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General Surgery
Management of Abdominal Trauma
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 161 slides
Overview
- Scope of this topic
- From mandatory laparotomy to selective management
Initial assessment of every injured patient
Primary survey, resuscitation, secondary survey, reassessment
- Components of the initial assessment
- Priorities of the primary survey
- Airway control in the injured patient
- Breathing assessment after the airway is secured
- Circulation and haemorrhage control
- Disability and exposure
- The secondary survey
- Reevaluation of the injured patient
Penetrating injury: assessment and diagnosis
Anatomy, mechanism, examination, imaging and the decision algorithms
- Boundaries of the abdomen
- The four clinical regions
- Kinetic energy and wounding potential
- Stab wounds compared with gunshot wounds
- Shotgun and air gun injuries
- Physical examination of the penetrating wound
- Auscultation and the unreliable abdomen
- Absolute indications for exploratory laparotomy
- Local wound exploration for anterior stab wounds
- Serial abdominal examination
- Plain radiography in penetrating injury
- Diagnostic peritoneal lavage in penetrating injury
- Computed tomography in penetrating injury
- Ultrasound and FAST in penetrating injury
- Diagnostic laparoscopy for thoracoabdominal wounds
- Reading the thoracoabdominal wound pathway
- Decision pathway for penetrating thoracoabdominal wounds
- Reading the anterior abdominal stab pathway
- Decision pathway for anterior abdominal stab wounds
- Reading the anterior abdominal gunshot pathway
- Decision pathway for anterior abdominal gunshot wounds
- Selective pathway using imaging
- Selective pathway for anterior abdominal stab wounds
- Reading the back and flank pathway
- Decision pathway for penetrating back and flank wounds
The trauma laparotomy and specific injuries
Setting up, controlling bleeding and soiling, then organ by organ
- Setting up the operating room
- Imperatives of a trauma laparotomy
- Preparation and incision
- Controlling exsanguinating haemorrhage
- Communication during packing
- Controlling contamination
- Systematic search for injuries
- When definitive repair must wait
- Small intestinal injury
- Colon injury
- Rectal injury below the peritoneal reflection
- Gastric injury
- Duodenal injury
- Pancreatic injury
- Splenic injury from a penetrating wound
- Gallbladder and simple hepatic wounds
- Operative options for complex hepatic injury
- Considerations for hepatic injury
- Renal injury in penetrating trauma
- Renal repair and drainage
- Ureteric injury
- Bladder injury
- Contents of the retroperitoneum
- Zones of the retroperitoneum
- Rules for exploring a retroperitoneal haematoma
- Exploration by retroperitoneal zone
- Damage-control laparotomy
- Stages of damage-control surgery
Blunt abdominal trauma: diagnosis
Peritoneal lavage, FAST ultrasound, computed tomography and injury grading
- Shift from operation to observation
- Diagnostic peritoneal lavage in blunt trauma
- Criteria for a positive lavage
- Diagnostic criteria for a positive peritoneal lavage
- Pitfalls of peritoneal lavage
- Focused abdominal sonography for trauma
- Windows scanned in a FAST examination
- Sonographic windows for a FAST examination
- Limits and use of the FAST result
- Computed tomography in blunt trauma
- Organ injury grading scales
- Spleen injury scale, grades I to III
- Spleen injury scale, grades III to V
- Liver injury scale, grades I to III
- Liver injury scale, grades III to VI
- Kidney injury scale, grades I to III
- Kidney injury scale, grades IV and V
- What the grades change in practice
- Detecting bowel injury on CT
- Free fluid and free air that are not injuries
- Oral contrast in trauma CT
- CT and pelvic fracture bleeding
Blunt splenic injury
Selection for non-operative care, embolisation, splenectomy and its consequences
- Why the spleen is injured so often
- Selecting patients for non-operative care
- Risk factors for failure of non-operative care
- Subcapsular haematoma and portal hypertension
- Weighing the decision as a whole
- Contrast blush and angioembolisation
- Follow-up imaging after splenic injury
- Return to normal activity
- Reading the blunt splenic injury pathway
- Relative contraindications to observation
- Decision pathway for blunt splenic injury
- Splenectomy: exposure
- Splenectomy: completing the operation
- Splenorrhaphy: preserving the spleen
- Overwhelming post-splenectomy infection
- Prophylaxis after splenectomy
Blunt hepatic injury
Non-operative care, embolisation, complications and the difficult operation
- The liver in blunt trauma
- Selecting patients for non-operative care
- How non-operative liver care fails
- Reported failure rates of non-operative liver management
- When embolisation or surgery is urgent
- Choosing between theatre and angiography
- Contrast blush without free bleeding
- Bile leak after liver injury
- Abscess and hepatic necrosis
- Gallbladder necrosis after embolisation
- Operative management of minor liver injuries
- First moves for a bleeding major liver injury
- Controlling a bleeding liver
- The Pringle manoeuvre
- Exposure for deep and juxtahepatic wounds
- Total hepatic vascular isolation
- The atriocaval shunt
- Using and judging the shunt
- Direct exposure as the alternative
- Resection and hepatic artery ligation
- Packing and planned reoperation
Blunt bowel and colon injury
The missed perforation, injury grading, and the case for primary repair
- The missed bowel injury
- Direct CT signs of bowel injury
- Indirect CT signs of bowel injury
- CT findings of blunt bowel injury
- Weighing the indirect signs
- AAST grading of bowel injury
- Destructive and non-destructive wounds
- Reading the bowel injury scales
- Small bowel injury scale, grades I to III
- Small bowel injury scale, grades IV and V
- Colon injury scale, grades I to V
- Colon repair: how the dogma changed
- Risk factors in destructive colon injury
- Results of resection and primary anastomosis
- Judgement at the operating table
- Operative sequence for bowel injury
- Repairing the bowel
- Layers of closure
- Stapled versus hand-sewn anastomosis
- Key messages
- What good trauma care depends on
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- Maingot's Abdominal Operations, 12th Edition