injuries are treated with urgent splenectomy.

Assessing the severity of splenic injuries has been standardized over the years. Currently, most surgeons use the 2018 modication of the American Association for the Surgery of Trauma (AAST) Organ Injury Scale which relies on intraoperative and/or CT ndings (see Table 58.1). However, due to the relative rarity of penetrating splenic injuries, these grading systems have been based largely, if not exclusively, on data from victims of blunt trauma. Typically, grade I–III injuries can be managed nonoperatively or with a splenic salvage procedure, while more extensive injuries to the spleen will require splenectomy. More recently, data has suggested that the addition of the arterial phase in high resolution CT imaging with higher sensitivity for vascular injury signifying a higher grade injury than measured by standard contrast CT might result in a higher threshold for angiographic or operative management at the time of initiation imaging rather than waiting for clinical deterioration as a trigger for intervention. Figure 58.1 shows a CT image from a stable penetrating left thoracoabdominal gunshot wound patient who based on a grade IV injury was taken to the operating room and underwent splenectomy and diaphragm repair.

R. Narayanan · H. P. Santry (*) Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, USA e-mail: ragavan.narayanan@ketteringhealth.org;

heena.santry@ketteringhealth.org

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length

subcapsular or parenchymal hematoma

Intraparenchymal >10cm

liver parenchyma

or one to three Couinaud segments

parenchyma into the peritoneum

lobe

R. Narayanan and H. P. Santry

cava/central major hepatic veins

Vascular Vascular injury with active bleeding contained within

Intra-parenchymal, <5cm in diameter Intra-parenchymal, <10cm in diameter

Ruptured subcapsular or parenchymal hematoma ≥5cm

Laceration Parenchymal disruption involving 25–75% hepatic lobe

Vascular Vascular injury with active bleeding breaching the liver

producing >25% devascularization

bleeding conned within splenic capsule

Vascular Juxtavenous hepatic injuries; i.e., retrohepatic vena

bleeding extending beyond the spleen into the peritoneum

Laceration Capsular tear, <1% parenchymal depth Laceration Capsular tear, <1% parenchymal depth

Spleen Liver

Grade Type Injury description Type Injury description

Table 58.1 2018 American Association for the Surgery of Trauma splenic injury grading scale

I Hematoma Subcapsular, <10% surface area Haematoma Subcapsular, <10% surface area

Laceration 1–3cm parenchymal depth Laceration Capsular tear, 1–3cm parenchymal depth, <10cm

II Hematoma Subcapsular, 10–50% surface area Haematoma Subcapsular, 10–50% surface area

III Hematoma Subcapsular, >50% surface area Hematoma Subcapsular, >50% surface area of ruptured

Laceration >3cm parenchymal depth or involving trabecular vessels Laceration Capsular tear, >3cm parenchymal depth

IV Laceration Parenchymal laceration involving segmental or hilar vessels

Vascular Any injury in the presence of a splenic vascular injury or active

Vascular Any injury in the presence of splenic vascular injury with active

V Laceration Shattered spleen Laceration Parenchymal disruption involving >75% of hepatic

Additional points

Advance one grade for multiple injuries up to grade III

Vascular injury (i.e., pseudoaneurysm or AV stula) appears as a focal collection of vascular contrast which decreases in attenuation on delayed images

Active bleeding, focal or diffuse collection of vascular contrast which increases in size or attenuation on a delayed phase

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Fig. 58.1 CT image from a hemodynamically stable patient who presented with a penetrating left thoracoabdominal gunshot wound

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58.1 Exposure

As with most cases of traumatic hemorrhage, a generous midline incision is the best approach for splenic trauma. If further exposure of the left upper quadrant is needed, as in the case of obese patients or those with an unusually narrow costal angle, you can extend the incision to the left hypochondrium—although it is rarely needed.

After opening the abdomen, you should pack all four quadrants or suction to clear hemoperitoneum and rapidly identify obvious injuries. A series of 225 penetrating splenic injuries found concomitant diaphragmatic (60%), hollow viscus (38%), liver (32%), renal (25%), abdominal vascular (10%), and pancreatic (1%) injuries. If you identify more pressing injuries to address than that of the spleen, you should quickly address them. In most cases of multiple injuries, with the exception of abdominal vascular injuries, you should address the spleen rst, as continued bleeding from the organ can harm the patient due to both ongoing blood loss and obscuring the operative eld. If you are having difculty identifying the source of bleeding in a particularly bloody abdomen despite packing and suctioning, you will identify the main source of bleeding by turning to the site of clot formation. Debrinated blood tends to spread freely throughout the peritoneal cavity whether or not the spleen is the source.

After quelling the bleeding with suctioning or packing the four quadrants and rapidly examining for associated injury, pack the small bowel inferiorly into the lower abdomen and pelvis. Then, deliver the spleen into the operative eld with gentle inferior and medial traction so as to not exacerbate the underlying injury. Depending on the length and density of

the splenic attachments to surrounding structures, you may not be able to fully deliver the organ without mobilization.

58.2 Mobilization

Start mobilizing the spleen by sharply dividing its superolateral attachment, the splenophrenic ligament, to the level of the esophageal hiatus, followed by its inferolateral attachment, the splenorenal ligament. Take care during this maneuver not to injure the left adrenal gland which is characteristically located in an anti-hilar position. Division of these attachments may be facilitated by placing a clamp or nger under these attachments prior to division to develop a plane (see Fig.58.2).

Once the lateral and inferior attachments are divided (Fig. 58.3), you rotate the spleen medially by cupping the palm of the right hand around the anti-hilar side of the spleen and engaging the ngers of your nondominant hand around the posterior aspect of the organ in the plane between itself and the retroperitoneal lining of the kidney. It will then be possible to bluntly dissect behind the tail of the pancreas and deliver the spleen and pancreatic tail as a unit into the midline wound. The degree of dissection required behind the tail will be determined by the length of the patient’s pancreas with shorter organs requiring less mobilization (see Fig.58.4).

The nal step in mobilization is the division of the splenocolic ligament. You may encounter sizable vessels traversing this ligament, and they should be appropriately controlled with the clamp and tie method using 3-0 silk sutures or a hemostatic device such as the LigaSure device or Harmonic scalpel (see Fig.58.4).

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Fig. 58.2 Splenic ligaments and attachments. Division of these attachments may be facilitated by placing a clamp or nger under these attachments prior to division to develop a plane

Splenic a. v.

Stomach

R. Narayanan and H. P. Santry

Splenic flexor of colon

Gastrosplenic ligament

Splenophrenic ligament

Pancreas

Left

kidney

12th rib

Splenorenal

ligament

11th rib

GastricRenal

Spleen

Colic

Fig. 58.3 Gently pull the spleen to easily detach the ligaments

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Short

gastric

vessels

Fig. 58.4 Mobilize the spleen and pancreatic tail gently after it has been freed of all attachments

58.3 Vascular Control

You can control excessive hemorrhage during the course of the mobilization by applying digital pressure on the hilum and gastrosplenic ligament with an assistant’s hand or in extreme circumstances with a clamp across the hilum. In general, the latter maneuver should be avoided prior to full mobilization as it puts the tail of the pancreas at risk for injury. After you have fully mobilized the spleen, as described above, you should address its dual blood supply.

With the spleen rotated inferiorly and medially into the eld in your assistant’s hand, you should control the short gastrics within the gastrosplenic ligament with the clamp and tie method with 3-0 silk ties or with the LigaSure (TM) device or Harmonic (TM) scalpel (see Fig.58.5). Standard electrocautery should not be used as the vessels will rebleed

Fig. 58.5 Control the short gastric vessels by taking the vessels closer to the specimen to avoid inadvertent gastric wall ischemia. If a vessel must be taken close to the gastric wall, consider inverting the area with a Lembert suture

if simply cauterized. You should divide and ligate the vessels along the greater curvature proximally and then distally. If ties are used and encompass a small area of the gastric wall, this poses a risk for later necrosis and leak from that area. In such instances, oversew the tied-off area along the greater curvature with 3-0 silk Lembert sutures to bury the potentially compromised area.

Finally, you address the hilar vessels. You serially dissect and individually divide the main arterial and venous branches heading into the hilum. Mass division must be avoided as it may result in later arteriovenous stula (AVF) formation. The individual branches into the splenic parenchyma from the main splenic artery and vein are variable in anatomy. You should divide each of these branches on the side of the pancreas with a suture ligature of 0-0 silk followed by a similar tie or with a vascular stapler. While the division should take place as close to the spleen side of the vessels as possible to avoid injury to the tail of the pancreas, do not waste time tying the side of the vessels that are to become part of the specimen (see Fig.58.6).

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Ligated splenic a.

R. Narayanan and H. P. Santry

• Bury short gastric ties that may compromise the stomach

wall with Lembert sutures to prevent future necrosis and

leak.

• Avoid mass ligation of the hilar vessel as this will result in

AVF formation.

• Clamp close to the spleen and tie on the pancreas side to

complete division of hilar vessels.

• Rule out diaphragm and left kidney injury.

• Leave a closed suction drain in place only for injuries to

the tail of the pancreas.

Splenic v.

Suggested Reading

Tail of pancreas

Fig. 58.6 Control of the hilar splenic vessels

58.4 Specimen Removal andFinal Inspection

After you divide the hilar vessels, the specimen will be free to pass off the table. You should reinspect the left upper quadrant at this point, or after addressing other injuries noted upon entry into the abdomen, for any missed injuries. In particular, the left kidney and the diaphragm are at risk when penetrating trauma has also injured the spleen severely enough to require splenectomy. Operative treatment of these injuries is discussed elsewhere in the text. You must also reexamine the tail of the pancreas closely. If injured by the original mechanism or by the splenectomy, leave a closed suction drain in place. Otherwise, the spleen bed does not require drain placement. Consider vaccinating the patient for pneumococcus, meningococcus, and H. inuenzae 2–3weeks after the splenectomy or upon discharge, whichever comes sooner.

Important Points

• Extend the midline laparotomy incision superiorly to the

left of the xiphoid if exposure is inadequate.

• Look for clotting to nd the bleeding source.

• Develop a plane under the lateral attachments using a

clamp or nger under these to ease the sharp division of these attachments.

• Mobilize the spleen medially with the tail of the pancreas

by getting into the plane between the retroperitoneal lining over the kidney and the posterior aspect of the spleen.

Berg RJ, etal. The contemporary management of penetrating splenic

injury. Injury. 2014;45(9):1394–400.

Brady RR, etal. Splenic trauma in Scotland: demographics and out-

comes. World J Surg. 2007;31(11):2111–6.

Carlin AM, etal. Factors affecting the outcome of patients with splenic

trauma. Am Surg. 2002;68(3):232–9.

Cirocchi R, et al. Is non-operative management safe and effec-

tive for all splenic blunt trauma? A systematic review. Crit Care. 2013;17(5):R185.

Como JJ, etal. Practice management guidelines for selective nonop-

erative management of penetrating abdominal trauma. J Trauma. 2010;68(3):721–33.

Hemachandran N, etal. Revised AAST scale for splenic injury (2018):

does addition of arterial phase on CT have an impact on the grade? Emerg Radiol. 2021;28(1):47–54.

Kozar RA, etal. Organ injury scaling 2018 update: spleen, liver, and

kidney. J Trauma Acute Care Surg. 2018;85(6):1119–22.

Lamb CM, Garner JP.Selective non-operative management of civilian

gunshot wounds to the abdomen: a systematic review of the evidence. Injury. 2014;45(4):659–66.

Morell-Hofert D, etal. Validation of the revised 2018 AAST-OIS clas-

sication and the CT severity index for prediction of operative management and survival in patients with blunt spleen and liver injuries. Eur Radiol. 2020;30(12):6570–81.

Navsaria PH, etal. Selective nonoperative management in 1106 patients

with abdominal gunshot wounds: conclusions on safety, efcacy, and the role of selective CT imaging in a prospective single-center study. Ann Surg. 2015;261(4):760–4.

Navsaria P, Ball C, Nicol A.Reply to the brave challenge of NOM for

abdominal GSW trauma and the role of laparoscopy as an alternative to CT scan. Ann Surg. 2017;265:e38.

Nicholas JM, etal. Changing patterns in the management of penetrating

abdominal trauma: the more things change, the more they stay the same. J Trauma. 2003;55(6):1095–108; discussion 1108–10.

Pachter HL, Grau J. The current status of splenic preservation. Adv

Surg. 2000;34:137–74.

Pallett JR, etal. A cross-sectional study of knife injuries at a London

major trauma centre. Ann R Coll Surg Engl. 2014;96(1):23–6.

Raikhlin A, etal. Imaging and transcatheter arterial embolization for

traumatic splenic injuries: review of the literature. Can J Surg. 2008;51(6):464–72.

Teuben M, etal. Selective non-operative management for penetrating

splenic trauma: a systematic review. Eur J Trauma Emerg Surg. 2019;45(6):979–85.

Penetrating Rectal Injuries

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AndrewJ.Nicol andPradeepH.Navsaria

The management of penetrating rectal trauma has been evolving over the last century. There has more recently been a shift in policy from the mandatory colostomy suggested from the military experience to the realisation that civilian low-velocity intraperitoneal rectal injuries can be managed similar to other colonic injuries. The introduction of laparoscopy in trauma has provided screening for and the identication of the transpelvic gunshot wound that has not breached the peritoneal cavity. This has allowed for a far more conservative but safe approach to the management of the extraperitoneal rectal injury. Debate has also arisen about the need for distal rectal washout and the effectiveness of presacral drainage.

59.1 Historical Perspective

The mortality rate from rectal injuries was in the order of 90% at the turn of the twentieth century. This rate dropped to 60% during the First World War due to debridement and primary repair of rectal wounds. Mandatory proximal faecal diversion and presacral drainage during the Second World War saw a further decrease in mortality to 30%. Irrigation of the distal rectal stump was introduced during the Vietnam and Korean conicts, and the wide availability of antibiotics, intensive care management and blood products saw a further decline in mortality to 15%.

There is no universal consensus on the application of this military surgical experience in the eld of civilian lowvelocity penetrating rectal trauma, but the following are presented as guidelines that have been effective and safe in the management of these injuries at our own institution.

A. J. Nicol (*) · P. H. Navsaria Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, South Africa e-mail: andrew.nicol@uct.ac.za; pradeep.navsaria@uct.ac.za

59.2 Surgical Anatomy

The surgical management of the penetrating rectal injury is dependent on the part of the rectum that is injured and whether this is extra- or intraperitoneal.

The rectum is around 12cm long and is divided into thirds according to the peritoneal attachments. The peritoneum covers the upper one-third of the rectum on the front and sides, and this is the intraperitoneal rectum. The middle third is only covered on the anterior aspect by peritoneum. The lower third is completely extraperitoneal as the peritoneum is reected on to the upper part of the bladder in the male (to form the rectovesical pouch) or on to the upper vagina in the female (to create the rectouterine pouch).

Injuries to the lower one-third of the rectum and to the entire posterior wall are considered to be extraperitoneal.

59.3 Incidence

Penetrating rectal injuries occur infrequently, but the majority (>80%) that occur are secondary to gunshot wounds as reported from most trauma centres. Our own experience has shown low-velocity gunshot injuries to be responsible for 99% of rectal trauma. Stab wounds and impalements are uncommon.

59.4 Special Investigations

The presence of blood on the rectal examination should alert the surgeon to the presence of a colonic injury. If there is suspicion of a potential rectal injury from the tract of the gunshot wound or the knife, then a sigmoidoscopy must be carried out to exclude this even in the absence of blood on rectal examination. Genitourinary tract injuries are commonly associated with rectal injuries, and indeed, concomitant bladder injuries have been present in up to one-third of patients with rectal trauma. Ensure that a CT scan (with

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A. J. Nicol and P. H. Navsaria

rectal contrast) and CT cystogram have been performed preoperatively on the haemodynamically stable patient. This will provide information with respect to the tract of the bullet and allow you to plan the most appropriate form of intervention.

59.5 Surgical Strategies

59.5.1 Patient Position

The patient should be positioned in the Lloyd-Davies position. This provides the best access into the pelvis particularly if bleeding is encountered and the extraperitoneal rectum requires mobilisation. A sigmoidoscopy should be performed on the haemodynamically stable patient in order to diagnose and locate the position of the rectal injury. A urinary catheter should already be in situ.

59.5.2 Laparotomy

A midline laparotomy is performed in haemodynamically unstable patients or in those with an acute abdomen. Ensure that your skin incision reaches the pubic symphysis. Do not injure the bladder on entering the peritoneal cavity. The principles of abdominal trauma surgery apply; control any haemorrhage and prevent contamination.

Intraperitoneal rectal injuries are dealt with in a similar fashion to other colonic trauma. Ensure that the wound edges have been debrided and are bleeding. Simple holes are closed with a single-layer absorbable suture. No drains are required.

In the event of a high-velocity destructive gunshot wound to the rectum, the surgeon should be in a damage control frame of mind, and the sigmoid should be ligated and the distal rectal stump transxed with a TA stapler. Identify the ureters bilaterally or follow them down from the bifurcation of the common iliac artery to ensure that they are not ligated. We nd a silk is superior to linen in the ligation of bowel. Simply pass an artery forceps through the mesentery and then pull the silk suture through and tie off the colon. A single suture usually sufces. At the subsequent relook laparotomy, the sigmoid colon is brought out as an end stoma and the injured rectum removed.

In stab wounds and in low-velocity gunshot wounds, the site of the injury needs to be identied. If there is a single hole, ensure that you are not missing the second hole. Place a nger in the hole and palpate the colon for any further holes. It can be easy to miss a hole where the mesentery attaches to the rectum. If there is any doubt, then the hole in the intraperitoneal rectum can be enlarged and looked at under direct vision. If there is a second hole but this is

extraperitoneal, then this second hole can be left unsutured and a proximal defunctioning loop sigmoid colostomy performed.

The extraperitoneal rectum only needs to be mobilised if there is massive haemorrhage adjacent and if there is involvement of the vessels in the mesorectum (superior and middle rectal arteries). This may also depend on the experience of the surgeon involved as these can also be packed with abdominal swabs into the pelvis for haemostasis. If the injury to the rectum is entirely extraperitoneal, then these holes do not need to be sutured. There is no advantage to repair, and in many cases, it is technically difcult to do so. A defunctioning sigmoid loop colostomy should be the mainstay in the management of these extraperitoneal injuries.

Look also for any bladder involvement. The bladder may even be opened in the anterior midline if necessary to exclude an injury. Another option is to have an unscrubbed assistant ll the bladder with a mixture of sterile water and methylene blue via the urinary catheter. Traumatic rectovesical stulas need to be recognised and dealt with. The bladder must always be repaired and then an omental pedicle placed between the bladder and the rectum in order to reduce the high incidence of rectovesical stulas from combined rectal and genitourinary trauma.

59.5.3 Laparoscopy andaTrephine Loop

Colostomy

A laparoscopy is indicated in the haemodynamically stable patient with a transpelvic gunshot wound who presents with blood per rectum but no abdominal peritoneal signs. If there is no blood or urine in the peritoneal cavity, then the patient can be safely managed with a trephine loop sigmoid colostomy in the left iliac fossa without the need for a laparotomy (Fig.59.1).

59.5.4 Distal Rectal Washout

The value of distal rectal washout in civilian injuries has been questioned. Present-day experience with low-velocity gunshot wounds tends to show no benet from distal rectal washout, and it is considered to be associated with a high risk of infection because of spillage from the unrepaired extraperitoneal rectal perforation. This has resulted in most trauma surgeons abandoning this procedure.

59.5.5 Presacral Drainage

The placement of a drain in the presacral space through an incision in the anococcygeal raphe was advocated in the mil-

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491

Fig. 59.1 Management strategy for an extraperitoneal gunshot wound of the rectum

Non-acute abdomen

Laparoscopy Laparotomy

Normal

No repair

Sigmoid loop colostomy

No presacral drain

No distal rectal washout

Perform sigmoidoscopy and note level of injury.

Exclude bladder injury with CT cystogram

Acute abdomen

Intra-peritoneal blood or breach of peritoneum

itary experience, but the only randomised clinical trial in the civilian setting has shown that this did not reduce septic complications and is currently not recommended.

59.5.6 Antibiotic Treatment

Broad-spectrum antibiotics should be administered for a full period of 7days in the event of an extraperitoneal injury that has been purely managed with a loop colostomy and no laparotomy, and the patient should be monitored closely for the development of pelvic sepsis. If this does occur, then the collection is usually amenable to percutaneous drainage under ultrasound guidance.

Important Points

• Always place the patient in the Lloyd-Davies position as the surgical access into the pelvis is improved.

• Identify and sling both ureters early in the dissection. This avoids an iatrogenic injury and helps exclude any traumatic injury to the ureter.

• Follow the tract of the bullet and ensure that any bone or joint involvement is extensively washed out.