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Abdominal Injuries

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⁕Possible injuries :

I) Solid organs : Liver , spleen , kidneys & pancrease .

II) Hollow organs : stomach , small & large intestine .

III) Retroperitoneal structures :Kidneys , pancrese &

major vessels .

⁕Complications :
1) Bleeding : which may be internal or external bleeding .
2) Hypovolaemic shock .
3) Peritonitis due to intra-peritoneal escape of blood,
intestinal contents, pancreatic secretions , bile or urine .
4) Septic shock .
5) Paralytic ileus.
6) Delayed complications: stricture or adhesions 
intestinal obstruction.

⁕Managment :

I)Pre-hospital treatment :
 Primary Survey and resuscitation : (A,B,C ,D ,E) (Mention in
short)

II) At the hospital:

A) Continue primary Survey and resuscitation until the

general condition of the patient become stable .

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 Life saving measures i.e primary survey and resuscitation

(mention) should be performed and have the first
priority before taking any history , performing any exam.
or investigation .

B) Secondary survey is started once resuscitation & stabilization of

vital signs occur .

 Method :
a) Complete history especially history of trauma( cause
, time, site & effect of injury ) .
b) Examination of the patient from head to toe and front to
back (mention).

 NB: Meticulous general exam. and investigations

for all systems of the body putting in mind that

associated multiple injuries are very common.

c) Urgent abdominal exam. to detect :

1- Evidences of trauma as abrasions, contusions, bruises or stabs

2- The site of trauma and physical signs usually denote the
preliminary diagnosis e.g.:
 Trauma to lower right ribs suggest chest , diaphragm &
liver injuries .
 Trauma to 9-11 left ribs suggest chest , diaphragm &
spleen injuries .
 Trauma to the loin suggest renal injuries .
 Suprapubic trauma with desire to void ( distended urinary
bladder ) suggest intra-peritoneal bladder injuries .

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 Pelvic trauma with fracture pelvis suggest extra-peritoneal

bladder injury or intra-pelvic rupture of urethra.
 Trauma to perineum suggest extra-pelvic rupture of
urethra.
 If the injury is restricted only to the abdominal wall ,
there are only pain & tenderness at the site of trauma with
no spreading physical sign & the vital signs are stable.

3- Internal haemorrhge : Due to rupture of solid organ or major

vessel ( aorta , IVC , portal vein)  hypovolaemic shock
( mention )

4- Shifting dullness in case of intra-peritoneal hemorrhage.

5- Cullen’s sign : ( see splenic injury) , in massive intra-

peritoneal haemorrhage .

6- Balance’s sign & kehr’s sign ( see splenic injuries )

7- Grey-turner’s sign: (see renal injury), in retro-peritoneal

haemorrhage especially renal or pancreatic injuries.

8- Ruptured hollow viscera  absence of liver dullness

(Pneumo-peritoneum) & peritonitis.

d) Emergency investigation:

 If the patient on clinical grounds , is in urgent need for

surgery, no time should be lost in doing investigation.

 After the general condition of the patient become

stable , the following investigations can be done :

1)HB% & haematocrite are decreasing in continuous bleeding.

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2)Routine lab. investigations: Blood grouping & cross matching ,

blood gases ( need for mechanical ventilator ) , for DM , blood urea
& serum creatinine and liver functions .
3) Urine examination: Haematuria is present in all cases of UT injury
& can give an idea about the progress of the case.
4) Plain X-ray: in stable patient , may show fracture ribs, F.B.,
raised copula of diaphragm, soft tissue shadow in characteristic site ,
air under diaphragm in perforated hollow viscus and associated chest
injuries. Obliteration of psoas shadow by haematoma in renal injury .
5) EFAST exam.:(Extended Focused Assessment with Sonography in Trauma)
 It is non-invasive , quick , inexpensive & can be performed at the
bedsite for unstable patient.
 It is an ultrasound protocol to examine the pericardial area , right &
left upper abdominal quadrantus & pelvis
 This show haemo-peritoneum ( more than 500 ml) , haemo-
pericardium ,any collection around the organ , size & contour of
the organ and presence of foreign body .
 It is extended to diagnose pneumothorax or haemothorax .
It is not sensitive in detection of bowel or pancreatic injuries .
6) C.T. abdomen & pelvis with IV contrast in stable patient is the
most accurate to detection of injury of solid organ and its
degree , non-viable tissues , other organ injuries , retroperitoneal &
diaphragmatic injuries and follow up of minor injuries.
7) IVU: to exclude UT injuries ( see renal injuries )
8) Selective coeliac angiography helpful for doubtful cases of liver
or splenic injuries or renal angiography may be needed in

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suspicious cases of renal artery thrombosis & to place a stent

across the thrombus.
9) Abdominal Paracentesis may show gross blood, enteric or
pancreatic contents in the peritoneal cavity.
10) Diagnostic peritoneal lavage (DPL) to detect minor bleeding in
unstable patient.
11) Diagnostic laparoscopy in stable patients.
⁕ Definitive Treatment :

The surgeon should decide whether the patient is

unstable and needs an urgent laparotomy or the patient
is stable and there is time to perform necessary
investigation and follow up the patient condition .

I) Conservative treatment:

 Indications: Minor closed injury, stable patient with no or

minimal shock, uncomplicated cases & no associated injuries
requiring surgery.
 Method :
1- Anti-shock measures .
2- Rest in bed & analgesics .
3- Prophylactic antibiotics.
4- Perform necessary investigations.
5- Regular follow up by CT scan.

5- Close observation : vital signs , urine output , haemtocrite ,

urine for haematuria .

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II) Urgent laparotomy after resuscitation.

 Indications:
 Unstable patient (severe progressive shock).
 Worsened abdominal signs.
 Deep penetrating injury with protruding viscera .
 Any missile injury of the abdomen.
 Blood, pancreatic or enteric contents in DPL.
 Complicated cases (e.g. intra-peritoneal hge. or peritonitis).
 Gas under diaphragm (perforated hollow viscera ) .
 GIT bleeding.
 Associated injuries requiring surgery.

 Method:

a) Pre-operative preparation : ( 3 anti + 2 tubes )

Anti-shock measures , antibiotics ( third generation cephalosporin

& metronidazole ) , tetanus prophylaxis , nasogastric tube &
urethral catheter .

b) Anaesthesia: General.

c) Position: Supine

d) Incision: Trans-peritoneal exposure through long midline

incision.

e) Exploration:

 All abdominal viscera should be explored start with solid organ

to control rapidly any bleeding first followed by hollow viscera.

f) Management of abdominal injuries as follows:

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1. Spleens, liver & kidneys: (as before).

2. Pancreas: Silk suture or distal pancreatectomy.

3. G.B. or cystic duct : Cholecystectomy.

4. Bile ducts: Repair over T. tube.

Repair of bile duct

over T. tube.

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5. Stomach: Explore the anterior and posterior wall and any

injury closed in 2 layers.

6. Small intestine & right colon:

 Tidy sharp injury: closure in 2 layers.

 Ragged injury: trimming of devitalized edge followed by

closure in 2 layers .

 Resection with primary anastomosis:

 Indications :

 Multiple tears in short segment.

 Gangrenous segment due to injury of mesenteric vessels

7. Transverse or left colon:

a)Localized injuries: One of the followings is performed:

 Exteriorization of the injury if possible to act as

colostomy .

 If exteriorization is not possible : Suturing of the tear

with proximal colostomy to divert the faeces away from the
injury .

 In either of the above mentioned cases, after 3 weeks the

colon is prepared: with elective closure of the colostomy.

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Exteriorization Proximal colostomy

b)Extensive injury:

 Resection of the affected segment but intestinal anastomosis

is not done in the same session.

 The proximal end is brought out as a terminal colostomy,

 The distal end is either:

 Brought out as a mucous fistula or,

 Closed & left inside the abdomen (Hartmann's procedure).

 After 3 weeks the colon is prepared with elective restoration of

bowel continuity is done.

8. Rectum and anal canal: Pelvic colostomy and repair.

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Hartmann’s
Procedure

9. Urinary bladder: (See bladder injuries).

10. Ureter:

 Ureteric injuries are usually iatrogenic e.g. during gynaecological

operation , abdomino-perineal resection of rectum , uretroscopy ,
ureteric catheter .

 To avoid ureteric injury during operation ,ureteric exposure by

preliminary ureteric catheterization early in the operation .

 The principles of ureteric repair are debridment , tension free , water

tight closure with ureteric stent & drainage .

 Favourable circumstances within first week :

 Tear in upper 2/3 ureter  end to end anastomosis .

 Tear in lower 1/3 of ureter  reimplantation of lower end of

ureter into urinary bladder .

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 Unfavourable circumstances : Urine diversion by percutaneous

nephrostomy and ureteric repair later on .

 Ureteric catheterization & stenting are recently done .

End to end anastomosis Uretero-vesical implantation

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Ureteric stenting

11. Vascular injuries:

 If major vessel  fatal. In survivors, arterial reconstruction is

needed.

 If minor vessel  Ligation or diathermy.

12. Peritoneal toilet & drainage and the abdomen is closed.

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