Academic presentationduring Junior residency rotation at general surgery unit, surgery department, AKTH by Dr Kabiru SALISU

1. By
Dr Kabiru Salisu

2.  Introduction
- Definition
- Epidemiology
 Indications
 Preoperative preparation
 Operative technique
 Post operative care
 Complication
 Conclusion
 References

3.  Abdominal injuries are important cause of
morbidity and mortality especially in the
patient with multiple injuries. It could be
- blunt trauma
RTA, fall and social violence.
- Penetrating trauma
stab injuries and shot (missile or arrows )

4.  Liver remain the commonest organ affected
by penetrating
 spleen in blunt injury
 Trauma is the commonest cause of death in
the 1st 4decade of life
 Abdominal trauma is of increase rate world
wide

5.  Twenty percent of all trauma operations are
performed for the management of abdominal
injury
 An exploratory laparotomy is carried out in
conditions where the need for an operation is
recognized but where a definitive diagnosis
cannot be made until the abdomen is opened.

6.  Is made from Hx, PE and relevant
investigation depending on the presentation
 History
- To determine type and mechanism of injury
- The severity of injury
- Other injuries eg thoracic, head injury, spinal
injury, genitourinary and long bones #
- Hx suggestive of disease viscus
- Aspirin or anticoagulant therapy
- Presence of comobidity

7. - Examination
- Look for systemic features of shock
- Anterior abdominal wall bruises
- Look for features of peritonitis
- Abdominal distension
paralytic ileus
large retro-peritoneal haematoma
- kehr’s/ balances signs
- Cullen’s signs

8. Investigation
1- base line
PCV, E U/ cr and G /m
Falling serial pcv indicate on going bleeding
2- X- RAYs-
Erect CXR
Abdominal X-ray

10.  May show
- free fluid or air in the peritoneum
- Wound tract bridging the peritoneum
- Solid organ injuries
- Bowel wall defect, thickening
- Diaphragmatic tear
5- IVU

11.  I- 4 quadrant tap
II- dignostic peritoneal labage
Positive
 5-10ml gross blood
 Pink perfusate
 >100,000 red cells/uL
 >500WBC/uL (if obtained 3 hours or more after
injury).
 >175 units amylase/dL
 Food perticles, bile stain and faeces
 Bacteria on gram-stained smear.

12. - Hemodynamic instability despite resuscitation
- Positive DPL
- Evisceration or herniation into thoracic cavity
- pneumoperitoneum
- Peritonitis
- Gun shot injury
- Thoraco–abdominal wounds.
- Haematemesis, blood in NG-tube drain
- Perrectal bleeding

14.  Intensive preoperative resuscitation reduce the
risk of perioperative complication and death
 unfortunately deterioration can also occur in the
presence of continuing haemorrhage
 Ensure air-ways and breathing
 Two wide bore canulae
 Sample taken for investigation
 Cristalloid rush appropraitely
 Urgent crossmatch and transfusion
 NG-Tube and urethral catheter should be
inserted

15.  Informed consent most be obtained either
from the patient , parent or guardian
 Shaving of the operation site
 G and cross match blood

16.  Aneasthesia
Laparotomy for trauma is done under GA with ETTc and
adequate relaxation
 Positioning
The patient is place supine with the arms abducted at the
right angle to the body. The lithotomy position is
employed when pelvic pathology is suspected an
simultaneous pelvic or vaginal procedure is required

17.  Skin preparation
Supra sternal notch to mid thigh
Laterally from Table to table.
 Draping
Done exposing the incision site and land- marks

18.  A long midline
incision is the
incision of choice.
Advantages
- It allows rapid and
easy access
- good exposure
- it can be extended
into a median
sternotomy

19.  Control of
bleeding
 Identification of
injuries
 Control of
contamination
 Reconstruction ( if
possible)

20.  Packing
-The intestines are eviscerated
-Gross blood is rapidly evacuated.
-Laparotomy pads are then rapidly placed in all
four quadrants to pack the abdomen;
the right upper quadrant
left upper quadrant
the lower two quadrants.
-Blood pressure may drop when the abdomen is
decompressed. Anesthesia should be given the
opportunity to catch up with resuscitation efforts
at this point

21.  In penetrating injury the site of injury is
approach directly
 In blunt injury remove pack from the least
expected area to the suspected site of injury
 Any bleeding not controlled by packing most
be given a serious attention

22.  Digital pressure
(finger superior to
clamps)
 Proximal vascular
control
- Aortic clamping
- clamping of hilium of
kidney or spleen
- Pringle’s manoeuvre

23.  Liver
 Spleen
 Stomach
 Colon from caecum to
rectum
 Small bowel from
ligament of treitz
 Duodenum / pancreas
 R & L hemi diaphragms
and retroperitoneum

24.  Inspect all bowel
completely front/back
 Clamps (Babcock)
 staples
 Suture closure
 Resection + Anastomoses

25.  Repair or control site(s) of 10 injury.
Full mobilization & exposure impt.
Re-asses pt’s condition
Address areas of potential injury
Definitive Repair or Damage control

26.  Damage control surgery is one of the major
advances in surgical technique in the past 20
years
 It is now well recognized that multiple
trauma patients are more likely to die from
their intra-operative metabolic failure than
from a failure to complete operative repairs

27.  Definitive repair delayed to prevent death
from leathal triad
- Severe metabolic acidosis
- coagulopathy
- Hypothermia
• Abdomen is packed and patient taken to ICU for
resuscitation
• Patient is return to theatre within 48-72hr for
definitive repair

28.  Zone 1 (central)
◦ Explore regardless of mechanism.
 Zone 2 (lateral)
◦ Explore penetrating trauma.
◦ Observe blunt trauma (nonexpanding,
nonpulsatile, no urologic indications)
 Zone 3: -( pelvic)
- Explore penetrating.
◦ Observe blunt.

29.  Repeat the initial exploration at end of the
definitive repair
 Copious irrigation with warm saline is done

30.  The speed and type of closure depend on
condition of the patient
 Abdomen should not be closed under tension
to prevent ACS
 Effort should be made to close the fascia
 Retention sutures can be applied if there is
risk of dehiscence
 Skin is tagged in case of gross contamination
Or closed

31.  Haemorrhage
 Respiratory difficulties
 Injuries to surrounding structures
 Abdominal compartment syndrome
 Fistulas
 Abscess formation
 Burst abdomen