Abdominal trauma is a common and potentially life-threatening condition that requires urgent surgical intervention. Understanding the evaluation, management, and surgical techniques involved in treating abdominal trauma is essential for medical aspirants.
In the NEET PG exam, there are often questions related to abdominal trauma, including the mechanism of injury, diagnostic workup, surgical approach, and postoperative care. Therefore, having a good understanding of this important surgery topic and its management is crucial for success in the NEET PG exam, as well as for providing safe and effective surgical care in clinical practice.
Read this blog further for a quick overview of this important topic.
FAST, DPL (Diagnostic Peritoneal Lavage) ,
One liner on Abdominal trauma
Most commonly injured organ in BTA - spleen > liver
Most commonly injured organ in penetrating trauma - liver > stomach > SI
Most commonly injured part of bowel in BTA – Jejunum
Most commonly injured organ in Gunshot injury – Small intestine
Most commonly site of injury in deceleration injury – Duodenojejunal junction
Most commonly injured structure in seat belt injury - Mesentery
1st inv. Done in patient of BTA - FAST
Gold standard investigation for stable patient of BTA - CECT
FAST (Focused Assessment with Sonography for Trauma)
It is an Emergency ultrasound i.e. performed very fast
Assess Potential sites of thoracoabdominal injuries (4P’s) - Pericardial sac
Perihepatic region
Peri-splenic region
Pelvis
4 traditional views in FAST
e - FAST (extended FAST)
Has two additional views (so, has a total of 6 views)
Right thoracic view
Left thoracic view
Pneumothorax on e-FAST shows barcode sign / stratosphere sign
Previous Year Question
Q. A patient with stab injury to anterior abdomen presents with a tag of ometum protruding through the abdominal wall near the umbilicus. On evaluation he is haemodynamically stable and shows no signs of peritonitis. Initial management of patient involve:
FAST
Exploratory laparotomy
Local wound exploration and suturing
CECT abdomen.
DPL (Diagnostic Peritoneal Lavage)
Performed for BTA patients
Catheter is inserted after infra umbilical incision & director towards pelvis
Aspiration is done
Instill IL of NS / RL →for lavage
Re-aspiration of fluid is done
↓
This fluid is sent for examination
This fluid is sent for examination
DPL is considered (+) ve
10 ml of frank blood is aspirated
Returned effluent contain:
RBCs →> 1 Lac/ mm3
WBCs →> 500/ mm3
Presence of bile, bacterial, fecal matter, vegetable matter
Amylase > 175 IU / dl
Previous Year Question
All of the following are suggestive of positive DPL except:
>10 ml of gross blood is aspirated directly from peritoneal cavity.
Effluent contains RBCs> 1 lac/ cubic mm
Effluent contains amylase>174IU/dl
None of the above.
PENETRATING TRAUMA
MC injured organ - liver > stomach > SI
MC injured organ in GSW – SI
Exp. Lap is mandatory - GSW (Gunshot wound)
Splenic trauma
MC injured organ in BTA
Kehr’s sign
Pain is referred to tip of Left shoulder in splenic rupture
Due to irritation of undersurface of diagram with blood →pain is referred to shoulder via fibers of phrenic nerve (C4, C5)
Ballance sign
Fixed area of percussible dullness in LUQ due to coagulation of blood
AAST Grading for splenic trauma (American Association for Surgery of trauma)
Grade
Hematoma
Laceration
I
Subcapsular hematoma involving < 10% surface area
Capsular tear < 1 cm in depth
II
S/C hematoma involving10 – 50 % Surface area
1 – 3 depth
III
S/C hematoma involving>50 % Surface area
> 3 cm or involving Trabecular vessels
IV
> 25% devascularization
Laceration involving Hilar vessels
V
Completely shattered spleen
Complete devascularization
Liver Trauma
MC injured organ in penetrating trauma
2nd MC injured organ in BTA
Most liver injuries involve - segment 6, 7, 8
Bleeding - mainly venous →low pressure tamponade is readily performed
4 ‘p’s in liver injury
Push
Plug
Pringle
Pack
Bear claw laceration - multiple linear lacerations of liver on CECT
PRINGLE’s Maneuver
aka Total Inflow Occlusion
Non-traumatic clamping in the foramen of Winslow and we occlude the Portal triad.
It controls bleeding from Portal Vein and Hepatic Artery.
Bleeding is effectively controlled from Portal Vein as compared to Hepatic Artery.
It doesn’t control bleeding from IVC and Hepatic Vein
AAST →Grading of liver trauma
Grade
Hematoma
Laceration
I
Subcapsular hematoma involving < 10% surface area
Capsular tear < 1 cm in depth
II
S/C hematoma involving 10 – 50 % Surface area
1 – 3 cm depth
III
S/C hematoma involving >50 % Surface area
> 3cm depth
IV
-
Parenchymal disruption involving 25-75% of hepatic lobe
V
-
Parenchymal disruption involving >75% of hepatic lobe
VI
Hepatic avulsion
DUODENAL TRAUMA
A/W pancreatic injuries
IOC for Dx of Duodenal trauma – CECT
On radiological Ix only sign is seen - gas or fluid in R/P & leakage of oral contrast
Injury of 1st, 3rd or 4th part - repaired like small bowel with sutures
Injury of 2nd part – Damage control surgery (Triple tube ostomy)
Triple tube ostomy
Decompressive Gastrostomy
Decompressive Duodenostomy
Feeding Jejunostomy
PANCREATIC TRAUMA
In adult: MC cause – Penetrating
In children: MC cause - Blunt trauma
Handlebar → bicycle
MC affected → body of pancreas
Grade
Hematoma
Laceration
I
Minor contusion without duct injury
Superficial laceration without duct injury
II
Major contusion without duct injury
Major laceration without duct injury
III
-
Distal transection or parenchymal injury with duct injury
IV
-
Proximal transection or parenchymal injury involving Ampulla
V
-
Massive disruption of pancreatic head
Diagnosis
IOC for Dx – CECT
ERCP - Most reliable test to demonstrate pancreatic duct integrity
Management
I – Observation
II – Debridement, drainage, possible repair
III – Distal resection, Roux-en-Y drainage
IV & V - Damage control surgery
Résection + Roux-en-Y drainage
Triple tube decompression
Pyloric exclusion
Duodenal diverticulization
PancreaticoDuodenectomy
MC complication seen after Pancreatic trauma - Pancreatic fistula / Persistent drain output
SEAT BELT INJURY
Associated with
High chances of internal organ injury
Also associated with pancreatico-Duodenal injuries
Unstable pt. → hypothermia / coagulopathy with normal contralateral kidney
Extensive renal injury
Poor functioning hydronephrotic kidney
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