Intra-abdominal Visceral Injuries Research Articles

Road Traffic Accident Traumatic Vehicle Seat Belt Abdominal Wall Hernia

Traumatic abdominal wall hernia (TAWH) is a rare type of hernia with an incidence of about <1.5%, resulting from blunt abdominal trauma, which leads to an increase in the intra-abdominal pressure and rupture in the abdominal musculature and fascia with herniation of the abdominal organs into the defect. Most TAWH contained either a small bowel (69%) or a large bowel (36%), with 16% containing both. This condition is often not present as an isolated case, as 30% to 60% of the cases are accompanied by other intra-abdominal injuries. The typical manner of presentation is a tender subcutaneous swelling across the abdomen wall with overlaying bruising and ecchymosis. The radiological investigative modality of CT scan has the highest index of diagnosing accompanied intra-abdominal visceral injuries. We present a rare case of a 23-year-old male patient diagnosed with TAWH containing both small bowel and sigmoid colon associated with psoas hematoma caused by a seat belt postroad traffic accident (RTA).

Frequency of intra-abdominal visceral injury due to penetrating trauma in the Emergency Department of Imam Khomeini Hospital in 2020

Introduction: Trauma is an injury that occurs due to the exchange of environmental energy with the body to an extent that is unbearable. In developing countries, such as Iran, trauma, especially abdominal trauma, has become increasingly important due to the enhanced development of vehicles and industries. The present study aimed to assess the frequency of intra-abdominal visceral injury due to penetrating trauma in the Emergency Department of Imam Khomeini Hospital in 2020. Methods: This descriptive cross-sectional study was performed on 162 patients with penetrating abdominal trauma who were selected via the census method out of the patients referring to the Emergency Department of Imam Khomeini Hospital in Urmia, Iran. Data were collected using a checklist which included items on gender, age, length of hospital stay, patient's final condition, and cause of trauma, injury outcome, location of the injury, and laparotomy outcome. Data were entered into SPSS software (version 18) and analyzed using descriptive statistics (frequency, percentage, mean, and standard deviation) and chi-square test. Results: Out of 162 impenetrable trauma patients, 135 (83.3%) and 27 (16.7%) cases were male and female, respectively. The mean age of patients was 33.25±18.99 years. The causes of trauma were accidents (75.4%) and falls from height (24.6%). Furthermore, regarding laparotomy results, 29.6% of patients had no intra-abdominal visceral injury, while intestinal, liver, and spleen injuries were observed in 24.7%, 25.9%, and 19.8% of cases, respectively. Conclusion: As evidenced by the results of this study, the majority of trauma patients were male. Moreover, the most common mechanisms of trauma in patients referring to the emergency department of this accident center and the most commonly injured organs were the spleen and intestine. Therefore, appropriate measures are required to prevent these injuries.

Intra-abdominal Lymph Nodes: A Privileged Donor Site for Vascularized Lymph Node Transfer.

Summary:A variety of donor options for vascularized lymph node transfer for the surgical treatment of lymphedema have been described. Intra-abdominal harvest sites including the gastroepiploic nodes within the omental flap and the mesenteric node flap are distinguished from their extra-abdominal counterparts by the absent risk of iatrogenic donor site lymphedema and discrete scar location, as well as the ability to harvest up to 3 vascularized nodal packets from 1 donor site. However, there are also potential morbidities including hernia and intra-abdominal visceral injuries. Patient selection and flap harvest techniques are reviewed.

Frequency of Correct Findings of Abdominal Ultrasonography Compared with CT Scan in Detection of Solid Intra-Abdominal Visceral Injuries

Frequency of Correct Findings of Abdominal Ultrasonography Compared with CT Scan in Detection of Solid Intra-Abdominal Visceral Injuries

Peritoneal Breach as an Indication for Exploratory Laparotomy in Penetrating Abdominal Stab Injury: Operative Findings in Haemodynamically Stable Patients

Introduction. Management of haemodynamically stable patients with penetrating abdominal injuries varies from nonoperative to operative management. The aim was to investigate whether peritoneal breach when used as an indication for exploratory laparotomy appropriately identified patients with intra-abdominal visceral injury. Methods. We conducted retrospective cohort study of all patients presenting with PAI at a major trauma centre from January 2007 to December 2011. We measured the incidence of peritoneal breach and correlated this with intra-abdominal visceral injury diagnosed at surgery. Results. 252 patients were identified with PAI. Of the included patients, 71 were managed nonoperatively and 118 operatively. The operative diagnoses included nonperitoneal-breaching injuries, intraperitoneal penetration without organ damage, or intraperitoneal injury with organ damage. The presenting trauma CT scan was reported as normal in 63%, 34%, and 2% of these groups, respectively. The total negative laparotomy/laparoscopy rate for all patients presented with PAI was 21%, almost half of whom had a normal CT scan. Conclusion. We found that peritoneal breach on its own does not necessarily always equate to intra-abdominal visceral injury. Observation with sequential examination for PAI patients with a normal CT scan may be more important than exclusion of peritoneal breach via laparoscopy.

Acute aortic occlusion in a child secondary to lap-belt injury treated with thromboendarterectomy and primary repair

Abdominal aortic injury as a result of blunt trauma is a rare event and has been described in few children. A 6-year-old girl presented with acute bilateral lower extremity ischemia, and a triad of acute aortic occlusion, intra-abdominal visceral injury, and a lumbar chance fracture after sustaining a seat belt injury from a motor vehicle collision. An emergency aortic thromboendarterectomy and primary repair were performed. This represents one of the few reports of acute traumatic aortic thrombosis in a child and highlights the surgical treatment of acute abdominal aortic injury in a pediatric patient.

Retroperitoneo scopic nephrectomy on the treatmet of non-functioning kidney with hydronephrosis(Report of 5 cases)

Objective To evaluate the operation method and results of retroperitoneoscopic nephrectomy on the treatment of non-functioning kidney with hydronephrosis.Methods Retroperitoneoscopic nephrectomy was performed in 5 cases with nonfunctioning kidney with hydronephrosis.The retroperitoneal cavity were established with the fingers separating method.Afterwards ,3 Trocars were inserted through lumbar ports,the kidney was liberated partially,and made a small hole,the intrarenal fluid was drawn out.Then the kidney was liberated fully,the renal pedicle were exposed,and blocked with titanium clips or Hem-o-lok and then cut off,the non-functioning kidney was taken out in a specimen bag.Results The 5 operations were successful.The mean operative time was 170 min(150-300 min),and blood loss was 30 ml(10-80 ml).Drainage tube was removed 2-3 days after operation,we have not found any massive hemorrhage,infection,peritoneum rupture,intraabdominal visceral injury,and other severe complications.Conclusion Retroperitoneoscopic nephrectomy for non-functioning kidney with hydronephrosis is proved to be ninimal invasive,safe,effective,and rapid recovery.It would become the first choice for this kind of disease. Key words: Retroperitoneoscopic; Non-functioning kidney with hydronephrosis; Nephrectomy

The Diagnosis of Intraabdominal Visceral Injury

This article outlines the different modalities that have been used for the diagnosis of intraabdominal visceral injury. The methods span decades, and their development was driven by the need to provide an accurate and rapid diagnosis of intraabdominal injury for the patient. Some of these modalities parallel the explosion in technology. Each has been validated and criticized but eventually had developed its own "niche" in the assessment of the injured patient. Finally, they have all withstood the test of time.

Patterns of injury seen in deaths from accidental falls down a staircase: a study from South Delhi

The present study is a retrospective analysis of 92 cases of death from an accidental fall down a staircase, which were autopsied at the All India Institute of Medical Sciences, New Delhi, India, during a ten-year period from 1996 to 2005. The cases were analysed with regard to age, sex, location, cause of death and pattern of injury. Males (62, 67.39%) outnumbered females (30, 32.61%). The commonest age group involved was 31-40 years (28.26%) followed by 21-30 years (18.47%) and 51-60 years (14.13%). The lowest number of cases (4.34%) was in the 11-20 years age group. All deaths were accidental in nature. The most common cause of death was head injury (80.43%) followed by haemorrhagic shock resulting from intra-abdominal and intra-thoracic visceral injuries (9.78%) and injury to the neck (4.34%). The parietal and temporal bones were those most frequently fractured in head injury cases. Cerebral oedema (n = 56, 70.88%), followed by subdural haematoma (n = 34, 43.03%) were the two most common intra-cranial injuries. Two females were accidentally hanged while descending stairs. The majority of accidents happened at home (n = 90, 97.82%). Alcohol was detected in ten cases (17.54%). Fatalities from falls down a staircase were most often reported in the rainy season.

Transabdominal Impalement: Absence of Visceral or Vascular Injury a Rare Possibility

Background: Abdominal impalement injuries are usually associated with visceral and vascular injury, causing significant morbidity and mortality. The management of these injuries poses specific challenges in prehospital care, transport, and management strategies. Objective: We report a case of transabdominal impalement with no injury to intra-abdominal visceral or vascular structures, demonstrating a chance occurrence. The literature regarding abdominal impalement injury is reviewed and the management of these injuries is discussed. Case Report: A 35-year-old man with a transabdominal impalement injury after an accidental fall from a tree on to a wooden fence was brought to the Accident and Emergency Department. The wooden fence piece was impaled and in situ. Laparotomy revealed no intra-abdominal visceral or vascular injury. Conclusion: Transabdominal impalement injuries pose peculiar challenges in prehospital care, transport to hospital, and management. Operative intervention is required in all cases for a conclusive and safe management, as the possibility of escaping intra-abdominal injury is very rare.

Surgical Management of Severely Displaced Pediatric Seat-Belt Fracture-Dislocations of the Lumbar Spine Associated With Occlusion of the Abdominal Aorta and Avulsion of the Cauda Equina

Case report. To present 2 cases of fracture-dislocations of the lumbar spine associated with injury to the aorta and avulsion of the cauda equina and present recommendations regarding urgent management of these injuries. The "seat-belt syndrome" was first described by Garrett and Braunstein in 1962 to describe intraabdominal visceral injuries with fractures of the lumbar spine. Although this syndrome has been described in previously, there have been no reported cases of pediatric patients with significant injury to the abdominal aorta. We present 2 seat-belt injuries occurring within a 4 month period at a pediatric trauma center with significantly displaced lumbar fracture-dislocation, abdominal aortic occlusion, and complete neurologic injury. Rigid fixation of the spinal fracture dislocation in both cases was delayed since these patients were deemed to be hemodynamically unstable. Aggressive mobilization, wound care, and pulmonary toilet were possible after stabilization of the spine. Despite this, 1 patient eventually died. These cases need to be managed according to principles established in the treatment of extremity fractures with vascular and neurologic injuries. That is, early rigid fixation of the fracture to protect the vascular repair.

The Sentinel Clot Sign: a Useful CT Finding for the Evaluation of Intraperitoneal Bladder Rupture Following Blunt Trauma

ObjectiveTo evaluate the frequency and relevance of the "sentinel clot" sign on CT for patients with traumatic intraperitoneal bladder rupture in a retrospective study.Materials and MethodsDuring a recent 42-month period, 74 consecutive trauma patients (45 men, 29 women; age range, 12-84 years; mean age, 50.8 years) with gross hematuria were examined by the use of intravenous contrast-enhanced CT of the abdomen and pelvis, followed by retrograde cystography. Contrast-enhanced CT scanning was performed by using a helical CT scanner. CT images were retrospectively reviewed in consensus by two radiologists. The CT findings including the sentinel clot sign, pelvic fracture, traumatic injury to other abdominal viscera, and the degree of intraperitoneal free fluid were assessed and statistically analyzed using the two-tailed χ2 test.ResultsTwenty of the 74 patients had intraperitoneal bladder rupture. The sentinel clot sign was seen for 16 patients (80%) with intraperitoneal bladder rupture and for four patients (7%) without intraperitoneal bladder rupture (p < 0.001). Pelvic fracture was noted in five patients (25%) with intraperitoneal bladder rupture and in 39 patients (72%) without intraperitoneal bladder rupture (p < 0.001). Intraperitoneal free fluid was found in all patients (100%) with intraperitoneal bladder rupture, irrespective of an associated intraabdominal visceral injury, whereas 19 (35%) of the 54 patients without intraperitoneal bladder rupture had intraperitoneal free fluid (p < 0.001).ConclusionDetection and localization of the sentinel clot sign abutting on the bladder dome may improve the accuracy of CT in the diagnosis of traumatic intraperitoneal bladder rupture, especially when the patients present with gross hematuria.

Management of patients with major trauma

The management of patients with major trauma has evolved through organizational and technical advances. A multi-disciplinary trauma team should be activated before the patient arrives in the resuscitation room. The team must include doctors with skills for advanced airway management, intravenous and intraosseous cannulation, thoracotomy and laparotomy. Initial fluid resuscitation need not aim to return the systolic pressure to the patient’s original level, but excessive hypotension may compromise organ perfusion. Patients with head injury and hypotension have a particularly poor outcome, and normotension is the only aim in this group initially. Recent studies on the care of patients with head injury support the use of protocols to ensure target cerebral perfusion pressure (CPP). Thus, patients who are comatose, or those with abnormal CT brain scans and altered conscious level, should be transferred to units capable of measuring intracranial pressure (ICP). These units should also use techniques to control ICP, such as external ventricular drain, jugular venous oximetry and decompressive neurosurgery. Patients with intra-abdominal visceral injuries may benefit from the use of guided ultrasound (FAST) to reduce the need for CT scan. There is increasing experience of the non-operative management of visceral injuries in adults, mirroring this long-standing practice in children. The non-operative technique requires close monitoring in an augmented care setting, particularly in units that see few of these patients. Recent advice on pelvic fracture management advocates radiological control of haemorrhage, following initial non-operative pelvic stabilization.

TRAUMATIC ISOLATED PERICARDIO-DIAPHRAGMATIC RUPTURE

Pericardio–diaphragmatic rupture is an uncommon problem that poses a diagnostic challenge to surgeons. This article reports an unusual case of traumatic pericardio-diaphragmatic rupture in a 36-year-old male who has no additional intraabdominal visceral injury or thoracic pathology. There was a 7 cm lateral tear on the left dome of the diaphragm and a 2 cm medial tear, also involving pericardio-diaphragmatic junction, with the heart uninjured. The partially herniated stomach was easily pulled out from the thorax cavity through the diaphragmatic rupture. The rupture was reparied by interrupted non-absorbable sutures. The patient had no complaints on his follow up.

Abdominal aortic injury associated with “seat belt syndrome”

Flexion–distraction spinal injuries and intra-abdominal visceral injuries have a well-recognized association with the use of passive restraints during motor vehicle collisions. Abdominal aortic injury due to blunt trauma is rare. However, there is a reported association of this injury with seat belt use. We report a case of a restrained passenger in a motor vehicle collision who sustained this triad of injuries, with the abdominal aortic injury not initially suspected.

CT cystography: radiographic and clinical predictors of bladder rupture.

Our goal was to identify radiographic and clinical variables that correlate with bladder rupture that may then be used as selection criteria for CT cystography in trauma patients. Hemodynamically stable trauma patients with hematuria were examined under standardized protocol with dynamic oral and i.v. contrast-enhanced CT of the abdomen and pelvis, followed immediately by CT cystography. CT cystography consisted of contiguous 5-mm axial scans of the pelvis after retrograde distention of bladder with 300-400 ml of 4% iodinated contrast material. Radiographic and clinical variables (pelvic fracture, pelvic fluid, intraabdominal visceral injury, degree of hematuria, hematocrit, units of blood transfused, base deficit, injury mechanism, seat belt use, sex, age) were assessed and statistically analyzed using the two-tailed Fisher's exact test and Wilcoxon's rank sum test. Positive and negative individual and multivariate predictors were analyzed. Of the 157 patients entered in our study, 12 (eight males and four females) had bladder rupture. One or more pelvic fractures were present in nine (75%) of the 12 patients (p < 0.001). Pubic symphysis diastasis, sacroiliac diastasis, and sacral, iliac, and pubic rami fractures were statistically associated with bladder rupture. Isolated acetabular fractures did not correlate with rupture. Eight (67%) of the 12 patients with bladder rupture revealed on CT cystography had gross hematuria (p < 0.001). No ruptures were seen in patients with <25 RBC/HPF (red blood cells per high-power field). All patients with rupture had pelvic fluid revealed on standard contrast-enhanced CT (p < 0.001). Gross hematuria, pelvic fluid, and specific pelvic fractures were highly correlated with bladder rupture; identification of these findings may help in selection of trauma patients for CT cystography.

Single rope tree swing injuries among children.

To examine the scope and severity of injuries sustained from falls from single rope tree swings among children. Twenty-six children formed the basis of this retrospective study. Patients were divided into three groups based on the estimated distance of their fall (one, two, or three stories). Data were analyzed with respect to mechanism of injury, age, gender, length of hospital stay, injury severity score, number and type of injuries, and mortality. Eighteen patients fell from ropes, and 8 from vines (all onto packed dirt). Fourteen falls occurred from one story or less, 8 from two stories, and 4 from three stories. One death occurred from intracranial injury following a two-story fall. No difference in age, gender, injury severity score, or length of hospital stay with respect to the height of the fall was observed. Falls from lower heights resulted in equally severe injuries as falls from higher heights. Overall, head trauma was the most common injury (58%) followed by long bone fractures (42%), axial skeletal fractures (23%), and intra-abdominal visceral injuries (8%). The present study demonstrated that recreational single rope tree swing injuries among children resulted in significant morbidity regardless of the height of the fall. This activity carries a substantial risk for serious injury. The mechanism of injury, clinical data, and the importance of medical awareness and patient education are emphasized.

腎下部下大静脈損傷が疑われた後腹膜血腫の１例

A 12-year old boy was hit by a truck and admitted to our hospital. On admission, he was in a semicoma and his abdomen was distended but blood pressure was normal. Emergent brain CT revealed multiple brain contusions which were treated conservatively. Abdominal CT revealed extensive retroperitoneal hematoma and emergent laparotomy was performed. The operative findings were retroperitoneal tamponade and no intra-abdominal visceral injury. Since the blood was dark in color and non-pulsatile, and there was no circulatory shock, we did not explore the retroperitoneum and simple laparotomy was established. Circulatory status was stable after the operation and there was no injury to the pancreas, duodenum, kidney, spine or pelvic bone. Follow-up abdominal enhanced CT was performed on 30-POD, and thrombus was found in infra-renal IVC. The size of the thrombus was 32mm×7mm at IVC angiography which suggested that the cause of the retroperitoneal hematoma was the IVC injury at this site. Anti-coagulant therapy was performed. The thrombus disappeared 2 months after the operation, and there was no evidence of pulmonary embolism. He recovered completely and now doing well 1 year after the operation. Although mandatory exploration of retroperitoneal hematomas is accepted, surgical IVC repair is not always controllable. In some cases with stable circulation and no active pulsatile bleeding, IVC injury may be worth treating conservatively.

Laparotomy for pelvic fracture

To establish criteria for laparotomy, the records of 224 patients admitted with an acute pelvic fracture were reviewed. Forty-four patients underwent laparotomy; 2 had no intraabdominal injury. The mechanism of injury was blunt trauma in 31 patients and gunshot wound in 13. All four patients who died had blunt trauma. Major or minor pelvic fracture classification did not predict intraabdominal visceral injury, except for bilateral pubic rami fractures, which were commonly associated with bladder rupture. The accuracy of the indications for laparotomy was calculated and criteria were established. Signs of an acute abdominal disorder, the presence of a penetrating wound, abnormal findings on pyelography or cystography, persistent shock, evisceration, and diminished distal pulses, singly or in combination, had a 90 percent accuracy in indicating correctable intraabdominal injury. Peritoneal lavage was less reliable, with a 57 percent accuracy. Additional criteria to be considered are enlarging palpable abdominal hematoma, fracture or dislocation with bony fragments protruding into the pelvis, signs of persistent bleeding, and rectal injury or a large perineal wound.

Diagnosis of diaphragmatic tears

Twenty-five cases of torn diaphragm with herniation of abdominal contents and 22 cases without herniation were studied. Without herniation, the chest radiograph was in most cases normal or almost so, the remainder showing haemothorax or pneumothorax attributable to associated lung or rib injury. With herniation, however, the chest radiograph was infrequently normal and a substantial number showed basal abnormality directly due to herniated viscera. The appearances were still, however, non-specific and led to a number of preliminary misdiagnoses and therefore diagnostic delays. The herniated bowel can flatten out beneath the lung base to resemble merely a mildly elevated hemidiaphragm (the “pseudo-diaphragm effect”). Torn hemidiaphragm is a frequently forgotten diagnosis, but is of great importance because of hernial bleeding or strangulation. The peritoneopleural pressure gradient eventually produces herniation and this is usually diagnosable by barium study of stomach and colon. Small bowel studies are probably unnecessary. The limbs of the herniated loop are pinched together as they pass through the tear, sometimes severely enough to obstruct the barium. Insufflated air may get through into an apparently obstructed hernia. Because it is a “blind alley”, the herniated gastric fundus will not produce these typical appearances and will be missed unless one looks for the “amputated fundus” sign. Immediately following injury, normal barium studies do not necessarily indicate that there is no tear because there may not have been time for herniation to occur. The only available signs may therefore be the presence of a pneumoperitoneum or of intra-abdominal visceral injury following a downward stab to the lower chest, or of pneumothorax following abdominal injury. Diagnostic pneumoperitoneum may have a place. A left-sided predominance in all series is probably due to the liver cushioning the right hemidiaphragm from rupture in abdomino-pelvic crush injuries and also preventing bowel from herniating through established stab wounds.