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Penetrating Injury
BY
PROF/ GOUDA ELLABBAN
EGYPT
Mechanisms
Gunshot wounds (GSW)
Stab wounds
Firearms
Low velocity: <2000ft/s (<609m/s)
High velocity: >2000ft/s (>609 m/s)
Most hand guns are low velocity
High velocity weapons are
increasing in availability
Wounding capability
KE = mv2
Double the bullet size 2x the energy
Double the muzzle velocity 4x the energy
Shotgun wounds
Low muzzle velocity (usually 630 m/s)
Multiple spherical pellets
Pellets lose energy very quickly
Close range (0.3-0.9m)
Massive contaminated wounds
Similar to high velocity GSW
Different management
Low velocity GSW / stab wounds
Damage due to direct injury to vital
structures
Management priorities of
penetrating abdominal trauma
1.
Management based on
haemodynamic criteria
Unstable patients
Any vital sign (BP, HR, RR) is altered
ABC if fluids do not help, or only help temporarily,
laparotomy is required
Stable patients
Decision based on mechanism of injury and physical
examination
Aims:
1. Initial damage control operation
2. Resuscitation in the surgical ICU
3. Planned reoperation after 24 - 48 hours
Contamination control
Hollow viscus ligation instead of repair
External tube drainage of biliary and pancreatic
injury instead of pancreatoduodenectomy
Avoidance of formal colostomy
Abdominal hypertension
Intraabdominal pressure rise to:
10 mmHg decreased venous return & CO
25 mmHg increased airway pressures
Bogot bag
(actually developed at University Hospital, Cali)
2.
Upper abdomen
(thoraco-abdominal area)
between diaphragm and lower costal margin
Insertion of diaphragm
Xiphoid process anteriorly
9th ICS midaxillary line
11th space posteriorly
Liver
Spleen
Stomach
Pancreas
Great vessels
Visceral arterial branches
Thoracoabdominal penetrating
injuries
Explore ALL patients due to risk of diaphragmatic
injury
Occurs in 15% of stab wounds, 46% GSW to TA area
(Reynolds MA,
Diaphragmatic rupture
Middle abdomen
Between lower costal margin and ASIS
Lower abdomen
False pelvis within the iliac bones to
sacral promontory (S1)
True pelvis below sacral promontory
Small bowel
Rectosigmoid colon
Rectum
Genitourinary system
Iliac vasculature
GSW
99% risk of significant injury
Therefore, explore ALL patients
Some evidence to contrary (after imaging)
Stab wounds
Local exploration of wound
Observe if no signs on examination. Perform serial examinations
or DPL
3.
Management based on anatomical
structure injured
Outline
Upper abdominal injuries
Spleen
Liver
Stomach
Duodenum
Pancreas
Vascular injuries
Splenic injuries
Splenic injury
In recent years there has been an
appreciable shift from operative
management toward nonoperative
management
(Corson & Williamson, 2001)
Non-operative management
Can avoid post-splenectomy sepsis
Only applicable when operating theatre is available at
short notice
Failure rates of conservative management:
Grades I,II,III 5%
Grades IV,V 18%
(Davis et al 1998)
Operative management
Splenorrhaphy
Uncommon if the patient needs a
laparotomy, splenectomy is usually indicated
Use of superficial haemostatic agents
(electrocautery, argon beam, topical thrombin,
oxidised cellulose, absorbable gelatin sponge)
Pledgeted repair
Resectional debridement
Mesh wrap
Splenectomy
Liver injuries
Liver injury
Non-operative management is increasing
Significantly lower transfusion requirements (where
injuries were matched for severity)
(Croce MA et al 1995)
(Ivatury RR et al 1986)
Omental packing
Resectional debridement
Mass liver suture- risk of injury to large vessels and bile ducts
- poor efficacy of producing haemostasis
Hepatic artery ligation
Total hepatic isolation - good for retrohepatic venous injuries
Atriocaval shunt
Stomach injuries
Stomach injuries
Quite common after penetrating trauma.
Very rare after blunt trauma
Diagnosis
At laparotomy for GSW to anterior abdomen
Haematemesis or grossly bloody nasogastric
aspirate after LUQ stab wound
Management of stomach
trauma
Thorough intraoperative examination
Divide the gastrohepatic or gastrocolic
ligaments if required
Duodenal injuries
Duodenal injuries
Relatively uncommon. 80% due to
penetrating trauma (Corson & Williamson)
Retroperitoneal organ diagnosis of injury
difficult
Mortality 5%-30%
Three times more likely to die if operation
delayed > 24 hours (Lucas CE, Ledgerwood AM. 1975)
Early death exsanguination due to associated
vascular injury
Late death sepsis
Pancreatic injuries
Pancreatic injury
Associated injuries in penetrating trauma
75% have injury to one of:
Aorta
Portal vein
Inferior vena cava
Exposure of pancreas
All penetrating injuries in the vicinity of
the pancreas mandate exposure and
inspection of the whole gland
Enter the lesser sac by incising the gastrocolic ligament
Retract stomach superiorly
Retract transverse colon inferiorly
Mobilise hepatic flexure
Kochers manoeuver
Remember to visualise
posterior part of gland
Signs of injury
Parenchymal injury
Central retroperitoneal haematoma
Oedema around the gland and in the lesser sac
Bile staining of the retroperitoneum
Ductal injury
Direct visualisation of a ductal injury
Complete transection of the gland
Laceration of more than one half of the gland
Central perforation
Severe maceration
Description of injury
II
III
IV
Operative management
Minor injuries (grades I and II)
No ductal injury
External drainage alone
Closed systems superior to sump systems
(Fabian TC et al 1990)
Grade III
Distal pancreatectomy (up to 80% of gland is well tolerated)
Spleen can be preserved in 50%
Grade IV
Most result in death
Wide external drainage is becoming more common
Distal resection (up to 95% of gland)
Grade V
Most die. Diversion procedures or pancreatoduodenectomy
Colonic injuries
Colon injury
20% of GSW cause colonic injury
Management recommendations
(EAST) depend on whether destruction
is such that resection is required
Very strong evidence (RCT) supporting
primary repair of nondestructive
wounds in the absence of peritonitis
(EAST)
Primary anastomoses
Anastomoses:
(EAST)
Rectal injuries
Rectal injury
Lack of adequate evidence
Rectum is different from rest of colon no
serosa over upper 2/3 posteriorly and lower 1/3
circumferentially
Serosa is important for secure suturing
Maybe?:
Primary repair is appropriate
Distal rectal washout not important
Post-exploration, lower wounds do not need retrorectal
drainage
Renal injuries
Perineal injuries
Perineal injury
50% are associated with pelvic fracture
Mortality 32% - 60% (Corson & Williamson)
Early death from exsanguination
Late death from sepsis
Bladder injury
When due to penetrating trauma it is
usually identified at laparotomy
When identified:
Explore bladder through cystostomy on dome
of bladder
Extraperitoneal injury Foley catheter
drainage alone
Intraperitoneal injury:
Repair in three layers with absorbable sutures
Some say that suprapubic catheter should be
inserted
ED management
Follows usual EMST protocols
BUT
REMEMBER, do not place i.v. cannulae in
femoral veins
Cross-clamping of descending thoracic
aorta
Stops intraabdominal haemorrhage
Improves perfusion of carotid and coronary
arteries
Risk of distal ischaemia and reperfusion injury
Intraoperative management
Prepare skin from neck to mid-thigh
(in case an
Midline incision
If laparotomy has commenced, and the patient
decompensates haemodynamically, cross-clamp
the aorta. The diaphragmatic crura may require
transection
Zone I aortic
hiatus to sacral
promontory, over
vertebrae;
supramesocolic and
inframesocolic parts
Zone II Pericolic
gutters
Zone I supramesocolic
(Asensio JA et al. 2002)
Zone I inframesocolic
SMA (3rd & 4th parts) primarily repair
Zone II
Renal arteries
primarily repair
OR
resect and replace with graft (prosthetic or
autogenous)
Zone III
Often associated colonic and genitourinary
injuries with significant contamination
Cautions
Second look operations are important
after SMA repair (assessing bowel
viability)
In contaminated wounds, all grafts should
be retroperitonealised
References
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Corson JD, Williamson RCN (eds). Surgery. 2001. Mosby. London
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Philadelphia: WB Saunders; 1996:313-323
Wise L, Connors J, Hwang YH et al. Traumatic injuries to the diaphragm. J Trauma 1973;13:946-950
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