Chapter 183 - Abdominal trauma Flashcards
Retroperitoneal trauma zones
Zone 1: midline from aortic hiatus to sacral promonitory
- supramesocolic: celiac, sma, renal, ivc, smv
- inframesocolic: infrarenal aorta, ivc
Zone 2: L+R kidneys, paracolic gutter, renal vessels
Zone 3: pelvic retroperitoneum; iliac vessels
Zone 4: perihepatic area with retrohepatic IVC + hepatic veins
Rate of vascular trauma in different indications for exploratory laparotomy
Gunshot - 14.3%
Stab - 10%
Blunt - 3%
Mechanisms of vascular injury after blunt trauma
1) rapid deceleration
2) direct anteroposterior crushing
3) laceration by bone fragment
Most common injured vessels in the abdomen in trauma in lists
IVC - 25% Aorta - 21% Iliac artery - 20% iliac veins - 17% SMV - 11% SMA - 10%
average number of vascular injuries in someone who had at least one
1.7
Rate of enroute deaths in vascular injuries from scene to hospital
14%
Signs of vascular injury after penetrating injury
1) abdominal distension
2) hypotension
3) asymmetric femoral pulses
Diagnostic evaluation for penetrating and blunt trauma
Penetrating: unstable = laparotomy
Stable = CTA
Blunt: FAST positive and unstable = laparotomy
FAST negative and unstable = peritoneal aspirate +/- CTA
SBP target for permissive hypotension
80-90 mmHg
Survival rate after resuscitative thoracotomy for abdominal trauma
2%
Temperature of infused fluid
40-42C
Ratio of massive transfusion products
1:1:1
When not to explore penetrating hematomas
Contained zone 4 retrohepatic hematoma
All others need exploration
When to explore blunt hematoma
All zone 1
Zone 2+3 if:
1) expanding
2) pulsatile
3) leaking hematoma
4) absent ipsilateral pulse
5) paraduodenal (to r/o duodenal injury)
6) root of mesentery with mesenteric ischemia
Steps of left medial visceral rotation
1) divide peritoneal reflection lateral to left colon
2) divide splenic flexure and mobilize spleen
3) mobilize fundus of stomach, tail of pancreas, colon, spleen and left kidney to right
Exposure for IVC injury
right medial visceral rotation: right colon, hepatic flexure and Kocher mobilization of duodenum and head of pancreas
Exposure for zone 3 vessels
Dissection of paracolic peritoneum and medial rotation of right or left colon
Damage control procedures
1) ligate all complex venous injuries
2) shunt all arterial injuries
3) pack diffuse retroperitoneal or parenchymal bleeding
4) vac abdomen, never close primarily
Intraabdominal hypertension definition
12 mmHg
Abdominal compartment syndrome definition
20 mmHg with organ dysfunction
Symptoms of abdominal compartment syndrome
1) tense abdomen
2) tachycardia
3) hypotension
4) respiratory dysfunction
5) high peak inspiratory and plateau pressures
6) oliguria
Measurement of abdominal compartment pressure
1) 20 ml saline into bladder
2) measure pressure
Most common types of blunt aortic injury
intimal flap = 60%
free rupture 30%
pseudoaneurysm 10%
Management of intimal tears in aorta
if small, non-operative
Associated organ injuries in vascular penetrating injury
Small bowel 45%
colon 30%
liver 28%
Surgical treatment of penetrating aortic injury
1) lateral aortorrhaphy
2) prosthetic graft (even if spillage)
Mortality of penetrating vs blunt aortic trauma
Penetrating: 67-85%
Blunt: 30%
Length of the celiac trunk
1-1.5 cm long
Tripod of Haller
Common hepatic
left gastric
splenic
Exposure of the celiac artery
right visceral rotation
Ligation of celiac and common hepatic
both tolerated if good collaterals
Mortality of celiac injury
38-75%
Location of celiac on spine level
T12-L1
Location of SMA on spine level
L1
Course of the SMA
1) anterior aorta
2) behind pancreas
3) over uncinate process of pancreas and third duodenum into root of mesentery
Branches of SMA
1) inferior pancreaticoduodenal
2) middle colic
3) arterial arcade (12-18 branches)
4) right colic
5) ileocolic
Zones of SMA
Zone 1: aortic origin to inferior pancreaticoduodenal
Zone 2: inferior pancreaticoduodenal to middle colic
Zone 3: distal to middle colic
Zone 4: segmental intestinal branches
Zones of SMA treatment strategy
Cannot ligate zone 1 and 2
Zone 3 and 4 can be ligated with segmental SB resection
Exposure of retropancreatic SMA
1) medial rotation of left colon, gastric fundus, spleen, tail of pancreas
2) leave kidney down
3) staple neck of pancreas if needed in emergency
Exposure of infrapancreatic SMA
1) cephalad retraction of inferior border of pancreas
OR
2) root of small bowel mesentery by incising and dissection of tissue to left of ligament of Treitz
Surgical management of SMA injury
1) lateral arteriorrhaphy (40% of the time it is possible)
2) ligation with bowel resection
Mortality with SMA injury
33-68%
Mortality with celiac injury
38-75%
Renal artery anatomy level of spine
L2
Right renal vs left in anatomy
Right higher and longer
Percentage of population with more than one renal artery
30%
Branches of left renal vein
1) left gonadal vein
2) left adrenal vein
3) descending lumbar vein
Which renal artery more likely to be injured
Left
1.3-1.6x more than right
Hours after injury for severe renal function impairment
3 hours total ischemia
6 hours partial ischemia
Timing to attempt renal revascularization
4-6 hours of ischemia time
unless bilateral injury or solitary kidney
Ways to revascularize kidney
1) arteriorrhaphy
2) vein patch
3) resection and anqastomosis
4) interpositional grafting
Renal vein repair
1) primary repair
2) ligation
Mortality of renovascular injury
0-57%
IMA anatomy origin
3-4 cm above aortic bifurcation
Treatment of IMA injury
ligation
iliac artery anatomy spine level
L4-L5
Iliac vein joins at which spine level
L5
Percentage of iliac injuries that are combined arterio-venous
26%
Mortality of iliac injuries
30-50% arterial
25-40% venous
Rate of IVC injury with associated aortic injury
18%
Hepatic vascular isolation
1) cross clamp infradiaphragmatic aorta FIRST
2) clamp suprahepatic IVC
3) clamp infrahepatic IVC above renal veins
4) clamp portal triad
why clamp aorta first in hepatic vascular isolation
reduced venous return = cardiac arrest
How to clamp suprarenal IVC
1) between superior surface of liver and diaphragm
2) right thoracotomy or sternotomy
Atriocaval shunt
1) tube through purse-string suture to atrial appendage of right atrium
2) direct tube into IVC distal to caval injury
Division of the liver
Divide along gallbladder-IVC plane to get direct exposure to IVC
Surgical repair of IVC
1) lateral venorrhaphy
2) repair backwall from inside
3) interpositional patch or bypass
4) ligation infrarenal IVC if needed (cannot ligate suprarenal)
Mortality of IVC injury
20-57%
Length of portal vein
6-10 cm
Location of portal vein to spine level
L2 origin
Anatomy of portal vein
Splits to right and left branches at hilum of liver
% of blood flow from portal vein to liver
80%
Splenic vein course
Superior border of pancreas
drains IMV just before meeting SMV
SMV course
crosses over third part of duodenum and uncinate process of pancreas
pass behind neck of pancreas
Exposure of portal ein
1) right visceral rotation with Kocher mobilization
2) division of neck of pancreas for best exposure
Ligation of portal vein and hepatic artery results in
DEATH
Surgical repair of portal vein
primary
patch
ligation but keep hepatic artery (survival 55-85%)
Key points after ligation of portal vein
patchy edema bowel
cannot close abdomen
need massive fluid replacement due to sequestration
Mortality of portal vein injury
50-72%
