Abdominal Trauma Surgery

Educational Objectives

The goal of this program is to improve the management of abdominal trauma. After hearing and assimilating this pro­gram, the clinician will be better able to:

1.   Recognize the advantages of and indications for using open abdomen techniques in bowel injuries.

2.   Describe methods utilized for temporary abdominal closure.

3.   Explain methods for preventing and managing enterocutaneous fistulas.

4.   Assess the need for surgery in a patient with abdominal trauma.

5.   Discuss the management of patients with stab wounds, gunshot wounds, or blunt trauma to the abdomen.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgements

Drs. Patton and McSwain were recorded at the Detroit Trauma Symposium, held November 6-7, 2008, in Detroit, MI, and sponsored by the Detroit Receiving Hospital and the Wayne State University School of Medicine. The Audio-Di­gest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Management of the GI Tract in the Open Abdomen

Joseph H. Patton Jr, MD, Division Head, Acute Care Surgery and Director of Trauma, Henry Ford Hospital, Detroit, MI

Damage control principles: term “aborted laparotomy” changed to “damage control”; deals primarily with control of gastrointestinal (GI) tract contamination; aim to address hemorrhage; open abdominal techniques effective and shown to improve survival; classic indications for open abdomen  —  liver, spleen, and retroperitoneal injuries where packing necessary; avoid hypothermia, acidosis, and coagulopathy leading to death; avoid or treat abdominal com­partment syndrome; allow return for second look, eg, ischemia, peritoneal toilet; speaker believes open abdominal techniques used too often; advantages of open abdomen in bowel injuries  —  surgery ended too soon; inherent need for reoperation, which leads to increased ventilator days, increased length of stay in intensive care unit, increased costs, increased time, and increased number of resources; loss-of-domain issue; metabolic problems (the longer ab­domen left open, the greater the potential for problems); risk for intestinal fistulas

Resection and anastomosis: primary repair ideal at initial operation; if resection of bowel necessary, safe to perform; 3 to 4 days maximum period to leave bowel in discontinuity (iatrogenic bowel obstruction); delayed reanastomosis after resection  —  feasibility not addressed in literature; depends on when reanastomosis performed and whether performed in small bowel or colon; when to perform  —  dictated by physiology of patient; if patient not in good con­dition, do not perform anastomosis at initial laparotomy; may lead to relative ischemia to anastomosis; reanastomo­sis at subsequent laparotomy  —  some data on small bowel; generally accepted practice to leave small bowel in discontinuity when doing damage control; study reported reanastomosis possible at second laparotomy in 12 of 13 small bowel resections with few complications; Vancouver study  —  looked at handsewn vs staple anastomosis and found fistula rate of 2.5% and abscess rate of 7%; concluded that anastomotic complications after enteroenteros­tomy or primary repair for trauma uncommon, regardless of technique, but requires caution during or after damage control; increased risk for enterocutaneous fistula formation seen with damage control

Repair of colon: primary repair ideal; resection and anastomosis in standard trauma laparotomy  —  safe to perform; not performed in setting of large-volume transfusion, shock, or medical comorbidities; unknown whether reanas­tomosis of colon safe after patient’s physiology restored; stomas  —  not necessarily safe, especially in swollen ab­domen; interfere with delayed closures; some data suggest that presence of stoma increases infectious complications; violation of abdominal wall near stoma causes further complications

Miller study: looked at patients with colonic anastomosis in damage-control setting and another group in non–dam­age-control setting; found no difference in abscess rate; difference seen in overall mortality, but not in colon-re­lated morbidity or mortality; no differences in colonic mortality whether colon reanastomosis performed in damage-control setting, delayed operation, or single laparotomy; found no difference between patients with re­anastomosis and those with colostomy; concluded that reanastomosis of colon at second or third operation safe; speaker’s institution found no difference in colon-related morbidity or mortality between reanastomosis and co­lostomy

Weinberg study:  compared damage-control patients to those requiring only single laparotomy; speaker believes this comparison invalid (damage-control patients sicker); damage-control group had higher complication (due to leaks) and mortality rates; in patients who received resection and colostomy, no difference seen; higher compli­cation rate (ie, leaks and abscesses) in group that received resection and anastomosis; damage-control group fared worse than single laparotomy group; found no statistical difference in complication or mortality rates when comparing patients who underwent damage control laparotomy with resection and anastomosis vs with colos­tomy; when colostomy compared to resection and diversion, trend toward higher complication rate in anastomo­sis group, but not statistically significant; colostomy not necessarily preferable due to increased complication rate (morbidity associated with colostomy closure »15%)

Temporary abdominal closure: key concepts  —  need to protect bowel and control drainage; avoid loss of domain; maintain mobility of anterior abdominal wall (helps with primary fascial closure); prevent evisceration and watch for secondary compartment syndrome (regardless of technique used and whether abdomen left open)

Skin closure:   fast; does not allow abdomen to retract; no significant loss of domain; possibly better hemostasis and tamponade; no longer done frequently, due to risk for compartment syndrome; bag  —  variety available; allows for expansion; preserves fascia; reaccessible; relatively inexpensive; highly temporary

Polygalactin 910 (Vicryl): good integrity and does not allow abdominal wall to slide laterally to great extent; reac­cessible; long-term use acceptable; does not mandate second operation to perform remanipulation of bowel; dis­advantages include need to sew to fascia (if performing primary fascial closure, necessary to leave fascia as intact as possible); not permanent (absorbable mesh)

Vacuum-pack closure: most popular form of temporary abdominal closure; fast; preserves fascia; controls drainage; keeps bed clean; disadvantages include opacity and risk for secondary compartment syndrome; risk associated with frequent manipulation (requires changing every 2-3 days); necessary to place nonadherent barrier out to gut­ters to maintain mobility of anterior abdominal wall; must exercise caution to avoid poking finger through previ­ous anastomosis

Enterocutaneous fistulas: almost always associated with previous bowel repair; seen in 7% to 25% of patients with open abdomen; serious complication; increasing in frequency as more abdomens left open; fistula formation rate associated with increased time to closure; raised question of whether type of temporary closure influences fistula rate

Study by Memphis group: compared vacuum-pack closure to polygalactin 910; neither method clearly superior; fistula rate with vacuum-pack closure 21% (5% with polygalactin 910); difference not statistically significant

Study by Vanderbilt group: looked at complications associated with open abdomen; fistula most frequent complica­tion (12%); also looked at whether type of closure influenced fistula rate; compared primary group (those with primary closure of fascia), temporizing group (those with vacuum-pack closure), and prosthetic group (polyga­lactin 910); temporizing group had highest rate of fistula formation, clearly associated with time to closure; evis­ceration possible as well when abdomen left open

Mayberry study: looked at experience with mesh; severity of intra-abdominal injury (ie, abdominal trauma index) only factor found to increase fistula rate; mean time to fistula 30 days, so speaker recommends closing abdomen within 3 wk; also recommends against using vacuum-pack closure on polygalactin 910 (leads to faster reabsorp­tion of polygalactin 910, loss of barrier protection, and higher fistula rate)

Polygalactin 910 mesh: development of layer of pseudopurulent material indicates readiness for skin graft; graft greatly improves integrity of granulation bed; should perform graft or close fascia as early as possible

Management of fistulas: necessary to control drainage and protect skin; should not operate too soon; goal to have skin on granulating bed; try various strategies; cadaver skin with fibrin glue used with varying success; speaker does not recommend placing tube on fistula; take-home points  —prevention best therapy; timing most crucial issue

Abdominal Trauma  —  When to Watch and When to Operate

Norman E. McSwain Jr, MD, Professor of Surgery, Tulane University School of Medicine, New Orleans, LA

Introduction: good trauma surgeon should determine type of problem, actions necessary to solve problem, and length of time to make decision; goal achieved by determining patient’s condition, skill and knowledge of surgeon, and available equipment; named blood vessel loses more blood than skin capillaries; need to cut quickly with knife to get to abdomen where major bleeding located; in surgery, “go where blood is”; test whose outcome has no effect on patient care worthless (only delays care that patient needs); hemostat, knife, and fingers serve as extension of eyes; should take only 15 to 30 sec to use surgical knife to cut through skin, subcutaneous tissue, and linea alba and tear off peritoneum; Bovie cautery not used until most extensive bleeding dealt with; “cold” patient  —  in shock; plasma with clotting factors highly effective in stopping bleeding; use surgical procedures to clamp “bleeders” (damage control resuscitation); humans derive energy from aerobic metabolism (production of adenosine triphos­phate [ATP]); must keep patient warm (producing enough ATP); calorie loss prevented by covering patient, but cannot replace calories until patient given enough red blood cells to switch from anaerobic metabolism to aerobic metabolism; therefore, resuscitation most critical action

Assessment of patient: critical; 2 priorities  —  bleeding and leakage of bowel contents; only minutes to ameliorate bleeding; £24 hr to correct leaking bowel; first, determine how much time available; clinician should know accu­racy of tests in his or her institution; physical examination (PE)  —  next, determine whether patient in shock, etiol­ogy of patient’s problems, how to stop hemorrhage, and whether abdomen distended; initiate massive transfusion protocol en route to operating room (OR; 6 U of blood and 6 U of plasma); give crystalloids in field, then switch to liquid plasma, followed by fresh frozen plasma; stab wound in abdomen — abdominal examination critical to de­termine whether surgery required; after PE, perform exploration of wound to determine whether peritoneum pene­trated; if not penetrated, patient discharged; if penetrated but PE shows no tenderness, rebound, or guarding, patient observed for 24 hr; if no tenderness develops, consider discharge; in trauma center, examination for tenderness per­formed every 2 hr; in nontrauma center, in patient’s best interest to surgically explore abdomen; study by Nance and Cohn  —  only 30% to 40% of stab wounds required surgery; same conclusion reached by Shaftan; Focused Abdom­inal Sonography for Trauma (FAST) examination  —  sensitivity »67% (allows identification of two-thirds of pa­tients requiring surgery); Scalia et al  —  computed tomography (CT) with triple contrast provides information concurring with studies described above (60% of patients with stab wounds do not require operation); conclusion — immaterial whether PE or tests performed, as results of all methods same; despite technology, no improvement in assessment of patients with stab wounds in abdomen over past 35 yr

Gunshot wound (GSW): if abdominal examination determines that GSW may have penetrated abdomen and injury repairable, patient goes to OR; if patient obese and penetration of abdomen unlikely, keep under observation to de­termine need for trauma laparotomy; in treatment of trauma, decisiveness important

Blunt trauma: utilize same techniques of PE, radiologic techniques, and ultrasonography (US); less imperative to rush patient to OR; again, knowing institutional accuracy of tests important; if patient neither in shock nor has pos­itive PE, utilize adjunctive measures to help determine need for surgery; speaker recommends that treating surgeon read test results (rather than depending on someone else’s interpretation); splenic injuries due to blunt trauma  —  if no hemorrhage, observe; if hemorrhage minimal, observation, embolization, or splenectomy recommended; if hemorrhage significant, perform splenectomy; liver injuries  —same approach as with blunt trauma; more difficult to intraoperatively manage hemorrhaging liver than hemorrhaging spleen; if free fluid identified on CT or US, and no solid organ injury present, fluid most likely due to injury of GI tract; in such cases, and particularly with seatbelt sign, speaker recommends taking patient to OR

Intestinal injuries: CT  —  delays diagnosis in 44% of patients; may or may not give useful information; PE most im­portant; other diagnostic techniques helpful; diagnostic peritoneal lavage (DPL)  —  highly sensitive (97% accu­racy) for detecting blood; however, presence of blood alone not adequate reason to take patient to OR; helpful in stab wounds, but not in all other situations; quick and easy to perform (5-10 min); minimal experience required (percutaneous technique); greater accuracy than other tests (eg, US); indicated for patient with head injury, and when concerned about intra-abdominal injury; beneficial when patient lost to PE, CT, or follow-up, or with equivo­cal PE

FAST examination: extremely operator-dependent; should be used like stethoscope or any part of PE; should never be used as sole guide to determine whether patient requires surgery; if patient hemodynamically unstable with large pelvic injury, US helpful in determining whether intra-abdominal injury present; also true for head injury; not indi­cated in patient with penetrating trauma

Managing patient with blunt trauma in nontrauma center: unstable patient taken directly to OR for damage-con­trol resuscitation and surgery; consider transferring to trauma center if within vicinity; in small hospital with little surgical experience, patient taken to OR for resuscitation only, or to control hemorrhage, then transferred to trauma center as soon as possible

Suggested Reading

Bee TK et al: Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma 65:337, 2008; Cothren CC et al: One hundred percent fascial approximation with sequential abdominal closure of the open abdomen. Am J Surg 192:238, 2006; Fabian TC: Damage control in trauma: lap­arotomy wound management acute to chronic. Surg Clin North Am  87:73, 2007; Goverman J et al: The "Fistula VAC," a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma 60:428, 2006; Hornyak SW et al: Value of "inconclusive lavage" in abdominal trauma management. J Trauma 19:329, 1979; Ly­ons WS: Abdominal compartment syndrome: iatrogenic or unavoidable? J Am Coll Surg 203:405, 2006; Miller MT et al: Not so FAST. J Trauma 54:52, 2003; Miller PR et al: Improving outcomes following penetrating colon wounds: applica­tion of a clinical pathway. Ann Surg 235:775, 2002; Miller RS et al: Complications after 344 damage-control open celioto­mies. J Trauma 59:1365, 2005; Murdock AD: What is the standard approach to temporary abdominal closure? J Trauma 62:S29, 2007; Nance FC et al: Surgical judgment in the management of stab wounds of the abdomen: A retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 170:569, 1969; Stassen NA et al: Abdominal seat belt marks in the era of focused abdominal sonography for trauma. Arch Surg 137:718, 2002; Tieu BH et al: The use of the Wittmann Patch facilitates a high rate of fascial closure in severely injured trauma patients and critically ill emergency sur­gery patients. J Trauma 65:865, 2008; Weinberg JA et al: Trauma laparotomy in a rural setting before transfer to a regional center: does it save lives? J Trauma 54:823, 2003.