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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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Zone III
13 Trauma
Abdominal exploration for trauma
Organ Exposure Management
463
Liver
Packing → pringle maneuver (clamp
hepatoduodenal ligament) → mobilization of
the liver and/or retrohepatic packing
Pancreas Open lesser sac
Duodenum Right medial visceral
rotation
Hollow viscus injury
Injury < 50% of lumen → primary repair
Injury involves >50% of lumen → resection and
anastomosis
Low rectal injuries Proximal diverting colostomy
Retroperitoneum Right and left medial
visceral rotations
Maneuvers for exposure Key steps Access to
Left medial visceral
rotation (Mattox
maneuver)
Mobilization of the
left colon, spleen,
pancreatic tail, and
Suprarenal aorta and its branches
left kidney
Right medial visceral
rotation (Cattell-Braasch
maneuver)
Mobilization of the
right colon medially
to the ligament of
IVC
Infrarenal aorta
Treitz and duodenum
(Kocher maneuver)
Distal duodenum
Head of pancreas
Zones of
retroperitoneum
Zone I (Central)
Location Exposed
structures
Aortic hiatus →
Aorta and IVC Always explore
sacral promontory
Zone II (lateral)
Lateral diaphragm →
iliac crest
Kidneys and
their vasculature
Zone III (pelvis) Pelvis Iliac arteries and
iliac veins
Zone II Zone II
Zone I
Management
Expanding or pulsatile
hematoma → explore
Penetrating injury → explore
Small, nonexpanding
hematoma → observe
Penetrating injury → explore
Blunt injury with nonexpanding
hematoma → observe
464
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. C. Gooding et al.
Case scenarios
Case scenario Management
Patient in extremis with abdominal blunt trauma Resuscitative endovascular balloon occlusion of aorta
(REBOA) → Operating room
Hypotensive + polytrauma patient + positive FAST Operating room for laparotomy
Hypotensive patient with renal artery transection
Right renal vein injury Right nephrectomy (no collateral venous ow)
Left renal vein injury Left renal vein ligation without nephrectomy (due to
If contralateral kidney is normal →nephrectomy
collateral venous ow)
Damage control laparotomy
Hypothermia (< 35 °C), acidosis (pH < 7.2), and coagulopathy
Indications
Key steps
Combined bowel and vascular injury
Inability to close the abdomen
Need to return to the operating room to access bowel viability or remove packing
Strategy of damage control laparotomy: control hemorrhage →control contamination →temporary
abdominal closure → resuscitation and rewarming in intensive care unit→ return to operating room
in 24–48 hours for denitive repair
Prep Chin to knees
Incision Perform a midline incision from xiphoid to 2cm above pubic symphysis
(in case you need to pack the pelvis)
Inform anesthesia before opening peritoneum (because the tamponade
effect of the closed abdomen is released)
Control bleeding Pack all four quadrants of the abdomen (start packing with the quadrant
where bleeding seems more signicant
Remove the packs to explore the abdomen (remove the packing from the
quadrant with the least bleeding rst)
→ ligate or shunt vessels
→ hemorrhage from spleen →splenectomy
→ hemorrhage from liver → pack liver
Control
contamination
Temporary
abdominal closure
Primary repair or stapled resection of bowel (leave bowel in discontinuity)
Primary repair or staple gastric injuries
Negative pressure dressings (allows peritoneal uid efux, improves the
ability to bring the fascial edges back together, and facilitates second- look
laparotomy)
13 Trauma
Abdominal compartment syndrome
BMI >30, base decit, pH <7.2, hypothermia, >10 units of PRBCs, >5 L/24 h
Risk factors
of resuscitation
465
Presentation
Diagnosis Measure pressure using intragastric or intravesicular catheters
Staging Grade Pressure (mmHg)
Management Abdominal compartment syndrome
Normal abdominal pressure → 5–7 mmHg
Normal abdominal pressure in obese → 9–15 mmHg
Organ system Effect
Cardiovascular Decreased cardiac output and decreased venous return
Central nervous system Increased ICP, decreased CPP
Pulmonary Increased intrathoracic pressure, increased peak
inspiratory pressure
Renal Decreased urine output, decreased GFR
Grade I 12–15
Grade II 16–20
Grade III 21–25
Grade IV >25
Management
case
Grade I and II Analgesia, sedation, paralysis, NGT
Grade III and IV Decompressive laparotomy
Research
Reference Findings
Brenner A, Belli A, Chaudhri R, Coats T,
Frimley L, Jamaluddin SF, Jooma R,
Mansukhani R, Sandercock P, Shakur-Still H,
Shokunbi T, Roberts I; CRASH-3 trial
collaborators. Understanding the
neuroprotective effect of tranexamic acid: an
exploratory analysis of the CRASH-3
randomised trial. Crit Care. 2020;24(1):560
• Tranexamic acid reduces early deaths in non-moribund
TBI patients regardless of TBI severity assuming it is
utilized within 24 h of injury
• Specically reducing death in patients with bleeding from
traumatic brain injury
• Use of TXA found to reduce early death and death within
28 days of use
466
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Abdominal vascular injuries
Characteristics Most common cause of death after penetrating abdominal trauma
R. C. Gooding et al.
Mechanism of
injury
Diagnosis Penetrating injuries with hemodynamic instability and/or peritonitis mandate immediate
Management Emergency Department Treatment
Penetrating trauma can be low velocity missiles causing direct injury to the vessel or as high
velocity missiles and blast leading to shockwave injury causing early or late thrombosis and
bleeding
Blunt trauma is caused by rapid deceleration causing avulsion or intimal tearing and thrombosis,
direct anteroposterior crushing, and direct laceration of a major vessel by bone fragment
laparotomy. Blunt injuries would proceed with a FAST exam and DPA/DPL if the FAST is
equivocal
AXR is performed to look for bullet fragments
CTA A/P is performed in stable patients who do not require immediate laparotomy and has an
excellent sensitivity and specicity for vascular injury
• Cardiac arrest → resuscitative thoracotomy vs endoluminal aortic occlusion (REBOA)
Management of individual vessel injury
Abdominal vessel Penetrating Blunt
Abdominal aorta Open repair Small intimal tear: non-op
Large intimal tear/rupture: open
vs. endo repair
Celiac artery Ligation (rare)
Superior mesenteric
artery
Open repair/reconstruction Open repair/reconstruction
Renovascular arteries Open repair vs. nephrectomy Endovascular repair
Inferior mesenteric
artery
Iliac arteries (MC Common Iliac)
Iliac veins Ligation or repair if no stenosis Ligation or repair if no stenosis
Inferior vena cava
Ligation (rare)
(MC Internal Iliac)
Open primary repair vs. patch
repair vs. prosthetic reconstruction
Retrohepatic → pack
Lateral venorrhaphy vs. ligation
Endovascular repair
Retrohepatic → pack
Lateral venorrhaphy vs. ligation
13 Trauma
Surgical approaches to exposure of abdominal vessels
Vessel exposed Approach Figure
467
Supraceliac abdominal
aorta
Suprarenal abdominal
aorta
Infrarenal exposure of
abdominal aorta
Dissection of the avascular gastrohepatic
omentum, retracting the stomach to the left
Left medial visceral rotation
Cephalad mobilization of the transverse colon and
rightward rotation of abdominal viscera
Celiac artery Dissection of the upper abdominal aorta through
the lesser sac or by medial rotation of the
abdominal viscera
Retropancreatic SMA medial rotation of the left colon, gastric fundus,
spleen, and tail of pancreas
Iliac arteries Medial rotation of right or left colon. Extend
midline incision by adding a transverse lower
abdominal incision
468
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Surgical approaches to exposure of abdominal vessels
Vessel exposed Approach Figure
Iliac veins Careful mobilization of iliac arteries, can ligate
right internal iliac
Control of bleeding at the iliac vein bifurcation
requires division of the right common iliac artery
Retrohepatic IVC Mobilization of the liver by dividing its ligaments
R. C. Gooding et al.
Infrarenal and
juxtarenal IVC
Medial rotation of the right colon, the hepatic
exure of the colon, and the duodenum
Duodenum
Ascending
colon
Abdominal Injury
Stomach injuries
Mechanism Blunt trauma including handlebar marks, seat belt mark, and being crushed between two
objects → high risk of gastric injury
Penetrating trauma to the thoracoabdominal region → high risk of gastric injuries
Presentation Peritonitis
Diagnosis Diagnostic modality Characteristics Findings
CT Free uid in the absence of solid
organ injury
DPL Used in
hemodynamically
stable patients without
signs of peritonitis
FAST
FAST positive →in the
absence of solid organ
injury suggest gastric
or bowel injury
FAST negative →does
not rule out gastric or
bowel injuries
>500 WBC/ml, elevated
amylase, bilirubin or particulate
material → suggest gastric or
bowel injury
13 Trauma
Stomach injuries
Management Stomach injury case Management
469
Key steps in repairing
gastric injuries
Injury to the body of the
stomach
Injury to the pylorus
requiring primary repair
Injury to pylorus requiring
reconstruction
Injury to the
gastroesophageal junction
Principles for management of stomach injuries
Exposure (open lesser sac to expose posterior stomach)
Debride devitalized tissue
Primary repair (in two layers) or resection and anastomosis
Primary repair with two layers
Heineke-Mikulicz pyloroplasty (transverse repair)
Billroth I or bilroth II
Roux-en-Y esophagojejunostomy
Stomach injuries
Grade Characteristics Management
Grade I Contusion/hematoma
Partial thickness laceration
Grade II Laceration <2cm in GEJ or pylorus
<5cm in proximal 1/3 stomach
<10cm in distal 2/3 stomach
Hematoma → evacuation of hematoma +
seromuscular closure
Laceration → Seromuscular repair
Two-layer primary repair
Grade III Laceration > 2cm in GEJ or pylorus
>5cm in proximal 1/3 stomach
>10cm in distal 2/3 stomach
Grade IV Tissue loss or devascularization <2/3
stomach
Grade V Tissue loss or devascularization >2/3
stomach
Two-layer primary repair
Depending on location of injury
Distal gastrectomy + reconstruction
Or proximal gastrectomy + reconstruction
Total gastrectomy + Roux-en-Y
esophagojejunostomy
470
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Small bowel injuries
R. C. Gooding et al.
Mechanism Blunt trauma including handlebar marks, seat belt mark, and being crushed between
Presentation Peritonitis
Diagnosis Same as gastric injuries
Management American Association for the Surgery of Trauma Grading and management
two objects → high risk of gastric injury
Penetrating trauma to the abdominal region → high risk of gastric injuries
Chance fractures or seat belt fractures caused use of lap belt during deceleration
injuries. They are associated with L4 transverse fractures and small bowel injuries
Grade Characteristic Management
I Hematoma without devascularization
Laceration → partial thickness
II Laceration <50% of circumference Primary repair
III
IV Transection of small bowel Resection and primary
V Transection of small bowel with
Laceration ≥50% of circumference
segmental loss
Devascularized segment
Seromuscular repair
Resection and primary
anastomosis
anastomosis
Resection and primary
anastomosis
Pancreatic and duodenal injuries
Pancreatic and duodenal injuries are more commonly seen after penetrating injuries than
Mechanism
Diagnosis
Management See tables below
blunt injuries
Blunt injuries to epigastrium with bicycle handlebar, steering wheel, or seat belt → high risk
of pancreaticoduodenal injuries
Diagnostic modality Characteristics Findings
CT with IV contrast Duodenal wall thickening/contrast
Amylase or lipase Not specic or sensitive Elevated amylase or lipase (if not elevated
extravasation/air in retroperitoneum/
hypoattenuating pancreas/ pancreatic
edema or hematoma
→ does not rule out injury)
13 Trauma
Duodenal injuries
Duodenal
injuries Characteristics Management
471
Grades I
Grade II
Grade III
Hematoma: Involving single portion of
duodenum
Laceration: partial thickness, no
perforation
Hematoma: Involving more than one
portion
Laceration of <50% of the duodenal wall
circumference
Laceration of 50–75% of the
circumference of the D2 segment or
50–100% of the circumference of the D1,
D3, or D4 segments
Hematoma causing gastric outlet obstruction →
nasogastric tube decompression for 5–7 days + TPN
Seromuscular repair
Primary repair (transverse closure)
Debride damaged tissue
Primary repair + leave a drain near repair
Primary repair (tension-free, horizontal fashion
utilizing one or two layers after debridement of the
wound edges) + buttress with omentum or bowel
loop
Resection/anastomosis
Roux-en-y duodenojejunostomy
Drainage (closed suction is placed as a controlled
stula)
Feeding access (jejunostomy tube)
If combined with pancreatic injury or tenuous
duodenal repair → pyloric exclusion to divert the
ow of gastric contents away from the injury while it
heals
Grades IV laceration of >75% of the circumference
of the D2 segment involving the ampulla/
distal CBD
Grade V Massive disruption or devascularization of
the duodenopancreatic complex
Drainage + feeding access (jejunostomy tube)
Delayed reconstruction
Drainage + feeding access (jejunostomy tube)
Delayed
reconstruction
472
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Protecting duodenal repair
R. C. Gooding et al.
Indications for protecting duodenal
repair
Decompressive procedures • Tube duodenostomy
Diversionary procedures • Duodenal diverticulization
• Blunt or GSW
>75% circumference injury
1st and 2nd portion of duodenum
Injury to repair interval >24 h
• Two-tube technique
– Retrograde duodenostomy
– Feeding jejunostomy
• Three-tube technique
– Gastrostomy added
• External drainage
– Closure of proximal duodenum
– Gastrojejunostomy
– Vagotomy
• Pyloric exclusion
– Oversew pylorus
– Gastrojejunostomy
• External drainage
Pancreatic injury grading and management
Grade Characteristics Management
Grades I and II Hematoma or laceration not
involving the pancreatic duct
Observe
Wide closed suction drainage
Grade III Distal transection or
parenchymal injury with duct
injury
Grades IV or V Proximal transection,
parenchymal injury involving
the ampulla, or massive
pancreatic head disruption
Pancreatic stula: drain amylase 3× serum amylase →
observation, enteral feeding distal to the pylorus, and serial
monitoring of drain output quantity and amylase content
Continued high-output stula drainage despite conservative
management is an indication for ERCP + pancreatic duct stenting
Distal pancreatectomy if distal to SMV ± splenectomy (depending
on hemodynamic status and the presence of associated injuries)
→ Splenic preservation if hemodynamically normal and have no
or few associated injuries
Wide drainage in the hemodynamically unstable patient
undergoing a damage control laparotomy
Denitive resection at take back
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