Emergency Abdominal Surgery For Penetrating Injury Dr Geoff

Emergency Abdominal Surgery For Penetrating Injury Dr Geoff Kohn 8 June 2002

Penetrating abdominal trauma • More common in areas of: – – High levels of poverty Low levels of education High alcohol consumption Larger populations

Mechanisms • Gunshot wounds (GSW) • Stab wounds

Firearms • Low velocity: <2000 ft/s (<609 m/s) • High velocity: >2000 ft/s (>609 m/s) • Most hand guns are low velocity • High velocity weapons are increasing in availability

Wounding capability • KE = ½ mv 2 – Double the bullet size 2 x the energy – Double the muzzle velocity 4 x the energy • Critical velocity: 600 m/s – Above this (“high velocity”): tissue compressed at periphery of impact by a shock wave temporary cavity created (ATLS student manual) – Cavity can be 30 times the diameter of the bullet • Yaw and tumble – Increase the surface area of the bullet with respect to the tissue it contacts

Shotgun wounds • • Low muzzle velocity (usually 630 m/s) Multiple spherical pellets Pellets lose energy very quickly Close range (0. 3 -0. 9 m) – Massive contaminated wounds – Similar to high velocity GSW • Long range (>18. 2 m) – Minimal torso injury

Stab wounds (non-ballistic penetrating trauma) • Most occur in upper quadrants • Injuries dependent on: – Instrument used – Patient motion • Parietal peritoneum penetrated in 70% – Only 50% of these (35% total) cause visceral injury

Different management • Low velocity GSW / stab wounds – Damage due to direct injury to vital structures • High velocity GSW – Wide debridement necessary – Organ injury generally requires more complex techniques

Management priorities of penetrating abdominal trauma

1. Management based on haemodynamic criteria

Three haemodynamic groups • Moribund patients – No spontaneous ventilatory effort, no femoral pulse and no response to painful stimuli • Laparotomy • Some recommend thoracic aorta occlusion prior to laparotomy to prevent cardiac arrest from sudden release of abdominal wall tamponade (Ledgerwood et al 1976) • Unstable patients – Any vital sign (BP, HR, RR) is altered • ABC – if fluids do not help, or only help temporarily, laparotomy is required • Stable patients • Decision based on mechanism of injury and physical examination

The idea of “damage control” • • • In the past, definitive repair of most lesions was attempted initially Multivisceral injuries and exsanguinated patients are bad candidates for major resections and time-consuming reconstructions The combination of trauma plus the surgical insult exceeds the physiological reserves of many patients • Aims: 1. Initial damage control operation 2. Resuscitation in the surgical ICU 3. Planned reoperation after 24 - 48 hours

Indications for damage control • • • Bleeding caused by coagulopathy Severe metabolic acidosis (p. H <7. 3) Severe base deficit (p. H >10) Hypothermia during operation (T° <34°) Inability to control the haemorrhage (hepatic, retroperitoneal, pelvic, thoracic or cervical) • Inability to formally close the abdomen because of intestinal oedema

Techniques of damage control • Haemorrhage control – Packing ± angiographic embolisation – Ligation of vessels instead of repair – Balloon catheter tamponade for deep or hepatic wounds • Contamination control – Hollow viscus ligation instead of repair – External tube drainage of biliary and pancreatic injury instead of pancreatoduodenectomy – Avoidance of formal colostomy

Abdominal hypertension • Intraabdominal pressure rise to: – 10 mm. Hg decreased venous return & CO – 25 mm. Hg increased airway pressures • How does it occur? – Capillary leak gastrointestinal oedema – Ongoing bleeding • Bogotá bag (actually developed at University Hospital, Cali) – Cloth zippered mesh with i. v. plastic fluid bag underneath – Allows reduction in intraabdominal pressures

Other aspects of care • Early enteral nutrition (even after bowel anastomosis) is better than parenteral, especially in the most severe trauma • Antibiotics: 1 day is as good as 3 or 5 days (Kirton OC et al 2000) • Abdominal sepsis occurs 20% (Rotondo MF, Zonies DH 1997)

2. Management based on area of abdomen injured

Upper abdomen (thoraco-abdominal area) • between diaphragm and lower costal margin – Insertion of diaphragm • Xiphoid process anteriorly • 9 th ICS midaxillary line • 11 th space posteriorly – Remember that diaphragm moves from T 10 at end -inspiration to T 5 at end-expiration • Contains: – – – Liver Spleen Stomach Pancreas Great vessels Visceral arterial branches

Thoracoabdominal penetrating injuries • Explore ALL patients due to risk of diaphragmatic injury – Occurs in 15% of stab wounds, 46% GSW to TA area MA, Richardson JD, 1996) – Right side equally affected as left side – Only 15% are > 2 cm long (Wise L et al, 1973) • Therefore, visceral herniation rarely occurs immediately • 85% result in herniation within 3 years – CXR rarely diagnostic of diaphragmatic injury – DPL, pneumoperitoneum on Xray, USS - all have low sensitivity • Laparoscopy vs. laparotomy – Difficulty to view all small bowel with laparoscope – Difficult to see right-sided diaphragmatic injury – May cause tension pneumothorax (Reynolds

Diaphragmatic rupture

(adapted from Ferrada R, Birolini D. 1999)

Middle abdomen • Between lower costal margin and ASIS – – Bowel – Small bowel and colon Kidneys Aorta IVC

Lower abdomen • False pelvis – within the iliac bones to sacral promontory (S 1) • True pelvis – below sacral promontory – – – Small bowel Rectosigmoid colon Rectum Genitourinary system Iliac vasculature

Anteroposterior division of the abdomen • Anterior (between anterior axillary lines) • Flanks (between anterior and posterior axillary lines) • Back (between posterior axillary lines)

EMST guidelines for management of anterior abdominal injuries – Laparotomy for all penetrating abdominal injuries with: • Hypotension • Peritonitis • Evisceration – GSW • 99% risk of significant injury • Therefore, explore ALL patients – Some evidence to contrary (after imaging) (Saadia R, Degiannis E. 2000) • If the injury is tangential, and the patient is stable, consider laparoscopy – Stab wounds • Local exploration of wound • Observe if no signs on examination. Perform serial examinations or DPL

Flank and back injuries • The thickness of the flank and back muscles is protective (skin to peritoneum: 10 -20 cm) • Wounds are more frequently tangential • Serial physical examinations are very accurate in detecting retroperitoneal or intraperitoneal injuries to flanks or back (EMST student manual) • Contrast CT scans are useful too

3. Management based on anatomical structure injured

Outline • Upper abdominal injuries – – – Spleen Liver Stomach Duodenum Pancreas • Middle abdominal injuries – Small bowel and mesentery – Colon – Renal • Lower abdominal injuries – Rectal – Perineal – Bladder • Vascular injuries

Splenic injuries

Splenic injury • In recent years there has been an appreciable shift from operative management toward nonoperative management (Corson & Williamson, 2001)

AAST Splenic injury grading system

Non-operative management • Can avoid post-splenectomy sepsis • Only applicable when operating theatre is available at short notice • Failure rates of conservative management: – Grades I, III 5% – Grades IV, V 18% (Davis et al 1998) • Probably more dependent of amount of haemoperitoneum. Attempts have been made to classify this by CT • Note delayed rupture occurs between 1 and 9 days (mean 3. 5 days) • Beware splenic artery false aneurysms (causing contrast blush) 62% failure rate

Operative management • Splenorrhaphy – Uncommon – if the patient needs a laparotomy, splenectomy is usually indicated • Use of superficial haemostatic agents (electrocautery, argon beam, topical thrombin, oxidised cellulose, absorbable gelatin sponge) • Pledgeted repair • Resectional debridement • Mesh wrap • Splenectomy

Liver injuries

Liver injury • Non-operative management is increasing – Significantly lower transfusion requirements (where injuries were matched for severity) (Croce MA et al 1995) • Most hepatic bleeding is venous, most splenic bleeding is arterial Maybe 80% of hepatic injury can be managed conservatively • Unstable patients require emergency laparotomy • Discrete contrast blush or frank contrast extravasation probably mandates embolisation or laparotomy

Operative management of liver injury • Gauze packing – may have infective complications • • • (Ivatury RR et al 1986) Omental packing Resectional debridement - risk of injury to large vessels and bile ducts Mass liver suture - poor efficacy of producing haemostasis Hepatic artery ligation Total hepatic isolation - good for retrohepatic venous injuries Atriocaval shunt

Stomach injuries

Stomach injuries • Quite common after penetrating trauma. Very rare after blunt trauma • Diagnosis – At laparotomy for GSW to anterior abdomen – Haematemesis or grossly bloody nasogastric aspirate after LUQ stab wound • Remember: the stomach is mobile and can be injured even from a stab wound to the lower abdomen

Management of stomach trauma • Thorough intraoperative examination – Divide the gastrohepatic or gastrocolic ligaments if required • If there is an injury to the anterior wall, assume an injury to the posterior wall – Divide gastrocolic ligament and enter lesser sac • Debride and close all injuries • Complications - mainly infective

Duodenal injuries

Duodenal injuries • Relatively uncommon. 80% due to penetrating trauma (Corson & Williamson) • Retroperitoneal organ – diagnosis of injury difficult • Mortality 5%-30% – Three times more likely to die if operation delayed > 24 hours (Lucas CE, Ledgerwood AM. 1975) – Early death – exsanguination due to associated vascular injury – Late death – sepsis

Diagnosis of duodenal injuries • Difficult • AXR changes (in 50%) - Air: – Outlining the right kidney – Along the psoas muscle • Water-soluble contrast (Gastrograffin®) follow -through examination • CT with i. v. and oral contrast

Repair of the duodenum • Most duodenal wounds can be closed primarily by duodenorrhaphy • Debride devitalised tissue • One or two layer closure • Pyloric exclusion for more difficult injuries GD et al 1977) – Primary repair, followed by – Side-to-side gastrojejunostomy along the greater curvature (Vauhgn

Pancreatic injuries

Pancreatic injury • Associated injuries in penetrating trauma – 75% have injury to one of: (Jurkovich. GJ, Carrico CJ. 1990) • Aorta • Portal vein • Inferior vena cava • Mortality rate: 10% – 30% • Manage haemorrhage and contamination first

Exposure of pancreas All penetrating injuries in the vicinity of the pancreas mandate exposure and inspection of the whole gland • • • Enter the lesser sac by incising the gastrocolic ligament Retract stomach superiorly Retract transverse colon inferiorly Mobilise hepatic flexure Kocher’s manoeuver Remember to visualise posterior part of gland

Signs of injury • Parenchymal injury – Central retroperitoneal haematoma – Oedema around the gland in the lesser sac – Bile staining of the retroperitoneum • Ductal injury – – – Direct visualisation of a ductal injury Complete transection of the gland Laceration of more than one half of the gland Central perforation Severe maceration

AAST pancreatic injury grade Grade Description of injury I Minor contusion / superficial laceration without duct injury II Major contusion / major laceration without duct injury or tissue loss III Distal transection or parenchymal injury with ductal injury Proximal transection (to right of SMV) or parenchymal injury involving ampulla IV V Massive disruption of pancreatic head Advance one grade for multiple injuries to the same organ

Operative management • Minor injuries (grades I and II) – No ductal injury – External drainage alone • Closed systems superior to sump systems (Fabian TC et al 1990) • Grade III – Distal pancreatectomy (up to 80% of gland is well tolerated) • Spleen can be preserved in 50% • Grade IV – Most result in death – Wide external drainage is becoming more common – Distal resection (up to 95% of gland) • Grade V – Most die. Diversion procedures or pancreatoduodenectomy

Colonic injuries

Colon injury • 20% of GSW cause colonic injury • Management recommendations (EAST) depend on whether destruction is such that resection is required Very strong evidence (RCT) supporting primary repair of nondestructive wounds in the absence of peritonitis (EAST)

Destructive colon wounds • There is quite strong evidence (nonrandomised prospective trials and controlled retrospective studies) (Steel M et al ANZ J Surg 2002) that: Destructive wounds requiring resection, can undergo primary anastomosis if: –Haemodynamically stable –No severe underlying disease –Minimal associated injuries –Do not have peritonitis • This probably applies equally well to small bowel injury

Primary anastomoses • Anastomoses: (EAST) – Single layer vs. double layer (double is slower but no better) – Absorbable vs. non-absorbable (probably no difference) – Stapled vs. hand-sewn (probably no difference)

Rectal injuries

Rectal injury • Lack of adequate evidence • Rectum is different from rest of colon no serosa over upper 2/3 posteriorly and lower 1/3 circumferentially • Serosa is important for secure suturing • Maybe? : – Primary repair is appropriate – Distal rectal washout not important – Post-exploration, lower wounds do not need retrorectal drainage

Renal injuries

Surgical management of renal injuries • Only a small proportion due to penetrating injury • Best management is unclear – A grading system exists to suggest indications for conservative management • Life-threatening injuries do not attempt renal salvage (unless there is only one kidney) • Debride devitalised segments partial nephrectomy • Obtain haemostasis with a horizontal mattress and a piece of omentum • Major laceration wrap kidney in absorbable mesh

Perineal injuries

Perineal injury • 50% are associated with pelvic fracture • Mortality 32% - 60% (Corson & Williamson) – Early death from exsanguination – Late death from sepsis

Management of perineal injury • • • Broad-spectrum antibiotics Laparotomy Diversion of faecal stream to prevent sepsis Washout of distal rectum Feeding jejunostomy Often have difficult to manage wounds – Frequent debridement and lavage – Grafts or flaps

Bladder injury • When due to penetrating trauma it is usually identified at laparotomy • When identified: – Explore bladder through cystostomy on dome of bladder – Extraperitoneal injury Foley catheter drainage alone – Intraperitoneal injury: • Repair in three layers with absorbable sutures • Some say that suprapubic catheter should be inserted

Abdominal Vascular Injuries

Incidence of abdominal vascular trauma • 27% - 33% of all vascular trauma is intraabdominal • Incidence of abdominal vascular injuries is rising

Mechanisms of injury to abdominal vasculature • Penetrating injuries most common – 90% to 95% of all abdominal vascular injuries • Of patients undergoing laparotomy for abdominal GSW – 25% have abdominal vascular injuries – (compared to 10% for stab wound laparotomies) • Usually associated with multiple other injuries • Multiple vessels occasionally involved

ED management • Follows usual EMST protocols BUT • REMEMBER, do not place i. v. cannulae in femoral veins • Cross-clamping of descending thoracic aorta – Stops intraabdominal haemorrhage – Improves perfusion of carotid and coronary arteries – Risk of distal ischaemia and reperfusion injury

Intraoperative management • Prepare skin from neck to mid-thigh (in case an autogenous saphenous vein graft is required) • Midline incision • If laparotomy has commenced, and the patient decompensates haemodynamically, cross-clamp the aorta. The diaphragmatic crura may require transection

Zone I – aortic hiatus to sacral promontory, over vertebrae; supramesocolic and inframesocolic parts Zone II – Pericolic gutters Zone III – sacral promontory to pelvis

Zone I supramesocolic (Asensio JA et al. 2002) • Coeliac axis ligation • SMA (1 st & 2 nd parts) repair ligation is theoretically possible grafts and temporary shunts have been used • Infrahepatic suprarenal IVC primarily repair from within the vessel where there has been massive destruction ligate (5% survival), or use prosthetic graft

Zone I inframesocolic • SMA (3 rd & 4 th parts) primarily repair can individually ligate the main jejunal and colic branches of 4 th part • Infrahepatic infrarenal IVC primarily repair, ligating the lumbar veins Ligation in cases of massive destruction is well tolerated

Zone II • Renal arteries – primarily repair OR – resect and replace with graft (prosthetic or autogenous) • Renal veins – repair or ligate – Right renal vein ligation requires right nephrectomy – Left renal vein ligation is better tolerated due to collaterals from left gonadal vein and renolumbar veins

Zone III • Often associated colonic and genitourinary injuries with significant contamination • Common iliac arteries repair can use autogenous or prosthetic grafts • • Internal iliac arteries ligation External iliac arteries repair Iliofemoral graft can be performed Iliac veins ligation is well tolerated

Cautions • “Second look” operations are important after SMA repair (assessing bowel viability) • In contaminated wounds, all grafts should be retroperitonealised

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