SOLID ORGAN INJURIES SPLEEN LIVER PANCREAS 2013 1

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SOLID ORGAN INJURIES SPLEEN , LIVER , PANCREAS 2013 1

SOLID ORGAN INJURIES SPLEEN , LIVER , PANCREAS 2013 1

Abdominal Injuries • • • 5 pillars Solid Organs: Bleed, shock Hollow Organs: Leak,

Abdominal Injuries • • • 5 pillars Solid Organs: Bleed, shock Hollow Organs: Leak, peritonitis Retroperitoneum: pancreas, large vessels Urinary system Diaphragm 2

Mechanism of injuries • Blunt: • spleen, liver, and small bowel • Penetrating stab:

Mechanism of injuries • Blunt: • spleen, liver, and small bowel • Penetrating stab: • liver, small bowel, diaphragm, colon • Penetrating gun shot: • small bowel, liver, colon 3

Splenic Function • Immunologic filter • Primary remover of non-opsonized bacteria • Produces tuftsin

Splenic Function • Immunologic filter • Primary remover of non-opsonized bacteria • Produces tuftsin and properdin • Properdin vital component of alternate pathway of complement activation • Immunoglobulin production 4

Splenic Anatomy • 100 -250 grams • 200 cc/min blood flow • Splenic artery

Splenic Anatomy • 100 -250 grams • 200 cc/min blood flow • Splenic artery • 85%-extrasplenic bifurcation • 15%-extrasplenic trifurcation • Ligamentous attachments • stomach, kidney, diaphragm, colon 5

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Diagnosis of Splenic Injury • Physical examination - poor sensitivity • Ultrasound - nonspecific

Diagnosis of Splenic Injury • Physical examination - poor sensitivity • Ultrasound - nonspecific • DPL-too sensitive, ? role in nonoperative management • CT-most common in hemodynamically stable pts • Laparoscopy-has not found a universal role 7

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Management of Splenic Injuries Factors Influencing Decision • • • Age of patient- >55

Management of Splenic Injuries Factors Influencing Decision • • • Age of patient- >55 yo splenectomy better Success of non-operative management- 68 -83% Risk of missed injury Risk of OPSI-0. 026 -1. 0% over lifetime Risk of blood transfusion-0. 014% per unit Risk of nontherapeutic laparotomy-0. 01 -6. 0% 9

Non-Operative Management • • • Proper patient selection Bed rest 2 -3 days Serial

Non-Operative Management • • • Proper patient selection Bed rest 2 -3 days Serial physical exams, Hcts x 24 -48 hours Follow-up CT scan at 3 -5 days Overall hospitalization 5 -10 days Severe injuries-3 months no contact sports 10

Non-operative management • Embolisation • Trans-arterial catheter aorta splenic artery • Partial or total

Non-operative management • Embolisation • Trans-arterial catheter aorta splenic artery • Partial or total splenic embolization • Splenic immunocompetence is preserved after splenic artery angio-embolisation 11

Operative Management • Midline incision, pack, examine abdomen • Systematic splenic mobilization • Splenorrhaphy-

Operative Management • Midline incision, pack, examine abdomen • Systematic splenic mobilization • Splenorrhaphy- Cautery, surgicell, pledgetted sutures, mesh wrapping • Splenectomy- life threatening bleeding • Autotransplantation-experimental • Vaccination-Pneumococcus, H. influenza, N. meningitidis 12

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Complications • Pneumonia most common • Subphrenic Abscess 3 -13% • Recurrent bleeding -

Complications • Pneumonia most common • Subphrenic Abscess 3 -13% • Recurrent bleeding - up to 45 days • 1% re-operative rate (for haematoma, or abscess drainage for example) • Acute gastric distention- kids usually • Thrombocytosis (very high platelets) 15

OPSI • • • Nausea, vomiting, confusion, sepsis Mortality 50 -70% Vaccine provides 60%

OPSI • • • Nausea, vomiting, confusion, sepsis Mortality 50 -70% Vaccine provides 60% protection Best timing of vaccine unknown Proper counseling a must Sensitive to malaria 16

HEPATIC INJURIES • • • ANATOMY INJURY CLASSIFICATION INITIAL PATIENT MANAGEMENT OPERATIVE TECHNIQUES SPECIAL

HEPATIC INJURIES • • • ANATOMY INJURY CLASSIFICATION INITIAL PATIENT MANAGEMENT OPERATIVE TECHNIQUES SPECIAL TOPICS • JUXTAHEPATIC VENOUS INJURIES • SUBCAPSULAR / INTRAHEPATIC HEMATOMAS • EXTRAHEPATIC BILIARY TREE INJURIES • COMPLICATIONS • Most commonly injured in stab wounds and blunt injuries • Present as bleeding with hemodynamic instability 17

ANATOMY • LIGAMENTOUS ATTACHMENTS • TRIANGULAR • CORONARY • FALCIFORM • COUINAUD CLASSIFICATION OF

ANATOMY • LIGAMENTOUS ATTACHMENTS • TRIANGULAR • CORONARY • FALCIFORM • COUINAUD CLASSIFICATION OF LOBAR / SEGMENTAL DIVISIONS 18

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DIAGNOSIS OF LIVER INJURY • • • ATLS primary / secondary surveys Peritoneal signs

DIAGNOSIS OF LIVER INJURY • • • ATLS primary / secondary surveys Peritoneal signs - exploration Hemodynamic instability - US or DPL Stable – CT scan with contrast (embolization) Non-operative management : hemodynamic stability, no other suspected injuries, alert patient*, ICU monitoring, accessible for re-examination, minimal transfusions 21

LIVER -Penetrating Wounds • STAB WOUNDS • • LOCAL WOUND EXPLORATION ULTRASOUND DPL ?

LIVER -Penetrating Wounds • STAB WOUNDS • • LOCAL WOUND EXPLORATION ULTRASOUND DPL ? LAPAROSCOPY • GUNSHOT WOUNDS • EXPLORE • ? ROLE FOR ULTRASONOGRAPHY • ? ROLE FOR LAPAROSCOPY 22

OPERATIVE TECHNIQUES • MANUAL COMPRESSION • EXPOSURE(INCISION + LIGAMENTS) • PRINGLE MANEUVER (32 -75

OPERATIVE TECHNIQUES • MANUAL COMPRESSION • EXPOSURE(INCISION + LIGAMENTS) • PRINGLE MANEUVER (32 -75 MINUTES) • Portal vein; hepatic artery: block inflow of blood; find source of bleeding • TOPICAL HEMOSTATIC AGENTS • BOVIE / ARGON BEAM COAGULATOR • FIBRIN GLUE 23

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OPERATIVE TECHNIQUES • Tractotomy / individual vessel and duct ligation • Omental packing •

OPERATIVE TECHNIQUES • Tractotomy / individual vessel and duct ligation • Omental packing • Resectional debridement • Absorbable mesh wrapping 25

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OPERATIVE TECHNIQUES • Drainage (grade III or better) • Laparotomy pad packing - remove

OPERATIVE TECHNIQUES • Drainage (grade III or better) • Laparotomy pad packing - remove before 3 days if possible • *Deep sutures • *Hepatic artery ligation • *Anatomic lobectomy *avoid if possible 27

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OPERATIVE TECHNIQUES • HEAT CONSERVATION • BEGINS WITH INITIAL PATIENT CONTACT • LIMIT HEMORRHAGE

OPERATIVE TECHNIQUES • HEAT CONSERVATION • BEGINS WITH INITIAL PATIENT CONTACT • LIMIT HEMORRHAGE • SPEED / EFFICIENCY COUNTS • EQUATES TO PROMPT DECISION-MAKING • DAMAGE CONTROL SURGERY: quick, manage bleeding and contamination; continue resus in ICU • PREVENT TRIAD OF ACIDOSIS, COAGULOPATHY AND HYPOTHERMIA 30 (affects clotting mechanism)

Control of Transhepatic Penetrating Wound 31

Control of Transhepatic Penetrating Wound 31

Juxtahepatic Venous Injury • Early recognition • Big (chest) incisions (laparotomy and thoracotomy) •

Juxtahepatic Venous Injury • Early recognition • Big (chest) incisions (laparotomy and thoracotomy) • Atrial-caval shunt or caval balloon shunt • Direct attack with or without hepatic vascular isolation • Packing alone 32

Atrial-Caval Shunt 33

Atrial-Caval Shunt 33

Subcapsular Hepatic Hematomas During non-operative treatment , operate for: • On-going hemorrhage • Progressive

Subcapsular Hepatic Hematomas During non-operative treatment , operate for: • On-going hemorrhage • Progressive expansion by ct scan • Signs of infection • Deteriorating transaminase measurements Intra-operative, if not expanding: • Leave alone in stable patients 34

Extrahepatic Biliary Tract Injury • Rare: 3 -5% of all abdominal trauma • Gallbladder

Extrahepatic Biliary Tract Injury • Rare: 3 -5% of all abdominal trauma • Gallbladder (most common) • cholecystectomy • CBD > RHD> LHD • <50% circumference - repair with or without Ttube; drain • >50% circumference - duct enterostomy; drain 35

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COMPLICATIONS • Recurrent bleeding - 2% to 7% • Fever - 65% to 75%,

COMPLICATIONS • Recurrent bleeding - 2% to 7% • Fever - 65% to 75%, grade 3 or more • Abscess - 2% to 10% (increased by shock, transfusion, colon injury) • Biloma / biliary fistula - 5% to 28% • Hemobilia - extremely rare; 1/3 have jaundice, upper GI bleed, right upper quadrant pain • Arterial portal venous fistula 37

Damage Control Considerations • • Deep suturing Packing Omental packing Drains Antibiotics Atrial-caval shunts

Damage Control Considerations • • Deep suturing Packing Omental packing Drains Antibiotics Atrial-caval shunts CT scan / non-operative management 38

PANCREATIC INJURY • RETRO-PERITONEAL ORGAN • PENETRATING INJURY – IS THE DUCT INTACT ?

PANCREATIC INJURY • RETRO-PERITONEAL ORGAN • PENETRATING INJURY – IS THE DUCT INTACT ? • BLUNT INJURY – TRANSECTION OF GLAND OVER THE VERTEBRAL COLUMN 39

PANCREATIC INJURY • • • DIAGNOSIS DIFFICULT HIGH INDEX OF SUSPICION CLINICAL EXAMINATION NOT

PANCREATIC INJURY • • • DIAGNOSIS DIFFICULT HIGH INDEX OF SUSPICION CLINICAL EXAMINATION NOT HELPFUL U/S, CT SCAN IF STABLE SERUM AMYLASE (increased? Duct intact? >>) • do ERCP 40

Diaphragmatic injury • • • Traumatic rupture (blunt trauma) More common on left side

Diaphragmatic injury • • • Traumatic rupture (blunt trauma) More common on left side (85%) Tear posterolateral from hiatus Herniation of stomach, colon, spleen into chest Penetrating injury usually a small hole, on either side 41

Diaphragmatic injury • Diagnosis: clinical difficult • Bowel sounds in chest on auscultation •

Diaphragmatic injury • Diagnosis: clinical difficult • Bowel sounds in chest on auscultation • CXR: high diaphragm on left side, or diaphragm invisible • Confirmation by passing a nasogastric tube, which can be seen in stomach in chest • Chronic: contrast studies (Ba meal or enema) 42

Diaphragmatic injury • Laparoscopy (or thoracoscopy) for diagnosis • Repair: surgical, via laparotomy (or

Diaphragmatic injury • Laparoscopy (or thoracoscopy) for diagnosis • Repair: surgical, via laparotomy (or thoracotomy), or endoscopic technique • Pitfall: PPV (positive pressure ventilation) reduced the abdominal organs from chest 43

Questions? 44

Questions? 44