Evaluation and Management of Hollow Viscous Injuries

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Evaluation and Management of Hollow Viscous
Injuries
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• Intra-abdominal hollow viscous injuries can
  include the stomach, small bowel, colon and
  rectum
• More commonly the result of penetrating trauma
  than blunt trauma
• Principles of operative management are generally
  the same

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Blunt Trauma

• Though uncommon, increased morbidity and
  mortality if missed or delayed
• Abdominal tenderness after blunt torso trauma
  frequently associated with intra-abdominal
  pathology
• Seat belt sign/flexion distraction fxs
  associated with increased relative risk of small
  bowel injury

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Blunt Trauma, contd

• Ultrasonography, CT, DPL the tools for evaluation
• Ultrasonography
• Highly specific and moderately sensitive in
  identifying intra-abdominal fluid
• Does not reliably distinguish solid-organ injury
  from hollow viscous injury (though DPL may help
  differentiate between the two)

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Blunt Trauma, contd

• CT currently the imaging modality of choice
• Isolated finding not greatly suggestive of
  hollow viscous injury
• Multiple findings highly suggestive

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Blunt Trauma, contd
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Blunt Trauma, contd
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Penetrating Trauma

• Evaluation contingent upon peritoneal penetration
• GSWs Generally necessitate exploratory
  laparotomy laparoscopy for tangential GSWs to
  rule out peritoneal penetration
• Stabbings Laparotomy with obvious signs of
  peritoneal penetration (omental/bowel
  evisceration) otherwise, local wound
  exploration, and laparoscopy if fascial
  penetration is evident.

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Penetrating Trauma, contd

• Posterior vs. Anterior Stab Wounds
• Posterior wounds carry lower risk of
  intra-abdominal injury
• Evaluated with CT augmented by intravenous, oral
  and rectal contrast
• Identifies posterior intraperitoneal violation
  and injury to retroperitoneal structures

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Operative Management

• Treatment of injury is dictated by location and
  severity. In general
• Antibiotics is administered before skin incision
  and for 24 hours if injury is confirmed
• Abdominal exploration performed through mid-line
  incision sufficient to access entire peritoneal
  cavity
• After initial control of any significant bleeding
  is achieved, inspection commences in a systematic
  fashion

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Operative Management, contd

• Injuries to the Stomach
• Treatment based grading system developed by AAST

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Operative Management, contd

• Grades I, II, III - primary repair
• Partial thickness hemostasis and seromuscular
  closure
• Full thickness hemostasis and closure in two
  layers
• Grade IV dependant upon associated injuries
• No associated injuries to duodenum, pancreas or
  esophagus distal gastrectomy and
  gastroduodenostomy
• Associated injuries distal gastrectomy and
  gastrojejunostomy
• Grade V complete devascularization or
  destruction
• Perform near-total or total gastrectomy with
  Roux-en-Y reconstruction

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Operative Management, contd

• Injuries to the Small Bowel
• Evaluated intraoperatively by running the
  bowel, from the ligament of Treitz caudad to the
  ileocecal valve

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Operative Management, contd

• Primary repair, resection or a combination
  thereof is employed at the discretion of the
  surgeon
• Grade I reapproximation of the seromuscular
  layers with interrupted sutures
• Grade II limited debridement and closure in
  either one or two layers
• Grade III repaired primarily if luminal
  narrowing can be avoided otherwise, resection
  and anastamosis
• Small bowel anastomoses usually hand sewn or
  stapled
• Grade IV and V resection and anastomosis

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Operative Management, contd

• Injuries to the colon

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Operative Management, contd

• Colonic injuries further categorized as either
  non-destructive or destructive
• Destructive - wounds that completely transect the
  colon (grade IV) or involve tissue loss and
  devascularized segments (grade V)
• Patients with destructive colonic injuries who
  had
• comorbid medical conditions
• required transfusions of more than 6 units of
  blood
• in shock
• delayed operationsignificantly higher risk for
  suture line breakdown when managed with resection
  and primary anastomosis

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Operative Management, contd

• Non-destructive wounds (grades I-III)
• Seromuscular closure for partial thickness
• Primary closure for full thickness
• Destructive wounds (grades IV-V)
• Repair with resection and primary anastomosis
• Destructive wounds with risk factors
• Resection with end colostomy or resection and
  primary anastomosis with proximal diversion
• Proximal diversion
• loop colostomy (with open or closed distal stoma)
• end colostomy (with a mucous fistula or closure
  of the rectal stump)

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Operative Management, contd

• Injuries to the Rectum
• Classified according to anatomic criteria
• Anterior and lateral sidewalls of the upper two
  thirds of the rectum managed in the same manner
  as colonic injuries
• Upper two thirds posteriorly and lower one third
  of the rectum circumferentially - extraperitoneal
• Upper two thirds - exploration and suture repair,
  fecal diversion with loop or end colostomy as
  adjunctive measure
• Lower one third - explored and repaired if
  accessible Fecal diversion recommended
• Wounds difficult to reach - proximal fecal
  diversion and presacral drainage