(1)
Department of Surgery Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Introduction
The abdominal organs, given their central location and lack of bony protection, are vulnerable to traumatic injury. The type of trauma can predict the pattern of injuries that are likely to have occurred. In blunt abdominal trauma—such as a fall from height, motor vehicle collision, or physical assault—the liver and the spleen are the most commonly damaged organs. The force of impact can cause these solid organs to fracture, leading to intra–abdominal hemorrhage. When examining a victim of blunt trauma, sites of ecchymosis on the abdominal wall can demonstrate points of impact and identify likely underlying organ injury. Bedside ultrasound, called the Focused Assessment with Sonography for Trauma (FAST) exam, can be used to assess for intra-abdominal bleeding. Visualization of a black hypoechoic stripe along the paracolic gutters or pelvic cul-de-sac indicates the presence of free fluid in the abdominal cavity.
Even in the presence of intra-abdominal bleeding, advances in supportive care have allowed the majority of blunt trauma patients to be spared operative exploration. In clinically stable patients, CT imaging is useful in identifying the extent of splenic laceration or liver laceration (Fig. 26.1). Minor intra-abdominal bleeding is typically self-limited, but if extravasation of intravenous contrast is seen, this indicates active bleeding that is unlikely to resolve. Interventional radiology techniques can be used to selectively embolize these bleeding vessels. Patients who remain hemodynamically unstable despite these efforts, or who continue to require blood products for resuscitation should be taken to the operating room for definitive control of bleeding sites.
Fig. 26.1
CT scan of a patient who was involved in a motor vehicle accident, the images demonstrate a large liver laceration with accompanying hemoperitoneum. The patient remained hemodynamically stable and operative intervention was not required
In contrast to blunt trauma, penetrating abdominal trauma is more likely to result in injuries that require surgical intervention. With stabbing injuries, damage will occur to whichever organs lie in the path of the weapon, often including the bowel and major blood vessels. The finding of frank peritonitis on examination implies bowel injury with the spillage of enteric contents and mandates operative exploration. If no peritonitis is present, wound sites can be explored at bedside to determine if the peritoneal cavity has been violated. With stabbings, it is important to keep in mind that the size of the skin wound does not correlate with the depth of penetration; a small skin defect may be the only indication of a deep wound with severe internal injury. CT imaging is not sensitive for identifying bowel injury. Therefore, any patient with a stab wound penetrating the peritoneum must have bowel injury ruled out with either a peritoneal lavage or operative exploration (Fig. 26.2).
Fig. 26.2
Technique of diagnostic peritoneal lavage [Reprinted from Lennquist S. Incidents Caused by Physical Trauma. In: Lennquist S (ed). Medical Response to Major Incidents and Disasters: A Practical Guide for All Medical Staff. Heidelberg, Germany: Springer Verlag; 2012: 111-196. With permission from Springer Verlag]
Gunshot wounds present the potential for complex thermal and mechanical damage. The heat produced by a bullet causes direct thermal injury to the surrounding structures. In addition, the tumbling of the bullet can cause more extensive damage than anticipated. Complex, multi-organ injury is virtually guaranteed with a gunshot wound to the abdomen, and as such all patients should be taken directly for operative exploration.
Surgical Technique
A generous midline incision is employed for a trauma laparotomy since this provides rapid access to the abdomen with good exposure to all potentially injured organs. Once the abdominal cavity is opened, an initial survey is quickly performed. If blood is present, multiple laparotomy pads are used to pack all four quadrants for control of hemorrhage. Bowel injuries causing gross spillage of enteric contents are provisionally closed to limit contamination. After initial damage control is obtained, a careful examination of the abdomen is conducted; packing is sequentially removed, and each quadrant is systematically inspected for injury.
Major vascular injuries take priority and are addressed by obtaining inflow and outflow control, and performing repair as appropriate. Stable retroperitoneal or pelvic hematomas are typically left undisturbed, since opening the retroperitoneum can decompress the space and disrupt hemostasis. Embolization of the pelvic arteries can be performed in interventional radiology to assist with control of the pelvic hematomas seen with extensive pelvic fractures.
The liver has a unique ability to achieve hemostasis, therefore bleeding from liver lacerations is usually self-limited or can be controlled with simple compression. In more serious injuries, a Pringle maneuver can be performed to control the blood inflow to the liver. By encircling the porta hepatis and applying manual pressure, the surgeon can occlude the portal vein and hepatic artery, and allow visualization of injuries (Fig. 26.3). Active arterial bleeding may require ligation of the hepatic artery to the bleeding lobe. Emergent liver resection is only rarely needed, but may be indicated for ongoing hemorrhage or a significant bile leak.
