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Abdomen & pelvis

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Damage control surgery
DPL

Abdominal and pelvic injury

Mechanism of injury

Regions of the abdomen

History

Examination

Investigations

Specific injuries

Pelvic injury

Retroperitoneal haemorrhage

NB If rapid surgical haemostasis is provided in penetrating trauma, delaying or limiting fluid resuscitation before surgery may improve outcome

Mechanism of injury

- blunt injuries most common cause. GI injury associated with use of seat belts. Abdominal and pelvic injuries more likely with side-on collisions whether occupants are on impact or non-impact side. Liver, spleen and kidneys organs most likely to be damaged in blunt trauma
- stab and laceration wounds. Entry sites do not accurately predict nature of deeper injury. Thoracic injury should be suspected with upper abdominal wounds and vice versa. Note that the diaphragm extends as high as T4 in expiration Intra-abdominal injury occurs in 44% of anterior abdominal wounds, 29% of flank wounds and 15% of back wounds. Organs most likely to be affected are liver, small bowel, colon and stomach
- gunshot wounds depend on missile calibre, velocity and trajectory. Laparotomy should be performed in all cases when peritoneal violation cannot be excluded as 89% of such patients have intra-abdominal injury. Note that gunshot wounds may have a circuitous trajectory and thus may injure multiple non-contiguous wounds

Regions of the abdomen

3 distinct anatomical compartments: peritoneum, retroperitoneum and pelvis

  • peritoneal cavity subdivided into:
    • intrathoracic segment
      • covered by bony thorax and includes diaphragm, liver, spleen, stomach and transverse colon
    • abdominal segment
  • retroperitoneum
    • aorta, vena cava, pancreas, kidneys, ureters and portions of duodenum and colon
    • injuries to this region notoriously difficult to diagnose because the area is remote from physical examination and is not sampled by peritoneal lavage
  • pelvic organs
    • rectum, bladder, iliac vessels, internal genitalia of women
    • injury also difficult to diagnose early because of anatomical location

History

Mechanism of injury

  • Blunt injury. Important questions:
    • time of injury
    • mechanism
    • estimated speed of impact
    • damage to involved vehicles
    • use and type of restraining device
    • condition of injured persons
  • Penetrating injury:
    • time of injury
    • type of weapon (eg knife length, handgun calibre)
    • distance from assailant (particularly for shotgun wounds)
    • number of stab attempts or shots
    • amount of blood at scene

Examination

  • clinical examination should include thoracic cage, back and pelvis including perineal and rectal examination for anal tone, prostatic position, blood or other evidence of injury
  • gastric aspirate and urine should be inspected for blood
  • listening for bowel sounds is not useful
  • serious intra-abdominal pathology cannot be excluded in presence of impaired consciousness, intellectual disability or other injury. Even in alert patients abdominal tenderness is absent in 25-30% of with intra-abdominal injury. As many as 20% of patients with acute haemoperitoneum will have benign abdominal examination when first seen in A&E
  • laparotomy is indicated without further investigation for:
    • shocked patients with signs of intra-abdominal haemorrhage (eg peritonism or increasing distension)
    • patients with penetrating trauma and evisceration or peritonism

Investigations

CXR

- (preferably erect) essential.
- ? free intraperitoneal gas, herniation of abdominal contents through ruptured diaphragm or other abnormalities

AXR

Of no benefit

Diagnostic peritoneal lavage

  • rarely indicated if FAST and CT are available

CT (contrast enhanced)

  • indications:
    • to assess retroperitoneum
    • indeterminate diagnostic peritoneal lavage
    • DPL contraindicated
    • persistent abdominal pain despite a negative DPL
    • penetrating flank trauma
    • mild abdominal tenderness in alert patients
  • contraindications: haemodynamically unstable patients
  • can detect very small quantities of blood in abdominal cavity
  • sensitive method of detecting injury to solid organs (eg up to 98% sensitive for splenic injuries when IV contrast given)
  • detection of bowel and pancreatic lesions is less sensitive, although helical abdominal CT has higher sensitivity for detecting blunt bowel injury
  • has advantage of delineating nature of intra-abdominal injury
  • in absence of splenic or liver injuries the presence of free fluid in the abdominal cavity on CT suggests an injury to GI tract and/or its mesentery, and mandates further surgical evaluation

Ultrasound

Can be performed in resuscitation room without compromising resuscitation. 91-100% sensitive and >98% specific in detecting haemoperitoneum. Less sensitive in detecting nature of injury, particularly in liver, pancreas and bowel.

FAST

  • focused abdominal sonography for trauma
  • aim of assessment is to detect haemoperitoneum
  • sensitivity is poor in some series although specificity is high. As a result patients with a normal FAST require further evaluation
  • ~30% of patients with intra-abdominal injury do not have haemoperitoneum (majority do not require intervention).

Diagnostic laparoscopy

  • may be useful in haemodynamically stable patient
  • good for looking at diaphragm and identifying need for laparotomy but may miss specific organ injuries, particularly of bowel
  • best suited for evaluation of equivocal penetrating wounds

Angiography

Almost no role in diagnosis of abdominal trauma however transcatheter embolisation has a role in management of persistent hepatic bleeding (not stopped by surgery) and in patients with bleeding from a traumatized lumbar or intercostal artery

Laparotomy

Specific injuries

Splenic injury

  • when associated chest or neurological injuries are severe minor splenic injury may not initially be detected unless further investigation is undertaken. Left rib fractures associated with a 4 times increased odds of splenic injury but if this is the only risk factor the incidence of splenic injury is low.
  • minor trauma may cause injury to enlarged spleen (eg from malaria, lymphoma, haemolytic anaemia
  • immediate splenectomy indicated in patients with severe multiple injuries, splenic avulsion, fragmentation or rupture, extensive hilar injuries, failure of haemostasis, peritoneal contamination from GI injury or rupture of diseased spleen
  • conservative non-operative approach:
    • stable patients <55 yrs in whom associated abdominal injuries have been excluded
    • observe in hospital for 10-14 days, bed rest for 1 week
    • no strenous activity for 6-8 weeks
    • no contact sports for 6 months
    • NB delayed rupture and haemorrhage may occur. Usually in first 48 h
  • nonoperative management of children with splenic or hepatic injury
    • if patient is haemodynamically stable
    • requires replacement of <1/2 of estimated blood volume (ie requires <40 ml/kg)
    • free of concomitant intra-abdominal injury requiring exploration
    • splenectomy avoided in >90% of children (only 13-50% of adults).
  • polyvalent pneumococcal vaccine should be given after splenectomy

Hepatic injury

  • second most commonly injured after blunt abdominal trauma
  • most frequently missed injury in trauma deaths
  • diagnosis made at laparotomy in unstable patients and by CT in stable patients. Latter enables conservative treatment in selected patients, particularly children. Patients should be stable, have no associated abdominal injuries, and be assessed repeatedly, including follow up CT
  • dilutional coagulopathy and thrombocytopaenia are common following hepatic repair
  • complications of liver injury:
    • early: relate to hypoperfusion or massive blood transfusion
    • late: sepsis

Management

  • Non-operative management. Criteria:
    • haemodynamically stable
    • absence of peritoneal signs
    • other intra-abdominal injury can be excluded with reasonable certainty
    • limited on-going transfusion requirements
  • Operative management
    • Packing and limited surgery may be best initial procedure particularly when coagulopathy or hypothermia develops

GI tract injury

  • more common following penetrating trauma
  • <5% of patients following blunt trauma. More common following direct blow to epigastrium
  • both DPL and CT may fail to diagnose duodenal perforation or haematoma. A high index of suspicion should be maintained in patients with persistent abdominal pain and tenderness
  • duodenal rupture
    • classically encountered in the intoxicated unrestrained driver involved in a frontal impact RTA. 40% have associated injury
    • bloody NG aspirate should raise suspicion of injury
    • contrast CT are indicated in high-risk patient following completion of secondary survey. (Alternative: duodenal "C-loop" gastrograffin studies
  • appearance of transverse linear ecchymosis on abdominal wall (seat belt sign) or presence of anterior lumbar compression fracture should raise suspicion of intestinal injury
  • colon injury
    • rare following blunt trauma

Pancreatic injury

  • often associated with duodenal, hepatic and splenic trauma
  • clue to diagnosis is in history. Most often due to direct epigastric blow compressing pancreas against vertebral column
  • also occurs in association with lower thoracic or upper lumbar vertebral #s
  • contrast CT most useful investigation but may not identify significant pancreatic trauma in the immediate post-injury period. Helical abdominal CT identifies approximately 2/3.
  • initial raised plasma amylase does not predict pancreatic or hollow viscus injury. Subsequent rise in amylase over next 24 h more useful

Treatment

  • severe injuries to the body of the pancreas are best managed by distal pancreatectomy
  • the majority of penetrating injuries can be managed with stump drainage alone.
  • pancreaticoduodenectomy indicated in fewer than 5% of cases.

Complications

Common

  • fistulae
  • abscess
  • pseudocyst are common

Urinary tract and renal injury

  • more common after blunt than penetrating injury
  • identification and treatment of other major injuries takes precedence
  • gross haematuria requires investigation (CT is examination of choice if haemodynamically stable), while microscopic haematuria does not unless there is unexplained shock. Degree of macroscopic haematuria not related to severity of injury
  • majority of renal injuries can be treated conservatively
  • bladder rupture commonly associated with pelvic fractures
    • >95% have macroscopic haematuria
    • Retrograde cystography is investigation of choice
    • Intraperitoneal rupture requires operative repair while extraperitoneal rupture can be treated conservatively
  • urethral trauma should be suspected if there is blood at meatus, perineal injury or abnormal position of prostate. Treatment is suprapubic drainage and delayed definitive repair

Diaphragmatic injury

  • <5% of cases of blunt trauma
  • left sided in 80%
  • suspect with penetrating injury below 5th rib
  • diagnosis may be difficult, especially in presence of IPPV, and may only become evident when ventilatory support withdrawn
  • ultrasound may be better than CT because of its variable angle of view. Laparoscopy provides good views of diaphragm
  • spontaneous healing does not occur

Penetrating injury

  • prophylactic antibiotics for 24h are satisfactory for penetrating injuries

Pelvic injury

Associated with a mortality of 13-23% and significant morbidity. In majority of patients massive retroperitoneal haemorrhage is direct cause or a major contributing factor to mortality

Mechanism of injury

Significant pelvic fractures are due to high energy blunt trauma. Usually a RTA, fall or crush injury.

Clinical features

  • suggested by pain on movement, structural instability, gross haematuria, peripelvic ecchymoses
  • rectal examination mandatory to identify rectal injury and prostatic position
  • if patient has a stable pelvic fracture hypotension is probably due to haemoperitoneum

Management

  • bleeding is usually bony or venous in origin
  • if patient is still haemodynamically unstable perform early open DPL. If grossly positive laparotomy should precede external fixation or angiography. If positive by cell count only risk of major intra-abdominal haemorrhage is low and control of pelvic bleeding becomes main priority
  • early stabilization with external fixators helps to minimize bleeding from veins and small arterioles near # sites. Also reduces volume of an open pelvis and thus improves tamponade
  • pelvic angiography with embolization often successful in controlling arterial haemorrhage but logistically difficult
  • large vessel bleeding requires surgical control
  • early operative stabilization of complex pelvic fractures preferred in ICU: facilitates respiratory care, pain control and early mobilization
  • compound fractures involving perineum, rectum or vagina require aggressive surgery to avoid high mortality

Complications of comminuted fracture of the pelvis

Acute:

  • major haemorrhage (leading cause of death); shock, elevated intra-abdominal pressure
  • visceral and soft tissue injury: fractures may be compound into the perineum or vagina, or be associated with lacerations into the rectum or bladder (esp. with lateral compression and vertically unstable injuries).
  • urethral injuries common in males. Iinsertion of a urethral urinary catheter contraindicated
  • sacral plexus injury
  • ileus
  • pain
  • fat embolization
  • acute respiratory distress syndrome: in about 15%. This is possibly related to the frequent occurrence of associated thoracic injuries, multiple blood transfusions, shock, and fat embolization.
  • DVT because of stasis resulting from prolonged bed rest, and prophylaxis is often contraindicated

Late:

  • infection-second most common cause of death
  • disability/immobility/instability
  • incontinence
  • pain

Retroperitoneal haemorrhage

- frequent following blunt trauma
- commonly caused by injury to:

  • lumbar spine
  • pelvis
  • bladder
  • kidney

- less commonly pancreas, duodenum, major vessels: cause central rather than lateral or pelvic haematomas
- CT with enteral contrast most useful investigation in stable patient
- central haematoma should be explored with proximal vascular control
- lateral or pelvic haematomas should not be explored unless there is evidence of major arterial injury, intraperitoneal bladder rupture or colonic injury


© Charles Gomersall and Ross Calcroft September 1999


©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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