17.1

Abdominal Injuries

Chapter 17

Abdominal Injuries

Introduction

Changing patterns of warfare together with improvements in

protective body armor combine synergistically to minimize

truncal trauma incidence, severity, and mortality, despite

increasingly lethal weapons systems. Despite these advances,

penetrating abdominal trauma still occurs and treatment of these

injuries will always be an important component of war surgery.

Trauma to the abdomen, both blunt and penetrating, can lead

to occult injury that can be devastating or fatal if not treated. In

the unstable patient with abdominal injury, the decision to

operate is usually straight forward and should be acted on as

soon as it is made. In a few rapidly hemorrhaging patients with

thoracoabdominal injuries, a rapid decision must be made as to

which cavity to enter first. This chapter addresses some of these

issues.

Penetrating injuries below the nipples, above the

symphysis pubis, and between the posterior axillary lines

must be treated as injuries to the abdomen and mandate

exploratory laparotomy.

 Posterior truncal penetrating injuries from the tip of the

scapula to the sacrum may also have caused retroperitoneal

and intra-abdominal injuries. A low threshold for exploratory

laparotomy in these patients is warranted when there are not

other diagnostic modalities available.

Diagnosis of Abdominal Injury

 Document a focused history to include time of injury,

mechanism of injury, previous treatments employed, and any

drugs administered.
17.2

Emergency War Surgery

 Inspection of the chest and abdomen will be the most reliable

part of the physical examination, especially regarding

penetrating injuries.

 Determine if the patient requires laparotomy, not the specific

diagnosis.

Indications for Laparotomy – Who, When, and Where

First imperative is to determine who needs surgery.

 Patients who have

ο Penetrating abdominal wounds as described in box above.

ο Other penetrating truncal injuries with potential for

peritoneal penetration and clinical signs/symptoms of

intraperitoneal injury.

ο Blunt abdominal injuries presenting in shock.

 When and Where.

ο When aeromedical evacuation is uncertain and will involve

substantial distance, unstable patients with life or limb

threatening circumstances should undergo laparotomy at

the nearest forward surgical team (FST).

ο Stable patients who can tolerate transport and delay of 6

hours or so, should undergo initial controlled resuscitation,

presurgical care (including antibiotics), and be transported

to the next level of care for surgery.

When the tactical situation is static, aeromedical evacuation

effective, and the distance between FST and combat support

hospital (CSH) or higher level hospitals is short, all casualties,

including those who are unstable, should bypass the FST and

be taken directly to a higher level hospital.

Diagnostic Adjuncts

Minimally invasive adjuncts to diagnosis—computed

tomography (CT) scan, diagnostic peritoneal lavage (DPL), and

ultrasound (US)—have been used to decrease the number of

negative laparotomies in stable, blunt abdominal trauma

patients in peace-time settings with good follow-up of patients.

Some have been used in lieu of laparotomy to evaluate those

with penetrating injuries, when the suspicion is high that no

intra-abdominal injury has occurred. This practice has the
17.3

Abdominal Injuries

potential of missing injuries. These diagnostic screening

procedures are primarily used in stable patients with a

mechanism of injury suggesting abdominal injury, but without

an obvious operative indication. They should be relied on only

when good follow up is possible. US and, to a limited extent,

DPL have some use in the unstable patient to indicate which

cavity should be entered first. US and DPL may also serve as

triage tools in the mass casualty situation.

Abdominal Ultrasound

 Advantages: Noninvasive, may repeat frequently, quick, easy,

identifies fluid in the abdomen reliably.

 Disadvantages: Operator dependant, may miss small

amounts of fluid associated with hollow-viscus injuries.

 Sonography (focused abdominal sonography for trauma

[FAST]) has become an extension of the physical examination

of the abdomen and should be performed whenever available

and when abdominal injury is suspected.

ο 3.5 to 5 MHz curved probe is optimal.

ο The abdomen is examined through four standard

sonographic windows.

 A FAST examination assists the surgeon to determine the need

for laparotomy in blunt-injured patients but does NOT

identify specific injuries.

ο A FAST examination does not identify or stage solid organ

or hollow-viscous injury, but reliably identifies free

intraperitoneal fluid.

 FAST aids in prioritization of penetrating injury patients for

the OR.

 FAST aids in identifying which cavity to open first in patients

with thoracoabdominal injuries.

 A FAST examination identifies pericardial fluid, and may

assist in the diagnosis of hemopneumothorax.

Ultrasound Views

A typical portable sonography device is shown in Fig. 17-1. The

standard locations for “sonographic windows” are shown in

Fig. 17-2. Examples of positive and negative sonographic

examinations are shown in Figs. 17-3 through 17-6.
17.4

Emergency War Surgery

Fig. 17-1. Typical sonography device.

Fig. 17-2 a,b. The standard four locations for sonographic windows.

a

LUQ

Cardiac

RUQ

Pelvic

b
17.5

Abdominal Injuries

a

b

c

Fig. 17-3 a,b,c. Normal and

abnormal negative sonographic

examinations for the right upper

quadrant.

a

b

c

Fig. 17-4 a,b,c. Normal and

abnormal negative sonographic

examinations for the cardiac

window.

normal normal

abnormal abnormal
17.6

Emergency War Surgery

a a

b b

normal normal

c c

abnormal abnormal, male

Fig. 17-5 a,b,c. Normal and

abnormal negative sonographic

examinations for the left upper

quadrant.

d

abnormal, female

Fig. 17-6 a,b,c,d. Normal and

abnormal negative sonographic

examinations for the pelvic

window.
17.7

Abdominal Injuries

Diagnostic Peritoneal Lavage

DPL has been a mainstay of blunt abdominal trauma diagnosis

for many years. Unfortunately, in-theatre combat medical units

from Level 1 to Level 3 are not routinely outfitted with

microscopic laboratory functions to provide cell counts or

fluid enzyme determinations. Thus, the only reliable

information obtained from DPL is the aspiration of 10 cc of gross

blood. Gross blood aspiration is the most infrequently

positive criterion of DPL, and its value is probably supplanted

by FAST.

 May be useful when US or CT are not available, or as triage

tool.

 Requires laboratory for most sensitivity.

ο Blunt: Aspiration of 10 cc of gross blood, RBCs > 1,000,000/

mL, WBCs > 500/mL, fecal material.

ο Penetrating: not recommended to ruling out (R/O) injury

in penetrating combat wound.

 May help determine which body cavity to enter first in an

unstable patient with truncal injury.

 Advantages: Sensitive to small amounts of fluid, including

hollow-visceral leaks; fairly quick.

 Disadvantages: Invasive, not repeatable, slower than US.

 Kits allow Seldinger technique.

ο Arrow (AK-09000).

ο Baxter Lazarus-Nelson (MLNK9001).

 Field Expedient substitution: Open technique with small,

vertical infraumbilical incision and any tubing (IV, straight

or balloon catheter). Cut at least a dozen extra side holes.

CT Scan

 Advantages: Defines injured anatomy in stable patients.

 Disadvantages: Slow; requires contrast use and equipment

availability; may miss small hollow organ leaks; requires

transport away from emergency care area; operator/

interpreter dependant; difficult to repeat.
17.8

Emergency War Surgery

Wound Exploration

 Blast injuries and improvised explosive devices (IEDs) create

many low-velocity fragments that may penetrate the skin but

not the abdominal cavity. Operative wound exploration in

the stable patient with a normal or equivocal examination

can help determine the need for formal exploratory

laparotomy.

ο When possible wound exploration should be performed

in the operating room with adequate instruments and

lighting.

ο Finding the fragment in the abdominal wall precludes

laparotomy.

ο If the tract is not adequately identified or the fragment

seen on plain film cannot be identified, formal laparotomy

should be performed.

Operative Planning and Exposure Techniques

 Give broad spectrum antibiotic pre-op, continue for 24 hours.

ο Redose short half-life antibiotics intraoperatively and

consider redosing antibiotics with large amounts of blood

loss.

 Perform laparotomy through a midline incision.

ο When wide exposure is needed, extend the incision

superiorly just lateral to the xiphoid process and inferior

to the symphysis pubis.

 Quickly pack all 4 quadrants while looking for obvious

injuries.

 Control hemorrhage.

 Assess physiologic status.

ο Considering casualty physiology, create operative plan to

control contamination and complete operation.

♦ Consider damage control (see Chapter 12, Damage

Control Surgery) early and often.

♦ If stabilized/improving, proceed with definitive surgery.

 Identify all organ and hollow-viscus injuries.
17.9

Abdominal Injuries

 Eviscerate the small bowel to increase workspace.

 Divide the ligamentous attachments of the liver to improve

exposure in the right upper quadrant or upper midline.

 Fold the left lateral segment of the liver down and to the right

to improve exposure at the gastroesophageal junction.

 Improve exposure to the liver by extending the incision into

the inferior sternum and across into the lower right chest

(thoracoabdominal).

Stomach Injuries

 The stomach is a vascular organ and will do well after almost

any repair.

ο Always enter the lesser sac to determine posterior wall injuries.

 Encircle the distal esophagus with a Penrose drain to provide

traction and improve visibility in high midline injuries.

 Minimally debride and primarily close stomach defects.

Duodenum Injuries

Injuries to the Duodenum are associated with massive upper

abdominal trauma. Early consideration for damage control

surgery should be considered (see Chapter 12, Damage Control

Surgery).

 Missed injuries of the duodenum have devastating morbidity.

 Bile staining or hematoma in the periduodenal tissues mandates

full exploration of the duodenum (Kocher maneuver).

 Minor injuries can be repaired primarily.

 Major injuries should be repaired if the lumen will not be

narrowed by more than 50%. Options for closing injuries of

greater than 50%:

ο Close duodenal wall around a tube duodenostomy.

♦ Use a No. 2-0 absorbable suture (Vicryl).

♦ Use the largest malecot catheter available.

ο Bring up a Roux-en-Y jejunal limb and create an

anastamosis between the limb and the injury (Fig. 17-7).

ο The procedure of last resort is pancreaticoduodenectomy.
17.10

Emergency War Surgery

Fig. 17-7. (a) Ligation of pylorius, (b) Duodenal injury, (c) Roux-en-Y

anastomosis.

 For major injuries, divert the gastric stream with a

gastrostomy and close the pylorus—two options:

ο Through a gastrotomy, ligate the pylorus with No. 0

absorbable suture.

ο Using a noncutting stapling device, staple but do not

divide the pylorus. Place a feeding jejunostomy for

nutrition at this controlled reconstruction.

 Widely drain all injuries with closed-suction drains.

 Any method used to close the pylorus will last only 14–21

days. The possibility of injury to the biliary and pancreatic

ducts should be considered when injuries involve the 2nd

portion of the duodenum or the pancreatic head.

Pancreas Injuries

 Any injury to the pancreas/duct requires drainage.

a

b

c
17.11

Abdominal Injuries

ο Even if ductal injury is not identified, it should be

presumed and drained.

ο Resect clearly nonviable pancreatic body/tail tissue.

 Transection or near-transection of the pancreatic duct can be

treated by

ο Distal end of proximal pancreas segment oversewn/stapled.

ο Proximal end of distal segment oversewn/stapled and

entire distal segment left in-situ.

ο Distal segment resection (typically requires splenectomy).

ο Distal segment drainage by Roux-en-Y anastomosis to

small bowel.

Major injuries to the head of the pancreas may require

pancreaticoduodenectomy, which SHOULD NEVER BE

ATTEMPTED in an austere environment but instead

treated by the principles of damage control surgery—

DRAIN, DRAIN, DRAIN.

Liver Injuries

 Most liver injuries can be successfully treated with direct

pressure and packing followed by aggressive resuscitation

and correction of coagulopathy.

 Generous exposure is required and should be gained early

and aggressively.

ο Mobilize triangular and coronary ligaments for full exposure

ο Use extension into right chest if needed.

ο Place several laparotomy pads above the dome of the liver

to displace it down into the field of view.

 Short duration clamping of hepatic artery and portal vein (Pringle

maneuver) may be required to slow bleeding while gaining other

control. If bleeding continues despite Pringle maneuver, especially

from behind the liver, this indicates a retrohepatic venous injury

or retrohepatic vena caval injury. The injuries should be

approached in only the most advanced settings with extraordinary

amounts of resources. On table retriage or aggressive packing

and intensive care unit (ICU) resuscitation should be employed.

 Use finger fracture of liver parenchyma to expose deep

bleeding vessels.
17.12

Emergency War Surgery

 Large exposed injuries of the liver parenchyma can be

controlled in a number of ways:

ο Exposed large vessels and ducts should be suture-ligated.

ο Overlapping mattress sutures of No. 0-Chromic on a blunt liver

needle is fast and effective for controlling raw surface bleeding.

ο Placement of Surgicel on the raw surface and high-power

electrocautery to “weld” it in place is also effective.

 Bleeding tracts through the liver can be controlled by tying

off the end of a Penrose drain, placing it through the tract,

and “inflating” it with saline to tamponade the tract.

 Urgent surgical resection is strongly discouraged:

ο Indicated only when packing/pressure fails.

ο Follows functional or injury pattern, not anatomic lines.

 Use a pedicle of omentum in a large defect to reduce dead space.

Avoidance of coagulopathy, hypothermia and acidosis is

essential in successful management of major liver injuries.

APPLY DAMAGE CONTROL TECHNIQUES EARLY.

Fig. 17-8. Atrio-caval shunt.

 Retrohepatic vena cava and

hepatic vein injuries require a

tremendous amount of resources

(blood products, OR time,

equipment) typically unavailable

in a forward surgery setting (ontable triage in mass casualty).

ο Packing is most successful

option.

ο If packing fails, consider an atriocaval shunt. (see Figure 17-8).

 Provide generous closed suction

drainage around major liver injuries.

Biliary Tract Injuries

 Injuries to the gall bladder are

treated by cholecystectomy.

 Repair common bile duct injuries

over a T-tube.
17.13

Abdominal Injuries

ο A No. 4-0 or smaller absorbable suture is used on the biliary tree.

 Extensive segmental loss requires choledochoenterostomy or tube

choledochostomy (depending on time and patient physiology).

 Drain widely.

Splenic Injuries

 Splenic salvage has no place in combat surgery.

 Drains should not be routinely placed postsplenectomy if the

pancreas is uninvolved.

 Splenic injury should prompt exploration for associated

diaphragm, stomach, pancreatic, and renal injuries.

 Immunize post-op with pneumococcal, haemophilus, and

meningococcal vaccines (may defer until Level 3/CONUS

MTF, but must not be forgotten).

Small-Bowel Injuries

 Debride wound edges to freshly bleeding tissue.

 Close enterotomies in one or two layers (skin stapler is a rapid

alternative).

 With multiple enterotomies to one segment of less than 50%

of small-bowel length, perform single resection with primary

anastomosis. Avoid multiple resections.

Colon Injury

Simple, isolated colon injuries are uncommon. In indigenous

populations and enemy combatants (eg, patients who cannot

be readily evacuated), diversion with colostomy should be

the procedure of choice, especially at Level 2. The often poor

nutritional status of these populations does not support

primary repair. The presence of any of the complicating

factors listed below mandates colostomy.

 Simple, isolated colon injuries should be repaired primarily.

ο Debride wound edges to normal, noncontused tissue.

ο Perform two-layer closure or anastomosis.

 For complex injuries, strongly consider colostomy/diversion,

especially when associated with:

ο Massive blood transfusion requirement.

ο On-going hypotension.

ο Hypoxia (severe pulmonary injury).
17.14

Emergency War Surgery

ο Reperfusion injury (vascular injury).

ο Multiple other injuries.

ο High-velocity injuries.

ο Extensive local tissue damage.

 Potential breakdown of a repair or anastomosis is highest in

the setting of concomitant pancreatic injury.

 Damage control technique: control contamination with

ligation/stapling of bowel, delay creation of the stoma to the

definitive reconstruction.

 Clearly document treatment for optimal follow-up

throughout Levels of Care.

 At the time of formation, a colostomy should be matured.

Rectal Injuries

Rectal injuries can be difficult to diagnose unless very

dramatic. Any question of an injury raised by proximity of

another injury, rectal examination, or plain abdominal film

radiography MANDATES proctoscopy. Gentle distal washout

with dilute Betadine solution is usually required to be able

to perform rigid proctoscopy. Findings can be dramatic

disruptions of the rectal wall but more commonly are subtle

punctuate hemorrhages of the mucosa. All abnormal findings

should prompt corrective intervention.

 Consider the traditional 4 “Ds” of rectal injury: Diversion,

Debridement, Distal washout, and Drainage.

ο Of these, diversion is the most important.

♦ Transabdominal sigmoid colostomy is easiest.

♦ If the injury has not violated the peritoneum,

exploration of the extraperitoneal rectum should NOT

be done at laparotomy unless indicated for an associated

nonbowel injury. This avoids contaminating the

abdominal cavity with stool.

ο Debridement and closure of small- to medium-sized

wounds is unnecessary in patients who have been

diverted and drained. In any but the lowest of wounds,

debridement and closure are difficult and troublesome.

ο Distal washout is usually necessary to assess the injury. Use

gentle pressure when irrigating to minimize contamination

of the perirectal space.
17.15

Abdominal Injuries

Fig. 17-9. Presacral drain.

ο Fecal contamination of the

perirectal space mandates

presacral drainage. Presacral

drains should be placed any

time the patient will leave

your immediate care.

♦ Drains are placed

through the perineum

into the retrorectal space

(Fig. 17-9).

 Peritonealized rectal injuries are

easily accessed transabdominally

and should be repaired and

protected with diversion.

 Hematoma in the perirectal space

should be drained either

transluminally by leaving the

injury open or by placing

presacral and/or intraabdominal

drains.

Retroperitoneal Injuries

 Left medial visceral rotation moves the colon, pancreas,

and small bowel to expose the aorta rapidly. Proximal

aortic control can be rapidly obtained with compression

or a clamp on the aorta at the hiatus, or through the left

chest.

 Right medial visceral rotation (colon plus Kocher maneuver to

elevate duodenum) exposes the subhepatic vena cava.

 Three zones of the retroperitoneum (Fig. 17-10).

ο I-Central, supracolic: explore for all injuries.

ο II-Central, infracolic: penetrating trauma, explore; blunt

trauma, explore for expanding hematoma.

ο III-Lateral: blunt trauma, avoid exploration if possible

because exploration increases the likelihood of opening a

stable hematoma and, thus, precipitating nephrectomy.

Explore for penetrating trauma.

 Gain proximal vascular control before entering the

hematoma.
17.16

Emergency War Surgery

Fig. 17-10. Three zones of the retroperitoreum.

Abdominal Closure

 Close fascia if possible.

ο Massive swelling associated with large amounts of blood

loss and resuscitation and large injuries may necessitate

temporary closures (see Chapter 12, Damage Control

Surgery). Otherwise, closure is usually possible.

 A few penetrating battlefield wounds are isolated, small, and

without visceral contamination, and it is perhaps safe to close

the skin. Most are not, and these patients will be passed

quickly from one surgeon to the next, so the risk of missed

and catastrophic infection is increased; the skin should not

be closed.

 Retention sutures are strongly recommended for the same

reasons.