PENETRATING ABDOMINAL INJURY :TO OPERATE OR NOT TO OPERATE

Agi Satria Putranto

Introduction• The Abdominal injury :

– Penetrating injury– Blunt injury– Requires a fairly immediate judgment or decision

as to management– Life-saving– a. Identify life-threatening injury– b. Appropriate resuscitation– c. Hemodynamically Stable or Unstable?

What are the 4 import regions of the abdomento considr in penetrating injury ??

1. Anterior abdomen Between the anterior axillary lines ;bound by the costal margin superiorly and the groin crease distally .

2. Thoracoabdominal area Area delimited by the costalmorgin inferiorly and superiorly by the fourth intercostal spaceanteriorly, sixth intercostal laterally and eighth intercostal spaceposteriorly. Note : injuries in the area increase likelihood ofdiaphragmatic , chest and mediasinal injuries.

3. Flanks Bound by anterior axillary line and posterior axillary line,inferior costal margin superiorly to iliac crests

4. Back Between posterior axillary lines extending from costalmargin to the iliac creasts

Boundaries of theThoraco Abdominal Region : Superior : Nipples (male), Inframamary fold (female)

Inferior : Costal marginNotes : Extend circumferentially to the back

for 360

Initial Management

Airway and Protection of Spinal Cord

Breathing and Ventilation

Circulation

Disability

Exposure and Control of the Environment

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Evaluation• Hemodynamically Stable

• Hemodynamically Unstable

Hemodynamically Stable

• Mechanism of trauma and the time of injury• Investigation to determine if there is intraperitoneal

injury / perforation, require operative repair ?• Many of these patients, will have some superficial

tenderness around the wound (no peritonitis)• Strategy depends on Abdominal Region or The

Standard Operating Procedure (SOP)• Selective management used to reduce the number of

laparotomy

Mechanism of Injury

Sword - Knife - Keris

Gunshot

Hemodynamically Stable

• There are several options to evaluatingPenetration Abdominal Injury in thehemodynamically stable trauma patientwithout sign of peritonitis

• Some evaluating :– Abdominal X Ray : confirmed abdominal free air

USG FAST

Hemodynamically Stable

• USG FAST :– Looking for free fluid in the abdominal cavity– A positive FAST indicates peritoneal penetration,

a negative FAST does not exclude significantperitoneal injury/ penetration

– Should be used in combination with otherinvestigation

Hemodynamically Stable

• Local wound exploration :

– Can be perform in the ER with local anasthesiaand sterile condition

– The wound tract is followed, the goal is identifythe end point of the track. It is penetrating toperitoneum (+) or not (-)

– Some institution have regulation that if there ispositive requiring laparotomy

Hemodynamically Stable

• Diagnostic Peritoneal Lavage (DPL):– The roe of DPL is to identify hollow viscus injury

(stomach, small bowel, colon) and diaphragmaticinjury

– A positive result is 100,000 RBCs for anteriorabdominal wounds, and 10,000 RBCs forthoracoabdominal wounds

– DPL is now used if FAST or CT Scan not available– DPL does not evaluate retroperitoneal

Hemodynamically Stable

• CT Scan Abdomen (IV contras):

– Optimal method for determining both peritonealpenetration and intra peritoneal injury

– Sensitivity 97 % for peritoneal damage– The best diagnostic and assessement for

retroperitoneal structure– Be ware that some diaphragmatic injuries will be

missed on CT examination

Hemodynamically Stable

• Serial physical examination:

– Best sensitivity and negative predictive value ofall modalities

– 24 hour closed observation, hourly examinationfor abdominal region (development sign forperitonitis) and circulation (pulse rate,arteryhypotension SBP<120,inadequate tissueperfusion)

Hemodynamically Stable

• If the patient develops any sign of peritonitisor hemodynamic unstable a laparotomy ismandatory

• If the patient is well the following day theystart a normal diet, after tolerated it, thepatient allow to discharged

Hemodynamically Stable

• Mandatory laparotomy :– Peritonitis– Evisceration– Free air– Multiple injury/trauma– Foreign bodies in abdomen region (knife)– On going bleeding– Gunshot (Low or High velocity )

GUNSHOT

Penetratinganteriorabdominalwound(stabbing)

Acute care surgery 2012

Hemodynamically Stable

• Consideration :

– Thoracoabdominal Wounds (occur in around 7%),be ware an injury of diaphragm. Laparoscopy orThoracoscopy is recommended

– Flank or Back wounds, be highly suspicious forinjury to retroperitoneal organ (colon most oftenmissed, UT, kidney, vessel)

Penetratingthoracoabdominal(gunshot/stabbing)

Acute care surgery 2012

Hemodynamically Stable

• Flank or Back injury :

– Triple contras CT Scan.. (+) or suspiciousinjury/high velocity injury, mandatorylaparotomy

– If does not have CT Scan, Serial physicalexamination and laboratory should be perform,and if develop sign of peritonitis requiringlaparotomy

Penetratingback/flank wound(gunshot/stabbing)

Acute care surgery 2012

Hemodynamically Unstable

• Require immediate Laparotomy• Includes no responders or transient

responders to initial fluid bolus• Unnecessary investigation or intervention

should be avoided

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