The only indication for surgical intervention in the child with blunt solid organ injury is bleeding. Contrary to the protocols still used in many adult trauma centers, the child with free intraperitoneal blood, a blush on CT scan, the need for blood transfusion, or persistent abdominal pain does not require laparotomy unless there is also evidence of ongoing bleeding or hemodynamic instability. In the stable patient, embolization is also an excellent alternative to laparotomy. Though some children have significant discomfort after embolization, in experienced hands it appears to be safe and effective. At laparotomy in the stable patient, partial splenectomy should always be considered and pediatric trauma surgeons should be acquainted with the various techniques that have been described. Liver injuries that require laparotomy are always life-threatening and there should be a low threshold to resort to a damage-control approach if the patient becomes unstable in the OR. Retrohepatic caval injuries are the most serious and, whenever possible, one should consider enlisting the help of an experienced transplant surgeon, who might be able to apply the portal venous bypass techniques commonly used during transplant hepatectomy to allow repair or reconstruction of the vena cava.
Renal injuries that require surgical repair commonly lead to kidney loss, justifying sometimes seemingly extreme efforts to treat non-operatively. Injuries to the head of the pancreas should be treated non-operatively whenever possible. Transections of the neck or body of the pancreas that involve the main pancreatic duct can be treated non-operatively (drains, ERCP with stenting, parenteral nutrition) but the subsequent clinical course can be extremely long and complicated. On the other hand, distal pancreatectomy or, if the transection is at the neck of the pancreas, a Roux-en-Y pancreaticojejunostomy is well tolerated and usually results in a much shorter time to full recovery. The operation can be performed within 72 h of the injury, but clearly an operation performed within 24 h is best. The proximal duct needs to be oversewn but, especially in small children, it is often impossible to visualize. In this case, it is preferable to oversew the entire cut surface or use a gastrointestinal stapling device across the parenchyma. Regardless, it is prudent to leave a closed-suction drain in case of a leak.
Frank small bowel perforation can develop up to 72 h after an injury to the abdomen, most commonly associated with a handlebar or seatbelt sign. These patients do not necessarily need to be hospitalized during the entire observation period but parents need to understand that a delayed presentation is not uncommon and what signs to look for. Laparoscopy is an excellent way to diagnose and treat isolated small bowel injuries, which can usually be simply oversewn. Mesenteric defects should be repaired and hematomas left undisturbed. Ileostomy or colostomy should rarely, if ever, be necessary except possibly as part of a damage-control operation in a patient who has multiple bowel injuries.