Hollow_Viscous_Injuries[1]

Hollow_Viscous_Injur - Evaluation and Management Evaluation and Management of Hollow Viscous Injuries Intra­abdominal hollow viscous injuries can

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Unformatted text preview: Evaluation and Management Evaluation and Management of Hollow Viscous Injuries Intra­abdominal hollow viscous injuries can include the stomach, small bowel, colon and rectum More commonly the result of penetrating trauma than blunt trauma Principles of operative management are generally the same Blunt Trauma Blunt Trauma Though uncommon, increased morbidity and mortality if missed or delayed Abdominal tenderness after blunt torso trauma frequently associated with intra­ abdominal pathology Seat belt sign/flexion distraction fx’s associated with increased relative risk of small bowel injury Blunt Trauma, cont’d Blunt Trauma, cont’d Ultrasonography, CT, DPL the tools for evaluation Ultrasonography Highly specific and moderately sensitive in identifying intra­abdominal fluid Does not reliably distinguish solid­organ injury from hollow viscous injury (though DPL may help differentiate between the two) Blunt Trauma, cont’d Blunt Trauma, cont’d CT currently the imaging modality of choice Isolated finding – not greatly suggestive of hollow viscous injury Multiple findings – highly suggestive Blunt Trauma, cont’d Blunt Trauma, cont’d Blunt Trauma, cont’d Blunt Trauma, cont’d Penetrating Trauma Penetrating Trauma Evaluation contingent upon peritoneal penetration GSW’s: Generally necessitate exploratory laparotomy; laparoscopy for tangential GSW’s to rule out peritoneal penetration Stabbings: Laparotomy with obvious signs of peritoneal penetration (omental/bowel evisceration); otherwise, local wound exploration, and laparoscopy if fascial penetration is evident. Penetrating Trauma, cont’d Penetrating Trauma, cont’d Posterior vs. Anterior Stab Wounds Posterior wounds carry lower risk of intra­ abdominal injury Evaluated with CT augmented by intravenous, oral and rectal contrast Identifies posterior intraperitoneal violation and injury to retroperitoneal structures Operative Management Operative Management Treatment of injury is dictated by location and severity. In general… Antibiotics is administered before skin incision and for 24 hours if injury is confirmed Abdominal exploration performed through mid­line incision sufficient to access entire peritoneal cavity After initial control of any significant bleeding is achieved, inspection commences in a systematic fashion Operative Management, cont’d Operative Management, cont’d Injuries to the Stomach Treatment based grading system developed by AAST Injured Structure AAST Grade Characteristics of Injury AIS-90 Score I 2 II Stomach Intramural hematoma < 3 cm; partial thickness laceration Intramural hematoma ≥3 cm; small (<3 cm) laceration 2 III Large (>3 cm) laceration 3 IV Large laceration involving vessels on greater or lesser curvature 3 V Extensive (>50%) rupture; stomach devascularized 4 Operative Management, cont’d Operative Management, cont’d Grades I, II, III ­ primary repair Grade IV – dependant upon associated injuries Partial thickness: hemostasis and seromuscular closure Full thickness: hemostasis and closure in two layers No associated injuries to duodenum, pancreas or esophagus – distal gastrectomy and gastroduodenostomy Associated injuries – distal gastrectomy and gastrojejunostomy Grade V – complete devascularization or destruction Perform near­total or total gastrectomy with Roux­en­Y reconstruction Operative Management, cont’d Operative Management, cont’d Injuries to the Small Bowel Evaluated intraoperatively by “running the bowel”, from the ligament of Treitz caudad to the ileocecal valve Injured Structure AAST Grade Characteristics of Injury AIS-90 Score I 2 II Small Bowel Contusion or hematoma without devascularization; partial-thickness laceration Small (<50% of circumference) laceration 3 III Large (≥50% of circumference) laceration 3 IV Transection 4 V Transection with segmental tissue loss; devascularized segment 4 Operative Management, cont’d Operative Management, cont’d Primary repair, resection or a combination thereof is employed at the discretion of the surgeon Grade I –reapproximation of the seromuscular layers with interrupted sutures Grade II –limited debridement and closure in either one or two layers Grade III –repaired primarily if luminal narrowing can be avoided; otherwise, resection and anastamosis Small bowel anastomoses usually hand sewn or stapled Grade IV and V – resection and anastomosis Operative Management, cont’d Operative Management, cont’d Injuries to the colon Injured Structure AAST Grade Characteristics of Injury AIS-90 Score I 2 II Colon Contusion or hematoma; partialthickness laceration Small (<50% of circumference) laceration 3 III Large (≥50% of circumference) laceration 3 IV Transection 4 V Transection with tissue loss; devascularized segment 4 Operative Management, cont’d Operative Management, cont’d Colonic injuries further categorized as either non­ destructive or destructive Destructive ­ wounds that completely transect the colon (grade IV) or involve tissue loss and devascularized segments (grade V) Patients with destructive colonic injuries who had: comorbid medical conditions required transfusions of more than 6 units of blood in shock delayed operation…significantly higher risk for suture line breakdown when managed with resection and primary anastomosis Operative Management, cont’d Operative Management, cont’d Non­destructive wounds (grades I­III) Destructive wounds (grades IV­V) Seromuscular closure for partial thickness Primary closure for full thickness Repair with resection and primary anastomosis Destructive wounds with risk factors Resection with end colostomy or resection and primary anastomosis with proximal diversion Proximal diversion loop colostomy (with open or closed distal stoma) end colostomy (with a mucous fistula or closure of the rectal stump) Operative Management, cont’d Operative Management, cont’d Injuries to the Rectum Classified according to anatomic criteria Anterior and lateral sidewalls of the upper two thirds of the rectum managed in the same manner as colonic injuries Upper two thirds posteriorly and lower one third of the rectum circumferentially ­ extraperitoneal Upper two thirds ­ exploration and suture repair, fecal diversion with loop or end colostomy as adjunctive measure Lower one third ­ explored and repaired if accessible Fecal diversion recommended Wounds difficult to reach ­ proximal fecal diversion and presacral drainage ...
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This note was uploaded on 12/21/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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