Abdominal Trauma

Abstract

Trauma is the leading cause of death and disability in the pediatric population. While head injuries are the most likely to be lethal, the abdomen is the most common sight of occult injury that results in death. The management of abdominal injuries has evolved in recent decades as non-operative strategies have been met with increasing success.

Appendices

Summary Points

Most blunt solid organ injuries can be managed non-operatively with a regimen of close observation, adequate fluid resuscitation, and gradual return to normal activities.

In a patient with a solid organ injury, the indications for intervention include hemodynamic instability unresponsive to fluid resuscitation and ongoing hemorrhage.

In the stable patient, many solid organ injuries with ongoing hemorrhage can be managed with selective angiography and embolization.

Liver injuries that require surgery are associated with a significant mortality.

Small bowel injuries can present in a delayed fashion and patients at risk (handlebar injury, epigastric blow) should be monitored carefully for signs of peritonitis.

Editor’s Comment

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.

Differential Diagnosis

Solid organ injury

• Spleen

• Liver

• Kidney

• Pancreas

Hollow viscus injury

• Duodenum

• Small intestine

• Colon

• Bladder

Parental Preparation

Most solid organ injuries produced by blunt trauma can be managed without surgery but this involves a strict adherence to activity restrictions, usually for several weeks.

When we operate for ongoing bleeding, there is a possibility that we will need to take extreme measures such as removing part of the organ involved or multiple operations.

In most cases, once the injury has healed, we expect that the child will have normal organ function throughout life.

Diagnostic Studies

Computed tomography

Ultrasound

CT cystogram

Technical Points

Splenic injuries that require surgery should be managed with partial splenectomy if possible.

Simple duodenal injuries can be repaired without diversion or extensive drainage.

Distal pancreatic transection can be managed by spleen-preserving distal pancreatectomy and oversewing the proximal pancreatic duct.

Patients with massive hemorrhage should be considered for damage control or salvage surgery in which the abdominal cavity is packed and partially closed and the patient is brought back to the ICU for resuscitation until a second operation 24–48 h later.

Small and large bowel injuries can usually be safely repaired primarily.

Colostomy or ileostomy should rarely be necessary and only when there is no other safe option.