Penetrating Injuries to the Abdomen - I
(Editors’ note: the review on penetrating abdominal trauma will be posted in two sections, in February and March 2009 and the associated online discussion and CME questions will continue throughout this period. A pdf of the entire review will be available March 2009)
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1. Introduction
In the US, penetrating injuries comprise approximately 6% and 10% of hospitalizations
and emergency room visits, respectively. However, they account for the second
most common mechanism of fatal injury after motor vehicle related injuries,
at 20% of all injury-related deaths.[1] The absolute numbers
vary across global locations but the epidemiological fact remains unchanged
- that penetrating injuries in particular, firearm related injury, are highly
lethal. In the next two months’ reviews we will discuss penetrating injuries
of the abdomen: the recognition, diagnosis, and the treatment decision-making
for intra-abdominal injury.
2. Initial Assessment
Trauma surgeons classify the torso into 5 main areas: chest, thoraco-abdominal,
anterior abdomen, flank and back. The organs found within the peritoneal
cavity can be injured by a penetrating wound in any 4 of these 5 regions.
The approach to diagnosis and treatment differs and is determined by the
type of weapon, either a firearm or a stab wound and the trajectory of its
entry. For the purposes of this discussion we will consider the use of the
word abdomen to refer to all 4 of the above noted regions of the torso (thoraco-abdominal,
anterior abdomen, flank and back) unless otherwise specifically delineated.
Historically, all patients who sustained a penetrating injury to the abdomen
were treated with an exploratory laparotomy as the accepted standard of
care. However, as the field of trauma surgery expanded to handle more civilian
injury and less war injury, trauma surgeons recognized that laparotomies
were being performed in a substantial number of patients without significant
internal organ injury.[102] In conjunction with this,
the consequences of a negative laparotomy were shown to be associated with
long term sequelae. [16]
Therefore, the first question to be asked when approaching a patient with
penetrating injury to the abdomen is as follows: “Is there an internal organ
injury?” The clinical examination remains the hallmark diagnostic test to
determine intra-abdominal injury. Any patient who presents with hemodynamic
instability or physical signs of acute peritonitis or diffuse abdominal
tenderness requires an immediate laparotomy, irrespective of the location
of the penetrating wound. This laparotomy should be performed in the midline
with an incision that extends from the xiphisternum to the symphis pubis
without exception. Remember, this is an operation to save the patient’s
life and therefore, any compromise on adequate exposure can affect the potential
positive outcome. If the weapon or object which penetrated the abdomen is
still in place at the time the patient arrives at the health facility, no
attempt at removal should be made in the emergency room. This can vary from
an unintentional impalement on an object to retained knives or arrows after
an intentional attack. The patient should be taken to the operating room
with the object remaining in place. If possible, the external portion of
the object can be removed close to the patient’s body to allow them to lay
flat once under general anesthetic. The laparotomy should be performed and
the object removed under direct vision of the organs and vessels that it
transects. It is only in this fashion that quick control of vascular and
major organ injuries can be accomplished safely. In the case of a potential
vascular injury, proximal and distal control of the involved vascular structure
should be obtained prior to removal of the impaled object.
Evaluation of hemodynamic instability requires the combined assessment of
vital signs such as pulse rate and pulse pressure, blood pressure, urine
output, sensorium, capillary and skin refill, and base deficit as measured
by the laboratory. All these factors must be taken together in a complete
picture to determine if the patient is hemodynamically stable or not. Factors
such as extremes of age, medication, pregnancy, spinal cord injury, illicit
substance intoxication, athletes, or pre-existing medical conditions such
as chronic hypertension can alter physical signs and symptoms such that
acute blood loss is masked.
The trauma patient, who initially does not display an immediate need for
operative intervention, does require repeat examinations. Any deteriorating
trend in vital signs and/or base deficit, especially in a patient who continues
to receive fluid or blood resuscitation, is a strong indication that the
patient is hemodynamically unstable and, potentially, has a clinically relevant
intra-abdominal injury. A rigid abdomen with involuntary abdominal wall
muscle contraction is the hallmark of peritonitis, but even diffuse abdominal
tenderness, especially when found away from the site of injury can be an
indicator of an intra-abdominal injury warranting exploratory laparotomy.
Only patients who have an associated spinal cord injury, severe head injury
or with severe intoxication require further investigation beyond clinical
examination alone to minimize missed abdominal injuries.
Patients with internal injury, who present after sustaining a penetrating
trauma without any of the signs or symptoms of an intra-abdominal injury,
pose a diagnostic dilemma to differentiate them from those patients who
have no intra-abdominal injuries. There are a number of diagnostic approaches
used in these situations that we will discuss in more detail in the next
section, but the first step in the approach to penetrating trauma depends
on the mechanism of injury. In the asymptomatic patient the mechanism of
injury: stab wound versus firearm as well as the location of that wound:
anterior abdomen, flank, back and thoraco-abdominal areas are the main determinants
for deciding on the treatment approach to undertake. A decision algorithm
for the approach to the patient with penetrating trauma to the abdomen is
summarized in Figure 1.
2.1. Initial Management
The initial management of any trauma patient should include the ABCs of
resuscitation, especially keeping the patient warm and cross-matching for
blood with the availability of uncross-matched blood for immediate use.
Any patient, who is hemodynamically unstable especially if hypotensive,
should preferentially be given blood rather than crystalloid as a resuscitation
fluid. Laboratory tests that can be useful in the initial care of the patient
are the coagulation profile, base deficit and hematocrit, if they are available.
All three are helpful for monitoring of the response to resuscitation and
for outcome prediction or patient prognosis. [25] No other
laboratory tests are useful at this point. In penetrating trauma, permissive
hypotension until the patient has reached the operating room has been suggested.[23]
Bickell et al. suggested using minimal fluid and blood products so that
the blood pressure was “allowed” to remain low-normal so as to minimize
bleeding from the internal injury until operative repair could occur at
which time full resuscitation would begin. He was able to show a reduction
in mortality but other authors have not been able to replicate this result.
[24] This approach is only for very select situations,
if at all, where select patients arrive at the trauma center within minutes
of injury and can be moved to the operating room expeditiously. Hypotension
should not be the routine goal for patients with penetrating injuries in
other settings.
An exploratory laparotomy in a trauma patient should always be performed
with a midline incision irrespective of the injury suspected, as it is the
only incision that allows wide exposure of the peritoneal, retroperitoneal
and pelvic areas. A right subcostal extension to the midline incision can
be added if necessary to improve exposure for biliary tract injuries. If
there is a significant amount of hemoperitoneum, then the first step after
releasing the tamponade is to pack all four quadrants of the peritoneal
cavity with laparotomy pads. If the patient is hypotensive or becomes hypotensive
after releasing the peritoneal tamponade, the surgeon should keep the packs
in and allow the anesthesiology team to give blood products to regain a
mean arterial pressure above 60.
2.2. Stab Wounds
Stab wounds to the anterior abdomen have been shown to be associated with
a 30-50% incidence of intra-abdominal injury that requires operative repair.
[11][12] Therefore, over half of the
patients can be discharged without an operation. Local wound exploration
can be performed using good lighting in the emergency department. If the
anterior fascia is intact and the patient has no abdominal tenderness then
the patient can be safely discharged from the hospital without need for
a period of observation. However, if an abdominal stab wound penetrates
the anterior abdominal fascia then that patient requires serial clinical
examinations for at least 24 hours before discharge as initially undetected
injuries will become symptomatic within this time frame. Evisceration of
bowel or omentum or free air on an abdominal radiograph has been reported
to be associated with intra-abdominal injury even in the absence of symptoms
and therefore, should mandate operative intervention. [14]
DPL and ultrasound play a limited role, if any, in deciding on operative
management in stab wounds and are rarely used as clinical adjuncts to the
physical examination.
Stab wounds to the back and flank result in an even fewer number of intra-abdominal
injuries, reported as low as 15% in one study. [13] However,
a patient who is otherwise asymptomatic, but displays hematuria, blood per
rectum or a right upper quadrant stab which may involve the liver, should
be considered for a CT scan or rigid sigmoidoscopy if available. Asymptomatic
patients with flank or back wounds in centers, without a CT scan available
to verify or eliminate peritoneal penetration, should be observed for 18-24
hours to rule out an intra-abdominal injury. There has been concern that
the physical examination is unreliable in the intoxicated patient, but it
has been shown that it can be reliable in the presence of mild to moderate
intoxication. [11]
In summary, for a patient who has sustained a stab wound to the abdomen
a careful clinical examination of the patient with a repeat examination
at frequent (4-8 hours), regular intervals, preferably by the same clinician,
is the most accurate approach to determine onset of signs and symptoms indicative
of the need for operative intervention.
2.3. Gun Shot Wounds
Gun shot wounds unlike stab wounds are associated with a higher likelihood
of intra-abdominal injury that requires repair, up to 90% of patients as
reported by some trauma centers.[17], [18]
Therefore, gun shot wounds are more likely to be taken directly to the operating
room, especially in centers where the frequency of gun shot wounds is less
common.
However, in other patient series, especially with gun shot wounds to the
back, the incidence of significant intra-abdominal injury is much lower
- prompting many trauma centers to consider selective management.[19],
[20], [21] Selective management is the
term given patients who present asymptomatic after an injury and who are
followed clinically rather than undergo immediate exploratory laparotomy.
However, the essential component to the adoption of selective management
is the ability to closely follow patients clinically and the ability to
intervene in a timely manner, if the patient’s condition changes, with an
immediately available operating room and staff. One main concern of selective
management is the risk of complications such as sepsis and even death due
to delayed diagnosis of injuries. However, in trauma centers that are able
to meet the key components mentioned above, only 0.3% of the patients developed
a complication that could be considered a result of the delayed operative
intervention and none of these patients died nor suffered long term morbidity.
[20] Therefore, a center that does not have 24 hour availability
of nursing staff, surgical staff and operating room staff as well as monitoring
capabilities should not undertake selective management of gun shot wounds
of the abdomen.
3. Diagnosis and Investigations
In the last section we discussed the absolute indications for operative
exploration of a patient with a penetrating injury to the abdomen and the
cornerstone of initial evaluation - clinical abdominal examination. However,
many patients may present with an intra-abdominal injury but lack the hard
signs of peritonitis, abdominal tenderness, hemodynamic instability and
the clinical examination of their abdomen is unreliable. In these patients,
further diagnostic tests and procedures are warranted. We will now discuss
the diagnostic and investigative options available to determine intra-abdominal
injury and the appropriate treatment approach in asymptomatic patients with
positive diagnostic findings.
3.1. Ultrasound
FAST, focused abdominal sonography for trauma, has become the standard of
care to detect intra-abdominal fluid during the initial assessment of the
injured patient with blunt and penetrating trauma. The FAST is now routinely
performed by surgeons and emergency medicine physicians in the initial assessment
of injured patients in the emergency department. A positive FAST examination
is highly sensitive for hemoperitoneum and clinically significant abdominal
organ injury in blunt trauma patients. [2] The FAST exam
is an operator dependent technique and therefore, results must be interpreted
in the context of the experience of the personnel performing it. The utility
of the FAST in abdominal penetrating trauma is less accurate, with a sensitivity
to detect hemoperitoneum being reported as low as 67%.[4]
The specificity of the FAST in penetrating trauma is higher (>90%) than
the sensitivity (45-65%), i.e. the ability to accurately choose patients
without injury as having no injury; but this is a clinically less
useful function. [15] However, the FAST is very sensitive and highly accurate
for detecting pericardial fluid (i.e. blood) in a patient who has sustained
a penetrating injury to the heart. [3] The patient who
has a wound in the cardiac box – a square formed by four lines that bisect
through the bilateral nipples and the costal margins and which includes
the epigastrum area of the abdomen, should have a pericardial FAST if ultrasound
is available. Therefore, in most trauma centers FAST may be performed on
a patient with penetrating trauma because it is often available, but it
plays a minor if any role in the decision making in the patient’s management.
3.2. CT Scan
Computed Tomography (CT scan) of the abdomen is the standard diagnostic
test for blunt trauma patients who clinically do not require immediate operative
intervention in resource-rich settings. The CT scan is accurate in showing
intraperitoneal fluid/blood and defining injuries in the solid organs after
blunt trauma.[5] The CT scan of the abdomen is now also
utilized to assess the possibility of intra-abdominal injury in patients
who have sustained a firearm injury who present without symptoms and thereby
are considered for nonoperative management.[6] The CT scan
can show the trajectory of the bullet tract and assist in deciding on peritoneal
penetration as well as any organ injury or the presence of hemoperitoneum.
If a patient has no peritoneal penetration confirmed by CT scan then he
may be discharged without a period of observation. Any ongoing bleeding
or any hollow viscus perforation requires operative repair. If the bullet
track passes near the colon, but without actual free air or contrast extravasation,
then the patient must be watched closely because of the potential for the
development of colon injury second to blast effect from the bullet. A CT
scan is usually obtained with double contrast – oral and IV. However, there
has been some evidence to suggest that oral may not increase the rate of
detection of bowel injury and may delay the timing of the CT scan as well
as a risk of aspiration.[7] For penetrating wounds to the
flank and back, many trauma surgeons suggest a triple contrast CT scan –
oral, IV and rectal contrast. The addition of rectal contrast has been shown
to increase the rate of detection of retroperitoneal colon injuries that
can occur in back or flank penetrating wounds.
3.3. DPL
The diagnostic peritoneal lavage (DPL) is performed predominantly by the
open technique where a small sagittal incision (2-3 cm) is made in the midline
just below or above the umbilicus. If there is an associated pelvic fracture
or a pregnant uterus then the incision should be made above the umbilicus.
The incision is carried through the subcutaneous tissue to the fascia in
which another 1 cm sagittal incision is made. A hemostat is used to bluntly
enter the peritoneal cavity through the peritoneum while the fascia is elevated
using Kelley instruments to avoid potential injury to underlying bowel.
At this point, a 10 cc syringe is attached to a long thin catheter or hollow
tubing (at least 10 cm in length) which is directed into the abdomen inferiorly
without pressure. If 10+ ml of gross blood is aspirated then the DPL is
positive and one should proceed with an exploratory laparotomy. If not,
then the catheter is attached to a one liter bag of normal saline which
is allowed to run into the peritoneal cavity. Once all the fluid is entered,
then the empty bag is placed on the ground and using gravity, the fluid
is allowed to run back into the bag. The fluid can be analyzed for cell
count and biochemistry (see Figure 2).
Figure 2: Cell count Criterion for DPL performed in Penetrating Injury
Microscopically: |
Biochemistry: |
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WBC Count |
Presence of one of the following: |
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Positive DPL Result |
>10,000 cells/mm3 |
>500 cells/mm3 |
Amylase |
Alkaline Phosphatase |
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Bilirubin |
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The fluid can also be inspected macroscopically by placing newspaper or
any printed paper behind the transparent fluid bag. If the printing is easily
readable through the red-stained fluid then the DPL is considered negative
or in other words, the cell count is reliably lower than the threshold cut-off
for positive determined by laboratory examination as described in Figure
2. If the print is unreadable, the DPL is positive and the surgeon should
proceed with an exploratory laparotomy.
The laboratory-determined red cell count threshold for a positive DPL is
lower in penetrating trauma than it is in blunt trauma. As a result, it
misses fewer injuries but does increase the number of non-therapeutic laparotomies
based on DPL findings alone. DPL is not often used in penetrating trauma
because of the high number of false positives. The indications include asymptomatic
patients who cannot be followed clinically because of other associated injuries
such as severe brain injury; if clinical observation by skilled personnel
is unavailable; or if operative treatment is not available locally and a
decision in regards to internal injury cannot be made clinically due to
associated other injuries such as brain injury and the need for transfer
to another facility needs to be confirmed.
3.4. Rigid Sigmoidoscopy
Rigid sigmoidoscopy is useful for examination of the extraperitoneal rectum.
For penetrating wounds to the lower back, buttocks or lateral upper thigh,
especially gun shot wounds and wounds that traverse the midline, there is
a potential for injury to the rectum. As the last 10-12 cm of rectum is
extraperitoneal, symptoms of perforation and injury such as pain, peritonitis
or sepsis may be nonexistent or present late in the course. A rectal exam
should always be performed first, but alone is an inadequate examination
for the entire extraperitoneal rectum. The rigid sigmoidoscopy will often
demonstrate the injury and allow primary repair in many instances.[8]
If blood is detected in the rectal lumen, even if no rectal wall perforation
or laceration is seen, an injury must be assumed and a diverting colostomy
performed (see 5.5. Rectal injury).[9] In a patient with
a pelvic gun shot wound who requires an exploratory laparotomy, the patient
can be placed in lithotomy and a rigid sigmoidoscopy can be performed before
or during the operation. This allows examination of the extraperitoneal
rectum without opening the peritoneal reflection from within the abdominal
cavity and potentially exposing another body area to contamination and ultimately
infection and abscess. [10]
3.5. Angiography
Angiography is rarely used in penetrating injury. However, in a stable,
asymptomatic patient chosen for selective management a CT scan may show
an isolated injury to the spleen, liver or kidney and angiography can play
a role in their management. Angiography may be used to rule out successful
nonoperative management of patients if their CT scan shows a vascular contrast
blush within the organ in question. This signifies ongoing hemorrhage despite
the patient’s present stability and predicts failure of nonoperative management.
This clinical scenario more commonly happens in the kidney as it is a retroperitoneal
organ where the bleeding can be more easily contained minimizing clinical
signs.[22] Also, in opening the hematoma around the kidney,
which is contained within the retroperitoneum, uncontrolled bleeding may
ensue that could result in the need for a nephrectomy. Therefore, in an
attempt to avoid surgical loss of the kidney, where the bleeding vessel
is localized, therapeutic angiographic embolization may be utilized instead
of operation. Angiography for diagnosis and embolization of a bleeding vessel
requires the appropriate equipment and personnel.
4.1. Hepato-biliary-pancreatic injuries
4.1.1. Liver
In any patient whose penetrating wound is in the right upper quadrant, injury
to the biliary tract should be suspected. Nonoperative management has been
utilized by some Level I trauma centers in the USA for right upper quadrant
gun shot wounds, but it can be associated with missed stomach and intestinal
injuries and late complications such as biliopleural fistulas. [26]
Only a center with the capability to do a CT scan, 24 hour regular patient
monitoring and 24 hour operating room availability should even consider
this approach for gun shot wounds of the right upper quadrant. The correct
approach for suspected right upper quadrant gun shot injury, in virtually
all situations in low-income countries, will be a midline laparotomy.
After removing the packs and inspecting the entire peritoneal cavity for
injury, the initial approach to control bleeding liver parenchymal injuries
include: 1) electrocautery 2) omental plug 3) direct suture ligation and
4) hemostatic agents. Any liver wound or bullet trajectory that is not bleeding
should not be probed or manipulated. As the blood supply to the liver is
predominantly the low pressure venous systems of the portal and hepatic
veins, a large number of injuries stop bleeding without any need for operative
repair.
Liver wounds can be compressed with direct pressure using laparotomy pads
while full exposure is gained by transecting the falciform, left and right
triangular and coronary ligaments (all or some of these ligaments are mobilized
depending on which segment/s of the liver are injured). Any ligament that
has a large hematoma contained within it should not be opened as this likely
represents a vena caval or hepatic vein injury and entering the hematoma
may result in brisk exsanguination. Ongoing bleeding after a period of initial
compression can be controlled by using electrocautery placed on coagulation
settings of at least 50 and up to 80-100. Direct ligation of visible bleeding
vessels using prolene or other nonabsorbable suture can be used. If bleeding
is not in one discrete area then a tongue of viable omentum can be used
as a type of “patch” placed into the defect. [26] Recently
a variety of absorbable hemostatic agents, blood-clot inducing material,
have become commercially available. The commonest examples are fibrin glue
a liquid made from a mixture of cryopreciptate (fibrinogen), thrombin and
calcium; surgicel, an oxidized cellulose material for laying on bleeding
surfaces and gelfoam, a syrofoam-textured material made from porous, purified
pork Skin Gelatin USP granules.[39] They are used extensively
in the USA, but provide the same function as do perihepatic packing, electrocautery,
suture ligation and omental patching in obtaining hemostasis but at greater
economic cost.
For the liver wound that is bleeding profusely, a Pringle maneuver can assist
in reducing flow so that the injury can be better visualized and repaired.
A noncrushing clamp is placed through the Foramen of Winslow across the
contents of the lesser omentum or porta hepatitis. If bleeding remains profuse,
this is a serious warning sign that there is a significant retrohepatic
injury: inferior vena cava, major hepatic injury or caudate lobe injury
which will be discussed below. In the case of severe exsanguinating hemorrhage
not controlled by the Pringle maneuver, then total vascular occlusion can
be utilized. This entails a Pringle maneuver, clamping of the aorta at the
diaphragmatic hiatus and clamping of the inferior vena cava at the superior
aspect of the liver at the diaphragm. A Pringle maneuver can be maintained
for upwards of 60-75 minutes but after 30 minutes, some surgeons would consider
opening the clamp for 5 minutes to allow for reperfusion. [27],
[28], [29] Obviously total vascular
occlusion will cause significant ischemia to the liver as well as the body
below the abdominal aorta and therefore, should only be used in patients
who are in extremis second to exsanguination from a severe liver parenchymal
or vascular injury.
In severe liver parenchymal injury the same approaches can be used for hemostasis:
electrocautery, direct suture ligation and omental patches, but the extent
of bleeding often requires more visualization. Fracturing liver parenchyma
by pinching the parenchyma between your fingers (“finger fracture”) or by
using a hemostat will widen and increase the wound edge or bullet tract
to allow better access to bleeding vessels in the wound so that they can
be selectively ligated, directly sutured, cauterized or clipped.[27]
This technique of hepatotomy requires ligation of any bile caniliculi or
vessels encountered while approaching the area of bleeding and can often
involve increased bleeding from this normal liver parenchyma. If the bullet
or stab wound tract is deep within a liver segment, which may require a
large amount of normal liver to be opened to access it, then an alternative
approach is to suture ligate the open superior and inferior aspects of the
wound with 0-chromic cat gut suture on a large blunt tipped needle using
figure of eight or mattress suture technique. This maneuver often tamponades
further bleeding within a deep bullet or stab wound tract. One must observe
the wound for 10 minutes to ascertain that no expanding hematoma is occurring
signaling the failure of this technique to achieve hemostasis. This 0-chromic
cat gut can also be used on lacerations that are not deep but are not controlled
by topical hemostasis like electrocautery or hemostatic agents. If placement
of the sutures is done blindly then they should not be placed deeper than
3-4 cm because an injury to a large vessel or bile duct branch could occur
which may cause hemobilia or an expanding intrahepatic hematoma.
Perihepatic packing is technically the easiest hemostatic method to perform,
is often successful and therefore is often the most widely employed for
significant liver hemorrhage. Folded laparotomy packs are placed ventral
and dorsal on the liver so that the liver is compressed between the anterior
thoraco-abdominal wall, diaphragm and the posterior retroperitoneum after
the liver has been mobilized as described above.[35] Packing
early has been associated with an improved survival.[36]
If this method is used as the definitive or an adjunct approach to hemostasis
the packs are left in for 24-72 hours, the abdominal fascia is not closed
(“open abdomen”) and the patient is taken to the intensive care unit to
optimize resuscitation with blood products including fresh frozen plasma,
cryopercipitate and platelet infusion, if available. The techniques involved
in damage control laparotomy where the abdomen is left “open” are beyond
the scope of this review but the commonest initial dressing for an open
abdomen is a plastic covering to protect the intestines followed by drains
for fluid collection and the last layer is an adhesive clear dressing, for
example IobanTM, to keep the dressing in place. The abdomen is left open
to prevent the development of abdominal compartment syndrome. The abdominal
compartment syndrome defined as an intra-abdominal pressure of greater than
25 mmHg causes significant morbidity. The large volume of resuscitation,
any ongoing intra-abdominal hemorrhage and the presence of laparotomy pads
combined place these patients at a very high risk of developing this syndrome.
The difficulty comes with pack removal for a raw newly hemostatic liver
surface which can rebleed. Feliciano and Pachter have suggested placing
a nonadherent plastic drape between the laparotomy pads and any raw liver
surfaces to minimize the chance of rebleeding at reoperation. [37]
The timing of pack removal remains controversial. The decision to remove
the packs is balanced between adequate time for physiological restoration
to allow for hemostasis and increased risk of sepsis secondary to foreign
bodies within the peritoneal cavity. One author showed that three days appeared
to be the threshold which, if passed, resulted in a substantial increase
in sepsis.[38] Furthermore at reoperation, it is paramount
to remove peritoneal clot and debride any devitalized liver parenchyma in
order to minimize the development of perihepatic infection after packing.
If the injury has transected one anatomic lobe or segment or when the injury
itself has devascularized the majority of that lobe or segment, then an
anatomic resection may be needed to achieve hemostasis. [32]
Anatomic resections for less severe injuries have not been associated with
improved survival. [31] The raw surface of the resection
can be covered with a viable omental patch. The omentum is first mobilized
from the transverse colon mesentery and then the greater curvature of the
stomach protecting the right gastric epiploic vessel.[30]
Then advancing a tongue of omentum on its vascular pedicle it can be placed
on the resection surface or within a wound to lessen the dead space. The
macrophage activity of the omentum is the key to its effective hemostatic
activity. Rather than attempt an anatomic resection in a hemodynamically
unstable patient, if there is extensive lobar damage not responding to suture
ligation or electrocautery, some trauma centers recommend application of
wide aortic clamps, across the entire bleeding area of the liver can sometimes
achieve hemostasis.[33] These clamps, if they slow the
hemorrhage, can then be left in place for even up to 36 hours and any resulting
necrotic liver tissue can be resected or debrided at a second operation.
Sattler and Gentilello have described a tamponade technique they named the
“liver bag”. [40] A radiographic cassette bag was placed
around the already-mobilized liver to completely encase the liver and the
opening of the bag was closed around the porta hepatitis using umbilical
tape to tamponade the hemorrhage. The patient had the bag removed after
3 days without recurrence of hemorrhage.
Bullet tracts that traverse the liver are often long and deep and visualization
of bleeding areas deep within the tract is impossible. Packing the tract
with omentum as described above will often be successful, but if not, Pegotti
and colleagues have advocated the use of balloon tamponade. [34]
The basic concept is to utilize a perforated tube or foley catheter covered
with a penrose drain which is tied at the distal and proximal end of the
tube and allow contrast (if available) or any sterile fluid to fill the
penrose drain from the central tubing once the tubing has been passed into
the full length of the tract. This allows the penrose drain filled with
fluid to tamponade the entire length of the bullet tract and if successful,
it can be left in place 24-48 hours to assure ongoing hemostasis. In institutions
where angiography is available, if a transhepatic tract continues to bleed
despite these maneuvers then the patient may have perihepatic packs placed
and undergo angioembolization. In patients with a single deep bleeding wound
that responds to the Pringle maneuver but not to the various methods already
mentioned, complete hepatic artery ligation can be considered. When the
portal vein remains patent, severe hepatic necrosis is uncommon but it is
more common in the traumatic patient who already has a hypoperfused liver
from the hemorrhagic shock. [41], [42]
When retrohepatic bleeding occurs either from the inferior vena cava or
the hepatic veins three approaches have been described to arrest bleeding:
1) direct suture repair with or without total vascular occlusion; 2) lobar
resection; and 3) tamponade and containment of the bleeding. [43]
The mortality rate for any of these injuries no matter the approach is high
and survival rates are below 50% in the best series. [44]
In the first approach, the surgeon mobilizes the liver, rotates it medially
and using finger fracture to reach the main vein that is bleeding, directly
repairs it with a running prolene or nonreactive nonabsorbable suture. In
order to visualize this area, shunting maneuvers have been proposed as alternatives
to total vascular occlusion. The most widely recognized shunt is the one
proposed by Schrock in 1968. The goal was to place a chest tube through
the right atrium of the heart into the infrarenal IVC and to continue to
allow flow through the IVC while bypassing the area of injury and giving
a bloodless operative field. However, this is a complicated technique which
requires a second incision (right thoracotomy) in an already severely hypoperfused
patient. In the literature, it is associated with a very high mortality
rate (70-90%) and as a result of this it is rarely employed. [45]
The second approach, lobar resection, is only recommended when the bullet
has already performed the majority of the resection, otherwise mortality
rates are very high. The third approach is presently thought to be the optimal
one and has the lowest mortality rates reported in the literature.[46],
[47]
Tamponade with laparotomy pads and omental patch when possible has been
shown to be effective even for major hepatic venous injury. If available,
angioembolization can be used as an adjunct for associated hepatic arterial
bleeding after packing.
Penrose drains left in and around the liver after injury have been shown
to be associated with increased infection and only closed suction drains
are recommended for use. The incidence of perihepatic abscess is unchanged
by the placement of a closed suction drain versus no drain unless there
is a bile leak present intra-operatively. The placement of a penrose drain
is associated with a substantially higher rate of infection and therefore,
they are no longer recommended.[48] The main complications
after penetrating liver trauma are recurrent hemorrhage, hemobilia, biliary
fistulae, and other rare fistulae. The bullet trajectory may connect surrounding
structures and can cause unusual fistulae.
4.1.2. Gall Bladder
and Bile Duct
Gall bladder injury is diagnosed mainly at laparotomy and any perforation,
avulsion or devascularization (second to a portal triad or hepatic artery
injury) should be treated with cholecystectomy. Injury to the gall bladder
is usually evident by direct inspection of the organ. There should never
be an attempt to primarily repair a gall bladder injury, even if it is a
relatively small injury.
Bile duct injury is one of the few organs more commonly injured after a
penetrating rather than a blunt trauma and it is more likely to be a partial
transection rather, than a complete transection.[49] Common
bile duct injuries are suspected during laparotomies where there is extensive
bile staining and leakage in the upper abdomen. Duct injuries that are not
obvious by direct inspection can be confirmed by squeezing the gall bladder
initially and looking for increased or new bile leakage. If no leakage is
seen, then infusion of a contrast solution into the gall bladder with a
gentle clamping of the bile duct above the cystic duct-common bile duct
junction will diagnosis the presence of any duct injury. Alternatively,
if x-ray facilities are unavailable, then an infusion of normal saline in
the same fashion as the contrast dye followed by careful inspection for
pooling or collecting of the saline extraluminally can assist in demonstrating
a ductal injury. Fortunately most penetrating injuries to the common duct,
like the gall bladder, are easily seen with diligent direct inspection.
Bile duct injuries should be repaired only after hemorrhage has been controlled.
If a person needs is to undergo damage control, a closed suction drain such
as a penrose drain can be left near the injury or a T-tube can be placed
across the injury and it can be repaired later after the patient has been
resuscitated.[50] Small lacerations and avulsions can
be repaired primarily with 6-0 polyglycolic (absorbable) suture without
T-tube placement being careful not to narrow the lumen.[50]
Complete transections can be repaired with primary end-end anastomosis over
a T-tube as long as there is no tension and care was taken, not to devascularize
the duct by excessive periductal dissection.[51] If there
is extensive ductal injury with loss of tissue, then the surgeon must use
an enteric anastomosis most commonly a Roux-en-Y hepaticojejunostomy with
cholecystectomy and T-tube drainage. This operation involves an anastomosis
between the common bile duct to a 40 cm Roux limb in an end-to-side anastomosis.
The T-tube will be placed in the common bile duct through a separate incision
in the duct with one arm of the tube crossing the enteric-duct anastomosis.
[50] This anastomosis is best performed using the proximal
common bile duct rather than the distal hepatic duct because of improved
vascularity. If the common bile duct injury is close to the bifurcation
of the right and left branches, then these can be sutured together medially
before performing the hepaticojejunostomy anastomosis. [52]
4.1.3. Portal
Vein
Portal vein injury is associated with a high mortality rate, and if associated
with a hepatic artery injury the mortality rate approaches 100%. [49]
If the injury is mid-vein then proximal and distal control is obtainable
and a primary repair is feasible. If the laceration is posterior to the
pancreas, then transection of the pancreas may be necessary to get adequate
exposure followed by a completion distal pancreatectomy which is performed
at the end of the procedure. [53] The only repair that
has a reasonable survival is lateral venoraphy or primary repair. This is
more likely a reflection of the severity of the injury than the success
of the repair. End-to-end anastomosis or interposition grafts with PTFE
or saphenous vein or port-caval shunts all have very poor survival rates.[54]
Portal vein ligation has been associated with survival but is only a salvage
maneuver for a patient who is in extremis from severe exsanguination. Patients
who have their portal vein ligated will have extensive bowel edema with
possible bowel necrosis and develop abdominal compartment syndrome. However,
flow studies show that the few patients who survive resolve their portal
hypertension over time. [55]
(to be continued March 2009)
Jana B.A. MacLeod MD, MSc, FRCS(C), FACS
Assistant Professor of Surgery, Assistant Director of Trauma
Emory University School of Medicine/ Grady Memorial Hospital,
Atlanta, Georgia
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