Approach and management of abdominal trauma..no problem!

1. BLUNT TRAUMA ABDOMEN

2. • INRTODUCTION
• MECHANISM N PATTERN OF INJURY
• DIAGNOSTIC APPROACH
• TRAUMA MANAGEMENT
• DCS N ABDOMINAL EXPLORATION
• DEFINITIVE ORGAN INJURY N MANAGEMENT

3. INTRODUCTION
• Greek word 'tpavua', trauma= injury
• injury (in + jus, 'not right') or wound
• structural alteration and/or physiologic imbalance
• most common cause of death for all individuals
between the ages of 1 and 44 years
• third most common cause of death regardless of age

4. Common causes Blunt Trauma Abd.
• Motor vehicle crash,
• Fall,
• Assault,
• Crush
• Recreational accidents
– blunt trauma is associated with multiple widely
distributed injuries

5. Mechanism of Blunt Trauma
• Result from the impact force and deformation
related to deceleration and compression
• Impact force = magnitude and duration
• Deformation = strain
• Strain
– Compressive/ crushing:
– Shearing /opposing:
– Tensile /stretching
• Strain > elasticity or viscosity = disruption/injury

6. Pattern of injury
• Solid organ laceration
– spleen (40-55%), liver (35-45%), kidney ,pancreas
• Tear or avulsion of mesentery /pedicle of solid organ 5%
• Rupture of small bowel or colon 5-10%
• GU injuries
• Vascular injury
• Fracture of Pelvis / Ribs n vertebrae
• Diaphragmatic rupture
• Abrasion/ laceration

7. DIAGNOSIS
• HISTORY
• CLINICAL EXAMINATION
• DIAGNOSTIC SURGICAL PROCDURE
• INVESTIGATION

8. HISTORY
• Mechanism of blunt trauma
• Time and place of injury
• Magnitude of force/Speed of Vehicle
• Status of other vehicle occupant
• Patient’s position in vehicle
• Duration of entrapment
• Use of protective gears/ safety devices
• Presence of alcohol or drug uses
• Presence of psychiatric illness

9. PRESENTATION
• H/O trauma
• Pain abdomen
• Abdominal distension
• Vomiting
• Haematuria/ urinary retention
• Loss of conciousness
• Abdominal wall injury
• Other associated injuries – # dislocation,

10. EXAMINATION
• General Physical Examination
• Systematic Abdominal examination
– Abrasions, ecchymosis, seat belt abrasions or contusion
,distension
– Generalized tenderness, rebound tenderness, guarding ,
rigidity,# ribs
– tympany in gastric dilatation or free air; dullness with
hemoperitoneum
– Bowel sound/ bowel sound in thorax
• DRE
– evaluate sphincter tone and to look for blood, perforation, or
a high-riding prostate

13. • Grey-Turner sign:
Bluish discoloration of lower flanks, lower back; associated
with retroperitoneal bleeding of pancreas, kidney, or pelvic
fracture.
• Cullen sign:
Bluish discoloration around umbilicus, indicates peritoneal
bleeding, often pancreatic hemorrhage.
• Kehr sign:
L shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abd bleeding)
• Balance sign:
Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.
• Seatbelt sign:
results from compression from an improperly positioned (too
high, over the abdomen instead of the bony pelvis) lap
seatbelt in a motor-vehicle crash

14. SEAT BELT SYNDROME
• first described by Chance in 1948
• resulting from hyperflexion of the spine about a fixed
axis anterior to the vertebral column. It includes
– # posterior process and/or the body of the lumbar spine,
– fractures of the neck of the pancreas and
– avulsions of the small-bowel mesentery
• Many trauma surgeons consider a true seatbelt sign as
an indication for operation, as it is associated with such a
high incidence of visceral injury.

15. PROBLEM IN EVALUATING
• altered sensorium (injury to the brain, ingestion of
alcohol or illicit drugs);
• altered sensation (injury to the spinal cord);
• injuries to adjacent structures (ribs, pelvis,
thoracolumbar spine); or
• physical examination is equivocal.

16. INVESTIGATION
• LAB:
– CBC, Coagulation profile, blood grp n cross matching,
– urinalysis, urine toxicological screen, and serum or
urine pregnancy tests in females of appropriate age.
– Serum amylase n lipase
• PLAIN X-RAY: CXR, pelvis; AxR
– Diaphragmatic injury, pneumoperitoneum, # ribs
/vertebrae
• CONTRAST X-RAY
– ( IVU, RETROGRADE URETHROGRAM,
PYELOURETEROGRAM/CYSTOGRAM, VOIDING
CYSTOURETHROGRAM)

17. • DPL
• FAST
• CECT
• OTHERS-
– ERCP/ANGIOGRAPHY
• Diagnostic Laparoscopy
– no clear advantage over less invasive modalities
such as DPL or CT scan and complications can
occur from trocar misplacement.

18. FAST
• Focused Assessment with Sonography for
Trauma
• The current examination protocol consists of 4
acoustic windows with the patient supine.
– pericardiac, perihepatic, perisplenic, and pelvic
(known as the 4 Ps).
– Sensitivity 76 - 90%
– Specificity 95 - 100%

19. FAST: Strengths and Limitations
Strengths
• Rapid (~2 mins)
• Portable
• Inexpensive
• Technically simple, easy to
train
• Can be performed serially
• Useful for guiding triage
decisions in trauma patients
Limitations
• Does not typically identify
source of bleeding,
• Requires extensive training
• Limited in detecting <250 cc
• Particularly poor at detecting
bowel and mesentery damage
(44% sensitivity)
• Difficult to assess
retroperitoneum
• Limited by habitus in obese
patients

21. Diagnostic Peritoneal Lavage
• unstable trauma patients in whom FAST results are
negative or inconclusive
• 98% sensitive 96 % specific for intraperitoneal bleeding
• Open or closed
• usually infraumbilical, but may be supraumbilical in
pelvic frxs or advanced pregnancy.
• Rapid, inexpensive

22. +VE DPL
• Free aspiration of blood , GI content, bile > 10 ml,
considered +ve
• If gross blood (> 10 mL) or GI contents not aspirated,
perform lavage with 1000 mL warmed NS. Allow to
mix, compress abdomen and logross paient, the sent to
lab. + test:
– >100,000 RBC/mm3,
– >500 WBC/mm3,
– >19 iu/l Amylase
– >2 iu/l ALP
– >0.01 mg/dl Bilirubin
– Gram stain with bacteria.
• Only approximately 30 mL of blood is needed in the
peritoneum

23. CT-SCAN
– Hemodynamically stable patients with positive FAST
– equivocal findings on physical examination,
– associated neurologic injury, or
– Significant pelvic fractures
– multiple extra-abdominal injuries.
– Inconclusive FAST with
• Persistent LUQ tenderness
• Gross haematuria
• Hct < 33 in adult n < 35 in paeds

24. + VE findings in CT
• Contrast extravasation
• Intrabdominal Hge
• Presence of
pseudoaneurysm
• Thickened bowel wall
• Streaking in the mesentry
• Free fluid without assoc
solid organ injury
• Free intraperitoneal air
CT is superior
• Source of bleeding
• Amount of blood in abd
• Precision of organ injury
• Verterbral / pelvic #

25. • “Death begins with a CT.” Never send an
unstable patient to CT. FAST, however, can be
performed during resuscitation.

27. MANAGEMENT

28. • ATLS protocol
Pre hospital triage
Primary survey
Resuscitation
secondary survey
Diagnostic evaluation
Definitive care

29. PHROPHYLACTIC MEASURES
• Antibiotics
• Tetanus prophylaxis
• Prevention of Venous thromboembolism n
assoc. complications
– Multiple # of pelvis n lower extrimites
– Ligation of large vein
– Coma or spinal injury
– Morbidly obese n age > 55 yrs
• Prevention of hypothermia

30. Maneuvers to prevent or reverse hypothermia
• Warm trauma resuscitation room
• Increase operating room temperature > 85°F
• Cover patient's head with a turban or warming device
• Cover body parts not being examined or out of the operative field
• Warm IV fluid and blood n blood products
• Irrigate nasogastric and thoracostomy tubes with warm saline during
laparotomy
• Irrigate open body cavity pericardial cavity, pleural cavities, and peritoneal
cavity during simultaneous sternotomy or thoracotomy and laparotomy
• Turn up heating cascade on anesthesia machine
• Arteriovenous rewarming for severe hypothermia

31. Transfusion Practices
• Target
– Hb % > 7 or 10 in acute phase of resuscitation
– INR > 1.5
– PPT > 45 secs
– Platelet cout > 50,000 to 1 lakh /ul
– Fibrinogen level > 100 mg/dl
• Components
– Whole blood
– PRBC
– FFP
– Cryopercipitate

32. Denver Health Medical Center's
MASSIVE TRANSFUSION PROTOCAL
Trigger: uncontrolled Hge, anticipated coagulopathy, SBP<90 despite 3.5 L crystalloid
• Surgery n Anesth response
– Continued Rx of shock
– Hge control
– Correct hypothermia
– Correct acidosis
– Normalise Ca
– Check labs q30m as
needed
– Consider Recombinant
Factor VIIa therapy
• Blood Bank Response
Shipment PRBC FFP Plat Cryo
1 4 2
2 4 2 1 10
3 4 2
4 4 2 1 10

33. *BLOODY VISCIOUS CYCLE*
Life threatening trauma
Blood Loss
Iatrogenic
factors
Cellular
shock
Tissue
injury
Massive RBC
transfusion
Preexisting
disease
Progressive systemic
coagulotpathy
Core
hypothermia
Metabolic acidosis
Acute endogenous coagulopathy
Clotting factors deficiency

34. DAMAGE CONTROL SURGERY
• The purpose is to limit operative time so the
physiological restoration is possible
• The objective is
– Control surgical bleeding
– Limit GI spillage
• Using temporary measures
ER OR ICU OR ICU

35. Intraoperative indications to perform ‘DCS’
Factor Level
Initial body temperature < 35°C 2.
Initial acid-base status ·
– Arterial pH <7.2 ·
– Base deficit
< –15 mmol/l for < 55
< –6 mmol/l for > 55
– Serum lactate > 5 mmol/l 3.
Onset of coagulopathy
– PT and /or PTT > 50 % of normal

36. Three phases of 'damage control' Surgery
1.Limited operation for control of hemorrhage and
contamination ·
• Ctrl He/ Resection, repair / Packing/ Alternate closure or
coverage
2. Resuscitation in the SICU ·
• Rewarm / Restore loss/ correct/ support / monitor ACS
3. Reoperation · 12 – 24 hr
• Completion of definitive repairs / search for injuries / formal
closure

37. Bowel Injuries
– Complete transection of bowel of segmental damage with GI stapler
– Whip stitch 2-0 prolene for small injuries
– Open end ligated using umbilical tape
Vascular Injuries
– Interposition PTEE graft for Aortic injuries
– Celiac artery can be ligated
– SMA must maintain flow - insertion of intravascular shunt
– Ligation of venous injuries except for supra renal IVC and Popliteal vein
Solid organs
– Excision rather than repair
– Packing and compression tamponade
Abdomen closed temporarily ( TOWEL CLIPS/ DRAPE)

39. ABDOMINAL COMPARTMENT SYNDROME
• It is intraabdominal hypertension due to
– Intra-abdominal injury ( primary)
– splanchnic reperfusion after massive resuscitation
(secondary)
• sources of increased IAP include gut edema,
ascites, bleeding, and packs, among others
• The cause of edema is multifactorial.
– Ischemia and reperfusion cause capillary leakage;/
dec oncotic pressure/ venous or lymphatic obstrucion

40. Recommended Treatment for Abdominal
Compartment Syndrome Grading According to Intra-
Abdominal Pressure (IAP)
Grading IAP in mmHg Treatment
I 10-15 Normal
II 16–25 Volume expansion; may
need decompression
III 26–35 monitor PO2, SaO2,
urine output; decompression
likely
IV >35 Decompress in OR

42. Abdominal Exploration
• Incision
• Liquid and clotted blood is evacuated – id major active bleeding
• Spleen n liver palpated n packed
• Infracolic mesentry inspected
• If SBP < 70 mmhg – clamp the abdominal aorta at hiatus
• uncontrolled liver bleeding- Pringle Maneuver
• Clamp the splenic hilum
• Mobilize the spleen

43. Pringle Maneuver

47. • Source of enteric contamination identified
• Anterior and posterior stomach inspected
• Duodenal injuries evaluated with kocher
maneuver
• Pancreas examined during expl of lesser sac

48. DIFINITIVE ORGAN INJURY
N
MANAGEMENT

49. HEPATIC TRAUMA
American Association for the Surgery of Trauma Grading Scales for Solid Organ Injuries
Subcapsular Hematoma Laceration
Liver Injury Grade
Grade I <10% of surface area <1 cm in depth
Grade II 10–50% of surface area 1–3 cm
Grade III >50% of surface area or >10 cm in depth >3 cm
Grade IV 25–75% of a hepatic lobe
Grade V >75% of a hepatic lobe
Grade VI Hepatic avulsion

50. NON- OPERATIVE Rx
• 80 to 85 % are stable
• nonoperative management is appropriate after a contrast
CT
• Patients are kept at bed rest, and their vital signs are
monitored in SICU
• Repeat CT at 5 to 7 days following injury to determine..
• Return to vigorous physical activity or contact sports is
prohibited until a late follow-up CT shows healing.
• fails in approximately 2 to 7 per cent

51. OPERATIVE MANAGEMENT

52. Indicaiton for Opertaion
• hypotension in the field or in the emergency center,
• persistent significant tachycardia despite aggressive
resuscitation,
• the presence of active hemorrhage from the liver, spleen, or
kidney on the contrast CT, or
• the presence of another organ injury mandating laparotomy.
• A falling hematocrit or continuing need for transfusion during
the nonoperative period
• New onset peritonitis and hypotension

53. General Principle
• Midline incision
• Evacuate blood n clot manually or suction device
• injured lobe is compressed between laparotomy pads
• Pringle maneuver
• Injuries of the portal triad vasculature should be
addressed immediately
• Assess for retrohepatic venacava n extrahepatic venous
injury---- may need sternotomy/ vascualr isolation for
repair

55. Simple technique of haemostasis
• 60 % with 5 min of compression,
• the application of topical hemostatic agents,
• Electro cautery or
• simple suture hepatorrhaphy

56. Advanced technique of hemostais
 perihepatic packing;
 extensive hepatorrhaphy;
 hepatotomy with
selective vascular ligation;
 viable omental pack;
 resectional debridement
with selective vascular
ligation;
 absorbable mesh
compression;
 formal resection;
 selective hepatic artery
ligation;
 intrahepatic balloon
tamponade;
 atriocaval shunt

65. EXTRA HEPATIC BILIARY INJURY
• Cholecystectomy
• T- tube insertion
– Small lacerations with no accompanying loss or
devitalization of adjacent tissue
• Roux-en-Y choledochojejunostomy
– all transections and any injury associated with
significant tissue loss

66. Complication
• Postoperative hyperpyrexia 2/3rd
• Early postoperative coagulopathies 15 %
• reoperations for persistent or late hemorrhage in 3 to 7 %.
• Self-limited biliary fistulas - 8 to 10 %
• Biliomas
• Hepatic necrosis
• Arterial pseudoaneurysm
• Intra-abdominal abscesses 4 to 10 %

67. SPLENIC TRAUMA
• most common
• may present as
– 'delayed‘ rupture
• 48 Hr after initial injury (expanding subcapsular
hematoma
– or 'spontaneous' rupture
• diseased spleen usually results from trivial trauma
• often associated with fractures of the left
lower ribs

68. SPLENIC TRAUMA
Subcapsular Haematoma Laceration
Grade I <10% of surface area <1 cm in depth
Grade II 10–50% of surface area 1–3 cm
Grade III >50% of surface area or >10 cm in depth >3 cm
Grade IV >25% devascularization Hilum
Grade V Shattered spleen/ completely
devascularised
American Association for the Surgery of Trauma Grading Scales for Solid Organ Injuries

69. NON-OPERATIVE
• Confirm extent of injury with USG, CT
• 20 to 45 %
• ICU care,
• Bed rest is imposed
• Transfer to ward 24 to 48 h of observation
• restrict activity for 4 to 6 wks n contact sports 6 mth
• Regular rescanning
• Resolution of the trauma, at 3 months in 90 per cent
• One-third 'fail' and require surgery

70. Conservative in Children
• overwhelming postsplenectomy infection.
• multiple injuries are also less common.
• Better capacity for haemostasis,
• Increased resilience of the cardiovascular system
to hypovolaemia,
• Increased compliance of the splenic capsule and
septa.

71. OPERATIVE
• SPLENECTOMY
• PATIAL SPLENECTOMY
– upper or lower pole injury
– Hemorrhage from the raw splenic edge is
controlled with horizontal mattress sutures, with
gentle compression of the parenchyma
• SPLENIC REPAIR (splenorraphy)

73. SPLENORRAPHY
• Aim - control of bleeding and to avoid causing or
leaving behind infarcted splenic tissue.
• Simple suture of the torn spleen often results in
further bleeding, but the use of a buttress technique
with collagen, omentum, or Teflon pledgets can be
effective.
• Haemostatic agents can be used in addition to the
sutures .
• electrocautery; argon beam coagulation
• The spleen may be wrapped in the greater Omentum
/Mesh to assist haemostasis,

74. INDICATION FOR SPLENECTOMY
20-30%
– Extensive hilar injury
– Avulsion
– extensive fragmentation
– failure to achieve haemostasis following attempted
splenorrhaphy
– any injury of grade II or higher in a patient with
coagulopathy or multiple injuries
– Haemodynamic instability

75. Complication
• Postop Hge / Recurrent Bleeding
• Subphrenic abscess
• Pancreatic ascites or fistula
• Thrombocytosis n thrombosis
• Postsplenectomy infection

76. SPLENOSIS N AUTOTRANSPLANTAION
• Splenosis, is spontaneous regrowth of splenic tissue
• lower incidence of overwhelming postsplenectomy
infection.
• may be as high as 50 per cent following trauma.
• 25 to 30 g of tissue is needed for protection
• splenic tissue can be autotransplanted at the time of
surgery
• normal splenic vasculature is crucial for maximum
protection.

78. MESENTRIC TRAUMA
• Blunt trauma to the abdomen- 5%
• The injury can result in
– mesenteric hematomas
– free intraperitoneal hemorrhage, or
– devascularization of the bowel causing ischemia .
– Compression tears the intima of the mesenteric
vessels, leading to secondary thrombosis.

81. • Observation
• Proximal vascular control,exploration n ligation
• Autogenous venous graft-SMA /vein with ext
ishcemia
• Non-viable intestine should be resected and
primary anastomosis n mesenteric defect sutured
• If bowel viability or graft patency are tenuous,
the proximal bowel can be brought out as an
enterostomy

82. STOMACH N SMALL BOWEL
• Gastric wounds can be oversewn with a running
single-layer suture line or closed with a TA stapler
• Most commonly missed injury
– Posterior wall thro n thro
– Within mesentry of lesser curvature
– High fundus
• Delineate a questionable injury,
• Partial gastrectomy may be required for
destructive injuries, or Drainage procedure if
vagus or nerve of laterjet injured

83. Small intestine injuries
• Primary repair for < 1/3 of cirucmference
injury.
– Transverse running 3-0 PDS
• segmental resection followed by end-to-end
anastomosis
– Single layer 3-0 polypropylene suture

84. DUODENUM
• spectrum of injuries
– hematomas,
– perforation
– and combined pancreaticoduodenal injuries
• duodenal hematomas are managed nonoperatively
with nasogastric suction and parenteral nutrition- 2 wk
• Small perforation n laceration- Primary repair using a
running single-layer suture of 3-0 monofilament
• Extensive injuries of the first portion of the duodenum
– débridement and end-to-end anastomosis.

85. • defects in the second portion of the duodenum
should be patched with a vascularized jejunal
graft.
• Duodenal injuries with tissue loss distal to the
papilla of Vater and proximal to the superior
mesenteric vessels are best treated by Roux-en-Y
duodenojejunostomy
• injuries in the distal third and fourth portions of
the duodenum (behind the mesenteric vessels)
should be resected, and a duodenojejunostomy

87. Pancreatic trauma
• Classification of pancreatic injuries (Lucas 1977)
Grade I
• Simple superficial contusions with minimal parenchymal damage
Grade II
• Deep lacerations, perforations, or transection of the tail or the body
of the pancreas with the possibility of pancreatic-duct injury
Grade III
• Severe transection, perforation, or crushing injuries to the head of
the pancreas with or without ductal injury, but with an intact
duodenum
Grade IV
• Combined pancreaticoduodenal injuries
– mild pancreatic injury or
– severe damage with ductal disruption

88. • Grade-I injuries
managed safely by drainage of the pancreatic bed
• Grade- II injuries
a distal pancreatectomy, with ligation of the stump of the
duct and drainage of the pancreatic bed. With or without
splenectomy
Roux-en-Y pancreaticojejunostomy preserve both spleen
n distal pancrease
Grade III n Grade IV injuries
Roux-en Y Choledochojejunostomy
Roux-en-Y pancreaticojejunostomy
Pyloric exclusion operation
Whipple's pancreaticoduodenectomy

91. Complication
• Delayed hge
• Pancreatic necrosis
• Abdominal infection
• Pancreatic fistula
• Duodenal fistula
• Pancreatic pseudocyst
• Intrabdominal abscess

92. COLON INJURY
• three methods for treating colonic injuries
– primary repair,
• Lateral suture repair
• Resection of damaged segement n reconstruction with
ileocolostomy or colocolostomy
– end colostomy, and
– primary repair with diverting ileostomy.

94. RECTAL INJURY
• Intestinal diversion is required
– Loop ileostomy
– Sigmoid loop colostomy
• Repair depends on accessibility of the injury
• If the rectal injury is extensive,
– end colostomy (Hartmann's procedure).
• Extensive injuries may warrant presacral drainage
• APR may be necessary in some destructive
injuries

96. Complication
• intra-abdominal abscess, -10%
• fecal fistula, 1-3%
• wound infection, and
• stomal complications 5%
– necrosis, stenosis, obstruction, and prolapse

97. GENITOURINARY TRAUMA
RENAL TRAUMA
• Blunt trauma causes 65 per cent of all renal
injuries: this usually results from a direct blow
• Indirect injury due to acceleration-deceleration
– Renal pedicle – 85%
– Renal vein – 70%
– Both – 10%

98. Grading of Renal Trauma by the American Association of
Surgery of Trauma
Grade I:
microscopic or gross hematuria, normal radiographic study
or contained subcapsular hematoma without a
parenchymal laceration.
Grade II:
non expanding perirenal hematoma or cortical laceration <
1cm deep
Grade III:
laceration > 1cm deep into the parenchyma without
extravasation
Grade IV:
laceration > 1 cm deep with extravasation, or segmental
arterial thrombosis
Grade V:
multiple major lacerations, shattered kidney or pedicle injury

99. • operative guidelines for GU injury :
– accurate assessment of the degree of injury;
– adequate debridement of injured tissue;
– meticulous hemostasis;
– watertight repair of the collecting system;
– adequate drainage of the renal bed
– tension-free spatulated anastomosis,
– and good urinary drainage with ureteral stents
and/or nephrostomy tubes

100. • 90% Blunt renal injuries Rx nonoperatively
• Minor (grade I and II) injuries are properly
treated by observation.
• Renovascular injuries n destructive
parenchymal injuries with hypotension
requires operative Rx

101. • Parenchymal renal injuries are treated with
hemostatic and reconstructive techniques
• The collecting system should be closed
separately, and the renal capsule should be
preserved to close over the repair of the
collecting system
• For destructive parenchymal or irreparable
renovascular injuries, nephrectomy may be the
only option

102. URETERAL INJURY
• Injuries to the ureters are uncommon but may
occur in patients with pelvic fractures
• methylene blue or indigo carmine iv used to
delineate the site of injury.
• In DCS, the ureter can be ligated on both
sides of the injury and a nephrostomy tube
placed

103. Distal Ureteral injury
– Debridement n reimplantation faciliated with a posas hitch
n /or Boari flap
– transureteroureterostomy
Mid n Upper Ureter injury
– The injured midureter is best repaired by primary
anastomosis . / transureterouretrostomy
For extensive damage
Ileal ureter or autotransplantation of kidney
Most anastomoses after repair of ureteral injury should
be stented for 3- 4 wks

104. UB INJURY
• 75 %of bladder injuries
• Fractured pelvis is the injury most commonly associated
with a ruptured bladder (at least 80 per cent).
Type of injury
• extraperitoneal extravasation
– Anterior wall injury
• Intrapertoneal extravasation
– Posterior wall injury/ rent in dome
• Injury best diagnosed with contrast study

105. • Bleeding from a contused bladder usually resolves with
drainage by urethral catheter.
• Most extraperitoneal ruptures of the bladder may be
managed nonoperatively bladder decompression for 2
wks
• Operative repair
– Heavy hematuria
– massive extravasation, and,
– injury to the bladder neck
• two-layer closure with absorbable suture from the
inside of the bladder

106. Intraperitoneal rupture - Operative .
• Running single layer with 3-0 absorbable
monofilament suture.
• Suprapubic cystotomy and urethral catheters in
all operative Rx.

107. URETHRAL INJURY
Posterior (membraneous)
unrethral injury
Anterior (bulbous)urethral
injury

108. POSTERIOR INJURY
• Immediate SPC 2-3 wks
– Voiding
cystourethrogram
• Delayed urethra
reconstruction
– Within 3 months
– Cystogram/urethrogram
– SPC and Foleys for 1
month
ANTERIOR INJURY
• Urethral contusion:
– Observation
• Laceration
– SPC
• Laceration with
extravasation
– Drainage n SPC
• Repair

109. complications
• Haemorrhage
• Urinoma
• Hydronephrosis
• Renal hypertension
• Calculus formation
• Pyelonephritis
• AV fistula
• stircture
• Pelvic abscess
• Urinary incontinence

110. VASCULAR INJURY
• blunt trauma most commonly involves renal
vasculature and rarely the abdominal aorta.
• Blunt avulsions of the SMA are rare but should be
considered in patients with a seat belt sign
• blunt injuries are typically intimal tears of the
infrarenal aorta and are readily exposed via a direct
approach.
• Heparinized saline (50 u/l) is injected
• To avoid future vascular-enteric fistulas, the vascular
suture lines should be covered with omentum

111. • Arterial repair should always be done for the aorta
,superior mesenteric, proper hepatic, renal, iliac,
femoral, and popliteal arteries.
• Venous repair should be attempted for injuries of the
superior vena cava, the inferior vena cava proximal to
the renal veins, and the portal vein, although the
portal vein may be ligated in extreme cases.
• Follow-up imaging is performed 1 to 2 weeks after
injury to confirm healing.

112. Options for the Treatment of Vascular
Injuries
• Observation / Digital compression
• Ligation
• Lateral suture repair
• End-to-end primary anastomosis
• Interposition grafts
– Autogenous vein
– Polytetrafluoroethylene graft
– Dacron graft
• Transpositions
• Extra-anatomic bypass
• Interventional radiology
• Stents
• Embolization

115. THANK YOU…