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Abdominal Injuries: Indications for Surgery

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The Poly-Traumatized Patient with Fractures

Abstract

This overview addresses the indications for laparotomy following trauma. The authors will suggest algorithms and tenants of care, but there is not a cookie-cutter approach that incorporates all trauma patients or their injuries. Laparotomy for trauma is an individualized decision based collectively upon clinical evaluation and diagnostic adjuncts. Multiple tools exist within the surgeon’s armamentarium, including focused abdominal sonography for trauma (FAST) exam, diagnostic peritoneal aspirate (DPA)/diagnostic peritoneal lavage (DPL), imaging, and laparoscopy, to facilitate diagnosis and management of the trauma patient. Care for each injured patient requires experienced clinical evaluation, time-honed judgment, and individualized treatment. Junior trainees are often reminded of the value of experience in the trauma bay when a misstep in management occurs. Appropriate and timely intervention will limit the number of nontherapeutic laparotomies and their attendant morbidity.

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References

  1. American College of Surgeons. Advanced trauma life support. 7th ed. Chicago: American College of Surgeons; 2004.

    Google Scholar 

  2. Dolich MO, McKenney MG, Varela JE, et al. 2, 576 ultrasounds for blunt abdominal trauma. J Trauma. 2001;50:108–12.

    Article  PubMed  CAS  Google Scholar 

  3. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995;39:492–8.

    Article  PubMed  CAS  Google Scholar 

  4. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. 1995;39:375–80.

    Article  PubMed  CAS  Google Scholar 

  5. Ochsner MG, Knudson MM, Pachter HL, et al. Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis. J Trauma. 2000;49:505–10.

    Article  PubMed  CAS  Google Scholar 

  6. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228:557–67.

    Article  PubMed  CAS  Google Scholar 

  7. Renz BM, Feliciano DV. Gunshot wounds to the liver. A prospective study of selective nonoperative management. J Med Assoc Ga. 1995;84:275–7.

    PubMed  CAS  Google Scholar 

  8. Demetriades D, Gomez H, Chahwan S, et al. Gunshot injuries to the liver: the role of selective nonoperative management. J Am Coll Surg. 1998;188:343–8.

    Article  Google Scholar 

  9. Malhotra AK, Fabian TC, Katsis SB, et al. Blunt bowel and mesenteric injuries: the role of screening computed tomography. J Trauma. 2000;48:991–8.

    Article  PubMed  CAS  Google Scholar 

  10. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling: spleen and liver. J Trauma. 1995;38:323–4.

    Article  PubMed  CAS  Google Scholar 

  11. Boyle Jr EM, Maier RV, Salazar JD, et al. Diagnosis of injuries after stab wounds to the back and flank. J Trauma. 1997;42:260–5.

    Article  PubMed  Google Scholar 

  12. Biffl WL, Cothren CC, Brasel KJ, et al. A prospective observational multicenter study of the optimal management of patients with anterior abdominal stab wounds. J Trauma. 2008;64:250.

    Google Scholar 

  13. Renz BM, Feliciano DV. Gunshot wounds to the right thoracoabdomen: a prospective study of nonoperative management. J Trauma. 1994;37:737–44.

    Article  PubMed  CAS  Google Scholar 

  14. Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006;244:620–8.

    PubMed  Google Scholar 

  15. Nance FC, Cohn I. Surgical judgment in the management of stab wounds of the abdomen: a retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg. 1969;170:569–80.

    Article  PubMed  CAS  Google Scholar 

  16. Velmahos GC, Constantinou C, Tillou A, et al. Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. J Trauma. 2005;59:1155–60.

    Article  PubMed  Google Scholar 

  17. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg. 1995;221:744–55.

    Article  PubMed  CAS  Google Scholar 

  18. Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, et al. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990 s. Ann Surg. 2000;231:804–13.

    Article  PubMed  CAS  Google Scholar 

  19. Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996;40:31–8.

    Article  PubMed  CAS  Google Scholar 

  20. Fang JF, Chen RJ, Wong YC, et al. Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma. J Trauma. 2000;49:1083–8.

    Article  PubMed  CAS  Google Scholar 

  21. Ciraulo DL, Luk S, Palter M, et al. Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries. J Trauma. 1998;45:353–8.

    Article  PubMed  CAS  Google Scholar 

  22. Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: a 25-year perspective. Ann Surg. 2000;232:324–30.

    Article  Google Scholar 

  23. Feliciano DV, Spjut-Patrinely V, Burch JM, et al. Splenorrhaphy: the alternative. Ann Surg. 1990;211:569–82.

    Article  PubMed  CAS  Google Scholar 

  24. Pickhardt B, Moore EE, Moore FA, et al. Operative splenic salvage in adults: a decade perspective. J Trauma. 1989;29:1386–91.

    Article  PubMed  CAS  Google Scholar 

  25. Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg. 2005;200:648–69.

    Article  PubMed  Google Scholar 

  26. Hurtuk M, Reed RL, Espositio TJ, Davis KA, Luchette FA. Trauma surgeons practice what they preach: the NTDB story on solid organ injury management. J Trauma. 2006;61:243–55.

    Article  PubMed  Google Scholar 

  27. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern association for the surgery of trauma. J Trauma. 2000;49:177–87.

    Article  PubMed  CAS  Google Scholar 

  28. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003;138:844–51.

    Article  PubMed  Google Scholar 

  29. Pachter HL, Guth AA, Hofstett SR, Spencer FC. Changing patterns in the management of splenic trauma: the impact of nonoperative trauma. Ann Surg. 1998;227:708–17; discussion 717–9.

    Article  PubMed  CAS  Google Scholar 

  30. Rojani RR, Claridge JA, Yowler CJ, et al. Improved outcome of adult blunt splenic injury: a cohort analysis. Surgery. 2006;140:625–31; discussion 631–2.

    Article  Google Scholar 

  31. Myers JG, Dent DL, Stewart RM, et al. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma. 2000;48:801–5; discussion 805–6.

    Article  PubMed  CAS  Google Scholar 

  32. Harbrecht BG, Peitzman AB, Rivera L, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the Eastern Association for the Surgery of Trauma. J Trauma. 2001;51:887–95.

    Article  PubMed  CAS  Google Scholar 

  33. Goan YG, Huang MS, Lin JM. Nonoperative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults. J Trauma. 1998;45:360–4; discussion 365.

    Article  PubMed  CAS  Google Scholar 

  34. Nwomeh BC, Nadler EP, Meza MP, Bron K, Gaines BA, Ford HR. Contrast extravasation predicts the for operative intervention in children with blunt splenic trauma. J Trauma. 2004;56:537–41.

    Article  PubMed  Google Scholar 

  35. Malhotra AK, Latifi R, Fabian TC, et al. Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma. J Trauma. 2003;54:925–9.

    Article  PubMed  Google Scholar 

  36. Schurr MJ, Fabian TC, Gavant M, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma. 1995;39:507–12; discussion 512-3.

    Article  PubMed  CAS  Google Scholar 

  37. Zumwinkle LE, Cothren CC, Moore EE, Kashuk JL, Johnson JL, Biffl WL. Blunt trauma induced splenic blushes are not created equal. Presented at the Western Trauma Association Annual Meeting, Crested Butte, CO. February 2009.

    Google Scholar 

  38. McIntyre LK, Schiff M, Jurkovich GJ. Failure of nonoperative management of splenic injuries: causes and consequences. Arch Surg. 2005;140:563–8.

    Article  PubMed  Google Scholar 

  39. Smith HE, Biffl WL, Majercik SD, et al. Splenic artery embolization: have we gone too far? J Trauma. 2006;61:541–4.

    Article  PubMed  Google Scholar 

  40. Leppaniemi AK, Haapiainen RK. Risk factors of delayed diagnosis of pancreatic trauma. Eur J Surg. 1999;165:1134–7.

    Article  PubMed  CAS  Google Scholar 

  41. Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children: mechanisms of injury. J Trauma. 1997;42:49–53.

    Article  PubMed  CAS  Google Scholar 

  42. Takishima T, Sugimoto K, Hirata M, Asari Y, Ohwada T, Kakita A. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg. 1997;226:70–6.

    Article  PubMed  CAS  Google Scholar 

  43. Patton Jr JH, Lyden SP, Croce MA, et al. Pancreatic trauma: a simplified management guideline. J Trauma. 1997;43:234–9; discussion 239–41.

    Article  PubMed  Google Scholar 

  44. Wales PW, Shuckett B, Kim PC. Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children. J Pediatr Surg. 2001;36:823–7.

    Article  PubMed  CAS  Google Scholar 

  45. Jobst MA, Canty TG, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg. 1999;34:818–23.

    Article  PubMed  CAS  Google Scholar 

  46. Lin BC, Liu NJ, Fang JF, Kao YC. Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury. Surg Endosc. 2006;20:1551–5.

    Article  PubMed  Google Scholar 

  47. Fakhry SM, Watts DD, Luchette FA. EAST Multi-Institutional Hollow Viscus Injury Research Group. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma. 2003;54:295–306.

    Article  PubMed  Google Scholar 

  48. Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma. 2000;48:408–14.

    Article  PubMed  CAS  Google Scholar 

  49. Niederee MJ, Byrnes MC, Helmer SD, Smith RS. Delay in diagnosis of hollow viscus injuries: effect on outcome. Am Surg. 2003;69:293–8.

    PubMed  Google Scholar 

  50. Ng AK, Simons RK, Torreggiani WC, et al. Intra-abdominal free fluid without solid organ injury in blunt abdominal trauma: an indication for laparotomy. J Trauma. 2002;52:1134–40.

    Article  PubMed  Google Scholar 

  51. Miller PR, Croce MA, Bee TK, Malhortz AK, Fabian TC. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma. 2002;53:238–42.

    Article  PubMed  Google Scholar 

  52. Rodriguez C, Barone JE, Wilbanks TO, Rha CK, Miller K. Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management. J Trauma. 2002;53:79–85.

    Article  PubMed  Google Scholar 

  53. McAnena OJ, Marx JA, Moore EE. Peritoneal lavage enzyme determinations following blunt and penetrating abdominal trauma. J Trauma. 1991;31:1161–4.

    PubMed  CAS  Google Scholar 

  54. Heneman PL, Marx JA, Moore EE, Cantrill SV, Ammons LA. Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma. 1990;30:1345–55.

    Article  Google Scholar 

  55. Velmahos GC, Gomez H, Falabella A, Demetriades D. Operative management of civilian rectal gunshot wounds: simpler is better. World J Surg. 2000;24:114–8.

    Article  PubMed  CAS  Google Scholar 

  56. Cogbill TH, Moore EE, Feliciano DV. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. 1990;30:1469–75.

    Article  PubMed  CAS  Google Scholar 

  57. Huerta S, Bui T, Porral D, Lush S, Cinat M. Predictors of morbidity and mortality in patients with traumatic duodenal injuries. Am Surg. 2005;71:763–7.

    PubMed  Google Scholar 

  58. Knudson MM, Harrison PB, Hoyt DB, et al. Outcome after major renovascular injuries: a Western trauma association multicenter report. J Trauma. 2000;49:1116–22.

    Article  PubMed  CAS  Google Scholar 

  59. Kozar RA, Moore FA, Cothren CC, et al. Risk factors for hepatic morbidity following nonoperative management: multicenter study. Arch Surg. 2006;141:451–9.

    Article  PubMed  Google Scholar 

  60. Giss SR, Dobrilovic N, Brown RL, Garcia VF. Complications of nonoperative management of pediatric blunt hepatic injury: diagnosis, management, and outcomes. J Trauma. 2006;61:334–9.

    Article  PubMed  Google Scholar 

  61. Goldman R, Zilkowski M, Mullins R, Mayberry J, Deveney C, Trunkey D. Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury. Am J Surg. 2003; 185:492–7.

    Article  PubMed  Google Scholar 

  62. Cocanour CS, Moore FA, Ware DN, Marvin RG, Clark JM, Duke JH. Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg. 1998;133:619–24; discussion 624–5.

    Article  PubMed  CAS  Google Scholar 

  63. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg. 2001;233(6): 843–50.

    Article  PubMed  CAS  Google Scholar 

  64. Smith WR, Moore EE, Osborn P, Agudelo JF, Morgan SJ, Parekh AA, et al. Retroperitoneal packing as a resusci­tative technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma. 2005;59: 1510–4.

    Article  PubMed  Google Scholar 

  65. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834–42.

    Article  PubMed  Google Scholar 

  66. Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009;17(7):447–57.

    PubMed  Google Scholar 

  67. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009;40 Suppl 4:S27–35.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery, Denver Health Medical Center and the University of Colorado Denver School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA

    Clay Cothren Burlew & Ernest E. Moore

Authors
  1. Clay Cothren Burlew
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  2. Ernest E. Moore
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Correspondence to Clay Cothren Burlew .

Editor information

Editors and Affiliations

  1. Klinik für Unfallchirurgie, Universitätsklinikum Aachen, Pauwelsstraße 30, Aachen, 52057, Germany

    Hans-Christoph Pape

  2. Florida Orthopaedic Institute, N. Telecom Parkway 13020, Temple Terrace, 33637, Florida, USA

    Roy Sanders

  3. Southwestern Medical Center at Dallas, University of Texas, Harry Hines Blvd. 5323, Dallas, 75390, Texas, USA

    Joseph Borrelli, Jr.

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Burlew, C.C., Moore, E.E. (2011). Abdominal Injuries: Indications for Surgery. In: Pape, HC., Sanders, R., Borrelli, Jr., J. (eds) The Poly-Traumatized Patient with Fractures. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-17986-0_9

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  • DOI: https://doi.org/10.1007/978-3-642-17986-0_9

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