Abdominal Trauma in Pregnancy - Surgery

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
• Longitudinal mesentery tear – Repair
• Transverse mesentery tear – Resection & anastomosis

Trauma Triad of death

Hypothermia Metabolic acidosis

↓ Myocardial performance

Damage control surgery (DCS)

Phase of Damage control surgery

Phase I (initial exploration)	Phase II (20 resuscitation)	Phase III (Definitive operation)
Initial exploration ↓ For Rapid control of hemorrhage + contamination Packing of 4 Quadrants For Perforation → Suture closure ↓ Segmental Stapled resection	Shift the pt. to ICU ↓ For 2° resuscitation 48 hours Correct hypothermia, coagulopathy & metabolic acidosis	Planned re-exploration Definitive repair of injuries

Stage of DCS

• Stage I → Patient selection
• Stage II → Operative control of hemorrhage and contamination
• Stage III → ICU resuscitation
• Stage IV → Definitive surgery
• Stage V → Abdominal closure

Abdominal compartment syndrome (ACS)

• ACS – ↑sed IAP (>20 mmHg) – Results in compression of abdominal structures
• Causes fatal complications
  • Pulmonary failure
  • Mesenteric vascular compromise
• Normal IAP: 5-7 mmHg
• Intra-abdominal HTN ≥ 12 mm Hg

Predominantly occurs in

• Patients of profound shock
• Patients requiring large amount of fluid or blood for resuscitation
• Major visceral or vascular abdominal injuries

C/F

• Sudden increase in IAP
• ↑ peak inspiratory pressure
• Hypoxia, hypercapnia, hypotension
• ↓sed Venous return to heart
• ↓sed Urine output

Physiological consequence of ACS

Decreased	Increased
↓ VR →↓ CO →↓ RBF →↓ GFR →↓ UO ↓ ↓ VBF (Visceral blood flow) ↓ Cardiac output – Hypotension ↓urine output – Oliguria, Anuria	Peak inspiratory pressure → Hypoxia Hypercapnia Pulmonary capillary wedge pressure Intrapleural pressure Central venous pressure Cardiac rate Systemic vascular resistance

Diagnosis

• Measure Bladder pressure -as it represents IAP
• Gold standard indirect method to measure IAP -Urinary bladder catheter 

Management (depends on grade)

Grade	Bladder pressure (mmHg)	C/F	Rx
I	12 – 15	None	Normovolemic resuscitation
II	16-20	Oliguria, Splanchnic Hypoperfusion	Hypovolemic resuscitation
III	21 – 25	Anuria, increased Ventilation pressure	Decompression
IV	> 25	Anuria, increased ventilation pressure + ↓PO2	Emergency re exploration

Pressure according to grade

• I →<10 – 15 cm H2O
• II →< 16 – 25 cm H2O
• III →< 26 – 35 cm H2O
• IV →> 36 cm H2O

RETRO PERITONEAL INJURIES  

Zone I – Central

• Extends from Esophageal hiatus to sacral promontory
• Hemorrhage or hematoma - usually located in midline
• A/W injuries of
  • Aorta & its proximal branches
  • IVC & its proximal tributaries
• It is divided into

Supra mesocolic Zone 1	Infra mesocolic Zone 1
Suprarenal aorta IVC Superior mesenteric vessels Proximal renal vessels	Infra renal aorta IVC	their bifurcation

Management

• Central hematoma – exploration with proximal & distal vascular control

Zone 2 – lateral

• Extends from lateral diaphragm to iliac crest
• Structures located - Distal renal vessels
• Management
  • Lateral hematoma (renal in origin) - Managed non-operatively (angio- embolization)

Zone 3- Pelvic

• Confined to retroperitoneal Zone of pelvis
• Structures located - Iliac vessels
• Management
  • Pelvic hematoma - Exceptional difficult to control
  • Usually it should not be opened
  • Packing / Angio-embolization

Zone 4 - Portal & retro hepatic areas

RENAL TRAUMA

• MC injured part of urinary tract – Kidney
• MC cause of renal trauma – RTA
• Best predictor of traumatic urinary system injury - Hematuria

Diagnosis

• IOC for Dx of renal injuries in stable patient – CECT
• IOC for Dx of renal injuries in unstable patient - single shot IVP (Assess function of C/L kidney)

Grading of Renal Trauma

Grade	Description
1	Microscopic /gross hematuria with normal urologic studies Sub capsular, non-expanding hematoma without parenchymal laceration (microscopic hematuria is > 3RBCs/HPF)
2	Non expanding perirenal hematoma Laceration < 1 cm in depth without urinary extravasation
3	Laceration > 1 cm in depth of renal cortex
4	Parenchymal laceration through collecting system Main renal artery or vein injury with contained hematoma
5	Completely shattered kidney Avulsion of renal hilum →devascularization of kidney

Management of Renal Trauma

• >95% of cases → Conservatively (low grade injury)
• < 5% of cases → Operative intervention

Indications of Renal exploration

Absolute	Relative
Persistent renal bleeding Expanding or Pulsatile perirenal hematoma	Urinary extravasation Non-viable tissue Segmental arterial injuries

Indications of Nephrectomy

• Unstable pt. → hypothermia / coagulopathy with normal contralateral kidney
• Extensive renal injury
• Poor functioning hydronephrotic kidney

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