- Email: [email protected]
Abdominal Trauma
Symposium on Trauma
Abdominal Trauma
Anthony A. Meyer, M.D., Ph.D.,* and Richard A. Crass, M.D. t
Abdominal trauma continues to account for a large number of trauma-related injuries and deaths. Motor vehicle accidents and urban violence, respectively, are the leading causes of blunt and penetraQng trauma to this area of the body. Most preventable deaths due to trauma are the result of inadequately treated abdominal injuries. 61 Advances in resuscitation, evaluation, and surgical technique have increased our ability to salvage people with major abdominal injuries and minimize preventable deaths. This article will describe our general approach to resuscitation, evaluation, and treatment of patients with abdominal trauma at San Francisco General Hospital and discuss some alternative approaches to the same problems.
RESUSCITATION Resuscitation and evaluation of traumatized patients should begin simultaneously. The extent of efforts and speed used to resuscitate a patient are individualized, depending upon mechanism of injury, hemodynamic stability, neurologic status, associated injuries, and suspected potential for rapid deterioration. One largebore intravenous line and frequent physical examination and assessment of vital signs constitute the minimal treatment for any victim of trauma who has the potential of having abdominal trauma. Additional intravenous lines, a central venous pressure line, type-specific blood, a urinary catheter, oxygen supplementation, and assisted ventilation can be included in the resuscitation if indicated. Restoring intravascular volume in patients with massive abdominal blood loss can be accomplished by saphenous vein cut-down and placement of shortened 8 to 10 Fr. feeding tubes or intravenous tubing in the vein connected to manual blood-pump sets. If there is any suggestion of vena caval injury, upper extremity veins can be used. When this is inadequate, an emergency left anterior thoracotomy with control of the aorta at the diaphragm, combined with manual heart compression, can maintain coronary and cerebral perfusion until control of the bleeding is obtained in the operating room. 3 *Chief Resident in Surgery, University of California, San Francisco, School of Medicine, San Francisco, California tAssistant Clinical Professor of Surgery, University of California, San Francisco, School of Medicine, San Francisco, California Surgical Clinics of North America-Vol. 62, No. l, February 1982
105
106
ANTHONY A. MEYER AND RICHARD A. CRASS
In addition, associated injuries are also treated, such as splinting fractures and stopping external hemorrhage. Resuscitation is continued throughout the period of evaluation until a treatment plan, surgery or observation, is established.
EVALUATION The evaluation of patients with abdominal trauma is as critical as the resuscitation because errors in the choice or interpretation of tests and delays from unnecessary studies can have profound effects on the outcome of the patient. Every effort should be made to be complete and expedient in arriving at a tentative diagnosis and course of treatment. Patients presenting with refractory hypotension, uncontrollable external hemorrhage, viscera extruding from a wound, free adominal air, or other acute states all require immediate surgery. 57 Further work-up of such patients should be directed at getting the patient ready for the operating room. It is important to assess the patient's general physiologic status by hematocrit, arterial blood gas, glucose, Na+, K+, and urinalysis and to examine organ systems whose status is important in making operative decisions, for example, a chest x-ray to look for hidden blood loss or a "single shot" intravenous pyelogram to document bilateral renal function. 25 ' 35 Most patients, however, do not have an obvious need for immediate operation. Further discussion of evaluation of abdominal trauma will be directed at this less obvious group. Blunt and penetrating trauma will be discussed separately, although there is great overlap between them in treatment as well as evaluation. All patients with suspected abdominal trauma, blunt or penetrating, should have a complete blood count with differential blood count, urinalysis, and chest xray. Abnormalities in these tests suggest an intra-abdominal injury and direct the physician to further tests or treatment. Normal results, however, do not rule out major abdominal injuries, but they do serve as a baseline to help follow patients with less obvious injuries with serial laboratory studies.
Blunt Trauma The evaluation of the patient with blunt abdominal trauma is one of the most difficult assessments in surgery. The physical examination has always been the most important part of this assessment. Although the history and physical examination have been shown to be in error initially in as many as 25 per cent of cases, 2 ' 6 ' 10 changes noted in subsequent examinations and vital signs are often the first evidence that a patient has suffered previously undetected intra-abdominal injury. 31 ' 55 Plain abdominal films are of little help diagnostically, even though visceral perforation from blunt trauma can occur. 28 ' 45 Invasive procedures are being used more frequently to evaluate blunt abdominal trauma. Needle paracentesis had been a common procedure, but its 86 per cent or less accuracy and potential for visceral injury have led to its decreasing use. 10' 48 Laparoscopy in the emergency room has also been used to assess blunt abdominal injury. 47 Many trauma centers recommend peritoneal lavage as a standard test in the evaluation of blunt abdominal trauma and measure cell counts, differential blood cell counts, and amylase levels with an accuracy of 90 to 97 per cent. 6 ' 15' 20 However, other series have found that as many as 67 per cent of patients with indeterminate cell counts have abdominal injuries 26 and that 26 per cent of injuries need no repair at the time of surgery. 16 Furthermore,
107
ABDOMINAL TRAUMA
29 per cent of patients with pelvic fractures have a false-positive peritoneal lavage. 27 ' 37• 41 There is no question that peritoneal lavage is an important diagnostic test for intra-abdominal bleeding, but it does have a certain morbidit/9 and often is of little value in determining a treatment plan for such a patient. 2 When peritoneal lavage is done, it should be performed by the open technique to decrease the chance of iatrogenic injury. 49 At San Francisco General Hospital we believe that stable patients who can be followed clinically by examination and serial blood studies do not usually need peritoneal lavage. We agree that it is the procedure of choice in patients who cannot have serial examinations, such as those with central nervous system injuries 57 or those who will be anesthetized to treat other injuries. In recent years we have more frequently obtained abdominal computed tomographic (CT) scans in equivocal cases and have been pleased with its sensitivity for hepatic, splenic, renal, and pancreatic injury. 19 Sonography has also been used to evaluate abdominal and retroperitoneal injuries. 21
Penetrating Trauma It is important when considering penetrating abdominal trauma to remember that any wound of the thorax, back, or abdomen might injure abdominal structures, especially low thoracic wounds.<•· 52 These all should be considered abdominal wounds until proved otherwise. Stab wounds to the abdomen have a 30 to 40 per cent incidence of visceral injury, and gunshot wounds have an 80 to 90 per cent chance of such injury. 55 Mandatory laparotomy used to be the treatment for all penetrating abdominal wounds, but most trauma centers have developed some screening technique to limit unnecessary operations in patients without an immediately obvious need for surgery. These techniques include simple observation, peritoneal lavage, and sonograms through the wound. 9 Stab wound and gunshot wounds will be discussed separately. One approach to the treatment of abdominal stab wounds is to observe for 24 hours patients who do not have shock, peritoneal irritation, absence of bowel sounds, evisceration, gastric or rectal blood, positive peritoneal lavage, intravenous pyelogram, or arteriogram. 38 ' 62 Another approach is to locally explore abdominal wounds and perform peritoneal lavage if the anterior fascia has been violated or the wound was on the lower anterior chest and to operate only if the lavage is positive. 53 · 56 However, one prospective study found that patients with fascial defects and negative peritoneal lavage had an incidence of visceral injury of more than 14 per cent. 23 For this reason, we prefer to explore the abdomen of stab wound victims with fascial defects on wound exploration and do not routinely use peritoneal lavage. Abdominal gunshot wounds have also been managed by peritoneal lavage and observation in some cases, 34 ' 38 but lavage is unreliable to evaluate intra-abdominal injuries by this mechanism. 53 As many as 97 per cent of patients will have visceral injury, 33 and injury can occur even without penetration of the peritoneal cavity. 5 · 17 We strongly contend that an exploratory laparotomy should be done on all patients with gunshot wounds that may have entered the abdomen. 33
TREATMENT Abdominal injuries from blunt or penetrating trauma are managed by the appropriate method of repair while other injuries and the general status of the patient
108
ANTHONY A. MEYER AND RICHARD A. CRASS
are simultaneously taken into account. General technical principles are adhered to, especially hemostasis, debridement of devitalized tissue, drainage of potential collections, guaranteeing good blood supply to areas of repair, and peritoneal toilet in contaminated cases. Preoperative antibiotics have been found to reduce infections in patients with penetrating trauma who are found to have colonic injury. 40 Secondlook operations can be helpful in selected cases to reexamine tissue of questionable viability or to control bleeding that is not manageable in the first operation. We will review important points regarding each organ system. Stomach. Gastric wounds rarely require anything other than simple closure in two layers, the inner one being hemostatic. A narrowed outlet can be managed by a gastrojejunostomy away from the visceral injury. Duodenum. Duodenal injuries have a high mortality, mostly due to a delay in diagnosis in blunt injuries. 7 Small lacerations can be repaired with the addition of decompression by tube duodenostomy (10 French Foley) if there is any question of the integrity of the closure. For extensive injury, the best results have been produced by diverting gastric contents from direct passage through the duodenum and tube duodenostomy and sump drainage (duodenal diverticularization). n. 51 These techniques and postoperative hyperalimentation have improved survival. .>t Small Bowel. Small bowel is usually repaired in one or two layers for simple wounds. Debridement or resection is needed for more complex wounds or for devascularized bowel. 24 • 43 Seromuscular contusions of both small bowel and colon from gunshot wounds should be treated like true penetrating injuries because of the potential for late perforation. 30 Colon. Controversy about primary repair or resection versus fecal diversion still exists. Primary repair can usually be done safely in patients with small, isolated injuries, no contamination or devascularization, and no associated major injuries or hemodynamic instability. 50 Exteriorized repairs have generally not been successful. Rectum. Fecal diversion with repair and presacral drainage is the standard treatment. Irrigation of the rectal stump has become controversial. 58 Liver. The liver is the most commonly injured organ, and death is usually due to hemorrhage. 18 Simple, non bleeding injuries should be left alone. 55 Cautery can be used for capsular bleeding, but parenchymal bleeding is best managed by suture ligation of specific vessels. Large raw areas of liver tissue should be drained. 59 Lobectomy and hepatic artery ligation are needed infrequently. 13 Debridement of nonviable liver parenchyma is important, especially in high velocity gunshot wounds and close-range shotgun wounds. 4 · 12· 59 Spleen. The spleen is frequently injured in blunt trauma. In unstable patients, splenectomy is prudent. Otherwise, attempts at salvage appear to be worthwhile (to prevent postsplenectomy sepsis) and safe. Several techniques have been used to repair splenic injury, but all require mobilizing the spleen into the wound. 13' 36 ' 46 Bile Ducts. Bile duct injuries that are treated with repair and T-tube have a high incidence of stricture and fistulae. Cholcdochoenterostomy is the preferred primary treatment for this injury. 7 · 8 Pancreas. Most injuries involve only the capsule and a limited amount of the pancreatic parenchyma and need only drainage and possibly debridement. Duct injuries, however, require resection of the distal pancreas. Pancreatoduodenectomy is rarely indicated. 13' 29 ' 39 Abdominal Vasculature. The major arterial supply to the abdominal viscera must be repaired, if possible. A vein graft can be used to bypass or patch complex
109
ABDOMINAL TRAUMA
arterial injuries. 1 Portal vein injuries should also be repaired if possible, but ligation can be tolerated if reconstruction is impossible. 7 Diaphragm and Abdominal WaU. Injuries of the diaphragm and abdominal wall should be carefully repaired to prevent postoperative hernia or evisceration. 22' 60 Debridement of blast-injured tissue is necessary and synthetic mesh support is occasionally required.
SUMMARY Abdominal trauma continues to be the major cause of morbidity and mortality in this country. Unnecessary deaths and complications can be minimized by improved resuscitation, evaluation, and treatment. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of unneeded surgery is an important goal of evaluation. However, most avoidable deaths result from failure to resuscitate and operate on surgically correctable injuries. 14 When the diagnosis is in doubt and clinical judgment suggests surgery, exploration provides definitive treatment as well as diagnosis; moreover, the risks of negative exploration have become acceptable. 31 ' 33' 42 The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however, still depend on experience and clinical judgment for application and determination of the best care for the injured patient.
REFERENCES l. Amato, J. T., eta!.: High-velocity arterial injury: A study of the mechanism of injury. J. Trauma, 11:412, 1971. 2. Bagwell, C. E., and Ferguson, W. W.: Blunt abdominal trauma: Exploratory laparotomy or peritoneal lavage. Am. J. Surg., 139:368--373, 1980. 3. Baker, C. C., Thomas, A. N., and Trunkey, D. D.: The role of emergency room thoracotomy in trauma. J. Trauma, 20:848, 1980. 4. Bell, M. J.: The management of shotgun wounds. J. Trauma, 11:522, 1971. 5. Ben-Menachem, Y.: Intra-abdominal injuries in non-penetrating gunshot wounds of the abdominal wall: Two unusual cases. J. Trauma, 19:207, 1979. 6. Bivins, B. A., et a!.: .Diagnostic peritoneal lavage is superior to clinical evaluation in blunt trauma. Am. Surg., 44:637, 1978. 7. Busuttil, R. W., et a!.: Management of blunt and penetrating trauma to the porta hepatis. Ann. Surg., 191 :641, 1980. 8. Charters, A. C.: Intra!Iepatic bile duct rupture following blunt abdominal trauma. Arch. Surg., 113:873, 1978. 9. Cornell, W. P., eta!.: A new nonoperative technique for the diagnosis of penetrating injuries to the abdomen. J. Trauma, 1:307, 1967. 10. David, J.J., Cohn, 1., and Nance, F.: Diagnosis and management of blunt abdominal trauma. Ann. Surg., 183:672, 1976. 11. DeMars, J. J., Bubrick, M. P., and Hitchcock, C.: Duodenal perforation in blunt abdominal trauma. Surgery, 86:632, 1979. 12. DeMuth, W. E.: The mechanism of shotgun wounds. J. Trauma, 11:219, 1971. 13. Dickerman, R. M., and Dunn, E. L.: Splenic, pancreatic, and hepatic injuries. SuRe. CuN. NoRTH AM., 61:3, 1981. 14. Dove, D. B., Sta!Il, W. M., and Del Guercio, L. R.: A five-year review of deaths following urban trauma. J. Trauma, 20:760, 1980. 15. Drew, R., Perry, J. F., and Fischer, R. P.: The expediency of peritoneal lavage for blunt trauma in children. Surg. Gynecol. Obstet., 145:885, 1977.
110
ANTHONY A. MEYER AND RICHARD A. CRASS
16. Du Priest, R. W., et al.: Open diagnostic peritoneal lavage in blunt trauma victims. Surg. Gynecol. Obstet., 148:890, 1979. 17. Edwards, J., and Gaspard, D. J.: Visceral injury due to extraperitoneal gunshot wounds. Arch. Surg., 108:865, 1974. 18. Elerdang, S. C., Aragon, G., and Moore, E. E.: Fatal hepatic hemorrhage after trauma. Am. J. Surg., 138:883, 1979. 19. Federle, M. P., Goldberg, H. 1., Kaiser, J. A., et al.: Evaluation of abdominal trauma by computed tomography. Radiology, 138:637, 1981. 20. Fischer, R. P., Beverlin, B. C., Engrav, L. H., et al.: Diagnostic peritoneal lavage fourteen years and 2,586 patients later. Am. J. Surg., 136: 701, 1978. 21. Foley, L. C., and Teele, R. L.: Ultrasound of epigastric injuries after blunt trauma. Am. J. Roentgenol., 133:593, 1979. 22. Freeman, J., and Fischer, R. P.: The inadequacy of peritoneal lavage in diagnosing acute diaphragmatic rupture. J. Trauma, 16:538, 1976. 23. Galbraith, T. A., et al.: The role of peritoneal lavage in the management of stab wounds to the abdomen. Am. J. Surg., 140:61, 1980. 24. Giddings, W. P., and McDaniel, J. R.: Wounds of the jejunum and ileum. In Surgery of World War II. Washington, D.C., Office of the Surgeon General, 1955. 25. Griffin, W. 0., et al.: Intravenous pyleography in abdominal trauma. J. Trauma, 18:387, 1978. 26. Hornyak, S. W., and Shafton, G. W.: Value of"inconclusive lavage" in abdominal trauma management. J. Trauma, 19:329, 1979. 27. Hubbard, S. G., et al.: Diagnostic errors with peritoneal lavage in patients with pelvic fractures. Arch. Surg., 114:844, 1979. 28. Hunt, K. E., Garrison, R. N ., and Fry, D. E.: Perforating injuries of the gastrointestinal tract following blunt abdominal trauma. Am. Surg., 46:100, 1980. 29. Karl, H. W., and Chandler, J. G.: Mortality and morbidity of pancreatic injury. Am. J. Surg., 134:549, 1977. 30. Lennquist, S., et a!.: Intestinal hematomas due to abdominal muscle wounds-pathophysiology and principles of treatment. Acta. Chir. Scand. (Suppl.), 489:211, 1979. 31. London, P. S.: Abdominal injuries-surgical aspects. A review. J. Roy. Soc. Med., 72:842, 1979. 32. Lowe, R. J., et al.: The negative laparotomy for abdominal trauma. J. Trauma, 12:853, 1972. 33. Lowe, R. J., et al.: Should laparotomy be mandatory or selective in gunshot wounds of the abdomen? J. Trauma, 17:907, 1977. · 34. McAlvanah, M. J., and Shaftan, G. W.: Selective conservation in penetrating abdominal wounds: A continuing reappraisal. J. Trauma, 18:206, 1978. 35. McDonald, E., et a!.: The role of emergency excretory urography in evaluation of blunt abdominal trauma. Am. J. Roentgenol., 126:739, 1976. 36. Mishalany, H. G., et al.: Modalities of preservation of the traumatized spleen. Am. J. Surg., 136:697, 1978. 37. Murr, P. C., eta!.: Abdominal trauma associated with pelvic fracture. J. Trauma, 20:919, 1980. 38. Nance, F. C., et al.: Surgical judgment in the management of penetrating wounds of the abdomen: Experience with 2212 patients. Ann. Surg., I 79:639, 1974. 39. Northrup, W. F., III, and Simmons, R. L.: Pancreatic trauma: A review. Surgery, 71:27, 1972. 40. O'Donnell, V. A., et al.: Role of antibiotics in penetrating abdominal trauma. Am. Surg., 44:574, 1978. 41. Palomar, J., Polanco, E., and Frentz, G.: Rupture of the bladder following blunt trauma: A plea for peritoneotomy in patients with extraperitoneal rupture. J. Trauma, 20:329, 1980. 42. Peterson, S. R., and Sheldon, G. F.: Morbidity of a negative finding at laparotomy in abdominal trauma. Surg. Gynecol. Obstet., 148:23, 1979. 43. Robbs, J. V., Moore, S. W., and Pillay, S. P.: Blunt abdominal trauma with jejunal injury: A review. J. Trauma, 20:308, 1980. 44. Sanbrasaga, F. A.: Penetrating thoracoabdominal injuries. Br. J. Surg., 64:638, 1977. 45. Schuck, J. M., and Lowe, R. J.: Intestinal disruption due to blunt abdominal trauma. Am. J. Surg., 136:668, 1978. 46. Sherman, R.: Rationale for and methods of splenic preservation following trauma. SuRe. CLIN. NoRTH AM., 61:127, 1981. 47. Sherwood, R., et al.: Minilaparoscopy for blunt abdominal trauma. Arch. Surg., 115:672, 1980. 48. Sloop, R. D.: The dominant role of paracentesis technic in the early diagnosis of blunt abdominal trauma. Am. J. Surg., 136:145, 1978. 49. Soderstrom, C. A., DuPriest, R. W., and Cowley, R. A.: Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg. Gynecol. Obstet., 151:513, 1980. 50. Steele, M., and Blaisdell, F. W.: Treatment of colon injuries. J. Trauma, 17:557, 1977. 51. Stone, H. H., and Fabia, T. C.: Management of duodenal wounds. J. Trauma, 19:334, 1979. 52. Talbert, J., eta!.: Peritoneal lavage in penetrating thoracic trauma. J. Trauma, 20:979, 1980. 53. Thai, E.: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J. Trauma, 17:642, 1977. 54. Thai, E.: Peritoneal lavage--its unreliability in gunshot wounds of the lower chest and abdomen. Arch. Surg., 115:430, 1980.
T ABDOMINAL TRAUMA
111
55. Thai, E. R., McClelland, R. N., and Shires, G. T.: Abdominal trauma. In Shires, G. T. (ed.): Care of the Trauma Patient. New York, McGraw Hill, 1979. 56. Thompson, J. S., et al.: The evaluation of abdominal stab wound management. J. Trauma, 20:478, 1980. 57. Tibbs, P. A., et al.: Diagnosis of acute abdominal injury in patients with spinal shock: Value of diagnostic peritoneal lavage. J. Trauma, 20:55, 1980. 58. Trunkey, D. D., Hays, R. J., and Shires, G. T.: Management of rectal trauma. J. Trauma, 13:411, 1973. 59. Trunkey, D. D., Shires, G. T., and McClelland, R.: Management of liver trauma in 811 consecutive patients. Ann. Surg., 179:722, 1974. 60. Waldschmidt, M. L., and Laws, H. L.: Injuries of the diaphragm. J. Trauma, 20:587, 1980. 61. West, J. G., and Trunkey, D. D.: System of trauma care: A study of2 counties. Arch. Surg., 114:455, 1979. 62. Wilder, J., and Kudchadkcer, A.: Stab wounds of the abdomen---
Abdominal Trauma
Anthony A. Meyer, M.D., Ph.D.,* and Richard A. Crass, M.D. t
Abdominal trauma continues to account for a large number of trauma-related injuries and deaths. Motor vehicle accidents and urban violence, respectively, are the leading causes of blunt and penetraQng trauma to this area of the body. Most preventable deaths due to trauma are the result of inadequately treated abdominal injuries. 61 Advances in resuscitation, evaluation, and surgical technique have increased our ability to salvage people with major abdominal injuries and minimize preventable deaths. This article will describe our general approach to resuscitation, evaluation, and treatment of patients with abdominal trauma at San Francisco General Hospital and discuss some alternative approaches to the same problems.
RESUSCITATION Resuscitation and evaluation of traumatized patients should begin simultaneously. The extent of efforts and speed used to resuscitate a patient are individualized, depending upon mechanism of injury, hemodynamic stability, neurologic status, associated injuries, and suspected potential for rapid deterioration. One largebore intravenous line and frequent physical examination and assessment of vital signs constitute the minimal treatment for any victim of trauma who has the potential of having abdominal trauma. Additional intravenous lines, a central venous pressure line, type-specific blood, a urinary catheter, oxygen supplementation, and assisted ventilation can be included in the resuscitation if indicated. Restoring intravascular volume in patients with massive abdominal blood loss can be accomplished by saphenous vein cut-down and placement of shortened 8 to 10 Fr. feeding tubes or intravenous tubing in the vein connected to manual blood-pump sets. If there is any suggestion of vena caval injury, upper extremity veins can be used. When this is inadequate, an emergency left anterior thoracotomy with control of the aorta at the diaphragm, combined with manual heart compression, can maintain coronary and cerebral perfusion until control of the bleeding is obtained in the operating room. 3 *Chief Resident in Surgery, University of California, San Francisco, School of Medicine, San Francisco, California tAssistant Clinical Professor of Surgery, University of California, San Francisco, School of Medicine, San Francisco, California Surgical Clinics of North America-Vol. 62, No. l, February 1982
105
106
ANTHONY A. MEYER AND RICHARD A. CRASS
In addition, associated injuries are also treated, such as splinting fractures and stopping external hemorrhage. Resuscitation is continued throughout the period of evaluation until a treatment plan, surgery or observation, is established.
EVALUATION The evaluation of patients with abdominal trauma is as critical as the resuscitation because errors in the choice or interpretation of tests and delays from unnecessary studies can have profound effects on the outcome of the patient. Every effort should be made to be complete and expedient in arriving at a tentative diagnosis and course of treatment. Patients presenting with refractory hypotension, uncontrollable external hemorrhage, viscera extruding from a wound, free adominal air, or other acute states all require immediate surgery. 57 Further work-up of such patients should be directed at getting the patient ready for the operating room. It is important to assess the patient's general physiologic status by hematocrit, arterial blood gas, glucose, Na+, K+, and urinalysis and to examine organ systems whose status is important in making operative decisions, for example, a chest x-ray to look for hidden blood loss or a "single shot" intravenous pyelogram to document bilateral renal function. 25 ' 35 Most patients, however, do not have an obvious need for immediate operation. Further discussion of evaluation of abdominal trauma will be directed at this less obvious group. Blunt and penetrating trauma will be discussed separately, although there is great overlap between them in treatment as well as evaluation. All patients with suspected abdominal trauma, blunt or penetrating, should have a complete blood count with differential blood count, urinalysis, and chest xray. Abnormalities in these tests suggest an intra-abdominal injury and direct the physician to further tests or treatment. Normal results, however, do not rule out major abdominal injuries, but they do serve as a baseline to help follow patients with less obvious injuries with serial laboratory studies.
Blunt Trauma The evaluation of the patient with blunt abdominal trauma is one of the most difficult assessments in surgery. The physical examination has always been the most important part of this assessment. Although the history and physical examination have been shown to be in error initially in as many as 25 per cent of cases, 2 ' 6 ' 10 changes noted in subsequent examinations and vital signs are often the first evidence that a patient has suffered previously undetected intra-abdominal injury. 31 ' 55 Plain abdominal films are of little help diagnostically, even though visceral perforation from blunt trauma can occur. 28 ' 45 Invasive procedures are being used more frequently to evaluate blunt abdominal trauma. Needle paracentesis had been a common procedure, but its 86 per cent or less accuracy and potential for visceral injury have led to its decreasing use. 10' 48 Laparoscopy in the emergency room has also been used to assess blunt abdominal injury. 47 Many trauma centers recommend peritoneal lavage as a standard test in the evaluation of blunt abdominal trauma and measure cell counts, differential blood cell counts, and amylase levels with an accuracy of 90 to 97 per cent. 6 ' 15' 20 However, other series have found that as many as 67 per cent of patients with indeterminate cell counts have abdominal injuries 26 and that 26 per cent of injuries need no repair at the time of surgery. 16 Furthermore,
107
ABDOMINAL TRAUMA
29 per cent of patients with pelvic fractures have a false-positive peritoneal lavage. 27 ' 37• 41 There is no question that peritoneal lavage is an important diagnostic test for intra-abdominal bleeding, but it does have a certain morbidit/9 and often is of little value in determining a treatment plan for such a patient. 2 When peritoneal lavage is done, it should be performed by the open technique to decrease the chance of iatrogenic injury. 49 At San Francisco General Hospital we believe that stable patients who can be followed clinically by examination and serial blood studies do not usually need peritoneal lavage. We agree that it is the procedure of choice in patients who cannot have serial examinations, such as those with central nervous system injuries 57 or those who will be anesthetized to treat other injuries. In recent years we have more frequently obtained abdominal computed tomographic (CT) scans in equivocal cases and have been pleased with its sensitivity for hepatic, splenic, renal, and pancreatic injury. 19 Sonography has also been used to evaluate abdominal and retroperitoneal injuries. 21
Penetrating Trauma It is important when considering penetrating abdominal trauma to remember that any wound of the thorax, back, or abdomen might injure abdominal structures, especially low thoracic wounds.<•· 52 These all should be considered abdominal wounds until proved otherwise. Stab wounds to the abdomen have a 30 to 40 per cent incidence of visceral injury, and gunshot wounds have an 80 to 90 per cent chance of such injury. 55 Mandatory laparotomy used to be the treatment for all penetrating abdominal wounds, but most trauma centers have developed some screening technique to limit unnecessary operations in patients without an immediately obvious need for surgery. These techniques include simple observation, peritoneal lavage, and sonograms through the wound. 9 Stab wound and gunshot wounds will be discussed separately. One approach to the treatment of abdominal stab wounds is to observe for 24 hours patients who do not have shock, peritoneal irritation, absence of bowel sounds, evisceration, gastric or rectal blood, positive peritoneal lavage, intravenous pyelogram, or arteriogram. 38 ' 62 Another approach is to locally explore abdominal wounds and perform peritoneal lavage if the anterior fascia has been violated or the wound was on the lower anterior chest and to operate only if the lavage is positive. 53 · 56 However, one prospective study found that patients with fascial defects and negative peritoneal lavage had an incidence of visceral injury of more than 14 per cent. 23 For this reason, we prefer to explore the abdomen of stab wound victims with fascial defects on wound exploration and do not routinely use peritoneal lavage. Abdominal gunshot wounds have also been managed by peritoneal lavage and observation in some cases, 34 ' 38 but lavage is unreliable to evaluate intra-abdominal injuries by this mechanism. 53 As many as 97 per cent of patients will have visceral injury, 33 and injury can occur even without penetration of the peritoneal cavity. 5 · 17 We strongly contend that an exploratory laparotomy should be done on all patients with gunshot wounds that may have entered the abdomen. 33
TREATMENT Abdominal injuries from blunt or penetrating trauma are managed by the appropriate method of repair while other injuries and the general status of the patient
108
ANTHONY A. MEYER AND RICHARD A. CRASS
are simultaneously taken into account. General technical principles are adhered to, especially hemostasis, debridement of devitalized tissue, drainage of potential collections, guaranteeing good blood supply to areas of repair, and peritoneal toilet in contaminated cases. Preoperative antibiotics have been found to reduce infections in patients with penetrating trauma who are found to have colonic injury. 40 Secondlook operations can be helpful in selected cases to reexamine tissue of questionable viability or to control bleeding that is not manageable in the first operation. We will review important points regarding each organ system. Stomach. Gastric wounds rarely require anything other than simple closure in two layers, the inner one being hemostatic. A narrowed outlet can be managed by a gastrojejunostomy away from the visceral injury. Duodenum. Duodenal injuries have a high mortality, mostly due to a delay in diagnosis in blunt injuries. 7 Small lacerations can be repaired with the addition of decompression by tube duodenostomy (10 French Foley) if there is any question of the integrity of the closure. For extensive injury, the best results have been produced by diverting gastric contents from direct passage through the duodenum and tube duodenostomy and sump drainage (duodenal diverticularization). n. 51 These techniques and postoperative hyperalimentation have improved survival. .>t Small Bowel. Small bowel is usually repaired in one or two layers for simple wounds. Debridement or resection is needed for more complex wounds or for devascularized bowel. 24 • 43 Seromuscular contusions of both small bowel and colon from gunshot wounds should be treated like true penetrating injuries because of the potential for late perforation. 30 Colon. Controversy about primary repair or resection versus fecal diversion still exists. Primary repair can usually be done safely in patients with small, isolated injuries, no contamination or devascularization, and no associated major injuries or hemodynamic instability. 50 Exteriorized repairs have generally not been successful. Rectum. Fecal diversion with repair and presacral drainage is the standard treatment. Irrigation of the rectal stump has become controversial. 58 Liver. The liver is the most commonly injured organ, and death is usually due to hemorrhage. 18 Simple, non bleeding injuries should be left alone. 55 Cautery can be used for capsular bleeding, but parenchymal bleeding is best managed by suture ligation of specific vessels. Large raw areas of liver tissue should be drained. 59 Lobectomy and hepatic artery ligation are needed infrequently. 13 Debridement of nonviable liver parenchyma is important, especially in high velocity gunshot wounds and close-range shotgun wounds. 4 · 12· 59 Spleen. The spleen is frequently injured in blunt trauma. In unstable patients, splenectomy is prudent. Otherwise, attempts at salvage appear to be worthwhile (to prevent postsplenectomy sepsis) and safe. Several techniques have been used to repair splenic injury, but all require mobilizing the spleen into the wound. 13' 36 ' 46 Bile Ducts. Bile duct injuries that are treated with repair and T-tube have a high incidence of stricture and fistulae. Cholcdochoenterostomy is the preferred primary treatment for this injury. 7 · 8 Pancreas. Most injuries involve only the capsule and a limited amount of the pancreatic parenchyma and need only drainage and possibly debridement. Duct injuries, however, require resection of the distal pancreas. Pancreatoduodenectomy is rarely indicated. 13' 29 ' 39 Abdominal Vasculature. The major arterial supply to the abdominal viscera must be repaired, if possible. A vein graft can be used to bypass or patch complex
109
ABDOMINAL TRAUMA
arterial injuries. 1 Portal vein injuries should also be repaired if possible, but ligation can be tolerated if reconstruction is impossible. 7 Diaphragm and Abdominal WaU. Injuries of the diaphragm and abdominal wall should be carefully repaired to prevent postoperative hernia or evisceration. 22' 60 Debridement of blast-injured tissue is necessary and synthetic mesh support is occasionally required.
SUMMARY Abdominal trauma continues to be the major cause of morbidity and mortality in this country. Unnecessary deaths and complications can be minimized by improved resuscitation, evaluation, and treatment. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of unneeded surgery is an important goal of evaluation. However, most avoidable deaths result from failure to resuscitate and operate on surgically correctable injuries. 14 When the diagnosis is in doubt and clinical judgment suggests surgery, exploration provides definitive treatment as well as diagnosis; moreover, the risks of negative exploration have become acceptable. 31 ' 33' 42 The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however, still depend on experience and clinical judgment for application and determination of the best care for the injured patient.
REFERENCES l. Amato, J. T., eta!.: High-velocity arterial injury: A study of the mechanism of injury. J. Trauma, 11:412, 1971. 2. Bagwell, C. E., and Ferguson, W. W.: Blunt abdominal trauma: Exploratory laparotomy or peritoneal lavage. Am. J. Surg., 139:368--373, 1980. 3. Baker, C. C., Thomas, A. N., and Trunkey, D. D.: The role of emergency room thoracotomy in trauma. J. Trauma, 20:848, 1980. 4. Bell, M. J.: The management of shotgun wounds. J. Trauma, 11:522, 1971. 5. Ben-Menachem, Y.: Intra-abdominal injuries in non-penetrating gunshot wounds of the abdominal wall: Two unusual cases. J. Trauma, 19:207, 1979. 6. Bivins, B. A., et a!.: .Diagnostic peritoneal lavage is superior to clinical evaluation in blunt trauma. Am. Surg., 44:637, 1978. 7. Busuttil, R. W., et a!.: Management of blunt and penetrating trauma to the porta hepatis. Ann. Surg., 191 :641, 1980. 8. Charters, A. C.: Intra!Iepatic bile duct rupture following blunt abdominal trauma. Arch. Surg., 113:873, 1978. 9. Cornell, W. P., eta!.: A new nonoperative technique for the diagnosis of penetrating injuries to the abdomen. J. Trauma, 1:307, 1967. 10. David, J.J., Cohn, 1., and Nance, F.: Diagnosis and management of blunt abdominal trauma. Ann. Surg., 183:672, 1976. 11. DeMars, J. J., Bubrick, M. P., and Hitchcock, C.: Duodenal perforation in blunt abdominal trauma. Surgery, 86:632, 1979. 12. DeMuth, W. E.: The mechanism of shotgun wounds. J. Trauma, 11:219, 1971. 13. Dickerman, R. M., and Dunn, E. L.: Splenic, pancreatic, and hepatic injuries. SuRe. CuN. NoRTH AM., 61:3, 1981. 14. Dove, D. B., Sta!Il, W. M., and Del Guercio, L. R.: A five-year review of deaths following urban trauma. J. Trauma, 20:760, 1980. 15. Drew, R., Perry, J. F., and Fischer, R. P.: The expediency of peritoneal lavage for blunt trauma in children. Surg. Gynecol. Obstet., 145:885, 1977.
110
ANTHONY A. MEYER AND RICHARD A. CRASS
16. Du Priest, R. W., et al.: Open diagnostic peritoneal lavage in blunt trauma victims. Surg. Gynecol. Obstet., 148:890, 1979. 17. Edwards, J., and Gaspard, D. J.: Visceral injury due to extraperitoneal gunshot wounds. Arch. Surg., 108:865, 1974. 18. Elerdang, S. C., Aragon, G., and Moore, E. E.: Fatal hepatic hemorrhage after trauma. Am. J. Surg., 138:883, 1979. 19. Federle, M. P., Goldberg, H. 1., Kaiser, J. A., et al.: Evaluation of abdominal trauma by computed tomography. Radiology, 138:637, 1981. 20. Fischer, R. P., Beverlin, B. C., Engrav, L. H., et al.: Diagnostic peritoneal lavage fourteen years and 2,586 patients later. Am. J. Surg., 136: 701, 1978. 21. Foley, L. C., and Teele, R. L.: Ultrasound of epigastric injuries after blunt trauma. Am. J. Roentgenol., 133:593, 1979. 22. Freeman, J., and Fischer, R. P.: The inadequacy of peritoneal lavage in diagnosing acute diaphragmatic rupture. J. Trauma, 16:538, 1976. 23. Galbraith, T. A., et al.: The role of peritoneal lavage in the management of stab wounds to the abdomen. Am. J. Surg., 140:61, 1980. 24. Giddings, W. P., and McDaniel, J. R.: Wounds of the jejunum and ileum. In Surgery of World War II. Washington, D.C., Office of the Surgeon General, 1955. 25. Griffin, W. 0., et al.: Intravenous pyleography in abdominal trauma. J. Trauma, 18:387, 1978. 26. Hornyak, S. W., and Shafton, G. W.: Value of"inconclusive lavage" in abdominal trauma management. J. Trauma, 19:329, 1979. 27. Hubbard, S. G., et al.: Diagnostic errors with peritoneal lavage in patients with pelvic fractures. Arch. Surg., 114:844, 1979. 28. Hunt, K. E., Garrison, R. N ., and Fry, D. E.: Perforating injuries of the gastrointestinal tract following blunt abdominal trauma. Am. Surg., 46:100, 1980. 29. Karl, H. W., and Chandler, J. G.: Mortality and morbidity of pancreatic injury. Am. J. Surg., 134:549, 1977. 30. Lennquist, S., et a!.: Intestinal hematomas due to abdominal muscle wounds-pathophysiology and principles of treatment. Acta. Chir. Scand. (Suppl.), 489:211, 1979. 31. London, P. S.: Abdominal injuries-surgical aspects. A review. J. Roy. Soc. Med., 72:842, 1979. 32. Lowe, R. J., et al.: The negative laparotomy for abdominal trauma. J. Trauma, 12:853, 1972. 33. Lowe, R. J., et al.: Should laparotomy be mandatory or selective in gunshot wounds of the abdomen? J. Trauma, 17:907, 1977. · 34. McAlvanah, M. J., and Shaftan, G. W.: Selective conservation in penetrating abdominal wounds: A continuing reappraisal. J. Trauma, 18:206, 1978. 35. McDonald, E., et a!.: The role of emergency excretory urography in evaluation of blunt abdominal trauma. Am. J. Roentgenol., 126:739, 1976. 36. Mishalany, H. G., et al.: Modalities of preservation of the traumatized spleen. Am. J. Surg., 136:697, 1978. 37. Murr, P. C., eta!.: Abdominal trauma associated with pelvic fracture. J. Trauma, 20:919, 1980. 38. Nance, F. C., et al.: Surgical judgment in the management of penetrating wounds of the abdomen: Experience with 2212 patients. Ann. Surg., I 79:639, 1974. 39. Northrup, W. F., III, and Simmons, R. L.: Pancreatic trauma: A review. Surgery, 71:27, 1972. 40. O'Donnell, V. A., et al.: Role of antibiotics in penetrating abdominal trauma. Am. Surg., 44:574, 1978. 41. Palomar, J., Polanco, E., and Frentz, G.: Rupture of the bladder following blunt trauma: A plea for peritoneotomy in patients with extraperitoneal rupture. J. Trauma, 20:329, 1980. 42. Peterson, S. R., and Sheldon, G. F.: Morbidity of a negative finding at laparotomy in abdominal trauma. Surg. Gynecol. Obstet., 148:23, 1979. 43. Robbs, J. V., Moore, S. W., and Pillay, S. P.: Blunt abdominal trauma with jejunal injury: A review. J. Trauma, 20:308, 1980. 44. Sanbrasaga, F. A.: Penetrating thoracoabdominal injuries. Br. J. Surg., 64:638, 1977. 45. Schuck, J. M., and Lowe, R. J.: Intestinal disruption due to blunt abdominal trauma. Am. J. Surg., 136:668, 1978. 46. Sherman, R.: Rationale for and methods of splenic preservation following trauma. SuRe. CLIN. NoRTH AM., 61:127, 1981. 47. Sherwood, R., et al.: Minilaparoscopy for blunt abdominal trauma. Arch. Surg., 115:672, 1980. 48. Sloop, R. D.: The dominant role of paracentesis technic in the early diagnosis of blunt abdominal trauma. Am. J. Surg., 136:145, 1978. 49. Soderstrom, C. A., DuPriest, R. W., and Cowley, R. A.: Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg. Gynecol. Obstet., 151:513, 1980. 50. Steele, M., and Blaisdell, F. W.: Treatment of colon injuries. J. Trauma, 17:557, 1977. 51. Stone, H. H., and Fabia, T. C.: Management of duodenal wounds. J. Trauma, 19:334, 1979. 52. Talbert, J., eta!.: Peritoneal lavage in penetrating thoracic trauma. J. Trauma, 20:979, 1980. 53. Thai, E.: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J. Trauma, 17:642, 1977. 54. Thai, E.: Peritoneal lavage--its unreliability in gunshot wounds of the lower chest and abdomen. Arch. Surg., 115:430, 1980.
T ABDOMINAL TRAUMA
111
55. Thai, E. R., McClelland, R. N., and Shires, G. T.: Abdominal trauma. In Shires, G. T. (ed.): Care of the Trauma Patient. New York, McGraw Hill, 1979. 56. Thompson, J. S., et al.: The evaluation of abdominal stab wound management. J. Trauma, 20:478, 1980. 57. Tibbs, P. A., et al.: Diagnosis of acute abdominal injury in patients with spinal shock: Value of diagnostic peritoneal lavage. J. Trauma, 20:55, 1980. 58. Trunkey, D. D., Hays, R. J., and Shires, G. T.: Management of rectal trauma. J. Trauma, 13:411, 1973. 59. Trunkey, D. D., Shires, G. T., and McClelland, R.: Management of liver trauma in 811 consecutive patients. Ann. Surg., 179:722, 1974. 60. Waldschmidt, M. L., and Laws, H. L.: Injuries of the diaphragm. J. Trauma, 20:587, 1980. 61. West, J. G., and Trunkey, D. D.: System of trauma care: A study of2 counties. Arch. Surg., 114:455, 1979. 62. Wilder, J., and Kudchadkcer, A.: Stab wounds of the abdomen---