Abdominal and Abdominal Vascular Injury

Abdominal and Abdominal Vascular Injury

Melike Harfouche, MD1 and Joseph DuBose, MD2

1 Division of Trauma and Acute Care Surgery, University of Maryland – Shock Trauma Center, Baltimore, MD, USA

2 Department of Surgery, Dell School of Medicine, University of Texas Austin, Austin, TX, USA

  1. A 40‐year‐old man sustained a single gunshot wound to the left gluteal region. He is hemodynamically normal, with no abdominal pain nor tenderness. A digital rectal exam reveals gross blood. A CT scan of the pelvis confirms the trajectory, which is consistent with an extraperitoneal rectal injury. An intraoperative sigmoidoscopy reveals a nondestructive injury to the lower one third of the rectum. The best choice below for the management of this injury involves:

    1. Exploratory laparotomy with primary repair of the injury
    2. Presacral drains, sigmoid diversion, and distal rectal washout
    3. Laparoscopy or laparotomy and sigmoid loop colostomy for proximal diversion
    4. Trans anal primary repair of the injury without diversion
    5. Laparoscopy, resection of the injury, with primary anastomosis

    Hemodynamically stable patients with suspected rectal injuries should undergo a CT scan of the abdomen and pelvis with IV contrast to further define trajectory. This should be followed by an intraoperative flexible or rigid sigmoidoscopy to delineate the extent of injury and whether it involves the upper two thirds or lower one third of the rectum. Injuries to the upper two thirds of the rectum can be repaired primarily (choice A), whereas injuries to the lower one third are usually inaccessible and not amenable to primary repair. Injury to the lower one third should undergo proximal diversion with a sigmoid loop colostomy (choice C). Distal rectal washout has been associated with increased morbidity related to infectious complications and is now no longer recommended (choice B). Presacral drains when performed routinely have also been associated with increased morbidity but can usually only offer benefit in the setting of destructive posterior rectal injuries. Prophylactic presacral drains for injuries to the anterior rectum or lateral wounds that do not traverse the posterior space may do more harm. Trans anal repair can be performed if the injury is easily visualized, or if edges can be approximated, but these repairs should prudently be combined with proximal diversion to offer the best chance for long‐term healing and morbidity reduction.

    Answer: C

    Bosarge, Patrick L., John J. Como, Nicole Fox, Yngve Falck‐Ytter, Elliott R. Haut, Heath A. Dorion, Nimitt J. Patel, et al. “Management of Penetrating Extraperitoneal Rectal Injuries: An Eastern Association for the Surgery of Trauma Practice Management Guideline.” Journal of Trauma and Acute Care Surgery 80, no. 3 (2016): 546–51. https://doi.org/10.1097/TA.0000000000000953.

    Weinberg, Jordan A., Timothy C. Fabian, Louis J. Magnotti, Gayle Minard, Tiffany K. Bee, Norma Edwards, Jeffery A. Claridge, and Martin A. Croce . “Penetrating Rectal Trauma: Management by Anatomic Distinction Improves Outcome.” The Journal of Trauma: Injury, Infection, and Critical Care 60, no. 3 (2006): 508–14. https://doi.org/10.1097/01.ta.0000205808.46504.e9.

    Brown, Carlos V.R., Pedro G. Teixeira, Elisa Furay, John P. Sharpe, Tashinga Musonza, John Holcomb, Eric Bui, et al. “Contemporary Management of Rectal Injuries at Level I Trauma Centers: The Results of an American Association for the Surgery of Trauma Multi‐Institutional Study.” Journal of Trauma and Acute Care Surgery 84, no. 2 (2018): 225–33. https://doi.org/10.1097/TA.0000000000001739.

  2. A 50‐year‐old woman sustained a single gunshot wound to the left lower quadrant. A plain film demonstrates a bullet in the right lower quadrant. She is hemodynamically normal but has peritonitis. The patient has been taken to the operating room right away for an exploratory laparotomy and several small bowel injuries, and a nondestructive injury to the sigmoid colon has been found. Which of the following intraoperative findings should be considered a contraindication to primary repair of the intraperitoneal colon injury?

    1. Extensive fecal contamination
    2. Intraoperative transfusion requirement of 2 units of packed red blood cells
    3. Concomitant abdominal vascular injury
    4. Involvement of greater than 25% of the bowel circumference of the sigmoid colon
    5. None of the above

    Management of colon injuries has undergone significant evolution over the past several decades. Initially, it was mandated during World War I that all colon injuries should undergo colostomy creation for all penetrating colon injuries. However, over time several randomized studies have demonstrated low leak rates in the setting of primary repair or primary anastomosis. Whereas initially the recommendation was to perform a diversion in the setting of extensive fecal contamination, concomitant vascular injury or blood transfusion requirements, several studies have demonstrated improved outcomes when compared to colostomy or diversion even in these settings. In the modern era, attempts should be made to either repair colon injuries when less than 50% of the bowel circumference is involved or perform a resection and primary anastomosis if the injury is >50% of the bowel circumference in all hemodynamically stable patients. In the 2001 study by Demetriades et al., risk factors for abdominal complications in terms of abscess formation in the setting of penetrating colon injury were severe peritoneal contamination, >4 units of blood transfusion in the first 24 hours, and single‐agent antibiotic prophylaxis. The type of repair performed (anastomosis vs. diversion) was not associated with increased complication risk. Since colostomy reversal with a second‐stage elective operation later is also associated with complications, overall the best result is repair of colon at the first index operation without a colostomy.

    Answer: E

    Stone, H. Harlan, and Timothy C. Fabian . “Management of Perforating Colon Trauma: Randomization between Primary Closure and Exteriorization.” Annals of Surgery 190, no. 4 (1979): 430–36. https://doi.org/10.1097/00000658‐197910000‐00002.

    Gonzalez, Richard P., Gary J. Merlotti, and Michele R. Holevar . “Colostomy in Penetrating Colon Injury: Is It Necessary?” Journal of Trauma and Acute Care Surgery 41, no. 2 (1996): 271–5.

    Demetriades, D., J. A. Murray, L. Chan, C. Ordoñez, D. Bowley, K. K. Nagy, E. E. Cornwell, et al. “Penetrating Colon Injuries Requiring Resection: Diversion or Primary Anastomosis? An AAST Prospective Multicenter Study.” The Journal of Trauma 50, no. 5 (2001): 765–75. https://doi.org/10.1097/00005373‐200105000‐00001 .

  3. In which of the following scenarios would nonoperative management of a gunshot wound with a defined tract through the right upper quadrant be considered an appropriate management option?

    1. Hemodynamically normal, no peritonitis but has a positive Focused Assessment with Sonography in Trauma (FAST) exam at Morrison’s Pouch
    2. Hemodynamically unstable with a positive FAST exam at Morrison’s Pouch
    3. Hemodynamically normal with negative FAST but has peritonitis
    4. Hemodynamically normal with a right hemothorax requiring a chest tube
    5. None of the above

    Literature has shown that selective nonoperative management of abdominal gunshot wounds resulting in solid organ injury is an acceptable practice associated with success rates nearing 100% in certain circumstances. Contraindications to nonoperative management are hemodynamic instability (Answer B) and peritonitis (Answer C). It is crucial that patients undergo CT scan of the abdomen and pelvis with IV contrast followed by serial abdominal examinations if the nonoperative approach is selected. If a hollow viscus injury is suspected, operative intervention should not be delayed. A positive FAST (Answer A) and/or high‐grade solid organ injury on CT imaging alone are not contraindications to nonoperative management in appropriate settings with close monitoring capabilities. Patients who sustain a right hemothorax from a gunshot wound to the right upper quadrant do not necessarily need operative intervention. Aside from chest tube placement, close observation is warranted as these patients are at risk for developing a thoracic biloma or biliary fistula, at which point chest exploration and drainage is indicated with diaphragm repair.

    Answer: A

    Schematic illustration of selective nonoperative manage ment of abdominal gunshot wound.

    DuBose, Joseph, Kenji Inaba, Pedro G.R. Teixeira, Antonio Pepe, Michael B. Dunham, and Mark McKenney . “Selective Non‐Operative Management of Solid Organ Injury Following Abdominal Gunshot Wounds.” Injury 38, no. 9 (2007): 1084–90. https://doi.org/10.1016/j.injury.2007.02.030.

    Schellenberg, Morgan, Elizabeth Benjamin, Alice Piccinini, Kenji Inaba, and Demetrios Demetriades . “Gunshot Wounds to the Liver: No Longer a Mandatory Operation.” Journal of Trauma and Acute Care Surgery 87, no. 2 (2019): 350–55. https://doi.org/10.1097/TA.0000000000002356.

  4. A 30‐year‐old‐man suffered multiple thoracoabdominal gunshot wounds. He has a thready pulse, with a systolic blood pressure of 60 mm Hg, and a positive FAST in the right upper quadrant. He is immediately taken to the operating room for an exploratory laparotomy. A large, nonpulsatile hematoma is identified in Zone 1, inferior to the transverse colon mesentery. You suspect an inferior vena cava injury. Which of the operative maneuver provides the optimal exposure to the infrarenal inferior vena cava?

    1. Right medial visceral rotation (Cattell‐Braasch maneuver)
    2. left medial visceral rotation (Mattox maneuver)
    3. Direct exposure at the base of the transverse colon mesentery
    4. Extraperitoneal approach via a Gibson incision
    5. Kocher maneuver

    Exposure of the infrarenal IVC for trauma is best done with a right medial visceral rotation, which is sometimes referred as the Cattell‐Braasch maneuver. This involves medial mobilization of the right colon in conjunction with medal mobilization of the C‐loop of the duodenum. The kidney is usually left in situ unless there is a posterior IVC injury, or an injury at the junction of the renal vein and IVC, which is better visualized if the kidney is also rotated medially. A left medial visceral rotation is often referred as the Mattox maneuver even though he was not the first to describe it. Dr. Mattox did, however, popularize it in the field of trauma. It is best for exposure of the supraceliac aorta (choice B). Although the IVC can be visualized through a midline retroperitoneal incision at the base of the mesentery, this approach is usually less familiar to the trauma surgeon and precious time may be lost if the surgeon is not experienced in this approach (choice C). Medial mobilization of the C loop of the duodenum alone, also known as a Kocher maneuver, is not optimal for exposure of the infrarenal IVC (choice C). Although an extraperitoneal exposure may allow adequate visualization of the infrarenal IVC, it will not allow for identification and repair of intraperitoneal injuries. The Gibson incision is right or left lower quadrant incision that is curvilinear and is commonly used for renal transplantation or as extra peritoneal approach to the distal ureter.

    Answer: A

    Burch, Jon M, David V Feliciano, Kenneth L Mattox, and Mark Edelman . “Injuries of the Inferior Vena Cava.” The American Journal of Surgery 156 (1988): 548–52.

    Graham, Joseph M., Kenneth L. Mattox, Arthur C. Beall, and Michael E. DeBakey . “Traumatic Injuries of the Inferior Vena Cava.” Archives of Surgery (Chicago, Ill.: 1960) 113, no. 4 (1978): 413–18. https://doi.org/10.1001/archsurg.1978.01370160071011.

  5. A 22‐year‐old woman with a gunshot wound to the right upper quadrant. She is hemodynamically unstable and has a positive FAST. Exploratory laparotomy reveals >50% transection of the infrarenal IVC. She remains hemodynamically unstable, with a temperature of 33 °C, lactate of 12 and base deficit of ‐13 from too much crystalloid infusion. Given this clinical presentation, what is the best approach to management and its most common associated complication?

    1. Interposition graft with ringed PTFE and graft infection
    2. IVC ligation and lower extremity compartment syndrome
    3. Primary repair of IVC and pneumonia
    4. Patch angioplasty of the IVC and acute renal failure
    5. Interposition graft with common femoral vein and lower extremity deep vein thrombosis

    IVC injuries carry a high mortality rate, with an in‐hospital mortality ranging between 38 and 66% due to uncontrolled bleeding. When on‐scene deaths are included, the mortality rate is much higher. Expedient hemorrhage control offers the patient the best chance for survival. Suprarenal IVC ligation should be avoided, as few will survive the morbidity of that operation. However, infrarenal IVC ligation is an acceptable approach for the moribund patient. Patients can avoid the lethal triad of acidosis, coagulopathy, and hypothermia with massive transfusion protocols, which will transfuse warm PRBC, FFP, and platelets. If room temperature crystalloid fluids are used, the lethal triad can occur more frequently. The most common complication associated with IVC ligation is lower extremity compartment syndrome, for which the patient should be closely monitored and undergo four‐compartment fasciotomies if needed. Some will apply ace wraps and elevate the legs after ligation of the IVC. Several series have shown IVC ligation to be associated with higher complication rates when compared to repair. However, there may be a selection bias as patients with more severe injury and bleeding may undergo ligation and the lesser injured vessels may undergo repair. If the uncontrolled hemorrhage has been controlled and the patient is stabilizing, venorrhaphy or interposition with ringed PTFE depending on the amount of destruction should be considered and performed. Graft infection and lower extremity DVT are also potential complications of IVC repair. The common femoral vein is usually too small in diameter to be used as an interposition graft for IVC injuries.

    Answer: B

    Matsumoto, Shokei, Kyoungwon Jung, Alan Smith, and Raul Coimbra . “Management of IVC Injury: Repair or Ligation? A Propensity Score Matching Analysis Using the National Trauma Data Bank.” Journal of the American College of Surgeons 226, no. 5 (2018): 752–759.e2. https://doi.org/10.1016/j.jamcollsurg.2018.01.043.

    Sullivan, Patrick S., Christopher J. Dente, Snehal Patel, Matthew Carmichael, Jahnavi K. Srinivasan, Amy D. Wyrzykowski, Jeffrey M. Nicholas, et al. “Outcome of Ligation of the Inferior Vena Cava in the Modern Era.” The American Journal of Surgery 199, no. 4 (2010): 500–6. https://doi.org/10.1016/j.amjsurg.2009.05.013.

  6. A 50‐year‐old man arrives to the emergency room having sustained a single stable wound to the left lower quadrant. He is alert, oriented, and cooperative, hemodynamically normal, with no signs of peritonitis nor abdominal tenderness on exam. The stab wound is 2 cm in length with no underlying hematoma or active bleeding. Which of the following options is the most appropriate management?

    1. Immediate exploratory laparotomy.
    2. Serial abdominal examinations for 4 hours, followed by discharge if no clinical changes.
    3. CT of the abdomen and pelvis with IV contrast followed by diagnostic laparoscopy if fascial penetration is suspected.
    4. Local wound exploration followed by exploratory laparotomy if penetration of Scarpa’s fascia.
    5. Diagnostic peritoneal aspirate followed by exploratory laparotomy if blood or succus aspirated.

    There are several options for the management of anterior abdominal stab wounds. The anterior abdominal area is defined by the costal margin, anterior axillary lines, and groin creases bilaterally. Stab wounds between the umbilicus and costal margins can also injure the diaphragm and cardiothoracic structures, which should be taken into consideration when evaluating these patients. Immediate laparotomy should be performed in patients who are hemodynamically unstable due to hemorrhage and/or have peritonitis, which is indicative of hollow viscous injury (choice A). Serial abdominal examinations is a valid option if the patient is examinable. Patients are not examinable if they are altered by drugs/alcohol, do not have distracting injuries and are not intubated. Serial exam is typically 8–24 hours in most practice guidelines and 4 hours is inadequate (choice B). CT imaging is highly sensitive and specific for intrabdominal injury, with several studies reporting numbers >90%, and can be performed in stable patients but should be done with IV contrast (choice C). A prospective study by Demetriades et al. found CT scan to have a negative predictive value of 100% for intraabdominal injuries requiring laparotomy. Depending on resources, diagnostic imaging can be the first step in assessment. If no injuries are identified, the patient can be observed or discharged based on clinician judgment. Depending on the surgeon’s skill set, this can be followed by exploratory laparotomy or diagnostic laparoscopy if fascial penetration is identified on CT. If the stab wound is amenable to local wound exploration (nonobese patient, sizeable stab wound, non‐tangential in appearance) and the patient is cooperative, this is an alternative approach to initial evaluation. If there is penetration of the anterior rectus fascia (not Scarpa’s), either serial abdominal exams or diagnostic imaging can be performed (choice D). Local exploration is most helpful when it definitively demonstrates that the anterior fascia has not been penetrated, and in these patients the wound can be irrigated and closed. Laparotomy is not mandatory, as a large proportion of these patients will not have intraabdominal injuries. Diagnostic peritoneal aspiration is not a commonly employed part of the algorithm for management of anterior abdominal stab wounds. Historically, it has been done and studied. Lavage showing microscopic red cell counts of 1000–100 000 has been used as the determining factor for the need for surgery. Using 1000 rbc results in unacceptably high number of nontherapeutic laparotomies and using 100 000 rbc results in unacceptably high missed injuries. Although serial examinations can be done to rule out hollow viscous injuries with high sensitivity, it does not always address facial injuries, which may need surgical repair.

    Answer: C

    Salim, Ali, Burapat Sangthong, Matthew Martin, Carlos Brown, David Plurad, Kenji Inaba, Peter Rhee, and Demetrios Demetriades . “Use of Computed Tomography in Anterior Abdominal Stab Wounds: Results of a Prospective Study.” Archives of Surgery (Chicago, Ill.: 1960) 141, no. 8 (2006): 745–50; discussion 750‐752. https://doi.org/10.1001/archsurg.141.8.745.

    Martin, Matthew J., Carlos V.R. Brown, David V. Shatz, Hasan B. Alam, Karen J. Brasel, Carl J. Hauser, Marc de Moya, et al. “Evaluation and Management of Abdominal Stab Wounds: A Western Trauma Association Critical Decisions Algorithm.” Journal of Trauma and Acute Care Surgery 85, no. 5 (2018): 1007–15. https://doi.org/10.1097/TA.0000000000001930.

  7. A 65‐year‐old woman involved in a motor vehicle collision is hemodynamically unstable with a positive FAST at Morrison’s pouch. She has been taken emergently to the operating room, where a splenectomy and non‐anatomic wedge resection of a liver injury is performed, followed by fascial closure. Throughout the operation, she undergoes massive transfusion of blood products. Over the subsequent 12 hours, her hematocrit stabilizes, but she develops decreased urine output, increased peak airway pressures, and hypotension. What is the next step in management?

    1. Check bladder pressure
    2. Bedside ultrasound and therapeutic aspiration of intraperitoneal fluid
    3. Stat ultrasound of the liver to evaluate for portal vein thrombosis
    4. Stat CT scan of the abdomen and pelvis to assess for missed injuries
    5. Crystalloid fluids and lasix

    Intraabdominal hypertension, defined as a sustained intraabdominal pressure (IAP) > 10 mm Hg, can be concerning. Abdominal compartment syndrome (ACS) is defined as an IAP > 20 mm Hg associated with new organ dysfunction. The most common manifestations of organ dysfunction are kidneys manifesting as oliguria and lungs manifesting as elevated peak airway pressures. Severely injured trauma patients are at high risk for developing ACS if they receive large volumes of crystalloids or pelvic fractures resulting in retroperitoneal hematomas. Delayed diagnosis of ACS can be lethal, and intervention should not be delayed for further imaging (choice C). The most common and cost‐effective way to measure IAP is by measuring bladder pressure by instilling 25 mL of saline into the bladder through a foley catheter and connecting the catheter to a pressure transducer. ACS can be managed in a variety of methods including decompressive laparotomy. In some cases, laparotomy can be avoided by placement of an indwelling percutaneous drainage catheter although this is usually done for non‐trauma patients who may have medical etiologies for their ACS. Simple aspiration may provide temporary relief if there is fluid, and it can be accessed. While this is useful approach to ACS, it is not typically useful nor recommended for the immediate postoperative period. Using ultrasound is useful in certain circumstances to find fluid but in the immediate postoperative period, ACS is typically from bowel edema and not fluid accumulation (choice B). Patients can still develop ACS with an open abdomen, usually secondary to abdominal packing. In these cases, the patients should be taken to the operating room and have the number of packs reduced until symptoms resolve. Crystalloids do not remain in the intravascular space, and it has been shown that less than 200 cc out of 1000 cc remains in the intravascular space in 1 hour. Diuresis may increase urine output, but infusing crystalloids and giving Lasix would make the patient more depleted in the intravascular space and can lead to acute kidney injury. It would also miss the diagnosis and make matters worse (choice E).

    Answer: A

    Meldrum, Daniel R., Frederick A. Moore, Ernest E. Moore, Reginald Franciose, Angela Sauaia, and Jon M. Burch . “Prospective Characterization and Selective Management of the Abdominal Compartment Syndrome.” The American Journal of Surgery 174, no. 6 (1997): 667–73. https://doi.org/10.1016/S0002‐9610(97)00201‐8.

    Kirkpatrick, Andrew W., Derek J. Roberts, Jan De Waele, Roman Jaeschke, Manu L. N. G. Malbrain, Bart De Keulenaer, Juan Duchesne, et al. “Intra‐Abdominal Hypertension and the Abdominal Compartment Syndrome: Updated Consensus Definitions and Clinical Practice Guidelines from the World Society of the Abdominal Compartment Syndrome.” Intensive Care Medicine 39, no. 7 (2013): 1190–1206. https://doi.org/10.1007/s00134‐013‐2906‐z.

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Abdominal and Abdominal Vascular Injury

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