Trauma Abdomen dr Jeffri SpBKBD.ppt

Abdominal [email protected]

Apa yang menarik????

BLACK BOXImpossible to know specific injury at initial evaluationThe important key is how to identify any abdominal injury

Gohil VD. Palekar HD. Ghoghari M. Diagnostic and therapeutic laparoscopy in various blunt abdomen trauma. WJ o Lap Surg. 2009;2(2):42-7

ATLS!!!!

Primary SurveyABCDEAdjunct to primary Survey CxR, Pelvic xRSecondary SurveyHead to toe

Anatomy of the AbdomenThoracoabdominal areaTransverse nipple line to costal marginAnterior abdomenCostal margin to groin crease to anterior axillary lines bilaterallyFlank areaAnterior axillary line to posterior axillary line, costal margin to iliac crestsBackMedial to posterior axillary lines, tip of scapula to iliac crests TorsoAll the above

Intraperitoneal contentsRetroperitoneal space contentsPelvic cavity contentsAnatomy of the Abdomen

Mechanism of Injury???

Blunt Abdominal Trauma

Penetrating Abdominal Trauma

Blunt Abdomen TraumaMVCSeatbelt injuryFall from heightCrash injurySport injuryPenetrating Abdomen Trauma

Seat Belt Sign Not Just the Abdomen

Blunt abdominal injuries carry a greater risk of morbidity and mortality than penetrating abdominal injuries.

What Are We Worried About?Bleeding:LiverSpleenKidneysMesenteryBowel:Rupture ContaminationBladder:Intraperitoneal ruptureDiaphragm:Rupture, mainly on the left side

How to diagnose??How to managed??

What is hemodynamic stability??

How to Investigate Blunt Abdominal Trauma? BMJ 2008Concealed or occult hemorrhage is the 2nd most common cause of death after traumaMissed abdominal injuries are a frequent cause of morbidity and mortalityAppropriate and expeditious investigations are importantNon-operative management of solid organ injury now more common

Diagnostic tools???

Tools Available For Abdominal TraumaPhysical examX-RaysUltrasound (FAST)Computerized Tomography (CT)Magnetic Resonance Imaging (MRI)Diagnostic LaparoscopyExploratory laparotomy

Tools Available For Abdominal TraumaPhysical exam bad for blunt, good for penetrating (serial physical exams)X-RaysUltrasound (FAST) helpful if positiveComputerized Tomography (CT) not for HVIMagnetic Resonance Imaging (MRI)Diagnostic Laparoscopy Exploratory Laparotomy if needed

Physical Exam Difficult to rule out internal bleedingExcellent to watch for the development of peritonitis (contamination)Less than 24 hours, usually by 13 hoursA modality usually employed in penetrating traumaVery poor to detect bladder or diaphragmatic injury

Focused Assessment With Sonography in Trauma (FAST)Free intra-abdominal fluid Also pericardial fluidNon-invasive, no radiation, repeatableHighly Sn (79-100%) and Sp (96-100%)Repeating FAST also increases SnMay still need other imaging modalities with a negative FAST Can be performed with equal accuracy by surgeonsUse controversial in penetrating trauma of the abdomenOnly helpful if positive

FAST

Diagnostic Peritoneal Lavage (DPL)Described in 1965, standard of careOpen or closed (Seldinger) approachHighly accurate for hemoperitoneum (Sn = 95%, Sp = 99%)Lead to a non-therapeutic laparotomy rate of 36%Laparotomy when:10 cc gross bloodEnteric contents1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3High false positives with pelvic fracturesDo a supraumbilical approachHigh Sn for hollow viscus injuriesRisk of visceral injury = 0.6%Retroperitoneum cant be assessed

Diagnostic Peritoneal LavageIn real life:Good tool if FAST equivocal in the HD abnormal pt. in the setting of a pelvic fractureFAST unavailable, pt. is HD abnormal

Computerized TomographyImaging modality of choice only in HD normal patientsPts crumping in CT a performance indicator in trauma centresSn = 92-97%, Sp = 99% for bleedingActive arterial contrast extravasation, blush or pseudoaneurysmOnly modality to directly detect retroperitoneal injuryLess accurate for HVIStill need serial physical examsIf pelvic fluid is present in absence of solid organ injury exploratory laparotomy is mandated, especially if moderate or large amounts of free fluid Chen, 20093% males may have pelvic fluid 2dary to resuscitationPoor test to diagnose diaphragmatic injury

Hypovolemic Shock Complex

How to DIAGNOSE hollow viscus injury, WHAT TOOLS???CT scan?? Sensitivity 53,5% and Specificity 92,06%CT alone cant screen hollow viscus injury, the decision to operate has to be based on MOI and clinical findings together with radiological evidence Predicting hollow viscus injury in BAT with CT. Bhagvan S, Turai M, Holden A, Ng A and Civil I. World J Surg.2013;37:123-6

Indications for Laparotomy Blunt Abdominal Trauma

Absolute Indications:

Shock PeritonitisBlood out of NG tube or on rectal examIntraperitoneal bladder ruptureDiaphragmatic rupture

Laparoscopic??Not widely used, but useful in selected patients with BAT, who have equivocal findings on clinical exam and imaging investigations in order to clarify the lesional diagnosis, thus avoiding unnecessary laparotomies.

Laparoscopy is safe, feasible, effective procedure and it can reduce nontherapeutic laparotomies.

Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma?Chirurgia 2011;106(1):59-66Choi YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17:421-7

Laparoscopic??Not widely used, but useful in selected patients with BAT, who have equivocal findings on clinical exam and imaging investigations in order to clarify the lesional diagnosis, thus avoiding unnecessary laparotomies.

Laparoscopy is safe, feasible, effective procedure and it can reduce nontherapeutic laparotomies.

Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma?Chirurgia 2011;106(1):59-66Choi YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17:421-7

Diagnostic accuracy of laparoscopyGohil VD. Palekar HD. Ghoghari M. Diagnostic and therapeutic laparoscopy in various blunt abdomen trauma. WJ o Lap Surg. 2009;2(2):42-7

Incidence of negative laparotomyGohil VD. Palekar HD. Ghoghari M. Diagnostic and therapeutic laparoscopy in various blunt abdomen trauma. WJ o Lap Surg. 2009;2(2):42-7

Role of Laparoscopy in PAT2569 patients underwent DL for PAT, 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy.33.8 % were converted ,16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries.Sensitivity ranged from 66.7-100 %, specificity from 33.3-100 % and accuracy from 50-100

OMalley E, Boyle E, OCallaghan A, Coffey JC, Walsh SR. Role of laparoscopy in penetrating abdominal trauma: a systematic review. WoJ Surg. 2013;37(1):113-22

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