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Intra-abdominal injuries in polytrauma

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Abstract

The most important preoperative objective in the management of the patient with abdominal trauma is to ascertain whether or not a laparotomy is needed and not the diagnosis of a specific organ injury. This objective is complicated in multiple trauma patients by the extra-abdominal injuries which change the abdominal findings. Peritoneal lavage is of great help in making this decision. The second important decision relates to whether or not the control of abdominal blood loss is to be achieved as a part of or after cardiopulmonary resuscitation. Clearly, the blood bank must be alerted and sufficient personnel must be available to pump the blood. Such surgery must always be conducted under full physiologic monitoring of cardiopulmonary function, with a warming blanket to prevent hypothermia, and with x-ray facilities. The third decision concerns the role of the laparotomy in the treatment of the other injuries the patient has received. It is usually wise to have 2 operating teams at work.

Given the nature of blunt trauma it is wise to prepare the patient from the sternal notch to mid-thighs so that any surgical eventuality may be managed. This is associated with a long midline incision. The first operative objective is control of hemorrhage; the second, prevention of further contamination; and the third, a precise diagnosis of the anatomy of each injury. The subsequent objectives for liver, pancreaticoduodenal, gastrointestinal, and splenic injuries are discussed in detail. In the severely contaminated abdomen, delayed primary closure of the wound above the fascia is utilized.

Résumé

L'objectif pré-opératoire le plus important dans le traitement des traumatismes abdominaux est de s'assurer de la nécessité de pratiquer une laparotomie et non de porter le diagnostic d'une lésion organique particulière. Cet objectif est difficile à attendre chez le polytraumatisé dont les lésions extra-abdominales peuvent supplanter les lésions abdominales. Le lavage peritoneal est à ce titre d'un grand secours. La seconde décision importante est de définir si le contrôle de l'hémorragie ultra-abdominale doit être assuré avant ou après la réanimation. En fait la banque de sang doit être sur le qui vive et l'équipe de transfusion pour transfuser doit être disponible. Ce type de chirurgie doit être effectué d'une part sous le contrôle physiologique constant des fonctions cardiopulmonaires, d'autre part en évitant tout refroidissement à l'aide d'une couverture chauffante et surtout en ayant recours à l'appareillage radiologique opératoire que toute chirurgicale d'urgence se doit de posséder. Le troisième élément d'importance décisive concerne le retentissement de la laparotomie sur le traitement des autres lésions. Il est recommandé de disposer de deux équipes chirurgicales susceptibles d'opérer simultanément.

Étant donné la nature de la contusion abdominale il est conseillé de préparer le champs opératoire depuis le sternum jusqu'á la partie moyenne des cuisses de facon á être prêt á toute éventualité. L'abdomen est préparé par une longue incision médiaire. Le premier objectif pour l'ouverture de la cavité abdominale est de contrôler l'hémorragie, le second est de prévenir la contamination éventuelle de la cavité péritonéale, le troisième enfin est de préciser le type des lésions. Le traitement des différents types de lésions hépatiques, spleniques, pancréatiques, gastro-intestinales est étudié en détail dans cet article. Lorsque la contamination intrapéritonéale est la suture retardée de l'incision abdominale au-dessus du fascia a été adoptée par les auteurs.

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Correspondence to Hiram C. Polk Jr. M.D..

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Polk, H.C., Flint, L.M. Intra-abdominal injuries in polytrauma. World J. Surg. 7, 56–67 (1983). https://doi.org/10.1007/BF01655913

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Keywords

  • Lavage Peritoneal
  • Splenic Injury
  • Sternal Notch
  • Multiple Trauma Patient
  • Warming Blanket