MANAGEMENT OF BLUNT AND

PENETRATING ABDOMINAL
INJURIES.

DR. TUMUSIIME GERALD

DEPARTMENT OF SURGERY-MUST.
Destiny is not a matter of chance, its a matter of
choice. Its not a thing to be waited for, its a thing to be
achieved.

INTRODUCTION.
Intra-abdominal injuries carry high morbidity and mortality

because they are often not detected or their severity is

underestimated. This is particularly common in cases of blunt
trauma , in which there may be few or no external injuries.
Abdominal trauma is classified as blunt abdominal trauma or

penetrating abdominal trauma, but the initial assessment and,

if required, resuscitation are essentially the same.
The aim of this lecture is to enable all those concerned with

management of patients with abdominal trauma to perform a

thorough examination and assessment with the help of
appropriate diagnostic tests and to institute safe and correct
treatment.
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Introduction contd
Wearing seat belts reduces the number of fatal head injuries but

increases the pattern of blunt abdominal trauma that is specific

to seat belts. This often includes avulsion injuries of the
mesentery of the small bowel.
The symptoms and signs of blunt abdominal trauma can be

subtle, and consequently diagnosis is difficult.

A high degree of suspicion of underlying intra abdominal injury

must be adopted when dealing with a patient with blunt

abdominal trauma.
Blunt abdominal trauma is usually associated with trauma to

other areas, especially the head, chest and pelvis.

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Causes (aetiology) of abdominal trauma.

Road traffic accidents
Assaults
Falls
Gunshots
Industrial accidents.
E.t.c.

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BLUNT ABDOMINAL TRAUMA.

Results from a direct force to the abdomen without any

associated open wound on the abdominal wall.

Most commonly follow road traffic accidents and assaults.
In blunt abdominal trauma, signs that may indicate intra

abdominal bleeding (haemoperitoneum) include referred

shoulder pain, abdominal rigidity and hypotension.
Oliguria associated with suprapubic pain suggests bladder

rupture.
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PENETRATING ABDOMINAL INJURIES.

Penetrating abdominal injuries follow gunshot wounds and

wounds induced by sharp objects such as knives or spears.

Exploratory laparotomy is indicated when the abdomen has

been penetrated regardless of the physical findings.

Signs of hypovolaemia or of peritoneal irritation may be minimal

immediately following a penetrating injury involving the

abdominal viscera.
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Diagnosis of abdominal trauma.

History
Physical examination

Inspection (Look)

Palpation (feel)

Purcuss

Ausultate (listen)

Investigations.

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History
Aims at establishing the possible cause, mechanism of injury,

previous medical and surgical history and possible

complications.
Shoulder pain is deliberately asked for in suspected

haemoperitoneum especially due to splenic injury.

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Examine for:
Vital signs of revealed or concealed haemorrhage and shock

(hypotension, tachycardia)
Abdominal signs
Kehrs sign hyperaesthesia over the shoulder (referred pain due

to subdiaphragmatic irritation by blood.)

Concurrent injuries.

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Investigations.
Erect chest x-ray to show:

Diaphragmatic injury

Rib fracture close to the liver or spleen

Subphrenic gas due to ruptured abdominal viscus.

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Abdominal x-ray to show:

Splenic, hepatic, renal shadow
Outline of psoas muscle (masked in retroperitoneal haematoma

and splenic injury)

Gastric bubble shape and situation (deviated medially in splenic

injury)
Ground glass appearance of intra abdominal bleeding.
Pelvic fractures.

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Other investigative procedures

Four- quadrant tap (needle paracentesis) is a quick test for intra

abdominal bleeding and is done with a wide bore needle and

syringe.
Diagnostic peritoneal lavage-more sensitive but time consuming.
Urgent intravenous urography (IVP) may show:

Presence or absence of functioning kidneys on each side

Unexpected pathology horse shoe kidney or tumour.

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Management of a patient with abdominal

trauma.
Abdominal trauma is a surgical emergency and its management

is divided into:
Primary survey and resuscitation
Secondary survey.
Definitive care.

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Primary survey and resuscitation involves

assessment of:
Airway and cervical spine control.
Breathing and correcting the causes of abnormal breathing.
Circulation and control of haemorrhage.
Dysfunction of the Central nervous system
Exposure and environmental control.
Take AMPLE history.

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AMPLE HISTORY.
Allergies
Medications
Past medical history
Last meal
Event leading to the injury and the environment.

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Immediate life threatening thoracic conditions

presenting with abnormal breathing:
Air way obstruction by foreign bodies and secretions.
Tension pneumothorax
Cardiac tamponade
Open chest wound (sucking chest wound)
Massive haemothorax
Flail chest

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Objectives of secondary survey.

Take a complete history.

Examine the patient from head to toe and front to back.
Assimilate all clinical, laboratory and radiological information.
Formulate a management plan for the patient.

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ABDOMINAL EXAMINATION.
Examine the whole abdomen, pelvis and perineum.
All bruising, abnormal movements, signs of male urethral injury

and wounds must be noted.

Any exposed bowel should be covered with warm, saline-

soaked gauze or mop.

Lacerations can be inspected but not probed blindly as further

damage may result.

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Exam contd
The abdomen must then be palpated and any sign of

tenderness recorded.
As squeezing the pelvis in two planes will detect only severe

abnormalities, all patients with blunt trauma must undergo pelvic

radiography.
Finally, a rectal examination must carried out and findings

documented.
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Abdominal exam contd

Pronounced abdominal distension is common in crying children,

adults with head or abdominal injury, and patients who have

been ventilated with a bag and mask.
The insertion of a nasogastric tube decompresses the stomach,

reduces the risk of aspiration, and facilitates the abdominal

examination of the patients.
Intra abdominal haemorrhage should be suspected if there are

signs of fractures of the ribs overlying the live and spleen (ribs 511), the patient is haemodynamically unstable, or there are
marks caused by seatbelts or tires over the abdomen.
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Exam contd
The detection of abdominal tenderness may be unreliable,

particularly in patients with sensory defects caused by

neurological damage or drugs, or if there are fractures of the
lower ribs or pelvis.
In these cases, diagnostic peritoneal lavage should be

performed to help rule out an intraperitoneal injury.

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Inspection for:
Abdominal distension
Bruises
Abrasions
Lacerations
External blood loss
Evisceration.

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Palpate for:

Tenderness
Pulsating masses
Guarding or rigidity.

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Purcuss for:

Shifting dullness

Percussion tenderness

Ausultate for the presence or absence of bowel sounds.

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Signs of urethral injury.

Blood at the external urethral meatus.

Bruising of the scrotum or perineum.
High riding prostate.

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Note on rectal examination:

Sphincter tone
Presence of rectal damage
Presence of pelvic fractures
Prostate position
Blood in the rectal residue.

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Signs of renal injury.

Haematuria
Flank bruising
Flank tenderness
Flank mass

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GENERAL GUIDELINES OF MANAGING

ABDOMINAL INJURY.
Give priority to the primary survey.
Establish a clear airway.
Secure good ventilation
Arrest external haemorrhage
Set up an intravenous infusion of normal saline or ringers lactate.
Send a blood sample for haemoglobin, haematocrite, typing

(grouping) and crossmatching.

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Management contd
Insert a nasogastric tube and begin suction and monitor output.
Insert a urinary catheter, examine the urine for blood and monitor

urine output.
Perform the secondary survey: a complete physical examination

to evaluate the abdomen and to establish the extent of other

injuries.
Administer small doses of intravenous analgesia, prophylactic

antibiotics and tetanus prophylaxis.

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Management contd.
If the diagnosis of intraabdominal bleeding (haemoperitoneum)

is uncertain, proceed with diagnostic peritoneal lavage.

Laparotomy is indicated when abdominal trauma is associated

with exposed abdominal viscera, obvious rebound tenderness,

frank blood on peritoneal lavage and hypotension.
Serial physical examinations, erect plain chest radiography and

abdominal ultrasound scan are helpful in equivocal cases.

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Management contd
Seek the opinion of colleagues to aid in evaluating equivocal

abdominal findings.
If you suspect a ruptured abdominal viscus in a very sick

patient, a lateral decubitus abdominal radiograph may show free

intraperitoneal air (pneumoperitoneum)

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DIAGNOSTIC PERITONEAL LAVAGE

(DPL): INDICATIONS.
Equivocal clinical abdominal examination
Difficulty in assessing the patient because of alcohol, drugs, or

head injury.
Persistent unexplained hypotension despite adequate fluid

replacement.
Multiple injuries, particularly if they include injuries of the chest,

pelvis or spinal cord.

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Technique of Diagnostic Peritoneal Lavage

(DPL)
Infiltrate a local anaesthetic with epinephrine (adrenaline) into

the anterior abdominal wall and peritoneum at an infra-umblical

site.
The epinephrine reduces abdominal wall bleeding.

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Technique contd
Make a 2.5cm midline incision which is carried down through

subcutaneous tissue to the linea alba.

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Technique contd
Apply counter traction to the fascia of the linea alba with two

stay sutures and make a 3-5mm incision through the fascia.

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Technique contd
Gently introduce a catheter on a stylet into the peritoneum and

advance the catheter into the pelvis.

Spontaneous return of blood or gross aspiration of blood is
an indication for laparotomy.

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DPL technique
If no blood returns, infuse 20mls/kg body weght in children or

1Litre in adults of intravenous saline or ringers lactate through

the catheter.
Attach the catheter to a closed container.

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DPL contd
Place the container on the floor.
About 100mls of fluid should flow back into the container.

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Laboratory analysis of the fluid.

If the returning fluid has greater than 100,000 red blood cells per

ml, or 500 white blood cells per ml, consider performing a

laparotomy.
The red and white blood cell count can be determined in the

laboratory along with an examination for bacteria and amylase.

Elevated amylase indicates injury to the pancreas.

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Note:
When laboratory evaluation is not available, the appropriate

decision to do laparotomy can be determined by looking at the

clarity of the fluid.
If you cannot read the newsprint through the fluid due to the red

colour, there is sufficient blood to indicate the need for laparotomy.

If the fluid is cloudy due to particulate material, it is likely that there

is a bowel injury and laparotomy is also indicated.

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Indications of a positive DPL

>5Ml free blood aspirated from the peritoneal cavity.
Enteric contents aspirated from the peritoneal cavity.
Lavage fluid leaking into the chest drains or urinary catheter.
In the lavage fluid:

>100,000 red blood cells/cu. mm.

Bile
Food products
Bacteria.

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KEY POINTS ABOUT DPL.

Its indicated when abdominal findings are equivocal (not

conclusive) in a trauma patient.

Should not be performed if there are indications for immediate
laparotomy.
Is rapid, sensitive and inexpensive.
May rule out significant abdominal trauma in health facilities
where patients may otherwise be unobserved and unmonitored
for extended periods of time.
Gross evaluation of the returned fluid must be performed and a
decision made if laboratory evaluation is not available.
Ignore a negative result on DPL if the patient subsequently
develops an acute abdominal. Do emergency exploratory
laparotomy.

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KEY POINTS ABOUT ABDOMINAL

INJURY.
Blunt trauma is classified as blunt or penetrating.
Intra-abdominal haemorrhage or gastrointestinal perforations

may be present without any evidence of abdominal wall injury.

Intra abdominal bleeding may be confirmed by peritoneal lavage

with saline, but a negative result does not exclude injury,

particularly in retroperitoneal trauma.
Suspect intra abdominal bleeding in cases of multiple trauma

especially if hypotension is unexplained.

In the presence of hypovolaemia, the chest, pelvis and femur

are other sites of major blood loss.

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Signs of urethral injury.

Blood on the penile meatus

High riding prostate
Bruised scrotum
Bruised perineum.

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PAEDIATRIC PATIENTS.
Many abdominal injuries can be managed without operation

(conservatively or non-operatively.)
Non-operative management is indicated if the child is

haemodynamically stable and can be monitored closely.

Insert a nasogastric tube if the abdomen is distended, as

children swallow large amounts of air.

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Indications for laparotomy in a patient with

abdominal trauma.
Unexplained shock or persistent shock.
Rigid and silent abdomen
Evisceration
Radiological evidence of free intraperitoneal air

(pneumoperitoneum)
Evidence of diaphragm injury (evidence of stomach or gut

herniation into the chest cavity.)

All gunshot wounds
Positive results of DPL.
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TRAUMA LAPAROTOMY.
Laparotomy is the surgical opening into the abdominal cavity.
Laparotomy is used to expose the abdominal organs so as to make a

definitive diagnosis and institute appropriate treatment of abdominal

trauma.
In an emergency, a midline incision is the incision of choice.
General anaesthesia should be given for an upper midline incision and

spinal anaesthesia may be used for low midline incisions in the stable
patient.
If there is doubt about the diagnosis, use a short paraumblical incision

and extend it up or down in the midline as indicated.

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MANAGEMENT OF A RUPTURED
SPLEEN.
In the tropical countries, enlargement of the spleen due to

tropical diseases like malaria, brucellosis and leishmaniasis is

common.
The affected spleen is liable to injury or rupture as a result of

trivial (minor) trauma.

Delayed rupture can occur up to three weeks after injury.
Splenic rupture is a surgical emergency.
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Diagnostic features of a ruptured spleen.

History of trauma with pain in the left upper abdomen (often

referred to the shoulder).

Nausea and vomiting.
Signs of hypovolaemia or shock ( cold clammy skin, rapid thin

pulse and reduced blood pressure.)

Abdominal distension, tenderness, rigidity and a diffuse

palpable mass.
Chest radiograph showing left lower rib fractures and a shadow

in the upper left quadrant displacing the gastric air bubble

medially.
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Specific management.
Consider conservative management particularly in children, if

the patient is haemodynamically stable and you are able to

monitor him closely with bed rest, intravenous fluids, analgesics
and nasogastric suction.
If the patients condition deteriorates, perform an exploratory

laparotomy and splenectomy.

Perform a laparotomy if you suspect a ruptured spleen and the

patient is hypovolaemic.
Repair the spleen ( perform splenorrhaphy) or remove the

spleen (do splenectomy.)

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Technique of splenectomy.
Place the patient supine on the operating table with a pillow or sandbag

under the left lower chest.

Open the abdomen through a long midline incision.

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Splenectomy contd
Remove clots from the abdominal cavity to localise the spleen.
If bleeding continues, squeeze the splenic

vessels between your thumb and the fingers

or apply intestinal occlusion clamps.
Assess the extent of splenic injury
and inspect other organs.

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Splenectomy contd
Make the decision whether to remove or preserve the spleen.
If the bleeding has stopped, do not disturb the area.
If a small tear is bleeding, try to control it with no. 0 absorbable

suture. This is particularly advisable in children.

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Splenectomy contd
To remove the spleen, lift it into the wound and divide the taut

spleno-renal ligament with scissors.

Extend the division to the upper pole of the spleen.

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Splenectomy contd
Apply a large occlusion clamp to the adjoining gastrosplenic

omentum containing the short gastric vessels

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Contd
Divide the omentum between large artery forceps.
Ligate the short gastric vessels well away from the gastric wall.

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Contd .
Dissect the posterior part of the hilum, identifying the tail of the

pancreas and the splenic vessels.

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Achieving haemostasis.
Ligate the splenic vessels three times.
If possible, ligate the artery first and divide them between the

distal pair of ligatures.

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Splenectomy contd
Divide the remaining gastrosplenic omentum between several

camps and finally divide the anterior layer of the lienorenal

ligament.
Remove the spleen, do suction of the remaining
haemoperitoneum and explore to look for any other injuries and
deal with them accordingly.
If there is excess bleeding in the splenic bed, insert a tube drain
and bring it out through a separate stab abdominal wall wound.
Count mops, gauze and instruments and ensure they are
complete.
Close the abdomen in layers.

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Key points.
Splenectomy is the treatment for severe injuries to the spleen, but

consider preserving the spleen if bleeding is not profuse.

The spleen has blood supply from the splenic artery and short

gastric arteries.
Vaccination with pneumococcal vaccine (pneumovax) and

prophylactic antibiotics and antimalarials are indicated due to the

immunodeficiency in a splectomised patient
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LACERATIONS OF THE LIVER.

Liver injuries follow blunt trauma to the right upper quadrant of

the abdomen and may result in significant bleeding.

Many liver injuries stop bleeding spontaneously and they should

not be sutured as this may result in significant bleeding which is

difficult to control.
Large liver lacerations should not be closed. Bleeding vessels

should be ligated and the liver defect packed with omentum or, if
unsuccessful, with a mop.
A large drain is indicated in all patients with liver injuries. It

should be removed after about 48hours unless bile continues to

drain.
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RUPTURE OF THE URINARY BLADDER.

Bladder rupture can be extraperitoneal or intraperitoneal.
Extraperitoneal rupture is most commonly associated with

fracture of the pelvis.

Intraperitoneal rupture often results from a direct blow to the

bladder or a sudden deceleration.

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Surgical options.
For extraperitoneal rupture, construct a suprapubic cystostomy.

If the rupture is large, also insert an abdominal drain.

For intraperitoneal rupture, close the rupture and drain the

bladder with a large urethral catheter or a suprapubic drain.

Carefully evaluate the patient to ensure that other injuries are

not missed.
A ruptured bladder is an indication for a full trauma laparotomy

to rule out other abdominal injuries.

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Words of wisdom.
Your success in life will be determined more by the depth of your

commitment to excellence than by any other factor, no matter

what your chosen field may be.
It is a sign of foolishness for one to keep doing the same thing the

same way he has been doing it and expect different results.

You can only leave the world of mediocres and advance into a new

world, where the desired destiny is, by doing more than before,
breaking the wall that surrounds your full potential.

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