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INJURIES UPDATE
07-08
Warko Karnadihardja
WHY IS IT IMPORTANCE ?
Preoperative diagnosis of these
INCIDENCE
Relatively uncommon
70% to 75%, due to penetrating injury
< 10% of abdominal trauma but
ASSOCIATED INTRA
ABDOMINAL INJURY-1
> 90% of pancreatic injuries
> 50% morbidity and immediate
ASSOCIATED INTRA
ABDOMINAL INJURY-2
Intra abdominal organs most
DIAGNOSIS
Should be suspected based on MIST
Physical examination & assessment
Serum amylase levels
FAST
DPL
CT-Scan
ERCP
MRCP
Isolated pancreatic injury is
uncommon
CRITIQUE ON
ASSESSMENT
Serum amylase levels are neither
Ruptur duodenum
Kasus
Pria 17 th, KLL terlempar dari
INTRAOPERATIVE
DIAGNOSIS
Depends on visual inspection and
IMPORTANT POINT
SUSPECTED PANCREATIC INJURIES
SHOULD BE SURGICALLY EXPLORED
IMPORTANT POINT
IDENTIFICATION OF INJURY TO THE
MAJOR DUCT IS THE CRITICAL ISSUE
IN INTRA OPERATIVE MANAGEMENT
OF PANCREATIC INJURY
BLUNT PANCREATIC
INJURY
High index of suspicion
Minimal findings or
equivocal exam
Serial enzymes
Normal CT-Scan
Repeat CT-Scan
Ductal integrity
ERCP
MRCP
EXTRAVASATION ON MRCP
MRCP ON TRAUMA
A reliable noninvasive diagnostic
Mortality
Early hemorrhage
Early
Late hemorrhage
Pancreatic pseudocyst
Hemorrhage
Late
Pancreatic fistula
Hemorrhage
Duodenal fistula
Duodenal fistula
Intraabdominal abscess
Pancreatitis
Obstruction
Uncontrolled sepsis
Malabsorption
MOF
Diabetes
PRINCIPLES OF TRATMENT
OF PANCREATIC INJURIES
1. Control hemorrhage
2. Debride devitalized pancreas, which
SURGICAL
EXPOSURES
SURGICAL EXPOSURES
Transection of Ligamentum Treitz
Exposure of the 4th portion of the
SURGICAL EXPOSURES
Kocher Maneuver
Medial rotation of
Duodenum
Pancreatic head
Distal CBD
SURGICAL EXPOSURES
Cattel Braasch Maneuver
Right abdominal visceral rotation
Technique of exposure of 3rd and
SURGICAL EXPOSURES
Aird Maneuver
Medial rotation of spleen and tail
of the pancreas
Open the
duodenum
Transect the tail
to
cannulate the
duct
Secretin stimulation
Intra operative ERCP
COMPLETE TRANSECTION
Debride to viable tissue
Primary repair with spatulation
Interrupted absorbable suture
CHOLECYSTOCHOLANGIOGRAPHY
Lesser sac is open to visualize the
pancreas
Radiographic contrast material and
methylene blue is injected into gall
bladder or the CBD
X-ray is taken looking for extravasation
Pancreas inspected for extra vasation of
methylene blue
Methylene blue pancreatography
I.V. fentanyl causes spasm of the
Sphincter Oddi
Methylene blue cholangiography
precisely identifies the site of injury
A Balancing Act of
Parenchymal preservation
Parenchymal resection
Risky anastomosis
Pancreatic insufficiency
Activated fistula
Malabsorption
Secondary hemorrhage
Diabetes mellitus
Wound complications
WHAT IS TREATMENT
OPTIONS FOR
1. Pancreatic contusion or capsular
Pancreaticoduodenectomy
TRAUMA TO THE
DUODENUM
Complete transection
Stop hemorrhage
Exposure
Location of injury
Primary repair
Protection of repair
ANATOMY OF THE
DUODENUM
The duodenum shares its blood supply with
the pancreas
There are 4 parts
1st portion duodenum = superior portion
intra peritoneal
2nd Portion duodenum = descending
portion, contains ampula Vateri
3rd Portion duodenum = transverse
portion-extends from the ampula Vateri to
SMA anteriorly, and the ureter, IVC, and Ao
posteriorly
4th Portion duodenum = ascending portion,
begins at SMA and ends at the jejunum
DIAGNOSIS OF DUODENAL
INJURIES
Clinical suspicion is based in MIST
Blunt injury:
Midepigastric or RUQ pain and tenderness
Can have peritoneal signs
The symptoms and findings can be subtle
X-ray study:
Retroperitoneal air
Obliteration of the right psoas margin
Diagnosis is generally made at
laparotomy
DIAGNOSIS OF DUODENAL
INJURIES
With penetrating mechanisms
Duodenal injury is found at
multiple segments
Non operative
NGT for 1 to 2 weeks
Surgical evaluation and
seromuscular repair of grade I or II
lacerations
Primary repair
Stapled, double layer or single
layer
Mild
Secondary to stab wound
< 75% circumference
3rd to 4th portion
Injury to repair interval < 24 hr
No associated pancreatic or
biliary injury
No
Yes
DECOMPRESSIVE
PROCEDURES
Three tube technique
Gastrostomy or
gastroduodenostomy
Retrograde duodenostomy
Feeding jejunostomy
Tube duodenostomy
External drainage
DIVERSIONARY
PROCEDURES
Duodenal diverticulation
Pyloric exclusion
Temporary GI dysconnection
External drainage
Simple duodenoraphy
Duodenojejunostomy
Reseksi
anastomosis
head
Grade V duodenal injury
Massive disruption of
duodenopancreatic complex
Duodenal devascularization
Non reconstructable injury to
pancreas, duodenum and distal
CBD
Pancreaticoduodenectomy
SECRETION
Bile
Pancreatic juices
: 1000ml/day
: 800-1000
ml/day
Gastric juices
: 1.500-2.500
ml/day
Mix in the duodenum
TREATMENT OPTIONS
1. Intramural duodenal hematoma
2. Duodenal perforation
Isolated injury to the duodenum
Associated vascular injury
Blunt injury
Missile injury
Associated common bile duct injury
3. > 75% of the wall involved
4. > 24 hours since injury
5. Combined injuries to the duodenum
OUTCOME-1
Mortality rate 40% if diagnosis is
OUTCOME-2
Retrograde to be decompression
THANK YOU