Surgical Therapy for Penetrating Abdominal Trauma

Although nonoperative intervention is increasingly used in selected patients, surgical therapy for penetrating abdominal trauma remains an essential part of overall management. ^{[1, 2, 3]} The indications for operative intervention include the following:

• Development of hemodynamic instability

• Development of increasing pain, peritoneal findings (eg, point tenderness, involuntary guarding, rebound tenderness)

• Diffuse and poorly localized pain that fails to resolve

The image below depicts a tangential gunshot wound to the liver.

Preoperative details

Surgical intervention begins with preparation of the patient in the operating room, as follows:

• 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

• Fluids and blood products should be readily available (and administered via warm lines)

• 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 the following:

• Control of bleeding

• Identification of injuries

• Control of contamination

• Reconstruction (if possible)

Procedure

• 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 penetrating abdominal trauma 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.

Colon injuries

Primary repair of colonic injuries may be considered if the patient is hemodynamically stable and if the injury is fairly small with minimal fecal contamination. A diverting colostomy should be performed if the patient has any of the following:

• Multiple injuries

• Requirement for significant blood product resuscitation

• Acidosis, hypothermia, and coagulopathy

• A large defect (>50% of the circumference) and considerable fecal spillage

Other organ injuries

• Diaphragm - Lower-grade injuries may be repaired either via laparotomy or with laparoscopic or thoracoscopic techniques

• Liver - The key rules are gaining adequate exposure and obtaining hemostasis

• Spleen - On the basis of the patient's hemodynamic status, comorbidities, and operative access, the surgeon will plan for splenorrhaphy or splenectomy

• Kidney – If at all possible, the kidney is salvaged with renography, using pledgeted sutures and wrapping, and capsular reapproximation; if nephrectomy is deemed necessary because of the severity of injury or instability of the patient, an intraoperative intravenous pyelogram is performed to confirm function of the contralateral kidney

• Stomach – Exposure and thorough inspection is necessary, facilitated by opening of the gastrocolic ligament; injuries extending into the lumen may be repaired quickly with a stapling device

• Diaphragm – For exploration, the Kocher maneuver is used to mobilize the duodenum, along with the pancreatic head and distal common bile duct; primary repair of injury is the goal, with protection of the repair using closed-suction drainage; diversion procedures are often used for protection

• Pancreas – Pancreatic duct status and injury location are determinants in the management; lacerations or contusions without ductal injury can be treated conservatively, while more severe injuries may require partial or complete pancreatectomy

Damage-control surgery

Damage control surgery involves abbreviated laparotomy after control of surgical hemorrhage and enteric spill, with physiologic resuscitation in the intensive care unit and staged abdominal reconstruction. ^[4]

Damage-control techniques include the following:

• Perihepatic or intra-abdominal packing and towel clip closure of the abdomen

• Therapeutic decompressive celiotomy

• Prophylactically leaving open the abdominal fascia after laparotomy

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 the following:

• Warming the patient

• Continuing fluid and blood product resuscitation

• Replacing electrolytes

• 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 or have temporary abdominal closures must return to the operating room within 24-48 hours for definitive repair

Complications

Prevention is important for the following complications:

• Deep vein thrombosis and pulmonary embolism

• Stress ulceration and bleeding

• Pressure ulcers

• Atelectasis

• Ventilator-associated pneumonia

• Catheter-related sepsis

• ICU psychosis

Early postoperative complications include the following:

• Ongoing bleeding

• Coagulopathy

• Abdominal compartment syndrome

Later complications include the following:

• Acute respiratory distress syndrome

• Pneumonia

• Sepsis

• Intra-abdominal fluid collections

• Wound infections

• Enterocutaneous fistulae

• Small bowel obstruction

• Incisional hernias

Although nonoperative intervention is increasingly used in selected patients, surgical therapy for penetrating abdominal trauma remains an essential part of overall management. ^{[1, 2, 3]} The indications for operative intervention include the development of hemodynamic instability or the development of increasing pain, peritoneal findings (eg, point tenderness, involuntary guarding, rebound tenderness), or diffuse and poorly localized pain that fails to resolve.

For further information on penetrating abdominal trauma, see the Medscape Reference article Penetrating Abdominal Trauma.

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.

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 penetrating abdominal trauma 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 penetrating abdominal trauma, the possible patterns of intra-abdominal injuries are countless. Hollow visceral injuries are frequent; discussions of the complex repair options are not within the scope of this article but generally include wound inversion, primary repair, anastomosis, or colostomy.

A brief description of specific organ injuries and the intraoperative approach to their management are outlined below.

Penetrating injuries to the diaphragm are graded as follows:

(I) Contusion

(II) Laceration, < 2 cm

(III) Laceration, 2-10 cm

(IV) Laceration, >10 cm

(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.

The key rules in operative hepatic injury are gaining adequate exposure and obtaining hemostasis. Simple lacerations may be managed by direct pressure, electrocautery, or topical hemostatic agents. Compression of the portal triad, the Pringle maneuver, is performed for more serious injuries; it controls ongoing hemorrhage from the portal venous and hepatic arterial systems.

The laceration may then be approached with finger fracture and direct ligation of the bleeding vessels. After obtaining hemostasis, the laceration is often tamponaded with a vascularized omental flap.

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

(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.

Guidelines from the World Society of Emergency Surgery suggest that angioembolization can be a useful tool in case of persistent arterial bleeding after nonhemostatic or damage-control procedures. Resuscitative endovascular balloon occlusion of the aorta may be used in hemodynamically unstable patients as a bridge to other, more definitive procedures for hemorrhage control. ^{[5, 6]}

On the basis of the patient's hemodynamic status, comorbidities, and operative access, the surgeon will plan for splenorrhaphy or splenectomy. Splenorrhaphy includes electrocautery, topical hemostatic agents, compressive mesh, or partial splenectomy.

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.

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

(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 pyelogram is performed to confirm function of the contralateral kidney.

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.

Injuries to the duodenum are graded as follows:

(I) Hematoma

(II) Partial-thickness laceration

(III) Laceration disrupting < 50% circumference of D1, D3, or D4, or 50-75% circumference of D2

(IV) Laceration disrupting 50-100% circumference of D1, D3, or D4, or >75% circumference of D2, or involving the ampulla or distal common bile duct

(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 diverticularization 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.

The pancreas, because of its protected retroperitoneal location, is less commonly injured. However, penetrating abdominal trauma accounts for 70-80% of pancreatic injuries, and mortality rates exceed 30%. Most pancreatic injuries are diagnosed intraoperatively. Pancreatic duct status and injury location are determinants in the management of pancreatic injuries.

Proximal injuries are to the right of the mesenteric vessels, while distal injuries are to the left. Proximal injuries are managed by closed suction drainage only. Distal pancreatic traumas with duct involvement undergo distal pancreatectomy and closed suction drainage.

Pancreatic injuries are graded according to the presence or absence of ductal injuries, as follows:

(I) Superficial laceration or minor contusion without ductal injury

(II) Major laceration or contusion without ductal injury

(III) Distal transections without duct injury or tissue loss

(IV) Proximal transection or parenchymal injury involving the ampulla

(V) 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.

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.

A diverting colostomy should be performed if the patient has any of the following:

• Multiple injuries

• Requirement for significant blood product resuscitation

• Acidosis, hypothermia, and coagulopathy

• A large defect (>50% of the circumference) and considerable fecal spillage

Attempts to definitively repair all injuries at an initial operation for abdominal trauma induce risks that may markedly outweigh possible benefit. An alternative approach, which has been termed damage control, involves abbreviated laparotomy after control of surgical hemorrhage and enteric spill, with physiologic resuscitation in the intensive care unit and staged abdominal reconstruction. ^[4]

Damage-control techniques involve perihepatic or intra-abdominal packing and towel clip closure of the abdomen. Included in the approach are therapeutic decompressive celiotomy and prophylactically leaving open the abdominal fascia after laparotomy.

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, continuing fluid and blood product resuscitation, replacing electrolytes, and 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 or have temporary abdominal closures must return to the operating room within 24-48 hours for definitive repair.

Complications are common in patients with penetrating abdominal trauma. They are usually managed by surgeons during the patient's hospital stay or after discharge from the hospital.

Complications tend to be concerns related to the breakdown of the surgical wounds, both intraperitoneal and extraperitoneal; intra-abdominal infections; and the development of abdominal compartment syndrome, which is diagnosed when the intra-abdominal pressures are greater than 30 mm Hg and is treated with opening of the abdomen and temporary closure.

• Prevention is also important for the following complications:

• Deep vein thrombosis and pulmonary embolism

  • A study by Karcutskie et al assessed whether the risk of venous thromboembolism (VTE) varies with blunt or penetrating trauma by monitoring 813 patients with blunt trauma and 324 with penetrating trauma. The authors found no significant difference in the rates of VTE between blunt or penetrating trauma however reported that vascular injury, severity of abdominal injury, and age 40 to 59 years were risk factors for VTE in patients with penetrating trauma. The risk factors for VTE in blunt trauma were receiving 4 or more transfusions, Glasgow Coma Scale score less than 8, and pelvic fracture. ^[7]

• Stress ulceration and bleeding

• Pressure ulcers

• Atelectasis

• Ventilator-associated pneumonia

• Catheter-related sepsis

• ICU psychosis

Early postoperative complications include ongoing bleeding, coagulopathy, and abdominal compartment syndrome. Later complications include acute respiratory distress syndrome, pneumonia, sepsis, intra-abdominal fluid collections, wound infections, and enterocutaneous fistulae, small bowel obstruction, and incisional hernias.