Laparotomy For Blunt Abdominal Trauma Research Articles

Visceral Injuries In Blunt Abdominal Trauma

Introduction: Blunt abdominal trauma is a common indication of emergency exploratory laparotomy. There are different modes of injury in Blunt abdominal trauma and a variety of abdominal viscera are injured. There is insufficient literature on it in this part of the country. Aim of study: To observe mode of injury and visceral injuries in patients with blunt abdominal trauma who underwent exploratory laparotomy. Materials and Methods: All operated adult patients with blunt trauma of abdomen in a teaching hospital from 1 st May 2015 to 30 th April 2016 were included in the study. Children below 12 years of age were excluded from study. This is a retrospective observational study. The mode and nature of visceral injuries were noted. Related data from history sheets and operation records were collected. Data are analyzed by statistical methods. Results: Total number of operated patients was 57. Among them only one was female. Modes of trauma wereRTA in 43(75.4%) patients, fall from height in 7(12.3%) patients, physical violence in 5(8.8%) patients and fall of heavy object on abdomen in 2(3.5%) patients. Twenty(36.84%) patients had splenic injury, 11(19.3%) patients had hepatic injury, 23(40.35%)patients had small bowel injury, 1(1.75%) patient had stomach injury, 1(1.75%) patient had duodenum injury, 5(6.67%) patients had mesenteric tear, 1(1.75%) patient had retroperitoneal haematoma, 1(1.75%)patient had inferior vena cava injury and 1(1.75%) patient had colon injury. Some patients had combined visceral injuries. Conclusion: Road traffic accident is commonest mode of injury that needed exploratory laparotomy for blunt abdominal trauma. Most common visceral injury is small bowel injury followed by splenic and hepatic injury. Multiple visceral injuries are seen in some patients.

Unenhanced Computed Tomography to Visualize Hollow Viscera and/or Mesenteric Injury After Blunt Abdominal Trauma

To identify and describe the major features of unenhanced computed tomography (CT) images of blunt hollow viscera and/or mesenteric injury (BHVI/MI) and to determine the value of unenhanced CT in the diagnosis of BHVI/MI.This retrospective study included 151 patients who underwent unenhanced CT before laparotomy for blunt abdominal trauma between January 2011 and December 2013. According to surgical observations, patients were classified as having BHVI/MI (n = 73) or not (n = 78). Sensitivity, specificity, P values, and likelihood ratios were calculated by comparing CT findings between the 2 groups.Six significant CT findings (P < 0.05) for BHVI/MI were identified and their sensitivity and specificity values determined, as follows: bowel wall thickening (39.7%, 96.2%), mesentery thickening (46.6%, 88.5%), mesenteric fat infiltration (12.3%, 98.7%), peritoneal fat infiltration (31.5%, 87.1%), parietal peritoneum thickening (30.1%, 85.9%), and intra- or retro-peritoneal air (34.2%, 96.2%).Unenhanced CT scan was useful as an initial assessment tool for BHVI/MI after blunt abdominal trauma. Six key features on CT were correlated with BHVI/MI.

Laparotomy for blunt abdominal trauma in a civilian trauma service.

This report looks at the group of patients who required a laparotomy for blunt torso trauma at a busy metropolitan trauma service in South Africa. Methods. A prospective trauma registry is maintained by the surgical services of the Pietermaritzburg metropolitan complex. This registry is interrogated retrospectively. All patients who required admission for blunt torso trauma over the period September 2006 - September 2007 were included for review. Proformas documenting mechanism of injury, age, vital signs, blood gas, delay in presentation, length of hospital stay, intensive care unit stay and operative details were completed. Results. A total of 926 patients were treated for blunt trauma by the Pietermaritzburg metropolitan services during the period under consideration. A cohort of 65 (8%) required a laparotomy for blunt trauma during this period. There were 17 females in this group. The mechanisms of injury were motor vehicle accident (MVA) (27), pedestrian vehicle accident (PVA) (21), assault (5), fall from a height (3), bicycle accident (6), quad bike accident (1) and tractor-related accident (2). The following isolated injuries were discovered at laparotomy: liver (9), spleen (5), diaphragm (1), duodenum (2), small bowel (8), mesentery (8) bladder (10), gallbladder (1), stomach (2), colon/rectum (2) and retrohepatic vena cava (1). The following combined injuries were discovered: liver and diaphragm (2), spleen and pancreas (1), spleen and liver (2), spleen, aorta and diaphragm (1), spleen and bladder (1) and small bowel and bladder (2). Eighteen patients in the series (26%) required relaparotomy. In 10 patients temporary abdominal containment was needed. The mortality rate was 26% (18 patients). There were 6 deaths from massive bleeding, all within 6 hours of operation, and 3 deaths from renal failure; the remaining 9 patients died of multiple organ failure. There were 8 negative laparotomies (7%). In the negative laparotomy group false-positive computed tomography (CT) scan findings were a problem in 3 cases, in 1 case hypotension and a fractured pelvis on admission prompted laparotomy, and in the other cases clinical findings prompted laparotomy. All patients who underwent negative laparotomy survived. There were 10 pelvic fractures, 5 lower limb fractures, 2 spinal injuries, 4 femur fractures and 2 upper limb fractures. CT scans were done in 25 patients. In 20 patients the systolic blood pressure on presentation was <90 mmHg and in 41 the pulse rate was >110 beats/min. In 16 patients there was a base excess of <-4 on presentation. Conclusion. Laparotomy is needed in less than 10% of patients who sustain blunt abdominal trauma. Solid visceral injury requiring laparotomy presents with haemodynamic instability. Hollow visceral injury has a more insidious presentation and is associated with a delay in diagnosis. CT scan is the most widely used investigation in blunt abdominal trauma. It is both sensitive and specific for solid visceral injury, but its accuracy for the diagnosis of hollow visceral injury is less well defined. Clinical suspicion must be high, and hollow visceral injury needs to be actively excluded.

Prediction of the delayed complications of intestinal and mesenteric injuries following experimental blunt abdominal trauma

Injuries to the intestine and mesentery are often found in patients undergoing laparotomy for blunt abdominal trauma. Although treatment of perforations is relatively straightforward, the same is not true for contusions. Few guidelines exist at present to aid the surgeon in deciding which injuries require resection in order to avoid the complications of delayed perforation and late stricture formation. The natural history of these non-perforating intestinal and mesenteric injuries has been examined in an experimental model to identify possible criteria on which future management can be based. In the immediate postinjury period peristalsis and local mesenteric pulsation were absent in the majority of injuries which went on to full recovery and these observations are thus of little predictive value in predicting outcome. The initial size of contusion (length of contusion along longitudinal axis of bowel) relative to bowel wall circumference (BWC) was related to complications as follows: contusion less than BWC (n = 47)--one complication; contusion greater than BWC (n = 8)--three complications (P = 0.02). Similarly, six mesenteric injuries which produced an initial ischaemia (assessed by fluorescein) less than twice the BWC did not result in any complications, compared with four complications which occurred in ten cases when the initial ischaemia was greater than twice the BWC. These results go some way towards providing a better understanding of these injuries and in turn may help the emergency surgeon in deciding which injuries require resection.

Les polytraumatismes sont plus graves après chute d’une grande hauteur qu’après accident de la voie publique

Aims. – To compare specific features and prognosis of polytrauma victims requiring urgent laparotomy, after a free fall from a height (FFH) or a motor vehicle accident (MVA). Patients and methods. – Urgent laparotomy was performed only in case of massive hemoperitoneum associated with hemodynamic instability. Injury severity score (ISS) and hospital mortality rate were used to determine the severity of trauma. Results. – Two hundred and four patients underwent urgent laparotomy for blunt abdominal trauma: 79 after FFH (intentional defenestration: 65, accident: 14), and 125 after a MVA. Mean ISS was higher after FFH (39 ± 11) than MVA (35 ± 12) ( P< 0.05). Spine injury and pelvic fractures were more frequent and more severe in FFH patients, with a high incidence of retroperitoneal hemorrhage. Juxta-hepatic veins and inferior vena cava tears usually occurred after FFH. Hospital mortality was 48% (38/79) after FFH and 30% (37/125) after MVA ( P< 0.01). Predominant cause of death was associated injuries. The height of the fall was not a prognostic factor, unlike the quality of the landing surface: the mortality dropped from 59% (34/58) when patient fell onto a hard ground, to 19% (4/21) in case of soft landing surface ( P< 0.05). Conclusion. – Blunt abdominal trauma requiring urgent laparotomy is more severe after FFH than after MVA. The usual cause of death is associated injuries in both groups. Quality of the landing surface is a discriminating factor for mortality after FFH.

Liver fracture and bleeding.

Abstract At laparotomy for blunt abdominal trauma a surgeon in a district general hospital encounters a fractured bleeding liver. How should the problem be handled? Professor J. E. J. Krige of Cape Town, South Africa, replies.

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.

The presence of hemorrhagic shock increases the rate of bacterial translocation in blunt abdominal trauma.

Sepsis and multisystem organ failure are common after hemorrhagic shock. The aims of this study were to determine whether hemorrhagic shock would promote the translocation of bacteria and if it correlates with clinical outcome in patients with blunt abdominal trauma. Twenty-six patients requiring laparotomy for blunt abdominal trauma (group I) and 30 patients operated electively (group II) were studied. Injury Severity Score, Trauma Score, and Acute Physiology and Health Evaluation (APACHE) II score were recorded before the operation. Peritoneal swab, mesenteric lymph node, portal venous blood, liver wedge biopsy, and spleen biopsy (in splenectomized patients) were sampled for culture after surgical hemostasis. Additionally, peripheral blood samples were taken preoperatively and postoperatively in group I patients for culture. The same samples were taken in group II patients except for the spleen biopsy. Moreover, patients in group I were further subdivided into subgroups A and B, indicating the presence or absence, respectively, of hemorrhagic shock (defined as systolic blood pressure < 90 mm Hg with identifiable blood loss). Postoperatively, patients were checked for infectious and septic complications. Mean Injury Severity Score, Trauma Score, and APACHE II score were 32.0, 12.1, and 10.9 in group I and 2.1 (APACHE II,p < 0.01) in group II, respectively. Two patients in group IA, eight patients in group IB, and one patient in group II demonstrated bacterial translocation (BT) (p < 0.01). Five patients with blunt abdominal trauma had major infectious complications, but only one had BT, and the same microorganism grew in the intra-abdominal abscess. There were two infectious complications in the control group. One of these patients had BT, and the same microorganism grew in the wound infection. We conclude that BT occurs after blunt abdominal trauma in humans and correlates with the presence of hemorrhagic shock, but the clinical significance of BT in trauma patients remains unclear.

Intra-abdominal Abscess After Blunt Abdominal Trauma

The relationship between blunt abdominal trauma and intra-abdominal abscess (IAA) is discussed infrequently; therefore we conducted a retrospective review of 4050 multiple blunt trauma admissions from January 1986 to July 1988. Of 325 patients who had a laparotomy for blunt abdominal trauma, we identified 15 (4.6%) who had 40 IAAs. The most common intra-abdominal injuries involved the spleen and liver. Splenectomy increased the risk for IAA in contrast to splenic salvage. Blunt injuries to the kidney and pancreas, when occurring in multiple trauma patients, carried a significant risk of IAA. Associated multiple extra-abdominal injuries and high transfusion requirements increased the risk for IAA formation. Most of the IAAs were located in the upper quadrants. There was a 46% incidence of multiple IAA, which in turn had an 80% chance of recurrence after initial drainage. Enterobacter species played an important role in the formation of IAA in our trauma patients. Three patients (20%) died. Poor prognostic indicators included a high injury severity score, high transfusion requirements, the presence of pelvic fracture, positive blood cultures, multiple organisms per abscess, and multiple-organ system failure.

Significance of serum amylase level in evaluating pancreatic trauma

A series of fifty-one patients who underwent exploratory laparotomy for blunt abdominal trauma is reviewed. Attempts to correlate preoperative serum amylase levels with pancreatic injury were unsuccessful. We could find no statistically significant correlation between elevated serum amylase and pancreatic injury. The accuracy of the test improved somewhat with markedly abnormal serum amylase levels (greater than 300 Somogyi units/ 100 ml), but even at these levels the correlation was not significant. One must conclude that there is no correlation between elevated serum amylase and pancreatic injury in blunt abdominal trauma. Decisions as to the advisability of operation in patients with such trauma should therefore be based on other parameters.