1. Management of
Abdominal Trauma &
Damage Control Surgery
EHSAN ULHAQ
P.G.R General Surgery

2. Case 1
 25 years old male, coal mine worker in dara adam
kheil
 Hit by trolley full of coal in left Flank area
 Examination
 Well oriented, cloth stained with blood and coal
 Airway: clear
 Breathing: 32
 Circulation: Pale, pulse 120, BP 90/60
 Disability: No LOC, moving all four limbs

3. Case 1
 ExaminationExposure:
 large wound in the left flank and abdominal
viscera was lying outside contaminated with coal
particles and dust
 Management:
 IV fluids, analgesics, antibiotics, tetanus
prophylaxis
 NG and urinary catheters were passed
 Patient was shifted to OT for Emergency
exploratory Laprotomy

4. Case 1
 Laprotomy findings
 Large wound in the left flank region
 All abdominal viscera contaminated with coal particles and
dust
 Disrupted descending colon and sigmond colon
 6 cm rent in the left diaphragm
 Haemi peritonem about 600 ml
 Spleen, liver, kidney and rest of the other viscera were
normal
 Fracture 10 and 11 th rib

5. Case 1
 Surgical procedures done:
 Left side chest tube was passed
 Left hemi diaphragm repaired
 Resection of disrupted descending colon and
sigmoid colon done with double barrel colostomy
 Peritoneal wash done with 5 litres of NS

6. Post operative Course
 IV fluids, IV antibiotics and analgesics were given
 2 pint of blood transfused
 Base line investigation were done
 X ray Chest and X ray pelvis
 Insentive spirometry
 Diet started on second post OP day
 Patient ambulated on 2nd post OP day
 Daily wound wash
 Chest tube taken out on 3rd day
 Patient discharge on 5th post op day

7. Case 2
 30 years old male
 RTA ( pedestrian vs motor cycle ) 2 hours
 Hit by motorcycle handle in the left hypo chondrium region
 Examination:
 Well oriented, pale looking, severe pain abdomen
 Airway: clear
 Breathing 30 /min
 Circulation: pale looking, pulse feeble, BP90/40
 Disability: No LOC, moving all four limbs

8. Case 2
 Examination:
 Abdomen: tense, tender
 Assessment: Blunt abdominal trauma with
haemodynamic instability
 Management:
 IV line passed, IV fluids, IV analgesic, IV antibiotics
given
 Urinary catheter and NG tube passed
 Patient shifted to OT for emergency exploratory
laprotomy

9. Case 2
 Laprotomy findings:
 Haemo peritoneum of about 2 litres
 Completely shattered spleen
 Kidneys, liver and all the other viscera were
normal
 Spleenectomy done
 Haemostasis secured
 Intra operatively 2 units of blood were transfused

10.  Post Operative Course:
 Patient shifted to ICU
 Base line investigation were done
 2 more units of blood were transfused
 IV antibiotics given
 Ca Gluconate 1 gm ( post transfusion)
 Chest x ray and x ray pelvis done
 Shifted to ward on 2nd post OP day
 NG out on 2nd post op day
 Ambulated on 2nd post op day
 Encapsulated organism prophylaxis given
 Patient discharged on 4 th post op day

11. Trauma
 Major health concern of modern world.
 leading cause of death in age group 14---44.
 Puts enormous strain on the resource of the
country.
Trauma Care in Pakistan, J Pak Med Assoc, Vol. 58, No. 3, March 2008

12. Trimodal distribution of death
 Immediate: death within minutes. e.g brain, brain
stem injuries, CV injuries.
 Early: death within hours. e.g thoraco abdominal
injuries
 Late: death within days. e.g sepsis, multi system
organ failure
 Golden hour: trauma patient should be operated
within first hour of presentation

13. Abdominal Trauma
 Commonly injured part of the body.
 Physical examination is unreliable.
 Head and spinal injuries, drugs and alcohol further complicate
the scenario.
 High degree of suspicion of intrabdominal injury, on the basis
of mechanism of injury.
 25 % of abdominal trauma patient require laprotomy

14. Aetiology of abdominal trauma
Penetrating Blunt Iatrogenic
FAI RTA Endoscopy
Stab wounds Blast injuries External cardiac
Crush injuries massage
Peritoneal dialysis
PTC
Liver biopsy
Essential surgical practice, 4th edition

15. Frequency of injury in penetrating
abdominal trauma
 Liver 37%
 Small bowel 26%
 Stomach 19%
 Colon 17%
 Major vascular 13%
 Retroperitoeum 10%
 Mesentry 10%
 Spleen 10%
 Diaphragm 05%
Essential surgical practice, 4th edition

16. Frequency of injury in blunt
abdominal trauma
 Spleen 25%
 Kidney 20%
 Intestine 15%
 Liver 15%
 Retroperitoneal haematoma 13%
 Mesentry 05%
 Pancrease 03%
Essential surgical practice, 4th edition

17. Diagnosis
 History of event
 Physical examination
 Diagnostic modalities
 The test of choice will dependent on the
hemodynamic stability of the patient & the
severity of associated injuires.

18. Diagnostic modalities
 Serial Physical Examination (PE)
 Local Wound Exploration (LWE)
 Diagnostic Peritoneal Lavage (DPL)
 Ultrasound (FAST)
 CT Scan
 Laparoscopy
 Laparotomy

19. Serial Physical Exams
 24 hour obs
 repeated physical exams
 Checking for hemodynamic
instability or development of
peritonitis

20. Local Wound Exploration
 Extend wound.
 Penetration of the peritonium
is considered positive.
 25% of anterior abdominal
stab wounds do not penetrate.
 Only 50% that do penetrate
actually require surgical
intervention.

21. Diagnostic Peritoneal Lavage
 Abdominal,
thoracoabdominal,
back, or flank stab
wounds
 Positive DPL
means emergent
surgical
exploration

22. DPL Procedure
 to identify hollow
viscus injury
(stomach, small
bowel, colon) or
diaphragmatic injury
 Introduce catheter
infraumbilically and
infuse fluid

23. When is it positive?
 Positive Tap = Gross Blood
 Anterior abdominal stab wound or tangential GSW=
100,000 RBC/mm3
 Back or Flank Stab Wound = 5000 RBC/mm3
 Thoracoabdominal Stab Wounds = 500 RBC/mm3
 Tangential gun shot wounds = 5000 RBC/mm3
 Better for small bowel and diaphragmatic injuries
 Does not evaluate retroperitoneum

24. FAST

25. FAST Scan
 Good for identification of free fluid.
 Rapid and cost effective.
 Can be perform with equal accuracy by surgeons.
 Does not evaluate retroperitonal injury.

26. Abdominal CT
 Blunt trauma
 Hemodynamic stablility
 Normal or unreliable physical examination
 Retroperitoneal organ damage duodenum,
pancreas

27. Diagnostic investigations
Stable Unstable
Penetrating trauma Stab wounds: Local wound OT
exploration.
Gunshot: OT
Blunt trauma US fast / CT scan OT
DPL +/-US fast
Plain radiograph
CXR: to rule out pneumo or haemo
pneumothorax
Xray pelvis: to rule out pelvic #

28. FAST: Comparison
Barry C. Simon. Ultrasound in Emergency Medicine. Table 7-2. Pages 158-159 .

29. Diagnostic laproscopy
 Improved diagnostic accuracy compared to
 FAST: poor specificity
 DPL: poor specificity, invasive, not informative for retroperitoneal
injuries
 CT: hollow viscus injuries difficult to identify
 reduction of nontherapeutic laparotomy rates.
 reduction of short and long-term morbidity.
 ↓ICU stay, ↓overall hospital stay
 ↓risk future adhesive bowel obstruction
 Not available in emergency.

30. Exploratory laprotomy
 Peritoneal signs.
 Hypotension + FAST +ve in
blunt trauma.
 GSW.
 Stab wound + hypotension.
 Visceral injury on CT scan
 Inability to evaluate
clinically

31. General resuscitation measures
 ABCDE.
 Spinal precautions.
 IV lines and tubes.
 Consent.
 Arrange blood product.
 Rapid transport to OT

32. Damage control surgery
 During past two decade, a new surgical
strategy developed to avoid high mortality in
severe trauma patients, during operation or
resuscitation.
 Stage surgery
 OT----ICU----OT

33. The lethal triad of death

34. Damage Control Surgery
•Part I: OT •Part III: OT
•Control of hemorrhage •Pack removal
•Control of contamination •Definitive repair
•Intra abdominal packing
•Temporary closure
•Part II: ICU
•Rewarming
•Correct Coagulopathy
•Maintained Hemodynamic
•Ventilatory Support
•Injury identification

35. Damage Control Surgery
 Un planned Re-Operation
 Continued bleeding despite normalization of
coagulation functions.
 Abdominal compartment syndrome.

36. Abdominal compartment syndrome
ACS is the result of acute increase in intra
abdominal pressure after major surgery or DCS.
Causes:-
 Peri hepatic packing.
 Bowel edema and congestion in major trauma
 Accumulation of blood in the mesentery and/ or
retroperitoneal space.
 Persistent intra abdominal bleeding.

37. Complication of ACS
 Decrease cardiac output
 ARDS
 Bowel gangrene and ischemia
 Renal failure
 Cerebral edema
 Death

38. Diagnosis of ACS
 Decrease urine output
 Elevated CVP
 IA pressure >25 cm of water
 IA pressure measure through foleys in bladder

39. Management of DCS
 Surgical decompression
 Be aware of good preparation because sudden
decompression can cause hypotension or
rarely asystole and death.

40. Situation in pakistan
 Worse situation.
 Increasing no. of trauma patient.
 A study from Karachi reported that 58% of the
victims of violence died before they could
reach the hospital.
 Lack of pre hospital care.
 Rescue 1122.
 No ATLS, BLS and ACLS certified staff.
Trauma Care in Pakistan, J Pak Med Assoc, Vol. 58, No. 3, March 2008

41. Summary
 ABCDE of resuscitation.
 Do not rely on physical examination
 High degree of suspicion of intra abdominal injury,
on the basis of mechanism of injury
 Blunt Trauma + HD stable observation
 Blunt trauma + HD unstable laprotomy
 Blunt trauma + +ve FAST laprotomy
 GS wound laprotomy
 Stab wound + HD unstable laprotomy.
 Stab wound + HD stable local WE

42. Summary
 Surgeons should be trained in doing FAST.
 DCS .
 Keep an eye on abdominal compartment syndrome.
 Pre hospital care in community by training police
personal, volunteers, teachers and other local bone
setters.
 ATLS, BLS and ACLS training of the medical and
para medical staff in all the hospital.