eMedicine Specialties > Trauma > Abdominal Trauma
Abdominal Trauma, Penetrating: Treatment
Updated: Jun 12, 2007
Treatment
Medical Therapy
Resuscitation of the patient with PAT begins immediately upon arrival. At least 2 large-bore peripheral intravenous catheters should be secured; central venous access may be necessary. Fluids should be administered rapidly. Normal saline or Ringer’s lactate solution can be used for crystalloid resuscitation. Patients arriving in shock or with obvious significant bleeding should receive blood products as quickly as possible. Arterial access for continuous blood pressure monitoring is standard. Efforts should be made to limit hypothermia, including warm blankets and prewarmed fluids. Antibiotics should be administered to patients undergoing exploration.
Preoperative Details
Surgical intervention begins with preparation of the patient in the operating room. The patient is placed in the supine position with arms extended. The entire chest, abdomen, and pelvis, including the upper thighs, are prepped and draped. This allows for access to the chest, should the injury tract extend above the diaphragm, and to the vasculature of the groins, should reconstruction become necessary. Fluids and blood products should be readily available (and administered via warm lines), and warming devices should be placed on the patient’s upper and/or lower extremities. Entering the abdominal cavity can release tamponade, resulting in a precipitous drop in blood pressure, so the anesthesia team must be informed when the midline incision is made.
Intraoperative Details
Essential components to the trauma laparotomy include control of bleeding, identification of injuries, control of contamination, and reconstruction (if possible). Initial control of bleeding is accomplished with 4 quadrant packing using laparotomy pads. The abdominal wall is retracted, the falciform ligament is taken down, and packs are placed above the liver and the spleen and in both sides of the pelvis after the bowel is swept cephalad. Once anesthesia has been given time to catch up with fluid resuscitation, the packs are removed one quadrant at a time, starting away from the sites of apparent bleeding. All areas are examined for injuries; each solid organ and the entire bowel are inspected. Contamination is controlled with the use of clamps, staples, or suture closures. Depending on the character of the defect(s), resection may be necessary. If the patient is stable enough to continue the operation, reconstruction may then be performed.
Occasionally, patients with PAT develop such significant metabolic acidosis and coagulopathy that proceeding with the reconstruction phase of the laparotomy is not possible. In these cases, the operation is considered damage-control surgery, and the abdomen is closed rapidly. Often, a temporary closure with an intravenous fluid bag or mesh (occasionally with a vacuum dressing) is used, as the patient has undergone massive fluid resuscitation and the bowel has become quite edematous, precluding primary closure of the abdomen. The patient is then transported to the intensive care unit for continued resuscitation and warming. Reconstruction then takes place upon return to the operating room in 24-48 hours.
In patients with PAT, the possible patterns of intra-abdominal injuries are countless. A brief description of specific organ injuries and the intraoperative approach to their management are outlined below.
Diaphragm
Penetrating injuries to the diaphragm are graded as follows: (I) contusion; (II) laceration, <2 cm; (III) laceration, 2-10 cm; (IV) laceration, >10 cm; and (V) total tissue loss, >25 cm2. Lower grade injuries may be repaired either via laparotomy or with laparoscopic or thoracoscopic techniques.
Essential components of repair include an airtight closure with nonabsorbable suture and liberal saline lavage of the hemithorax if there has been a concomitant bowel injury with soilage of the field. The closure may be running or interrupted, and a chest tube is often placed for drainage. Large defects may require placement of a prosthetic patch.
Liver
Liver injuries are also classified by grade. Components of the different grades pertinent to penetrating injuries include the following: (I) nonbleeding capsular tears, <1 cm deep; (II) lacerations, 1-3 cm deep and <10 cm long; (III) laceration, >3 cm deep; (IV) parenchymal disruption involving 25-75% of a lobe or 1-3 segments; (V) parenchymal disruption of >75% of a lobe or >3 segments or juxtahepatic venous injury; and (VI) hepatic avulsion.
Operative management of liver injuries can involve many techniques, including simple packing or wrapping, local hemostasis, and resectional debridement. Knowledge of hepatic anatomy is crucial, because exposure and vascular control are necessary for the safe repair of injuries. Packing may successfully control minor hemorrhage; however, packs may need to be left in place and the abdomen closed temporarily. After resuscitation is complete, the patient may return to the operating room for removal of the packs, at which point bleeding is most often resolved.
Several hemostatic agents have been used in liver repair, including thrombin, fibrin sealant, collagen/gel preparations, electrocautery, argon beam and radiofrequency coagulation, omental packing, or even intrahepatic balloon tamponade as in the case of through-and-through injuries. Resectional debridement is much less commonly required in the treatment of penetrating liver injuries but may be accomplished with finger fracture, cautery, sutures, clips, or stapler device.
Spleen
Penetrating injuries to the spleen can cause significant bleeding. Irreparable vascular injuries, including total avulsion and extensive lacerations, are indications for splenectomy. Splenectomy may also be necessary for less substantial injuries for the patient in extremis. Time permitting, the spleen is completely mobilized, and care should be taken not to injure the pancreas. If there is a reparable laceration, digital pressure should be applied at the hilum and interrupted pledgeted splenorrhaphy performed.
Kidney
Injuries to the kidney are also graded according to severity, as follows: (I) contusion; (II) lacerations, <1 cm; (III) lacerations, >1 cm; (IV) lacerations to the collecting system; and (V) vascular avulsion.
As with spleen injuries, the kidney is salvaged with renography, using pledgeted sutures and wrapping, and capsular reapproximation if at all possible. If nephrectomy is deemed necessary because of the severity of injury or instability of the patient, an intraoperative intravenous pylorogram is performed to confirm function of the contralateral kidney.
Stomach
Exposure and thorough inspection of the stomach is necessary to evaluate and treat penetrating injuries to the stomach. This is facilitated by opening of the gastrocolic ligament, which allows entrance into the lesser sac. Injuries extending into the lumen may be repaired quickly with a stapling device.
Duodenum
Injuries to the duodenum are graded as follows: (I) hematoma; (II) partial thickness laceration; (III) laceration disrupting <50% circumference of D1, D3, D4, or 50-75% circumference of D2; (IV) laceration disrupting 50-100% circumference of D1, D3, D4, or >75% circumference of D2, or involving the ampulla or distal common bile duct; and (V) massive disruption of the duodenopancreatic complex or devascularization of the duodenum.
The Kocher maneuver is used to mobilize the duodenum, along with the pancreatic head and distal common bile duct, so that penetrating injuries can be fully explored. Primary repair of injury is the goal, with protection of the repair using closed-suction drainage. Diversion procedures are often used for protection. Duodenal diverticulartization diverts biliary and pancreatic secretions using T-tube drainage and gastric decompression with a gastrostomy. Pyloric exclusion involves closure of the pylorus with nonabsorbable suture with bypass via gastrojejunostomy; the pylorus opens spontaneously in 4-6 weeks. Grade V injuries require pancreaticoduodenectomy, which is often done as a staged procedure in the unstable trauma patient.
Pancreas
Pancreatic injuries are graded according to the presence or absence of ductal injuries. Grades I and II include superficial or major laceration or contusion without ductal injury, respectively. Grade III injuries are distal transections without duct injury or tissue loss. Grade IV lacerations involve proximal transection or parenchymal injury involving the ampulla. Grade V injuries are massive disruptions of the pancreatic head.
After hemorrhage is controlled and the pancreas is exposed, the extent of the injury must be identified. Debridement must be selective to preserve as much endocrine and exocrine function as possible. Grade I and II injuries can be managed conservatively, but Grade III injuries are best treated with distal pancreatectomy and splenectomy. Grade IV injuries require near total pancreatectomy with reconstruction of pancreatic drainage into the gastrointestinal tract with either Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. If the patient is too unstable, wide drainage of pancreatic tissue without anastomosis may be necessary.
Small bowel
Control of contamination is of high priority with penetrating injuries to the small bowel. Clamps or staples may be used for temporary control as the entire length of the small bowel is examined.
If less than 50% of the bowel circumference is disrupted, the defect can be closed in a transverse fashion with sutures or staples.
If there is a single defect larger than 50% circumference, there are multiple defects in a short segment of bowel, or there is a devascularizing injury to the mesentery, resection of the involved segment is appropriate. Side-to-side stapled anastomosis can be accomplished quickly.
In the unstable patient, a damage-control procedure may be performed, with control of contamination and resection of devitalized segments without anastomosis. The patient returns to the operating room within 24-48 hours for reexploration, resection of any further devitalized segments, and restoration of continuity with one or more anastomoses.
Colon
The management of colonic injuries depends on the extent of the defect, the amount of contamination, and the stability of the patient. Primary repair may be considered if the patient is hemodynamically stable and if the injury is fairly small with minimal fecal contamination.
If the patient has multiple injuries; if the patient has required significant blood product resuscitation; if the patient is acidotic, hypothermic, and coagulopathic; and/or if there is a large defect (>50% of the circumference) and considerable fecal spillage, then a diverting colostomy should be performed.
Postoperative Details
Patients should be monitored closely in the surgical intensive care unit after trauma laparotomy. Many patients will remain intubated and require ventilatory support. Attention should be paid to warming the patient, to continuing fluid and blood product resuscitation, to replacing electrolytes, and to monitoring drain outputs. Patients with evidence of ongoing bleeding may benefit from angiographic evaluation for possible embolization; some require reexploration for control of hemorrhage. Patients who have undergone damage-control procedures and/or who have temporary abdominal closures must return to the operating room within 24-48 hours for definitive repair.
Follow-up
For excellent patient education resources, visit eMedicine's Wounds Center. Also, see eMedicine's patient education article Puncture Wound.
Complications
Early postoperative complications include ongoing bleeding, coagulopathy, and abdominal compartment syndrome. The latter is treated with opening of the abdomen and temporary closure.
Later complications include acute respiratory distress syndrome, pneumonia, sepsis, intra-abdominal fluid collections, wound infections, and enterocutaneous fistulae.
Late complications include small bowel obstruction and incisional hernias.
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References
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Jacobs LM, et al. Advanced Trauma Operative Management: Surgical Strategies for Penetrating Trauma. Connecticut: Cine-Med Inc; 2004.
Mattox KL, Feliciano DV, Moore EE. Trauma. 4th ed. New York: McGraw-Hill; 1999.
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Murphy SH. National Vital Statistics Reports. Deaths, final data for 1998. 2000;Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48_11.pdf. [Full Text].
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Thal ER. Operative exposure of abdominal injuries and closure of the abdomen. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, eds. Scientific American Surgery. New York: Scientific American; 1996: revised 1997.
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Further Reading
Lawson R, Goosen J. Abdominal Stab Wound Exploration. eMedicine from WebMD. Updated May 31, 2007. Available at: http://www.emedicine.com/proc/topic82869.htm.
Keywords
gunshot wound, GSW, gut shot, stab wound, missile injury, celiotomy, diagnostic peritoneal lavage, DPL, diagnostic laparoscopy, intra-abdominal injuries, intraabdominal injuries, advanced trauma life support, ATLS
