Abdominal injury

and Management
Dr.Mohammadzadeh

13 Feb 2013
 Background
• Traumatic injury is the leading cause of
morbidity and mortality in children >1 year
in U.S.
• Trauma to the abdomen is often initially
unrecognized
• Abdominal trauma accounts for 8-10% of
all trauma admissions to peds hospitals
• Blunt injuries account for > 80% admits

ATLS, 7th Edition, 2004

 Factors Unique to Pediatrics
• Anatomic
– Larger relative size of solid organs
– Rib cage and abdominal muscles less
protective
– Bladder intraabdominal until adolescence
– Large head: often have multisystem injury
• Physiologic
– Hypotension is a late finding in shock
– Increased relative surface area  prone to
hypothermia
ATLS, 7th Edition, 2004
 Mechanism
• Blunt abdominal trauma
• Penetrating abdominal trauma
• Overall about 20% require surgical
operation
 Blunt abdominal trauma
•Motor vehicle crush ( MVC) injury
•Seat belt injury
•Handle bar injury
•Fell from height
 Penetrating abdominal injury

• Stab wound – low energy transfer

• Gun shot wound – high energy transfer
 Anatomy
• Between diaphragm and pelvic floor
• Beware of diaphragmatic injury in
penetrating chest injury below the nipples
(5th ICS)
• Mid-axillary line
• Retro-peritoneal spaces – zone I, II & III
 anatomy
Anterior abdomen
flank
Back
intraperitoneal contents
Retroperitoneal space contents
 Pelvic cavity contents
o Anterior abdomen:
trans-nipple line, , anterior axillary lines, inguinal
ligaments and symphysis pubis.
o flank:
anterior and posterior axillary line ;sixth
intercostal to iliac crest
o Back:
posterior axillary line; tip of scapula to iliac crest
• Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-
small bowel, sigmoid colon

• Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys,
ureters,ascending and descending colons

• Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia
 Anatomy
• Solid organs – liver, spleen, kidney
(blood)
• Hollow organs – blood, bile, urine, food,
digestive juice, air
• Remember the diaphragm which is
neither solid nor hollow organ
 First step of Management

• Resuscitation of patients with suspected

abdominal injuries – same as other trauma
patients
• ATLS
• Surgical plan
 Basic plan of Surgical Decision

• Is there any abdominal injury? (PE)

• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)
 Assessment and diagnosis
• Normal abdominal finding
• Obvious injury to the abdomen
eg gun shot wound
• Equivocal findings requiring further
investigation and re-assessment
eg blunt abdominal trauma
 Investigations
• Diagnostic peritoneal lavage DPL
• FAST USG
• CT scan
• (Laparoscopy)
 DPL
• Previously the standard investigation
• Replaced FAST
• Detect blood
• Bowel content : bacteria, food particles, bile
• Accuracy up to 98%
• Miss diaphragmatic and retroperitoneal
injury
Diagnostic Peritoneal Lavage
 Diagnostic Peritoneal Lavage
(DPL)
• Amount of warmed Ringer’s lactate for lavage:
– 10 ml/kg in a child
– 1 liter in an adolescent/adult
• Positive DPL:
– >100,000 RBC/mm3
– >500 WBC/ mm3
– Gram stain with bacteria
– Aspiration of gross blood, GI contents,
vegetable fibers, or bile

ATLS, 7th Edition, 2004

 FAST
• Detect fluid (blood) inside peritoneal cavity
• Accuracy comparable to DPL
• Non invasive and repeatable
• Operator dependant
• Miss specific injuries
• Obesity
• Replace DPL in many trauma centre
 FAST
• Focused areas of exam:
– Hepatorenal fossa
– Splenorenal fossa
– Pericardial sac
– Pelvis (pouch of Douglas)
Hepatorenal view normal
Hepatorenal view abnormal
Splenorenal view
 FAST in Pediatrics
• Multiple studies have prospectively
evaluated FAST with CT +/- ex lap as a
gold standard
• Results are variable:
– Sensitivity: 70-80%
– Specificity: 97-100%

Suthers, et al. Am Surg. 2004 Feb; 70(2):

164-7
Corbett, et al. Am J Emerg Med. 2000 May; 18(3):
244-9
Thourani, et al. J Pediatr Surg. 1998 Feb; 33(2):
 CAT scan
• Document specific organ injury
• Retro-peritoneal organs
• Accurate
• Haemo-dynamically stable patients
• Can still miss diaphragmatic injury and
bowel injury
Computerized Tomography (CT)

• Lifetime cancer mortality risk attributed to

radiation exposure in 1 year old:
– Abd CT: 0.18%
– Head CT: 0.07%
• 500 out of 600,000 children will die secondary to
malignancy from radiation exposure

Brenner, et al. Am J Roentgenol. 2001 Feb; 176(2):

Computerized Tomography (CT)
• Reasons to scan:
– Abdominal tenderness with hematuria
– Low GCS
– + FAST in stable pt
• Reasons not to scan:
– Normal exam

Richards, et al. Am J Emer Med. 1998 Jul; 16(4):

 Spleen/Liver
• Contrast enhanced CT has 95% sensitivity
and specificity for diagnosing splenic and
hepatic injuries

Minarik, et al. Pediatr Surg Int. 2002 Sep; 18(5-6):

 Bowel injury
• Less sensitive/specific for hollow viscous
injury
• Nonspecific findings common
• Serial exams most inportant
 Pancreas

• Of 1045 children with BAT, 18 sustained injuries

seen on autopsy, laparotomy, or clinically
– 13/18 seen on CT with fluid in lesser sac
– SN = 72%; SP = 99%

Sivit, et al. Am J Roentgenol. 1992 May; 158(5):

Renal Laceration (Grade IV)
Renal Laceration (Grade IV)
Renal Laceration (Grade IV)
 Basic plan of Surgical Decision

• Is there any abdominal injury? (PE, Ix)

• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)
 Surgical decision

• Normal abdominal finding

• Obvious injury to the abdomen
• Equivocal abdominal findings
 Normal abdominal finding
• Re-assessment and physical finding by
same experienced surgeon in haemo-
dynamically normal is usually sufficient
• ? CAT scan before other extra-abdominal
surgery in awake and alert patients
• FAST or DPL in unstable patients
 Surgical decision

• Normal abdominal finding

• Obvious injury to the abdomen
• Equivocal abdominal findings
 Obvious injury to the abdomen
• Mostly applied to penetrating injury
• Virtually all penetrating abdominal injury
should be “explored” promptly, especially
in the presence of hypotension
• Local wound exploration
• Laparoscopy / laparotomy
• Gun shot wound - laparotomy
• CAT scan
 Surgical decision

• Normal abdominal finding

• Obvious injury to the abdomen
• Equivocal abdominal findings
 Equivocal abdominal findings
• Further investigation very much depends
on haemo-dynamic status of the patients
• Haemodynamically normal: reassessment ,
CAT scan, other investigation
 Equivocal abdominal findings
• Haemodynamically stable : CAT scan
• Whether the patient has bled into the
abdomen
• Whether the bleeding has stopped.
• Detect specific organ injury
 Equivocal abdominal findings
• What if CT shows free fluid without solid
organs injury in a stable patient?
• Blood, bowel content, bile, urine
• ? Mandatory laparotomy
• But non-therapeutic laparotomy is up to
92% in one of the US multi-centre
prospective study
• Re-assessment
 Equivocal abdominal findings
• Haemodynamically unstable : DPL or
FAST
• Positive finding : operation
• A negative finding is also important : we
have to focus on the other compartment
(chest, pelvis, long bones) or external
haemorrhage
 Basic plan of Surgical Decision

• Is there any abdominal injury? (PE, Ix)

• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)
 Conservative management
• NOM
• Liver injury (esp grade I – III)
• Splenic injury (esp grade I – III, paediatric
group)
• Renal injury
• Interventional radiologist
 Conservative management
• Beware of concomitant solid and hollow
organ injury
• ~7%
• It is still safe to adopt non operative
management to stable patients with solid
organ injury patients but repeated
assessment is required
 Basic plan of Surgical Decision

• Is there any abdominal injury? (PE, Ix)

• Is intervention required? (conservative
treatment + close monitoring +/- serial Ix)
• Is surgery required? (interventional
radiology)
• Damage control or definitive surgery
(correct physiology then anatomy)
 Is urgent surgery required?
• Radiological evidence of intraperitoneal gas
• Radiological evidence of ruptured diaphragm
• Gunshot wounds
• Evisceration
• Positive result on diagnostic peritoneal
lavage
• Rigid silent abdomen or unexplained shock
 Aim of urgent operation

• Haemorrhage control
• Contamination control
• Anatomical repair
 Aim of urgent operation

• Haemorrhage control
• Contamination control
• Anatomical repair
• Haemorrhage control + contamination
control – anatomical repair = damage
control surgery
 Damage control
• US Navy, term used for battle ship
• staged laparotomy, surgical resuscitation,
temporary abbreviated surgical control
(TASC)
• Focus on restoring function / physiology
• Defer treatment of structural / anatomical
disruption
• Temporary abdominal closure
 Damage Control Surgery
• Inability to achieve haemostasis (liver injury)
• Combined vascular, solid and hollow organs
injury
• anticipated need for time consuming procedure
• Demand for other control of other injury
• Inaccessible major venous injury
• Evidence of poor physiological reserve
(acidosis, hypothermia, coagulopathy)
 Role of laparoscopy
• Both as diagnostic and therapeutic tools
• Particularly good in detecting
diaphragmatic injury
• Operator dependant
• Difficult to do full trauma evaluation – esp
retro-peritoneal space
 Role of laparoscopy
• Contraindication : haemodynamically
unstable patient
• Uses in stable patients
1. Stab wound after LWE
2. Fever or raised WBC in patient under NOM,
such as in case of liver laceration
 Interventional radiologist
• Work with arteries
• Cannot help in hollow organ injuries except
drainage of post op collection
• Common sites : liver, spleen, pelvis
• Contra-indication : haemodynamically
unstable patients (except after damage
control procedure in some scenario)
• Organ infarction
Interventional radiologist
Specific organs injury
Liver Anatomy
 Liver Laceration
GRADE DESCRIPTION
I < 1cm parenchymal depth
II Depth 1-3cm, < 10 cm in length
III Depth > 3cm
IV 25-75% of hepatic lobe
V > 75% of hepatic lobe
Grade 4 Liver laceration
 Hepatic injury
• Grade I to VI
• VI – hepatic avulsion
• Contrast CT scan - very accurate in diagnosis
and grading
• Conservative treatment : stable low grade injury
• Angiographic embolization : higher grade injury
with evidence of continuous bleeding
• Surgery : Unstable patients
 Surgery in hepatic injury
• Pringle manoeuvre (occlusion of both inflow to liver
ie. portal vein and hepatic arteries.)
• Failed to control bleeding => aberrant Lt or Rt
hepatic arteries or retro-hepatic venous injury
• Parenchymal suture
• Peri-hepatic packing
• Consider embolization
• Bile leak
 Splenic Lacerations
GRADE DESCRIPTION
I Subcapsular hematoma <10% surface area
Laceration <1 cm in depth
II Subcapsular hematoma 10-50% surface area
Laceration 1-3 cm in depth w/o vessels involved
Intraparenchymal hematoma <5cm diameter
III Subcapsular hematoma >50% surface area or
expanding/ruptured hematoma
Laceration >3 cm in depth or w/ vessels involved
Intraparenchymal hematoma >5cm diameter
IV Devascularization of >25% of spleen
V Shattered spleen or hilar vascular injury
Grade 5 splenic laceration
Grd 4-5 splenic laceration
 Splenic injury
• Grade I – V
• V – shattered spleen or hilar vascular injury
• Conservative treatment (children, stable, intra-
abdominal injury, no significant brain injury)
• Angiographic embolization (even up to 80% in
grade IV to V stable patients in one study, Hann
JM 2005)
• Suturing, wrap, total or partial splenectomy
Pancreatic Anatomy
 Pancreatic injury
• Grade I – V
• Grade I & II – intact main duct
• blunt injury (steering wheel, handle bar)
• Retro-peritoneal structure => not much
peritoneal sign
• Amylase level not reliable in initial evaluation
• CAT scan (contrast)
 Pancreatic injury
• CT scan
1. Specific (>90%) but not sensitive (~50%)
2. May require repeated scan
• ERCP to assess main duct integrity (in
EDU or intra-op)
 Pancreatic injury
• Grade I, II cases => closed suction
drainage (in selected cases NOM)
• Grade III – V => resection.
• Common site of injury at neck which is
compressed against the spine => distal
pancreatectomy with splenic preservation
Pancreatic injury
Pancreatic injury
Pancreatic injury
Pancreatic injury
 Bowel injury
• Bowel perforation (peritonitis, free gas,
bowel content in DPL) should never be
treated by non-operative management
• Small bowel injury – primary anastomosis
• Colonic injury – colostomy or primary
anastomosis +/- second look laparotomy
• Duodenal injury – retroperitoneal sturcture
 Duodenal injury
• Even perforation, abdominal sign not florid
• May required extensive mobilization of
surrounding structure for repair
• Duodenal haematoma after a blunt injury can
be managed by conservative treatment
Handlebar Injury
Duodenal Hematoma
Duodenal Hematoma
Renal injury
Kidneys and Urinary Tract
 Renal Injury
GRADE INJURY
I Contusion: hematuria (micro/gross)
Hematoma: subcapsular, nonexpanding w/o
parenchyma involved
II Hematoma: perirenal, nonexpanding
Laceration: <1 cm depth
III Laceration: >1 cm depth

IV Laceration: through cortex, medulla, collecting system

Vascular: main artery/vein injured; bleed confined
V Laceration: completely shattered kidney
Vascular: complete hilar avulsion
 Renal injury
• Grade I to V
• Haematuria (30%)
• Contrast CAT scan
• Angiographic embolization
• Urinoma, sepsis, hypertension
Abdominal compartment syndrome
• Sequestration of fluid and edema of bowel
wall and mesentery
• Increase intra-abdominal pressure =>
decrease perfusion of viscera => further
increase capillary leakage in bowel wall
causing a viscous cycle
• oliguria, increase peak inspiratory pressure,
increase CVP & PAWP (false), decrease
cardiac output
Abdominal compartment syndrome

• Indirect measure through Foley catheter

• Normal < 5mmHg
• <25mmHg – fluid resuscitation
• >25mmHg + oliguria with adequate blood
volume => consider decompression
• Bogota bag, sandwich-vacuum closure,
other commercial packs
Thank you