Abdominal trauma

Section: Trauma Curriculum: Curriculum, page 79

• Liver - Curriculum, page 87
• Pancreatic-duodenal trauma - Curriculum, page 91
• Splenic trauma - Curriculum, page 92
• Small bowel trauma - Curriculum, page 62

Resus vs Definitive surgery

• Resus - Damage control resuscitation and damage control surgery
  • Only lifesaving surgery - stopping bleeding and more contamination
  • Physiologically unstable
    • Complex Abdominal Injury requiring damage control approaches
      • Major liver injuries
        • Mobilization and packing +/- angioembolization
      • Pancreaticoduodenal injuries
      • Aortic and vena caval injuries
      • Complex pelvic #’s
• Definitive surgical treatment
  • Physiological stable enough for definitive procedure

Trauma Laparotomy

Overview

• Rapid entry
• Large and adequate incision from xiphisternum to pubis
• Control of massive haemorrhage by:
  • ID of all injuries
  • Packing
  • Direct control
  • Proximal control
• ID of injuries
• Control of contamination
• Reconstruction if possible
• Give abx prophylaxis – Cef + Met or Augmentin
  • Give longer duration abx if enteric or colonic soiling
• Temperature
  • Should be higher than usual
  • Bair hugger/warm air blankets during surgery
  • Warmed anaesthetic agents, IVF and wash
• Blood collection and autotransfusion
  • With cell saver if available
  • Draping
  • Expose from jugular notch to knees
    • Allows access for Median sternotomy, thoracotomy and groin access

Steps

• Incision
  • 2 swipes of blade - 1 to fascia and into abdomen
  • Mayo scissors for fascia and parietal peritoneum
  • If hostile abdomen anticipated - do thoracotomy for proximal control first
    • Aortic cross clamping OR
    • REBOA - Retrograde Endovascular Balloon Occlusion of Aorta
• Procedure
  • Scoop out clot/contaminants and use Poole sucker
  • Eviscerate SB, assess for major vessel injury, control bleeding
  • Packing with dry swabs
    • Paracolic gutters
    • Pelvis
    • Under left diaphragm and above/right of liver
    • Subhepatic pouch and other areas of bleeding
• Identify where major source of bleeding is and pack
• Let anaesthetics catch up physiologically
• Work from top down/systematically after major things have been dealt with
• To assess if bleeding is mesenteric or retroperitoneal
  • Need to mobilise the whole root of mesentery up from Caecum to DJF
• Deal with lesions in order of lethality
  • Haemorrhage
    • Major blood vessels
    • Solid organs
    • Mesenteric and hollow organ
    • Retroperitoneal
  • Contamination
• Definitive Packing
  • Facts
    • Dry folded packs placed flat
    • Effective for venous bleeding
    • Be efficient with pack use
  • Liver
    • Dissect gastrohepatic ligament and vessel loop portal triad (Pringle’s maneuver) in preparation for liver bleeding if it is suspected
    • Pack liver - If controlled → venous and should settle
    • If not controlled → Pringle’s maneouvre
      • Suspect Portal Vein or Hepatic Artery → Hepatorrhapphy
      • If it doesn’t settle with Pringle’s → ?IVC/Hepatic Vein injury
        • Compress against post abdo wall and pack
  • Spleen
    • Splenectomy by vascular clamping across hilum if needed
  • Pelvis
    • Extraperitoneal packing

Routes of Access

• Lesser omentum (along Lesser Curve)
  • Coeliac Artery
  • Body of Pancreas
• Greater omentum
  • Body and tail of pancreas
  • D1 posterior and D2 medial
  • Do a Kocher’s maneuver if suspected pancreas head injury
• Kocher’s
  • Medial mobilisation of Duodenum to ID D2 and D3 fully
  • Aorta and IVC
  • Right Kidney
  • Porta Hepatis
  • Posterior surface of Head of Pancreas
• Right medial visceral rotation
  • Procedure
    • Mobalise the hepatic flexure and ascending colon via dividing the line of Toldt
    • Then mobilise the SB mesentery from caecum/RLQ to ligament of Treitz and reflect right colon to LUQ
    • Then Kocherise the Duodenum
  • Provides exposure to
    • Entire duodenum - particularly D3 and D4
      • Accessing D3 with SM vessels there
      • Need to be retracted upwards
    • Pancreas - Head, neck and proximal body
    • Access to IVC and renal vessels
    • Right kidney
• Left medial visceral rotation
  • How
    • Retract small bowel and descending colon to the right
    • Mobilizing the left and sigmoid colon by incising the white line of Toldt
    • Divide splenic attachement to the diaphragm
    • Staying on the abdominal wall muscles enter the plane lateral and then posterior to the kidney medialising it
    • Note - in elective surgery a left medial visceral rotation (not Mattox) is performed leaving the kidney down but rotating the spleen/colon/SB
      • Left kidney is maintained in the Gerota’s fascia, in order to be protected from the traction injury, but the left renal vein hinders access to the anterior aorta.
  • Exposure of
    • Aorta and its branches
    • Pancreas - distal body and tail
    • Left Kidney
• Specific Organ Techniques
  • Liver injury - debridement, resection, fibrin glue and collagen fleece
  • Splenic injury - splenectomy
  • Pancreatic injury - suture repair if duct not involved, fibrin glue and drainage
  • Retroperitoneal haematoma - packing
• Abdominal closure
  • Principles to consider
    • Patient stability/lethal triad
    • Blood loss pre- and during surgery
    • IVF volume given
    • Degree of contamination
    • Nutritional status and intercurrent diseases
  • Options
    • Primary closure
    • Temporary abdo closure

Tips and tricks

• Headlight
• Lithotomy position
• Table tilt
• Move as needed
• Pericardial window
  • Central tendon of diaphragm and pericardium both originate from Septum Transversum (See Diaphragm anatomy)
  • Dissect through central tendon near xiphisternum to treat tamponade
• Wash
• Drains for pancreatic and duodenal injuries
• Bivalved bladder repairs with suture apposition of mucosa is key
  • Needs both SPC and urethral catheter
• Early tracheostomy - usually seldinger in ICU if needed these days

Abdominal Vascular Injury

• General
  • 3 things to consider
    • Need for ED thoractomy and aortic cross clamping
      • Loss of CO or imminent
      • Stops arterial bleeding and perfuses heart and brain
    • Need for immediate surgery
      • Requires ongoing resus to maintain CO
    • Need CT
      • Stable patient only

Retroperitoneum exposure

• General
  • Injuries are often missed, underestimated or have high rate of mortality
• Zones
  • I - Central
    • Between both psoas muscles and contains the abdominal aorta, inferior vena cava, pancreas, and midline duodenal structures
  • II - Lateral x 2
    • Lateral to the psoas muscles on bilateral sides and contains the kidneys, ureters, and portions of the colon
  • III - Pelvic
• Management
  • Zone 1 - Upper midline central retroperitoneal haematoma
    • All should be explored
    • Potential sites of injury
      • Aorta/IVC
      • Kidneys, Ureters, Renal vessels
      • Duodenum/Pancreas
      • Colon
  • Zone 2 - Lateral retroperitoneal haematomas
    • Only explore if expanding, thought to have injury to Colon or Ureter
    • Usually related to renal bleed which should tamponade
  • Zone 3 - Pelvic
    • Non - expanding - don’t explore
    • Ongoing bleeding
      • External fixation of pelvis
      • Angioembolization
      • If angio is unavailable and enlarging pelvic haematoma/ongoing bleeding
        • Extra-peritoneal pelvic packing
    • General
      • Unstable and peritonitis - Laparotomy
      • Observe if stable, not too sore and imaging is reassuring
      • Serial abdominal examinations

Retroperitoneal Haematoma

• Zones
  • I - central (further subdivision based on apex of haematoma)
    • Supracolic
      • Juxtarenal or suprarenal aorta, SMA, coeliac
    • Infracolic
      • Aortic bifurcation/IMA
      • Transperitoneal or left medial visceral rotation approach
    • Left or right
      • If apex is right of midline and primarily venous bleeding
        • Right medial visceral rotation
        • Access to Infrarenal IVC, aorta and portal vein
      • If apex is left of midline and primarily arterial bleeding
        • Left medial visceral rotation
        • Access aorta, coeliac, SMA, splenic A/V, left renal A/V
        • Mobilise kidney to access posterior wall of aorta
  • II - Lateral x 2
    • Leave alone if not expanding
    • Renal injuries - non operative and selective embolization approach
    • If penetrating injury or expanding - explore
      • Need to rule out occult post colonic and ureteric injury
      • To prevent abscess/urinoma formation
  • III - Pelvic
    • If stable and CT proven blush - Angioembolise
    • If found at surgery and non-expanding - Leave alone
    • If found at surgery and expanding - Manage
      • Extraperitoneal pelvic packing
        • Pelvic binder is on
        • Grasp peritoneal edge of inferior 25% of laparotomy wound
        • Develop Retzius space (pre-peritoneal plane) all the way round to posterior rectum on both sides
        • Evacuate clot
        • Packs x 2-3 on each side
        • If fails then culprit Internal Iliac Artery ligation
        • If works then to IR for assessment/embolization
        • Pelvic fixation/binder

Major Abdominal Vessels

Aorta

• Supracoeliac Aortic cross clamping
  • Retraction
    • Left Liver lobe → Right shoulder
    • Body of Stomach → Left hip
  • Dissection
    • Lesser omental window (Pars flaccida)
    • Crus peritoneum incised to expose muscle fibres which are split
    • Retract oesophagus to patients left
    • Adventitia of Aorta exposed, develop bilateral planes and clamp
    • Satinsky clamp placed supracoeliac
• Suprarenal aortic exposure
  • First do a supracoeliac clamp
  • In context of central supracolic haematoma
  • Then left medial visceral rotation
  • Exposes coeliac/SMA/L renal vessels/iliacs
  • SMA and coeliac nerve plexuses require dissection to access them
• Distal Aorta
  • Retraction
    • SB right | Transverse Colon superior | Descending Colon left
• Injury Treatment of Aorta
  • Aortic injuries need repair

Coeliac Axis

• Proximal control - supracoeliac aortic clamping or anterolateral thoracotomy
• Left medial visceral rotation and may need to mobilise left triangular lig and segments 2+3
• Difficulties
  • Dissection coeliac plexus of nerves - dense and fibrous
  • Short origins of left gastric, splenic and common hepatic
  • All can be tied off if SMA and IMA are intact - collateralization
• How
  • 3.0 prolene suture repair

SMA

• Left medial visceral rotation or root of SB mesentery
• Comes off aorta distal to coeliac and proximal to left renal A
• If damage control → Shunt it
• If can’t be repaired then should be replaced with graft to infrarenal aorta
  • Graft can kink if proximal end is placed too high
  • Keep it away from pancreas
• SMV can be shunted or ligated

IMA

• Can be tied off
• Colon viability needs assessment

Renal Artery

• Repair via infrarenal or medial rotation access
• Down time poorly tolerated - 45mins = Complete loss of function
• Therefore may need nephrectomy at that time

Iliacs

• Proximal and distal control
• Mobilise sigmoid colon and caecum
• May need groin access for distal control
• Beware of the ureters crossing the iliac bifurcation
• Veins closely adhered to back of arteries - Don’t dissect, just enough to clamp

IVC

• Suprahepatic ? chest access
  • Not controlled by Pringle’s maneuver
  • Controlled with direct downward pressure of liver onto IVC
  • Exposure and clamping of infrarenal IVC
  • Divide coronary ligaments to displace superomedially and see supra IVC
• Infrahepatic
  • Right medial visceral rotation
  • Kocher’s will show infrahepatic IVC well and right renal vascular pedicle
  • Direct pressure with swabs above and below
  • With penetrating injury it may be through and through
  • But all posterior injuries do not require repair
  • If it does, repair them transcaval as can’t get posterior on outside easily
  • Caval injuries below Renal Veins can be ligated if extensive but prefer lateral repair
  • Above Renal Veins should be repaired - ligation is unsurvivable

Portal Vein

• In free edge of lesser omentum - Portal Triad
• Pringle’s maneuver
• If more proximal: Kocher’s
• If damage control: Shunt
• Portocaval shunting is a high mortality option to consider

Shunting

• Indications
  • Can’t be repaired
  • Damage control situation
• Rationale
  • Allows flow to occur
• Rules
  • Diameter of tube - ⅔ circumference of vessel
  • Length of tube – 3 x length of defect
• What to use
  • NGT/ETT/chest drain/anything
• Other issues
  • Ends should be beveled
  • Tie silk around tube - ⅓ | ⅔ division
• Technique
  • Proximal and distal control
  • Proximal control applied
  • Place ⅔ end in
  • Use suture to pull back to distal end
  • Secure with ties
• Last for 2-3 days

Bowel, Rectum and Diaphragm

General

• Assess from diaphragm/OGJ to rectum and systematically with 2 hands and 4 eyes
• Common areas for missed injury
  • Diaphragm/GOJ
  • Lesser and greater curve
  • Posterior stomach and pancreas
  • SB
  • Retroperitoneal colon/rectum
  • If there’s one defect, look for a second defect

Diaphragm repair

• With penetrating injury without herniation, diaphragm injury cannot be ruled out with CT
• Needs trauma laparoscopy or laparotomy
• With soiling, may need to extend the wound radially to wash the chest out, close the diaphragmatic defect by pulling ends up with allis and suturing with continuous non-absorbable suture then placing a chest drain, then dealing to abdo washout
• Left side more common due to absence of liver on this side
• And right-handed assailant
• Be suspicious with thoracoabdominal injury below T5
• Large defects may need PTFE patch best placed via thorax
• Later complications include hernia with incarceration

Stomach

• Babcocks to grasp and inspect
• NGT in situ useful - can be grasped and used as a retractor
• Assess posterior wall either via anterior injury or in lesser sac along with pancreas
• 3.0 PDS repair full thickness
• Simple - debride edges and close
• Complex - Non-anatomic resection, reconstruct at relook

Duodenum

• Kocherise it if there is a haematoma as it is mandatory to inspect the posterior aspect

Small bowel

• Stable pt - repair or resect and anastomosis
• Unstable - staple off and leave ends in
• With missiles like shotguns (multiple small pellets), run SB through water ? gas leak

Colon

• Broadly similar to SB management
• Colostomy as definitive procedure rather than anastomosis dependent on patient factors at time of relook/definitive surgery
• Stomas should be placed laterally and at the level of the umbilicus, away from wounds

Rectum

• Intraperitoneal upper ⅓ and distal ⅔ extraperitoneal
• Mx with repair and diversion if upper and diversion alone if lower
• Flexi sig and rectal contrast CT useful

Mesentery

• Tie off bleeders/oversew and watch out for bowel ischaemia

Liver and Biliary System

Liver

General

• Cantile’s Line - GB to IVC - Left and right functional lobes
• Glisson’s Capsule = Visceral peritoneum of liver and covers porta hepatis structures
• Portal triad runs WITHIN segments
• Hepatic veins run BETWEEN segments (true on the right - not completely true on the left)
  • Also have no valves, no Glisson’s capsule protection and are majority intraparenchymal (8-12cm length with 1-2cm extrahepatic)
• Retrohepatic IVC is encase by liver – important re: mobilisation
  • 3-11 short hepatic veins go from liver direct to IVC
  • Also small branches from caudate lobe direct to IVC
• Bile ducts rely on Hepatic Artery for supply
  • Liver parenchyma mainly relies on portal vein so is ok with embolisation/ligation
• Blunt injury = Direct compressive or shear
  • Arteries resistant, veins and biliary ducts also but less so
  • Parenchyma is weak
    • Tears along segmental fissures mainly (where hepatic veins are)
• Regardless of liver injury grade - physiology determines management
• Hepatorhapphy or resectional debridement should be done if can’t control bleeding

Disposition

• Stable without peritonism – non-op
  • Otherwise can have FAST or CT with IV contrast in arterial and portal venous phase
• Unstable - operate
  • If bleeding → OT

AAST Liver Injury Grading

• Imaging based but criteria also exist for operative findings and pathological criteria
  • 5 grades
    • First 3 based on haematoma and laceration
    • Last 2 based on disruption of parenchyma and vascular injury
  • Laceration = Depth
  • Subcapsular = Surface Area %

Management

• Non-operative - Over 80% of liver injuries managed this way
  • Requirements for Non-Op management:
    • Haemodynamic stability
    • Absence of peritoneal irritation and confidence that isolated injury
    • High quality CT-scan with experienced radiologist
    • 24/7 availability of monitoring, repeat clinical assessment and intervention
  • Can use IR for embolization if blush present
  • Subcapsular haematomas as long as they are not expanding
• Operative
  • Majority is venous bleeding manage with packing/pressure

Operative Approach to Liver Trauma

• Initially compress right and left lobes together then push backwards for compressive effect
  • i.e. Push, Pack, Pringle, then Total Vascular Isolation
• Options
  • Packing | Pringle’s | Liver clamp | Diathermy | Haemostatic agents/glue | Hepatic suture | Hepatorrhaphy and non-anatomic resection
• Packing
  • Dry, folded packs with radioopaque marker
  • Remove within 1-3 days - Can cause infection
  • Complications
    • Reduced CO - Too tight, compress IVC
    • Respiratory deterioration - increased pressures from diaphragm reduced compliance
• Other options
  • Hepatic tourniquet
  • Tract tamponade balloon - with Sengstaken Blakemore tube is ideal
  • Pringle’s
    • Diagnostic - Hepatic Artery/Portal Vein vs Hepatic Vein/Caval bleeding
    • Therapeutic
      • Timing
        • 1 hr max
        • Less ischaemia with 10 mins on 5 mins off
  • Sometimes need to finger fracture to get access to deeper bleeders within parenchyma
  • Can staple off or ligasure bleeding segments along anatomical planes
  • Anatomical lobectomy acutely has high mortality
    • Situations where anatomical lobectomy is needed
      • Left lateral segment extensive injury - can’t pack
      • Non-viable liver segment post-packing
      • Almost free segment
      • Devitalized liver at pack removal
• Seldom have to mobilise the liver fully, acutely and without specialist help
• Hepatic isolation
  • Inflow - Pringle
  • Outflow - Clamp IVC infrahepatic and suprahepatic
    • Thoracic or abdominal approach
• Complications of severe liver injuries
  • Perihepatic infection
  • Biloma
  • Biliary fistulae

Spleen

• Relevant Anatomy
  • Mobilisation of ligaments
    • Gastrosplenic
    • Splenorenal
    • Splenocolic

Grading

• Similar to liver with regards to 5 grades, haematoma, laceration, disruption and vascular injury

Management

• HD stable and grade 1-3 → NOM
  • Re-bleed rate 1-8% - acceptably low
  • Angioembolization is useful adjunct
    • Indications
      • Evidence of ongoing bleeding
      • Significant Hb drop
      • Tachycardia
      • Contrast extravasation on CT-A (blush)
      • Pseudoaneurysm
      • NB: Prophylactic embolisation is useful and should be performed, i.e. arterial blush but patient is haemodynamically stable
  • Benefit of NOM
    • Avoid morbidity of non-therapeutic laparotomy
    • Fewer intra-abdominal complications
    • Reduced transfusion risk
    • No risk of post-splenectomy OPSI and pancreatic leak
• HD unstable → Open Splenectomy
  • Indications
    • HD unstable
    • Other injury requiring laparotomy
    • Evidence of continued splenic haemorrhage
    • Replacement of > 50% of pts blood volume
• Surgical Approach
  • Midline laparotomy/bookwalter/right tilt/headlight
  • Left hand pulls spleen anteriorly and medially
  • Divide splenorenal and splenophrenic ligs
  • Divide gastrosplenic lig with short gastrics closer to spleen sides
  • Can pack laterally to bring spleen closer
  • Can leave a closed suction drain if concern for pancreatic tail injury
• Vaccinations
  • If urgent splenectomy give vaccines within 14 days (/on discharge)
  • 2 weeks pre-op or post-op
    • To cover Haemophilus influenzae B, pneumoccoccus and Neisseria meningitidis
• Risk of OPSI
  • Opportunistic Post-Splenectomy Infection
  • Encapsulated organisms can cause overwhelming infection
  • Prevent by getting regular vaccinations including annual flu vaccine and COVID vaccines
  • Take abx at the earliest sign of infection incl. suspected viral illness Pathogenesis of OPSI
  • Insufficient opsonization filter function
  • Delayed and impaired production of immunoglobulin
  • Lack of splenic macrophages
  • Minimal tufts production
  • Reduced number of memory B-Cells – usually produce IgM to promote clearance of polysaccharide-encapsulated bacteria
• Other
  • Medic alert bracelet
  • Emergency abx script - amoxil 3g initially then 1g TDS
  • Flu and covid vaccine
  • Children get Amoxil until 18yrs old
  • Document on splenic vaccination register
• Vaccination/Abx splenectomy spiel
  • Prevent risk of OPSI
    • 2 weeks before or 1 week after splenectomy
    • Unvaccinated patients
    • Place on National immunisation register
    • Medic alert bracelet
    • 5 vaccines
      • Pneumoccocal (4)
        • Dose 1 conjugate
        • Dose 2-4 polysaccharide
        • Timing = 2mths, 5yrs, 5yrs or age 65 (later)
      • Meningococcal (lifelong)
        • Doses = conjugate + B
        • Timing - 2mths then 5yrly for life
      • Haemophilus influenza B (Hib) (1)
        • One off dose
      • Annual flu vaccination
    • Covid vaccination
  • Abx
    • Amoxil 250mg daily for 3 years
    • Lifelong if immsupp, prev sepsis or splenic malignancy
    • Allergy - Roxi 150 daily

Pancreas

• Anatomy
  • Closely related to IVC/Aorta | SM vessels | Renal vessels
• Mechanisms of Injury
  • Blunt - High impact - in a well-protected position
  • Penetrating - Can cause duct disruption
• Diagnosis
  • Clinical assessment, serum lipase and USS minimally helpful
    • Grey-Turner sign - Flank ecchymosis
    • Cullen sign - Periumbilical ecchymoses
  • Lipase not a reliable marker
  • CT useful but can miss injuries esp. early
  • MRCP is the best way to assess but can’t be done on unwell pt - delayed
  • ERCP is useful to visualise ductal injury and localise it but can risk pancreatitis
    • Best reserved for stable patients with equivocal MRCP
    • Could place PD stent but mixed evidence

Pancreas Grading AAST

Management

• NOM
  • For grade 1 and 2 found on imaging and at time of surgery
  • Adjunctive delayed ERCP can be considered for stenting
• Operative
  • For distal injuries without duct injury or any proximal injury - Drain
  • For distal injuries with duct disruption - Distal Pancreatectomy
  • For grade 3 and 4 found on imaging and at time of surgery
    • Consider exclusion for high grade injuries with Pyloric Exclusion and Gastrojejunostomy

Operative managment

• Operative Findings
  • Central haematoma
  • Bile staining
  • Peripancreatic oedema
  • Saponified fat - from pancreatic enzymes
• Surgical Approaches
  • Via Lesser Sac
  • Kocher’s
  • Right and left medial visceral rotation
  • All allow the entire pancreas to be assessed from all surfaces
  • PD assessment
    • Give Secretin to stimulate PD secretions
    • IOC via GB, duodenal defect, anterior duodenotomy
• Contusion and Parenchymal Injuries
  • If there’s duct disruption and left of SM vessels
    • Ligate duct
    • Distal pancreatectomy
    • Splenectomy as well if pt is unstable
    • Extra time required to preserve spleen
  • If duct is not disrupted
    • Leave a suction drainage device
  • Risks with distal pancreatectomy
    • Fistula/leak
    • Diabetes
• HOP and duodenal injuries
  • Damage control surgery
    • Drains/packing
    • Tube into duct directly
  • Pyloric Exclusion with Gastrojejunostomy
    • Why
      • Minimise exocrine pancreatic stimulation by Gastric Acid and Duodenal filling
      • Pylorus usually spontaneously opens in 2-3 weeks then the GJ anastomosis normally closes down on its own too
  • T-tube drainage (duodenal injury)
  • Whipple’s is an option but should be done in a staged approach
    • Indications
      • Massive disruption of the pancreaticoduodenal complex (Gd5)
      • Duodenal devascularization
      • Extensive duodenal injury involving ampulla or distal CBD

Pancreatic Trauma Complications

• Early
  • Pancreatitis (duct disruption) - Self limiting
  • Fistula
    • Low output - Self limiting
    • High output
      • Mx
        • Nutrition - Distal enteral feeds ideally
        • Drainage - Percutaneous/suction drain
        • ERCP and Pancreatic Duct stenting for duct disruption
    • Abscess
      • True pancreatic abscesses are rare and require debridement
• Late
  • Pseudocyst
    • Mx
      • Cystgastrostomy
      • Endoscopic stenting
      • Resection
  • Exocrine and endocrine dysfunction
    • Unlikely with distal resection - only need 20% functioning gland
    • Insulin and Creon

Summary of Pancreas Trauma

• Duct not involved
  • All - leave a drain
• Duct involved
  • Distal
    • Distal Pancreatectomy
  • Proximal
    • Damage control
    • Consider whipple’s
  • Consider Pyloric Exclusion

Duodenum

• General
  • Relatively well-protected like the pancreas
  • If it’s injured then very likely for other things to be injured too
  • Doesn’t present with peritonitis making dx hard
• Mechanism of Injury
  • Penetrating (more common and seldom isolated)
  • Blunt (associated pancreatic injury, steering wheel/handle bar/chance # of L1/L2)
• Presentation
  • Dependent on location of injury and where it drains
  • Retro | Lesser Sac | Greater Sac
• Signs of duodenal injury at surgery
  • Retroperitoneal haematoma
  • Peri-duodenal air bubbles
  • Peri-duodenal haematoma
  • Bile staining of tissues
• Investigation
  • CT
  • Laparotomy Duodenal Injury Scale

Operative management

• Techniques for repair of a duodenal injury
• Surgical Approach
  • Key factors
    • Proximity to ampulla
    • Injury characteristics - Simple vs complex
    • Circumference of involved duodenum
    • Associated injuries - Biliary tree, pancreas, vascular
  • Can’t really dissect D2 away from pancreas - closely apposed and inter-reliant on blood supply
  • D3 exposure via left medial visceral rotation - Cattell Brasch and SB mesentery mobilisation
  • D4 exposure by mobilising ligament of Treitz
  • Intramural haematoma
    • Leave alone if possible
    • Can cause duodenal obstruction but should settle with time
    • If doesn’t - warrants exploration
• Operative Possibilities
  • Simple suture repair
  • Patch
  • Duodenal diversion
  • Suction drainage peri-duodenal
  • Damage control preceded Whipple’s
• Options
  • Laceration and perofation
    • Simple suture repair
      • Closure of longitudinal duodenotomy transversely if length <50% is of circumference
    • Omental or serosal patch
  • Complete transection
    • Primary anastomosis often possible if mobility permits (D1,D3,D4)
    • May need reconstruction
      • Proximal to ampulla - antrectomy and Bilroth II
      • Distal to ampulla - R&Y duodenojejunal anastamosis and closure of distal duodenum
      • D2 - R&Y end-to-side duodenojejunal anastamosis
  • Pyloric exclusion with gastrojejunostomy
    • Consider this in high risk repairs to divert gastric content and improve chance of healing + make a leak easier to manage
  • Other options
    • Duodenal Diverticulation - this is dated
      • This is Bilroth II gastrectomy + closure of duodenal injury + placemnet of a decompressive catheter into the duodenum (also described is performing a truncal vagotomy and biliary drainage at the same time to decrease the fluid in the repair)
    • Triple tube decompression
    • Damage control surgery followed by Whipple
• Consider cholangiogram if close to ampulla/bile duct Difficult duodenum

Renal Injuries

• General
  • Blunt > Penetrating
  • Haematuria (5 RBC/HPF) in 95% of renal injury but its absence does not exclude
• Diagnosis
  • Macrohaematuria
  • Microscopic haematuria - Urinalysis
  • Unstable pt → OT
  • Stable pt
    • Triple phase CT
      • Grade injury to guide ideally NOM (up to and incl. Grade 4 without vascular injury)
    • Contrast-enhanced and duplex USS can ID active intra-renal bleeds/AV fistula
  • IVP = Give IV contrast (2 mg/kg) then do x-ray of renal tract 10 mins after contrast

Renal Injury Grading

grade I

• subcapsular haematoma and/or contusion, without laceration

grade II

• superficial laceration ≤1 cm depth not involving the collecting system (no evidence of urine extravasation)
• perirenal haematoma confined within the perirenal fascia

grade III

• laceration >1 cm not involving the collecting system (no evidence of urine extravasation)
• vascular injury or active bleeding confined within the perirenal fascia

grade IV

• laceration involving the collecting system with urinary extravasation
• laceration of the renal pelvis and/or complete ureteropelvic disruption
• vascular injury to segmental renal artery or vein
• segmental infarctions without associated active bleeding (i.e. due to vessel thrombosis)
• active bleeding extending beyond the perirenal fascia (i.e. into the retroperitoneum or peritoneum)

grade V

• shattered kidney
• avulsion of renal hilum or laceration of the main renal artery or vein: devascularisation of a kidney due to hilar injury
• devascularised kidney with active bleeding

Management

• Unstable
  • Findings of renal injury at laparotomy - Retroperitoneal haematoma
  • Options
    • Single shot on table IVP
    • Ensure kidney functionality
    • Exploration of injured kidney
  • Pack and get out (DCS)
• Stable
  • Grade 1 or 2 injuries - NOM
  • Grade 3 - Major lacs through cortex and into medulla/CD
    • May need drainage
  • Grade 4 - Multiple renal lacs and vascular injury
    • Usually require nephrectomy
    • If HD stable could consider partial
  • Grade 5 - Pelviureteric junction injuries - avulsed or lac (incomplete tear)
    • Nephrectomy
• Kidney is designed to facilitate non-op mx
  • Segmental pattern of division of blood supply
  • Haematoma displaces renal tissue but doesn’t disrupt blood vessels
  • Closed retroperitoneal space to tamponade in
  • Kidney rich in tissue factor - activates extrinsic coagulation cascade - haemostasis
• Options
  • Drainage and embolization!
  • Urine - Ureteric stenting
  • Collection/Urinoma - Percutaneous drainage
  • Embolization
• Surgical Approach
  • Need to get vascular control
    • Good exposure of the Aorta and IVC
    • Left and right medial visceral rotation and Kocher’s
      • Need to see both ends of renal arteries and veins
      • Also need to mobilize the kidney to get behind it
    • Try and keep Gerota’s fascia intact until you have vascular control
    • Origin of Right Renal Artery is adjacent to IVC therefore need to dissect between the 2
  • Exposure of the Right Kidney
    • Kocherise Duodenum
    • Mobilise Right Colon
  • Try and repair the Right Renal Vein if possible
    • Lack of collaterals
  • 2 ways to improve access to Left Renal Artery
    • Ligate the Left Renal Vein tributaries
      • Adrenal | Gonadal | Lumbar
    • Ligate the Left Renal Vein distally (close to IVC)
      • Collateral drainage via the 3 more proximal tributaries
  • With proximal control → Ischaemic time should be limited to 30 mins
    • Allows time to open Gerota’s, debride, suture and partial nephrectomize
  • Repair
    • Suture close the medulla then the cortex/capsule
    • Can use omentum/mesh to fill gap of large defect or suture over repair
    • Close Gerota’s
    • Leave a suction drain to monitor for urine leak
  • Can consider nephrostomy tube/ureteric stents later if needed
  • Adjuncts
    • Pledgets - Closing capsule can be hard
    • Sealants
    • Drains
• Complications
  • Urinomas (infected or non-infected) - Perc/transureteric
  • Perinephric abscess - Perc/transureteric
  • Delayed bleeding - IR
  • HTN - Late

Ureteric Injuries

• General
  • Usually missed or late dx
• Diagnosis
  • Scans can miss it
  • Intra-op methylene blue testing can help
• Surgical Approach
  • As described earlier for vessel access gives good access to ureters
  • Do not denude them over long segments - Segmental supply
  • Proximal injuries accessed via rotations
  • Distal injuries accessed through local peritoneal incisions and mobilising bladder
• Management
  • Unstable
    • Leave alone
    • Stent
    • Ligate (nephrostomy tube later)
    • Nephrectomy (esp. if concurrent colonic injury)
  • Stable
    • Injury between PUJ and Pelvic Brim
      • End to end spatulate ureteric anastomosis
      • Interrupted and over a ureteric stent
    • PUJ injuries
      • Same but add a nephrostomy tube
    • Pelvic brim ureter injuries
      • Anastomose ureter to neobladder with a reflux mechanism (specialised)
        • Boari flap
      • Or anastomose ureter to other ureter
      • End ureterostomy (if loss of length)
      • Nephrectomy
    • Ensure that retroperitoneal drains, urethral/SP catheters are left
• Complications
  • Stricture and hydronephrosis
  • Anastomotic leak
  • Urinoma
  • Infection

Bladder Injuries

• General
  • Associated with pelvic #’s/fixation
• Diagnosis
  • Lower urinary tract symptoms
  • Intraperitoneal injuries - high Cr, high urea, low Na - peritoneum absorbs urine
  • USS/CT
    • FF | bladder clots | change in filling shape of bladder
    • CT cystogram ideal - ? intra or extraperitoneal
    • Retrograde cystography in ED - Inject contrast diluted into bladder
      • Get AP and lateral X-rays
      • Do post voids too
      • Does contrast go into abdo and can see SB loops
      • Or into EP plane around scrotum/pelvic bones etc.
• Management
  • Urgent surgery
    • All intraperitoneal
    • Some extraperitoneal injuries
  • Delayed surgery for failure of NOM
    • Most blunt extraperitoneal injuries will heal with NOM
  • Non-Operative Management
    • What is it
      • Urethral IDC or SPC for 2 weeks then Cystogram
      • If ongoing leak → Surgery
    • Contraindications
      • Bladder neck injury
      • Presence of bony fragments in bladder wall
      • Infected urine
      • Associated female genital tract injury
  • Pitfalls of extraperitoneal repair during laparotomy for other reasons
    • Opening into a tamponaded pelvic haematoma
    • Takes time - DCS setting
• Surgical Approach
  • All repairs intraperitoneally from within the lumen of the bladder
    • Longitudinal incision on the anterior surface of the bladder
  • Repair method
    • EP injury - single layer mass closure
    • IP injury - separate layer closure
  • Consider option of catheterise ureteric orifices to prevent iatrogenic injury when suturing in the vicinity
• Leave drain in Retzius space and IDC/SPC for 2 weeks
• If can’t get SPC in easily, inflate bladder with H20 with a needle under USS guidance first to facilitate insertion

Urethral Injuries

• General
  • Associated with pelvic fractures
  • Relevant Anatomy
    • Posterior urethra
      • Prostatic and membranous
    • Anterior urethra
      • The remainder
• Diagnosis
  • Suspicion → Mechanism | Blood at Meatus | Haematuria | High Riding Prostate
  • Retrograde cystography - catheter in Fossa Navicularis
  • SPC is for dx and subsequent tx
• Management
  • Principles
    • Divert urinary stream
    • Refer to specialist for delayed reconstruction/repair
  • SPC
    • Don’t enter pelvic haematoma (may need to do intraperitoneal insertion)
  • Surgical Options
    • Urethral Repair
      • Immediate repair indications
        • Penetrating injuries of posterior urethra and most of anterior
        • Posterior injuries with rectal and bladder neck injuries
        • Wide separation of urethral ends
        • Penile fracture
      • Types
        • End to end anastomosis
        • End realignment and stenting over foley catheter
        • Can be manipulated by flexi cystoscopy