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SOLID ORGAN INJURIES
SPLEEN , LIVER , PANCREAS
2013
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Abdominal Injuries
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5 pillars
Solid Organs: Bleed, shock
Hollow Organs: Leak, peritonitis
Retroperitoneum: pancreas, large vessels
Urinary system
Diaphragm
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Mechanism of injuries
• Blunt:
• spleen, liver, and small bowel
• Penetrating stab:
• liver, small bowel, diaphragm, colon
• Penetrating gun shot:
• small bowel, liver, colon
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Splenic Function
• Immunologic filter
• Primary remover of non-opsonized bacteria
• Produces tuftsin and properdin
• Properdin vital component of alternate
pathway of complement activation
• Immunoglobulin production
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Splenic Anatomy
• 100-250 grams
• 200 cc/min blood flow
• Splenic artery
• 85%-extrasplenic bifurcation
• 15%-extrasplenic trifurcation
• Ligamentous attachments
• stomach, kidney, diaphragm, colon
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Diagnosis of Splenic Injury
• Physical examination - poor sensitivity
• Ultrasound - nonspecific
• DPL-too sensitive, ? role in nonoperative
management
• CT-most common in hemodynamically stable
pts
• Laparoscopy-has not found a universal role
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AAST SPLEEN INJURY SCALE (1994 REVISION)
Grade
Injury Description
I
Hematoma Subcapsular, nonexpanding, < 1 0% surface area
Laceration Capsular tear, nonbleeding, < 1 cm parenchymal depth
II
Hematoma Subcapsular, nonexpanding, 10-50% surface area;
intraparenchymal, nonexpanding, < 5 cm in diameter
Laceration Capsular tear, active bleeding; 1-3 cm parenchymal depth
which does not involve a trabecular vessel
III
Hematoma Subcapsular, > 50% surface area or expanding; ruptured
subcapsular hematoma with active bleeding;
intraparenchymal hematoma > 5 cm or expanding
Laceration > 3 cm parenchymal depth or'involving trabecular vessels
IV
Hematoma Ruptured intraparenchymal hematoma with active
bleeding
Laceration Laceration involving segmental or hilar vessels producing
major devaculadzation (> 25% of spleen)
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Laceration Completely shattered spleen
VI
Vascular
Hilar vascular injury which devascularizes spleen
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Management of Splenic Injuries
Factors Influencing Decision
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Age of patient- >55yo splenectomy better
Success of non-operative management- 68-83%
Risk of missed injury
Risk of OPSI-0.026-1.0% over lifetime
Risk of blood transfusion-0.014% per unit
Risk of nontherapeutic laparotomy-0.01-6.0%
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Non-Operative Management
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Proper patient selection
Bed rest 2-3 days
Serial physical exams, Hcts x 24-48 hours
Follow-up CT scan at 3-5 days
Overall hospitalization 5-10 days
Severe injuries-3 months no contact sports
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Non-operative management
• Embolisation
• Trans-arterial catheter  aorta  splenic artery
• Partial or total splenic embolization
• Splenic immunocompetence is preserved after
splenic artery angio-embolisation
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Operative Management
• Midline incision, pack, examine abdomen
• Systematic splenic mobilization
• Splenorrhaphy- Cautery, surgicell, pledgetted
sutures, mesh wrapping
• Splenectomy- life threatening bleeding
• Autotransplantation-experimental
• Vaccination-Pneumococcus, H. influenza,
N. meningitidis
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Complications
• Pneumonia most common
• Subphrenic Abscess 3-13%
• Recurrent bleeding - up to 45 days
• 1% re-operative rate (for haematoma, or
abscess drainage for example)
• Acute gastric distention- kids usually
• Thrombocytosis (very high platelets)
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OPSI
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Nausea, vomiting, confusion, sepsis
Mortality 50-70%
Vaccine provides 60% protection
Best timing of vaccine unknown
Proper counseling a must
Sensitive to malaria
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HEPATIC INJURIES
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ANATOMY
INJURY CLASSIFICATION
INITIAL PATIENT MANAGEMENT
OPERATIVE TECHNIQUES
SPECIAL TOPICS
• JUXTAHEPATIC VENOUS INJURIES
• SUBCAPSULAR / INTRAHEPATIC HEMATOMAS
• EXTRAHEPATIC BILIARY TREE INJURIES
• COMPLICATIONS
• Most commonly injured in stab wounds and blunt injuries
• Present as bleeding with hemodynamic instability
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ANATOMY
• LIGAMENTOUS ATTACHMENTS
• TRIANGULAR
• CORONARY
• FALCIFORM
• COUINAUD CLASSIFICATION OF LOBAR
/ SEGMENTAL DIVISIONS
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LIVER INJURY SCALE (1994 REVISION)
Grade
Injury Description
I
Hematoma
Laceration
Subcapsular, nonexpanding, < 1 0 cm surface area
Capsular tear, nonbleeding, < 1 cm parenchymal depth
II
Hematoma
Subcapsular, nonexpanding, 10-50% surface area: intraparenchymal
nonexpanding< 1 0 in diameter
Capsular tear, active bleeding; 1-3 cm parenchymal depth, < 1 0 cm in length
Laceration
III
Hematoma
Laceration
Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma
with active bleeding; intraparenchymal hematoma > 10 cm or expanding
> 3 cm parenchymal depth
IV
Hematoma
Laceration
Ruptured intraparenchymal hematoma with active bleeding
Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinaud's
segments within a single lobe
V
Laceration
Parenchymal disruption involving > 75% of hepatic lobe or > 3 Couinaud's
segments within a single lobe
Juxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic
veins)
Vascular
VI
Vascular
Hepatic avulsion
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DIAGNOSIS OF LIVER INJURY
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ATLS primary / secondary surveys
Peritoneal signs - exploration
Hemodynamic instability - US or DPL
Stable – CT scan with contrast (embolization)
Non-operative management : hemodynamic stability, no
other suspected injuries, alert patient*, ICU monitoring,
accessible for re-examination, minimal transfusions
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LIVER -Penetrating Wounds
• STAB WOUNDS
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LOCAL WOUND EXPLORATION
ULTRASOUND
DPL
? LAPAROSCOPY
• GUNSHOT WOUNDS
• EXPLORE
• ? ROLE FOR ULTRASONOGRAPHY
• ? ROLE FOR LAPAROSCOPY
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OPERATIVE TECHNIQUES
• MANUAL COMPRESSION
• EXPOSURE(INCISION + LIGAMENTS)
• PRINGLE MANEUVER (32-75 MINUTES)
• Portal vein; hepatic artery: block inflow of blood; find
source of bleeding
• TOPICAL HEMOSTATIC AGENTS
• BOVIE / ARGON BEAM COAGULATOR
• FIBRIN GLUE
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OPERATIVE TECHNIQUES
• Tractotomy / individual vessel and duct
ligation
• Omental packing
• Resectional debridement
• Absorbable mesh wrapping
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OPERATIVE TECHNIQUES
• Drainage (grade III or better)
• Laparotomy pad packing - remove before 3
days if possible
• *Deep sutures
• *Hepatic artery ligation
• *Anatomic lobectomy
*avoid if possible
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OPERATIVE TECHNIQUES
• HEAT CONSERVATION
• BEGINS WITH INITIAL PATIENT CONTACT
• LIMIT HEMORRHAGE
• SPEED / EFFICIENCY COUNTS
• EQUATES TO PROMPT DECISION-MAKING
• DAMAGE CONTROL SURGERY: quick, manage
bleeding and contamination; continue resus in ICU
• PREVENT TRIAD OF ACIDOSIS,
COAGULOPATHY AND HYPOTHERMIA
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(affects clotting mechanism)
Control of Transhepatic Penetrating
Wound
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Juxtahepatic Venous Injury
• Early recognition
• Big (chest) incisions (laparotomy and
thoracotomy)
• Atrial-caval shunt or caval balloon shunt
• Direct attack with or without hepatic
vascular isolation
• Packing alone
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Atrial-Caval
Shunt
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Subcapsular Hepatic Hematomas
During non-operative treatment , operate for:
• On-going hemorrhage
• Progressive expansion by ct scan
• Signs of infection
• Deteriorating transaminase measurements
Intra-operative, if not expanding:
• Leave alone in stable patients
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Extrahepatic Biliary Tract Injury
• Rare: 3-5% of all abdominal trauma
• Gallbladder (most common)
• cholecystectomy
• CBD > RHD> LHD
• <50% circumference - repair with or without Ttube; drain
• >50% circumference - duct enterostomy; drain
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COMPLICATIONS
• Recurrent bleeding - 2% to 7%
• Fever - 65% to 75%, grade 3 or more
• Abscess - 2% to 10% (increased by shock,
transfusion, colon injury)
• Biloma / biliary fistula - 5% to 28%
• Hemobilia - extremely rare; 1/3 have jaundice,
upper GI bleed, right upper quadrant pain
• Arterial portal venous fistula
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Damage Control Considerations
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Deep suturing
Packing
Omental packing
Drains
Antibiotics
Atrial-caval shunts
CT scan / non-operative management
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PANCREATIC INJURY
• RETRO-PERITONEAL ORGAN
• PENETRATING INJURY – IS THE DUCT
INTACT ?
• BLUNT INJURY – TRANSECTION OF
GLAND OVER THE VERTEBRAL COLUMN
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PANCREATIC INJURY
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DIAGNOSIS DIFFICULT
HIGH INDEX OF SUSPICION
CLINICAL EXAMINATION NOT HELPFUL
U/S, CT SCAN IF STABLE
SERUM AMYLASE (increased? Duct intact? >>)
• do ERCP
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Diaphragmatic injury
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Traumatic rupture (blunt trauma)
More common on left side (85%)
Tear posterolateral from hiatus
Herniation of stomach, colon, spleen into chest
Penetrating injury usually a small hole, on either
side
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Diaphragmatic injury
• Diagnosis: clinical difficult
• Bowel sounds in chest on auscultation
• CXR: high diaphragm on left side, or diaphragm
invisible
• Confirmation by passing a nasogastric tube,
which can be seen in stomach in chest
• Chronic: contrast studies (Ba meal or enema)
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Diaphragmatic injury
• Laparoscopy (or thoracoscopy) for diagnosis
• Repair: surgical, via laparotomy (or thoracotomy),
or endoscopic technique
• Pitfall: PPV (positive pressure ventilation)
reduced the abdominal organs from chest
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Questions?
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