Trauma

Question 1

In trauma, how are colon injuries diagnosed?

Answer 1

Most colon injuries are the result of penetrating trauma, and are suspected because of either the wound track or signs of peritonitis, which may develop slowly after injury. May have blood per rectum.

CT scanning and other diagnostic imaging types are rarely reliable or useful in establishing a diagnosis, so if injuries are suspected (diffuse pain), laparotomy for definitive diagnosis and/or repair is mandatory. Need G- and anaerobe coverage (ertapenem vs zosyn).

CT may show unexplained free fluid, colonic wall thickening, mesocolic hematoma, extraluminal air, oral/rectal contrast extrav. Some minor findings will be DC home - educate them on when they need to return.

Question 2

Describe the four distinct methods of repairing colon injuries in trauma.

Answer 2

• Lateral repair - suture oversewing of perforations only
• Resection of injured segment, end colostomy and mucous fistula
  
  • Exteriorization of the injured segment with of a loop colostomy at the injury site
• Oversewing of the injury site (lateral repair), loop or end colostomy proximal to divert the fecal stream.
• Repair of the injury site (lateral repair), exteriorization of the injured segment as a loop colostomy, with the intent of returning to the abdomen in 7 to 10 days.

Question 3

What are the usual causes of trauma extraperitoneal rectal injuries?

Answer 3

Penetrating trauma, usually from a gunshot wound, which traverses the bony pelvis.

Blunt trauma that results in severe fractures, particularly diametric fractures, which result in the formation of jagged bone fragments.

Question 4

How should trauma extraperitoneal rectal injuries be diagnosed?

Answer 4

• They should be suspected by mechanism (a gunshot wound across the pelvis, or severe fractures) and presence of blood on rectal examination.
• Confirm w/ extraluminal bubbles of air on flat plate or CT scan of pelvis w/ rectal contrast.
• If HDS, rigid proctosigmoidoscopy should be performed to directly visualize or exclude injury.
  
  • Define location and extent.
  • Fecal diversion alone vs end colostomy if >50% luminal circumference.

Question 5

What surgical treatment is required for perforating injuries of the extraperitoneal rectum?

Answer 5

• Proximal diversion of the fecal stream, usually with an end-sigmoid colostomy,
• No presacral drainage, no washout.
• If the site of perforation can be visualized, it can be sutured, but access is generally difficult and closure is not mandatory.

Question 6

You are operating on a patient with penetrating injuries to the upper abdomen and encounter an odd number of hollow viscous perforations. How will you proceed?

Answer 6

• Probably missed an injury
• Laparotomy incision can be modified to aid in exposure
• Identify missing perforation(s) or determine if existing perforation(s) are tangential
• Re-run the bowel, look at the diaphragm
• May require exposure of entire stomach, duodenum, pancreas, CBD, vasculature, etc
  
  • ​Open the gastrocolic (lesser sac), retract transverse colon inf; unroof hematomas
  • ​Gastroduodenal ligament division, Kocher, release mes attachments, release LoT
  • Mobilize hepatic flexure, divide gastrocolic ligament

Question 7

You encounter an injury to the gastroesophageal junction during a trauma laparotomy in a patient with a stab wound to the subxiphoid region. How will you proceed?

Answer 7

• Recognize that adequate exposure is imperative and begins with division of the left triangular ligament and retraction of the left lobe of the liver. May need to take short gastrics.
• Retraction of the gastroesophageal junction must be performed while limited tension on the area is applied through encircling techniques.
• Understand the repair techniques employed to include a protective fundoplication: primary repair w/ 2 layers and buttressing (fundoplication). If blown out, divert.

Question 8

You are operating on a patient who has been stabbed in the upper abdomen. At laparotomy, you find a laceration on the anterior gastric wall. What are the next steps in the operation?

Answer 8

Discuss mobilization of the stomach to inspect the posterior gastric wall.

If a posterior laceration is found, discuss the potential associated injuries.

Describe the management of an associated injury to the pancreas.

Question 9

A patient has sustained a shotgun blast to upper abdomen. You have successfully packed and stopped the hemorrhage from the liver. The spleen has been removed due to a through and through injury to the hilum. There is a zone 2 retroperitoneal hematoma that is stable. You identify a grade IV injury to the stomach. The patient has received 11 units of packed red blood cells, 8 units of fresh frozen plasma, and 6 units of platelets. The patient’s temperature is 35.6 ºC, and his blood is not clotting well. How will you proceed?

Answer 9

• (1) control hemorrhage, (2) control enteric contamination, (3) 1:1:1.
• Identify patients who would benefit from damage control operation.
• Pack the liver: dome, over bowel/under liver (sandwich); may need lateral pack.
  
  • If packing doesn’t work, then probably arterial bleeding - Pringle.
  • If still bleeding, probably retroperitoneal caval bleed - high mortality.
• Stable zone 2 hematoma in blunt case ok to leave. Penetrating needs exploration.
• Control contamination - close gastric defect, repair later. No gastrectomy.

Question 10

A 32-year-old male is taken to the operating room for a gun shot wound to the abdomen. At laparotomy, a hematoma is found in the retroperitoneum, behind the hepatic flexure is found. Describe the operative steps in evaluating suspected duodenal injury in this setting.

Answer 10

• Indications for exploring retroperitoneal hematomas: all zone 1, all expanding, all penetrating.
• Know how to mobilize the right colon and duodenum to allow complete retroperitoneal inspection.
• Know how to inspect the posterior proximal duodenum within the lesser sac and at the ligament of Treitz.

Question 11

During abdominal exploration for a stab wound, a 6 cm laceration to the duodenum is found at the lateral wall, with part of the duodenal wall devitalized. Describe the operative techniques and adjuncts for optimizing the integrity and durability of a duodenal repair for this injury.

Answer 11

• Most duodenal injuries are amenable to simple repair using conventional techniques.
  
  • Debride necrotic tissue.
  • Assess CBD and pancreas - may need ant/post tubes/drains
  • Place NGT and distal DHT.
• May need duodenal augmentation with a Roux-en-Y jejunal limb.
• Adjuncts include proximal or distal drainage (duodenostomy or jejunostomy) and gastric fluid control (sew/staple pylorus shut and do gastro-J)

Question 12

A 22-year-old female presents in shock after a motor vehicle crash. The focused assessment with sonography in trauma (FAST) exam is positive for hemoperitoneum, and the patient is taken to the operating room for immediate laparotomy. At exploration, blunt lacerations to the duodenum and adjacent pancreas are found. How does your approach to combined injuries to the pancreas and duodenum differ (if at all) from the approach to isolated duodenal injuries? What alternative surgical techniques might be utilized?

Answer 12

• Evaluate the pancreas completely: Kocher (1-3rd portion of duod, head/neck of panc), divide gastrocolic ligament (posterior/medial duod, ant panc), divide retroperitoneum inferior to pancreas (post panc), right medial visceral rotation (more 3rd portion of duod), mobilize LoT (distal panc, 4th portion duodenum)
• Assess duct: IOCP, IO ERCP, damage ctrl and postop ERCP
• Assess location of duct injury: left (distal) or right of SMV
• Combined injuries: tx as individual; may require dmg ctrl and delayed recon
• Adjunct: duodenal decompression - duod vs jejunostomy to prevent fistulas
• Adjunct: pyloric exclusion - suture pylorus and do loop gastrojejunostomy; pylorus will spontaneously open in weeks; risk marginal ulcer

Question 13

A 15-year-old male presents with complaints of abdominal pain following a bicycle crash. On abdominal CT, a 4 cm hematoma is seen in the duodenal wall. Describe the approach to the non-operative management of this patient and the indications for laparotomy.

Answer 13

• Found on CT, and usually resolve nonop w/ nutrition and repeat imaging studies
• If gastric outlet obstruction: NGT, TPN, UGI contrast study in 5-7 days
  
  • ​if possible, DHT is preferred
• If persists after 2 weeks: ex-lap - eval for perforation, stricture, pancreatic injury
  
  • ​main indication is ischemia - acidosis, sepsis
  • try not to operate
  • ​hematomas often decompress spontaneously during duodenal mobilization

Question 14

A 55-year-old male is 7 days post-operative following the repair of a blunt duodenal “blowout” laceration 7 days ago. He has been doing well, but now complains of acute-onset abdominal pain with bilious output from a drain left adjacent to the duodenum. Outline your approach to the diagnosis and management of this patient.

Answer 14

• Possible leak (stump blowout) or missed injury
• Need to control/define fistula and divert
• CT w/ PO/IV contrast
• If contained, IR intervention - perc drain, PTC
• If needs ex-lap (unstable): NGT, DHT, drains
• Fungal coverage
• Provide nutrition
• If leak is high-output or persists - reoperate
  
  • small defects can be repaired primarily
  • large defects need jejunal patch or Roux-en-Y

Question 15

A 65-year-old female is the restrained driver in a head-on MVC. During laparotomy for refractory hypotension and intraperitoneal fluid seen on FAST, she is found to have hemorrhage from sigmoid mesentery laceration with associated full thickness injury to the colon. What is your operative approach for managing these injuries during trauma laparotomy?

Answer 15

• Control Bleeding.
• Halt contamination.
• Assess additional injuries, clinical stability: dmg ctrl vs definitive mgmt.
• Grade IV (transection) and grade V (transection with tissue loss / devascularized segment) colon injuries require resection or debridement of the injury with primary anastomosis and consideration of proximal fecal diversion or resection of the injured segment with end colostomy and Hartman’s pouch.
• Assess comorbidities and patient status: hypotension, coagulopathy, acidosis, blood product transfusion requirement, time from injury to operative management

Question 16

A 26-year-old male presents to the emergency department after being stepped on by a horse. He is hemodynamically stable. CT of the abdomen with IV contrast demonstrates fluid within the lesser sac anterior to the neck of the pancreas and wall thickening in the distal gastric antrum. What is your approach to evaluating this patient further?

Answer 16

• CT findings concerning for blunt injuries to both the stomach and pancreas.
• Initial approach: repeat physical examination to assess for clinical signs of peritonitis, HD instability or emergent OR indications
• In absence of immediate OR indication, early ERCP to evaluate for pancreatic ductal injury and the need for repeat CT of the abdomen within 24 hours. Initial CT, soon after the injury, may not fully demonstrate the extent of the injury.
• Non-op is ok for low-grade pancr injuries (AAST I / II) w/o ductal involvement, while early dx and surgery for grade III injury improves prognosis.
• If the patient deteriorates and requires OR prior to preoperative ERCP - eval the pancreas (Kocher, cut gastrocolic, cut inferior panc peritoneum, cut LoT). Possible administration of cholecystokinin to elicit effluent from pancreatic injury. Cholecystocholangiopancreatography to evaluate the pancreatic duct vs intraop ERCP. Possible direct ampullary cannulation via duodenotomy.

Question 17

A 32-year-old male is brought to the emergency department 30 minutes after sustaining a gunshot to the lower abdomen. Upon operative exploration, the bullet trajectory appears to traverse the extraperitoneal pelvis.

Answer 17

• Penetration inj to pelvis, perineum, buttock, upper thigh - eval for rectal injury.
• DRE is mandatory but has a high false negative rate.
• Rigid proctoscopy should be performed if there is concern for rectal injury.
• Injuries to the rectum should be classified by anatomic location in relation to the peritoneal reflection, as treatment differs for intraperitoneal versus extraperitoneal injuries.
• Intraperitoneal injuries and those to the most proximal extraperitoneal rectum which may be explored operatively are often treated similarly to injuries of the colon with primary repair or with resection / debridement with primary anastomosis and consideration of proximal diversion.
• Injuries to the extraperitoneal rectum require dissection and exposure of the extraperitoneal space. This extended exposure may allow for contamination of the remaining peritoneal cavity should the repair fail. Thus, these injuries are often not explored and treated adequately with proximal fecal diversion utilizing either end- or loop colostomy.
• Mandatory presacral drainage of extraperitoneal rectal injuries remains a subject of debate. As an adjunct to fecal diversion, presacral drain placement aims to prevent significant morbidity of extraperitoneal abscess formation and the potential mortality from pelvic sepsis. Not recommended as default.
• Injuries to the extraperitoneal rectum which are treated with proximal diversion ± presacral drainage can be evaluated to verify rectal healing with a Gastrografin enema, 6 - 8 weeks later, in preparation for colostomy takedown.

Question 18

Describe the treatment of pancreatic transection with duct disruption at the level of the SMA.

Answer 18

• Pancreatic transection with duct involvement requires operative management.
• Discuss the anatomic distinction between proximal and distal pancreas defined by the location of the superior mesenteric vessels passing behind the junction of the head and body of the pancreas. At SMA is distal.
• Describe distal pancreatectomy, with or without splenectomy or distal pancreatic preservation with Roux-en-Y pancreaticojejunostomy.
• Distal pancreatic transection with duct injury, in both adults and children, is best treated by distal pancreatectomy. Non-operative management of these injuries has a high risk of pancreatic pseudocyst, abscess, prolonged hospitalizations and need for multiple drainage procedures.
• Distal pancreatectomy with splenic preservation adds to the operative time and may compromise patients undergoing emergent intervention in the setting of trauma.
• Distal pancreatic preservation with Roux-en-Y pancreaticojejunostomy may be indicated for more proximal pancreatic injuries, to the right of the mesenteric vessels, when resection would result in severe pancreatic insufficiency. The goal is to preserve as much gland as possible dictated by the location of the injury. Preserving at least 20% residual pancreas may minimize postoperative complications and attenuate postoperative endocrine / exocrine dysfunction.

Question 19

You are assessing a patient who was crushed against the steering wheel during a motor vehicle collision. He is normotensive, mildly tachycardic, and non-intubated. He endorses epigastric pain, greater than the tenderness appreciated on abdominal exam. What is your differential diagnosis, and what would be your next steps?

Answer 19

• Select CT scanning with IV contrast to further evaluate the abdomen; usually oral contrast is not initially used in the trauma patient (although it could be appropriate in this patient.)
• Recognize significance of retroperitoneal air, retro/intraperitoneal fluid, or extravasation of oral contrast: suggestive or diagnostic of a duodenal/pancreatic injury. If no clear injury, follow-up studies would include CT A/P with oral contrast or upper GI series, or exploratory laparotomy.
• Understand the role of IV and oral contrast in CT scanning of the abdomen in blunt trauma.
• Include retroperitoneal duodenal and pancreatic injury in the above situation in the differential diagnosis.
• Understand that the retroperitoneal location of D2 and D3 can make abdominal physical exam less dramatic, and that peritonitis can occur in a delayed fashion.
• Demonstrate a high level of suspicion for duodenal and pancreatic injury, given the mechanism of injury.

Question 20

In the course of an exploratory laparotomy for trauma, you encounter a simple laceration of the first portion of the duodenum that comprises 40% of the duodenal wall circumference. How would you manage this defect, and what other issues must you address intraoperatively?

Answer 20

Understand that primary closure is appropriate and that more extensive techniques (pyloric exclusion, Berne diverticulization, resection and anastomosis) are not indicated.

Exhibit awareness of the potential for suture-line leak and institute prophylaxis against this via (1) external drainage of the area adjacent to the repair and (2) options for buttressing repair with omentum or serosal surface of small bowel. Recognize the advantages of protecting the duodenal repair line and the possible advantage of a jejunal feeding route.

Question 21

Upon encountering a complete disruption of the duodenum at the junction of the second and third portions during exploration for trauma, what are your concerns for associated injuries, and how would you address these concerns while treating this patient’s injury?

Answer 21

Understand that the first priority is to control hemorrhage, the next is to manage fecal contamination, and finally to address the duodenal injury.

Understand that this type of injury requires assessment of the ampulla of Vater, distal common bile duct, and proximal pancreatic duct; know to use intraoperative cholangiography to aid in this assessment.

Exhibit awareness of patient’s hemodynamic and metabolic condition in the setting of massive injury, and employ staged resection and reconstruction when indicated (recognize lethal triad of coagulopathy, acidosis, and hypothermia).

Recognize the shared blood supply among the duodenum, pancreatic head, and ductal structures, and manage resection options appropriately, ensuring that well-vascularized tissues and anastomoses remain in situ.

Question 22

A patient sustained a gunshot wound to the abdomen with injury to the second portion of duodenum and the left half of pancreas. What is your operative approach?

Answer 22

• Determine the hemodynamic stability of the patient before deciding treatment.
• Assess the ampulla and common bile duct, the need for repair of the duodenum, distal pancreatectomy with splenectomy, or repair of the common duct and pyloric exclusion.
  
  • ​May need a total pancreatectomy if ampulla is injured along w/ distal panc.
• A wide drainage of the area, enteral feeding access.
• Postoperative complications must be discussed.

Question 23

A 12-year-old boy sustained an injury to the upper abdomen after a bicycle accident. He is hemodynamically stable; CT shows he has a grade II liver laceration and the pancreatic margins are indistinct. How will you approach this patient?

Answer 23

Understand the need for possible laparotomy or serial abdominal examination. Trauma FAST and CT. CT may be repeated after 12 to 24 hours to define the presence of pancreatic injury.

Serum amylase and lipase may be measured but have a low sensitivity and specificity.

If the pancreas appears injured on CT, ERCP or magnetic resonance cholangiopancreatography (MRCP) is needed to assess ductal integrity. Nonoperative treatment in children is a possibility and is increasingly recommended by pediatric surgeons. A pseudocyst may be the result in approximately 40% of children and may be treated by percutaneous drainage.

Question 24

In a patient after distal pancreatectomy, the drain in the pancreatic bed continues to produce about 500 mL of thin serous fluid over a 24-hour period. How will you treat this patient?

Answer 24

• Establish a diagnosis of pancreatic fistula: drain/serum amylase (3x serum).
• Rule out abdominal sepsis: clinical and CT findings - undrained collections.
• Observe, maintain nutritional: watch for pain, N/V, jaundice, fever
  
  • If septic, send fluid for gram stain and cx, start IV abx.
  • Okay to try to feed. Consider octreotide.
  • If can’t feed, TPN, then increase enteral feeding in the absence of increased fistula output.
• Output <200 mL/day is low-output - will resolve in 2 to 3 wks.
  
  • Observe, TF distal to the pylorus, rule out sepsis and ductal disruption.
• Repeat CT/MRI in 6-8 wks: high output or sx - ERCP +/- ductal stenting.
• In rare cases, panc-J, rsection, or fistulojejunostomy may be necessary.

Question 25

A 63-year-old female is admitted with abdominal pain after a motor vehicle collision. Her serum amylase level is elevated. What will you do with this data?

Answer 25

Recognize that hyperamylasemia is not a reliable indicator of pancreatic trauma. Understand that 1) patients can have a normal amylase level in the presence of a pancreatic injury or conversely may have an elevated amylase without pancreatic injury and 2) the timing of amylase evaluation relative to the pancreatic injury is important; sensitivity and positive predictive value of amylase values may be improved when obtained more than 3 hours after injury. Given this patient’s mechanism of injury, abdominal symptoms, and elevated amylase level, suspect a pancreatic injury that should be evaluated by abdominal CT scan or surgical exploration depending on the patient’s hemodynamic status and physical exam findings. If nonop otherwise and stable, do ERCP if suspecting pancreatic injury.

Question 26

An 18-year-old female with blunt abdominal trauma has a CT scan with findings suggestive of pancreatic injury. You decide to take the patient to the operating room for surgical exploration. What is your approach to determining whether injury to the main pancreatic duct has occurred?

Answer 26

Discuss the importance of complete exposure of the pancreas including: 1) opening the lesser sac through the gastrocolic ligament, 2) downward retraction of the transverse colon and upward retraction of the stomach, 3) complete Kocher maneuver to provide adequate visualization of the pancreatic head and uncinate process, 4) mobilization of the hepatic flexure to facilitate visualization of the pancreatic head and neck, and 5) exposure of the splenic hilum to inspect the pancreatic tail. Discuss the use of intravenous secretin or cholecystokinin pancreozymin to stimulate pancreatic secretions enough to localize a major pancreatic duct injury. Discuss the possible need for intraoperative imaging of the pancreatic duct and methods to perform this imaging: 1) the use of endoscopic retrograde cholangiopancreatography (ERCP), 2) duodenotomy and direct open ampullary cannulation, and 3) needle cholangiopancreatography.

Question 27

Upon surgical exploration of a 55-year-old male who sustained an abdominal crush injury, he is diagnosed with a main pancreatic duct injury. How would you treat this injury?

Answer 27

Determine extent of resection relative to the superior mesenteric vessels. Discuss the need for a distal pancreatectomy to be performed with or without splenic preservation depending on associated injuries and the hemodynamic status of the patient. Discuss the need for a Roux-en-Y pancreaticojejunostomy to be performed for injuries to the right of the superior mesenteric vessels.

Question 28

A 42-year-old male is undergoing exploratory laparotomy for an abdominal gunshot wound. He is found to have concomitant injuries to the duodenum and head of the pancreas. How would you manage this patient?

Answer 28

Determine the need for a staged operative approach (damage control laparotomy) if the patient is hemodynamically unstable, hypothermic, acidotic, and coagulopathic after control of hemorrhage and contamination. Evaluate the integrity of the ampulla, proximal pancreatic duct, and common bile duct. Given the severity of injury to the duodenum and pancreas, determine whether: 1) simple repair of the duodenal injury can be performed, 2) pyloric exclusion is necessary, 3) wide drainage of the pancreatic injury should be performed, and 4) need for Roux-en-Y pancreaticojejunostomy exists. Decide, given the severity of injury to the duodenum, pancreas, and associated structures, whether pancreatoduodenectomy should be performed.

Question 29

Postoperatively, a 35-year-old female with a pancreatic contusion treated with debridement and closed suction drainage develops bloody output from her drains and decreasing hematocrit levels. What would you do next?

Answer 29

* Dx: postoperative hemorrhage * Usually 2/2 inadequate debridement and external drainage vs intra-abdominal infection * Assess the hemodynamic status, begin fluid resuscitation or blood as needed * Tx if stable/transient responder: angiographic embolization for control of hemorrhage * Tx if failure of embo: re-exploration

Question 30

Which is more likely to produce small bowel injury - blunt or penetrating trauma?

Answer 30

Penetrating trauma. A bullet or knife track will likely penetrate some portion of the small bowel if it traverses the mid-portion of the abdomen. Blunt injury rarely injures the small bowel, as it is largely mobile and can move aside with the blunt impact.

Question 31

What is a Chance fracture and what relationship does it have to small bowel injury?

Answer 31

Chance fractures are transverse fractures of the L-4 vertebrae body. They occur because of massive compressive force to the vertebral body, either with forced hyperflexion of the spine or massive vertical force transmitted from the legs to the spine. They occur with extreme deceleration injuries when only a lap seatbelt is worn, but do not occur with lap-shoulder belts. The magnitude of these injuries also commonly creates shear injuries of the small bowel and/or colon, so whenever an L-4 fracture is seen, these should be suspected.

Question 32

What is the significance of finding an odd number of holes in the small bowel after penetrating trauma?

Answer 32

It usually indicates that a hole has been missed, because the number of holes is normally even unless an injury has occurred tangentially.

Question 33

What determines whether small bowel holes should be closed individually or treated by resection of the segment of bowel where they are located?

Answer 33

## Footnote Either method is acceptable, and the decision is made intraoperatively based on what can be done most expeditiously.

Question 34

What clinical signs are normally present with small bowel perforations after penetrating trauma? How does this affect management?

Answer 34

Clinical signs are normally minimal to absent with small bowel spillage for the first several hours, because small bowel contents are not irritating to the peritoneum. Most diagnostic studies are similarly inexact. Deferring operation and repair for several hours in such patients dramatically increases the incidence of sepsis and mortality, so an aggressive approach to abdominal exploration is indicated.

Question 35

Is it ever permissible to resect the injured bowel and staple the remaining ends, without restoring bowel continuity?

Answer 35

In the event of massive injury and an unstable patient, this is acceptable management, with the understanding that the patient will be re-explored in 24 to 48 hours and continuity re-established.

Question 36

A 23-year-old male is 18 hours post-flame injury resulting in 75% total body surface area partial and full thickness burns. He has required significant fluid resuscitation, but has developed hypotension that is no longer responding to fluid boluses. You notice significant abdominal distension, and he has not had any urine output in the last hour. What is your approach to evaluate the source of this patient's hypotension and oliguria?

Answer 36

Recognize that severe inflammatory states such as burns and aggressive fluid resuscitation are major risk factors for development of abdominal compartment syndrome (ACS). Recognize that hypotension unresponsive to fluid resuscitation and rapid onset oliguria/renal failure are part of the clinical syndrome of ACS. Perform judicious fluid resuscitation, acknowledging that overaggressive fluid replacement can worsen bowel wall edema, ascites formation, intraabdominal pressures, and mortality in patients with ACS, and can be ready to anticipate the need for invasive monitoring. Understand that bladder pressure measurement is a rapid and easy technique for confirming the diagnosis of ACS. Intraabdominal hypertension dx (pressure greater than 20 mm Hg) or ACS (greater than 25mm Hg) by measuring intra-vesicle pressures with a pressure transducer connected to a clamped Foley catheter and can perform rapid abdominal decompression and temporary abdominal closure (TAC).

Question 37

A 51-year-old female has abdominal compartment syndrome. How would you prepare the patient for operative decompression?

Answer 37

Understand that ACS will affect multiple organ systems such as hemodynamics, pulmonary mechanics, intestinal perfusion, and renal function, and plan for invasive monitoring with arterial line, central line, Foley catheter, pulse oximetry, and frequent checks of peak airway pressures and arterial blood gases. Understand that gentle fluid resuscitation may be required to maintain preload, but over-aggressive crystalloid infusion will worsen bowel wall edema, retroperitoneal edema, and ascites formation resulting in increased intraabdominal pressures and increased morbidity and mortality. Anticipate that reperfusion syndrome is a possibility following decompression and consider resuscitation with sodium bicarbonate. Emphasize close communication with anesthesia at the time of decompression, anticipating possible hypotension, arrhythmias, and acidosis.

Question 38

You have just finished a necrosectomy for severe necrotizing pancreatitis in a 48-year-old female. There is marked bowel wall edema, and when you attempt to close fascia, the anesthesiologist informs you that the patient's peak airway pressures has risen from 20 to 48. What is your approach to the immediate management of this patient?

Answer 38

Recognize that the severe inflammatory process and bowel wall edema has precluded definitive fascial closure and understand that further attempts at closure may result in ACS. Describe the different methods of TAC (absorbable mesh, Bogota bag, and vacuum-assisted wound closure) and their risks and benefits. Understand that all TAC methods require careful monitoring after placement for development of recurrent ACS, bleeding, and bowel injury.

Question 39

A 33-year-old male underwent lapartomy with splenectomy and packing for hemorrhage following motor vehicle crash. TAC was performed with vacuum-assisted wound closure. What is your approach to postoperative care of this patient?

Answer 39

Understand that limited fluid resuscitation and restoration of physiology (particularly normothermia) are key to minimizing the significant mortality following TAC for ACS. Recognize that meticulous care of the dressing and routine removal/changing of packing material are key to preventing mortality and infectious morbidity in patients with TAC. Understand that attempts at definitive closure should be undertaken as soon as normal physiology has been restored and the intestinal edema and distension have subsided.

Question 40

Following resolution of abdominal compartment syndrome in a 29-year-old male, what is your approach to definitive management of the fascial defect?

Answer 40

Recognize that attempts to close the fascia primarily should be undertaken as soon as the patient’s status permits to minimize abdominal wall retraction, maximize success, and minimize risk of morbidity associated with TAC. Understand that primary closure should be undertaken, with many surgeons preferring interrupted sutures to continuous sutures due to increased risk of dehisence with or without the addition of retention sutures. Understand that residual fascial defects can be bridged with component separation or with placement of mesh or closure of the skin with planned ventral hernia creation and staged closure at later date.

Question 41

In a patient with blunt hepatic injury, identify the most commonly injured hepatic structures and explain the anatomic considerations accounting for this distribution.

Answer 41

* Liver - MC intraabdominal organ injured in blunt trauma, 2nd in penetrating * Most of the liver is located beneath the right rib cage - injuries to the chest wall can result in hepatic injury. * The liver edge extends below the rib cage – up to T12 with respiration – and can be susceptible to injury in abdominal trauma. * In blunt trauma, the most common area of injury is the posterior portion of the right lobe of the liver.

Question 42

Describe physiologic derangements caused by severe blood loss following blunt hepatic injury and their implications for management.

Answer 42

Extreme blood loss in all forms can lead to acidosis, cooling, and coagulopathy, leading to more blood loss.

Question 43

Describe signs and symptoms associated with blunt hepatic injury as well as expected changes in vital signs and laboratory values.

Answer 43

* Physical exam: chest wall injury, right flank bruising, right-sided abdominal pain. Note, a negative exam does not rule out hepatic injury. * Large-volume hemorrhage is heralded by hypotension and tachycardia. * HCT upon arrival to the ED bay during a trauma may not reflect the degree of hemorrhage given that dilution of the remaining blood volume has not occurred.

Question 44

Explain the utility of the FAST exam for patients with blunt hepatic injury and describe its diagnostic limitations.

Answer 44

* FAST is sensitive and specific for intraabdominal free fluid, which in the setting of trauma is blood until proven otherwise. * Limitations: often cannot definitively identify sources of bleeding; cannot identify retroperitoneal bleeding

Question 45

Identify findings on the primary and secondary survey that would require immediate operative management for a patient with blunt hepatic injury.

Answer 45

Hemorrhagic shock on primary survey combined with intraabdominal free fluid on FAST exam should prompt emergent trauma laparotomy. FAST exam may identify blood collection in the hepatorenal recess. Secondary findings of peritonitis should also prompt emergent laparotomy.

Question 46

In a patient undergoing operative treatment for blunt hepatic injury, propose an initial plan for hemorrhage control as well as describe secondary and salvage maneuvers, should initial attempts fail.

Answer 46

* Laparotomy: packing of all 4 quadrants. Allow resuscitation to occur. Remove packing from the quadrants you least expect bleeding from first. * Divide _triangular ligs_ and _falciform_, do not disrupt tamponade * Assess source of hepatic bleeding. * Anterior/posterior pressure can control most hepatic bleeding. * Suture ligation of vessels and repair of lacerations should occur. * Uncontrollable bleeding = Pringle Maneuver = clamp or vessel loop around the hepatoduodenal ligament - can stop portal and hepatic arterial flow * Retrohepatic IVC injury is an extremely dangerous condition. Consider packing and reserve an IVC to right atrial shunt (Shrock) or veno-venous bypass for patients who do not respond to packing. * Do not explore non-bleeding retrohepatic IVC injuries. * Bleeding due to coagulopathy should prompt abdominal packing followed by ICU resuscitation.

Question 47

Given a hemodynamically stable patient undergoing non-operative management (NOM) for blunt hepatic injury, state the expected failure rate of NOM as well as describe radiographic findings and patient factors that increase the likelihood of NOM failure.

Answer 47

* Treatment of choice for all hemodynamically normal patients with hepatic injury no matter grade * 90% success rate * Extravasation of contrast on abdominal CTA is associated with higher rates of failure. * Grades IV and V injuries are associated with higher rates of failure.

Question 48

Discuss the relative indications for endovascular management of blunt hepatic injury as well as common risks associated with this approach.

Answer 48

* Blush on primary CTA of the abdomen - consider hepatic arterial embolization. * Ischemic complications can occur necessitating hepatic debridement. * Complications of nonoperative management are greater in patients with a greater degree of liver injury.

Question 49

Describe the most common long-term complications and morbidity associated with severe blunt hepatic injury as well as their workup and management.

Answer 49

* The incidence of morbidity increases with grade of injury. * Biliary tree disruption: 0.5 to 21% of patients * associated with RUQ pain, biloma formation, SIRS * CT for diagnosis * Hepatic necrosis: pain and SIRS * Hemobilia: typically several days after injury * presents as UGI bleed * CT angiography and/or embolization for dx/tx

Question 50

A hemodynamically unstable patient presents to the ED after a high-speed motor vehicle collision. Chest x-ray is normal except for right-sided 8th, 9th, and 10th rib fractures. Pelvis X-ray demonstrates no acute fracture. What is your approach to evaluating this patient further?

Answer 50

* Low R-side rib fx associated w/ hepatic injury * FAST - not reliable in grading severity * Resuscitate - MTP, access, monitoring * CT scan if able to resusct * IR if transiently responds * OR if unable to resuscitate

Question 51

During laparotomy for a large, right lobe hepatic parenchymal laceration extending towards the hepatic vein, what is your approach to obtaining hemostasis?

Answer 51

* evac hemoperitoneum and confirm liver as source * initial - manual compression (A/P) and perihepatic packing * if not working, use digital compression of portal vein/hepatic artery (Pringle) - umbilical tape, dremel clamp * ​foramen of Winslow * if bleeding continues, suspect hepatic vein or retrohepatic IVC * sternotomy can expose the IVC - clamp the SVC and IVC to isolate the liver (along w/ Pringle) * ligate intraparenchymal vessels, argon raw surfaces, pack what you can, consider R hepatectomy if isolated * resuscitate in ICU

Question 52

Four weeks after undergoing transarterial embolization for a grade V blunt hepatic injury, a patient presents to the ED with fevers, chills, and RUQ pain. What is your approach to management?

Answer 52

* DDx: hepatic necrosis (MC), biliary leak/biloma, biliary fistula, hemobilia, cholangitis * Hx: RUQ pain, sepsis, jaundice; UGI bleed is suspicious of hemobilia * Dx: CBC, CMP, LFTs. CT will dx. * ​US can also detect collections or duct dilation, HIDA can define leak * Tx: go from least invasive to most invasive in management * ​Bile leak - perc drain, ERCP w/ stent; sphincterotomy considered * Hepatic necrosis - perc mgmt, OR if dying * Hemobilia (unlikely) - CT angio/embo is dx and tx * Cholangitis - ERCP, abx

Question 53

You are performing the FAST examination on a patient who sustained multisystem blunt trauma from a motor vehicle crash. The patient's BP is 60 mmHg. The FAST is positive in the right upper abdominal quadrant. What should you do?

Answer 53

* suspect bleeding * ABCs - access, resuscitate (MTP) * OR - FAST positive in hypotensive patient - 95% something to fix in OR

Question 54

You are performing the FAST examination on a patient who sustained a stab wound to the right parasternal area. The patient is hemodynamically normal and the FAST is positive in the pericardial window. What do you do?

Answer 54

* DDx: pericardial tamponade * Dx: US - dark anechoic stripe; JVD, hypotension, distant sounds * assess for tamponade, global abnormality, RV filling * CXR - PTx and hemothorax gets CTb * echo for workup * **Tx HDS: pericardial window (sub-xiphoid, L thoracotomy, through diaphragm, median sternotomy)** * **​If clotting blood is found - go to median sternotomy** * Tx HD unstable: pericardiocentesis to temporize, thoracotomy for definitive​ * Decompress before intubation if possible (intubation can worsen)

Question 55

You are performing the FAST examination on a patient who was assaulted and complains of right back and flank pain. The patient has hematuria and the FAST shows normal findings. What should you do?

Answer 55

* Abdominal part of the FAST is meant for detecting the presence or absence of blood in the peritoneal cavity and that it does not visualize the retroperitoneal structures. It is a screening tool. * Assess vitals and resuscitate as necessary. * Suspect kidney, ureter, bladder, urethral injury * Retrograde urethrogram, CT abd/pelvis w/ delays and cystogram * Extra-peritoneal injury gets Foley. Intra-peritoneal goes to OR.

Question 56

You are performing the FAST examination on a patient who fell three stories. He is hemodynamically normal but complains of shortness of breath, and the FAST is positive in the right and left upper abdominal quadrants. The e-FAST shows absence of comet tail artifacts and pleural sliding on the right chest. What is your next step?

Answer 56

* PTX is clinical dx. You don't need an XR, but in a stable patient - wait for XR then CT if negative. FAST is NOT diagnostic. * You will still get one after the chest tube is placed. * Peritonitis goes to OR. * CT scan will define injuries if stable w/o peritonitis. If solid organ and contained, consider IR. If free extrav or no solid organ injury (suspect bowel perforation), go to OR.

Question 57

You are performing the FAST examination on a patient who sustained multisystem injury and a severe traumatic brain injury. The FAST shows normal findings. The patient becomes hypotensive while in the trauma bay. After volume resuscitation, what should be done?

Answer 57

If there is a change in patient status, restart the exam. * Can repeat ABCs - resuscitate * Can repeat FAST * Ex-lap

Question 58

A 27-year-old restrained male driver presents in the trauma bay after a motor vehicle accident in which his vehicle was struck on the driver's side by an automobile traveling approximately 35 miles per hour. Vital signs reveal tachycardia (heart rate, 105 beats/min) and normotensive (blood pressure, 98/57 mm Hg). The patient reports left flank and chest wall pain. Tachycardia improves after volume resuscitation with 1 L of crystalloid intravenous fluids. Describe the evacuation and initial management of this patient.

Answer 58

A high-energy side collision and the patient's complaint of left flank pain and tachycardia warrant evaluation with a primary and secondary survey per ATLS protocol. If the patient remains hemodynamically stable, further evaluation with abdominal CT with intravenous contrast is appropriate. If the patient becomes hemodynamic unstable, evaluation of the abdomen for hemoperitoneum using FAST is necessary. With hemodynamic instability and positive FAST, the patient should be taken to the operating room for exploration. Criteria for nonoperative management of splenic injury include monitoring in a hospital with 24-hour operating room access, frequent hemodynamic monitoring, and serial abdominal examinations. The patient should be free of peritonitis and neurologic injury as well as other injuries that require operative intervention. Often the goal is to remove the spleen before exposing the patient to risk of transfusions. Splenic angioembolization adjunctive therapy plays a role in the nonoperative management of splenic injuries. Multiple retrospective and prospective studies have shown correlation between splenic artery angioembolization and avoidance of splenectomy. But controversy still exists with regards to the role of angioembolization in nonoperative management of splenic injuries.

Question 59

Abdominal CT with intravenous contrast is obtained for a hemodynamically stable patient who sustained blunt abdominal trauma. Laceration of segmental vessel of the spleen with blush is apparent. Discuss the organ injury scale. Describe the next steps in the operative and nonoperative treatment of this patient.

Answer 59

Nonoperative management of splenic injuries has become commonplace in most major trauma centers. Alternatives to operative management are appropriate in patients who are hemodynamically stable without peritonitis, those without a high injury burden, and those whose transfusion requirements are less than two units of packed red blood cells. Angiography with embolization is indicated for patients who are hemodynamically stable with a blunt mechanism of injury and findings of active extravasation, pseudoaneurysm, arteriovenous fistula, moderate hemoperitoneum, or grade IV and V lacerations. Operative management of splenic injuries is recommended for patients who are hemodynamically unstable, those at facilities without angiographic capabilities, or those with other injuries that require operative intervention. Stable patients who undergo operative intervention for other injuries or who are at facilities capable of performing angioembolization should be considered for operative splenic salvage (ie, splenorrhaphy or partial splenectomy).

Question 60

An 18-year-old young man is admitted for monitoring and serial abdominal examinations after he suffers blunt abdominal trauma during a football game. He is found to have a grade II splenic laceration (subcapsular hematoma of 25% spleen; nonexpanding with no active bleeding) and a small amount of hemoperitoneum. He is progressing as expected on bed rest until a significant increase in left flank pain and tachycardia (heart rate of 110 beats/min) develops 22 hours after admission. Describe the differential diagnosis and evaluation of this patient.

Answer 60

Appropriate selection of patients for nonoperative management of splenic injuries is critical. Hemodynamically stable patients at facilities with 24-hour access to operating rooms should have close hemodynamic monitoring and serial abdominal examinations. This not only helps recognize failure of nonoperative management but also aids in the detection of missed injuries. In the majority of cases, nonoperative management of splenic injuries occurs within 24 hours; however, there may be delayed hemorrhage for up to several weeks after injury. Nonoperative management has been reported to have up to a 97% success rate. Failure may present with tachycardia, hypotension, increased abdominal/flank pain, peritonitis, or need for transfusion. Evaluation should include repeat abdominal CT with intravenous contrast. Complications of failure of nonoperative management of splenic injuries include delayed hemorrhage, splenic infarctions, splenic abscesses, and splenic artery pseudoaneurysms. Repeat imaging with abdominal CT with intravenous contrast for detection of pseudoaneurysm in splenic injuries at 48 hours is performed at some trauma centers to evaluate for missed injuries, blush, and/or persistent extravasation following angioembolization. Other centers perform reimaging based on the clinical course of patients, with indications being persistent inflammatory state, declining hematocrit in stable patients, and/or continued/worsening abdominal pain.

Question 61

A patient presents to a primary care provider with complaints of runny nose, sore throat, and headache. History is significant for splenectomy approximately 6 years ago. Prior to being seen by the physician, the patient collapses on the floor in the waiting room. Describe the postsplenectomy complication and appropriate management of it.

Answer 61

OPSI typically presents with upper respiratory symptoms (ie, runny nose, sneezing, headache, sore throat, cough, mild fever), which rapidly progress to sepsis and multiple organ failure in a short period of time. The highest risk for OPSI is in the first 2 years after splenectomy and in children younger than 5 years of age. Some series have shown incidence to be significant (40%) after 5 years postsplenectomy. Mortality is between 50% and 70%. Encapsulated bacteria account for the most severe infections seen with OPSIs, specifically group A S pneumoniae, N meningitidis, and H influenzae type B. However, Eschericha coli, Capnocytophaga species, and intraerythrocytic parasites also have been known to cause OPSI. A high level of suspicion leading to use of early broad-spectrum intravenous antibiotics and supportive measures can decrease mortality.

Question 62

A patient who underwent splenectomy 5 days ago is found to have thrombocytosis (platelet count of 875,000/µL) and leukocytosis (white blood count of 13,000/µL) on laboratory tests obtained immediately prior to discharge. The postoperative course was uncomplicated. Vital signs are unremarkable. He is tolerating his diet, has return of bowel function, and his pain is controlled. Describe further evaluation and treatment if needed.

Answer 62

Leukocytosis and thrombocytosis are relatively common laboratory findings following splenectomy. Multiple early and late complications of splenectomy include pneumonia (most commonly of the left lower lobe), left pleural effusion, iatrogenic pancreatic or gastric injury, and reactive thrombocytosis. Thrombocytosis usually spontaneously resolves 2 to 3 weeks postoperatively. The risk of cardiovascular and thrombotic events should be evaluated when determining if antiplatelet therapy is appropriate. (The risk appears to be highest in patients with myeloproliferative disorder.) Although there is insufficient evidence for starting aspirin, some centers start low-dose antiplatelet therapy for platelet counts greater than 1,000,000/µL. Reactive thrombocytosis typically resolves within 3 months without any interventions.

Question 63

Given a patient with blunt injury of the liver, the resident is able to identify the clinical and radiographic findings that identify the need for operation compared to nonoperative management.

Answer 63

Operation is indicated in patients with persistent hypotension from hepatic injury while nonoperative management is the treatment of choice in hemodynamically stable patients with hepatic injury. Patients must be hemodynamically stable for nonoperative management. Patients should not have other indications for abdominal exploration. Patients with higher grade liver injuries more commonly fail nonoperative management.

Question 64

Given a patient who requires operative repair of the liver, the resident can name the ligaments that need to be divided for mobilization of the liver and identify the important vascular structures for isolation of hepatic blood flow.

Answer 64

The liver is mobilized by ligation and division of the falciform ligament and incision of the triangular and coronary ligaments. When mobilizing the triangular and coronary ligaments, care must be taken to avoid injury to the posteriorly located hepatic veins. There are three major hepatic veins, with most patients having a right hepatic vein that joins the right anterior wall of the inferior vena cava (IVC) and a middle and left hepatic vein that converge into a common trunk before joining the IVC. The hepatoduodenal ligament extends from the porta hepatis to the duodenum and contains the proper hepatic artery, common bile duct, and portal vein. It can be clamped to decrease blood inflow to the liver.

Question 65

Given a patient with hepatic injury, the resident can describe the role of interventional radiology in the control of hepatic hemorrhage.

Answer 65

Hepatic embolization should not be considered in hemodynamically unstable patients. Hepatic embolization may be necessary as an adjunct to improve rates of nonoperative management or failed nonoperative management. Hepatic embolization appears to be most successful when used preemptively in hemodynamically stable patients who demonstrate extravasation of contrast on the initial abdominal computed tomography (CT) scan. Hepatic embolization can also be used to manage patients with ongoing bleeding or rebleeding from the liver after surgical management.

Question 66

Given the patient with blunt hepatic injury who has been managed nonoperatively, the resident can recognize failure of nonoperative management and identify those patients who require operative intervention.

Answer 66

Failure of nonoperative management is generally related to bleeding and becomes apparent by the need for ongoing fluid resuscitation, transfusion, or hemodynamic instability. Nonoperative failure may manifest as persistent tachycardia despite adequate fluid resuscitation. Patients with grade IV or V injuries are more likely to fail nonoperative management than lower grade injuries. The need for more than 3 to 4 units of blood transfusion should be an indication for operative intervention or angiographic embolization. Patients who develop hemodynamic instability have failed nonoperative management and should be undergo immediate exploratory laparotomy. Arterial embolization should not be considered in the hemodynamically unstable patient.

Question 67

Given a hypotensive patient with severe hepatic injury, the resident can describe the initial surgical maneuvers for hemorrhage control.

Answer 67

Rapid evacuation of the hemoperitoneum and systematic four-quadrant laparotomy pad packing of the abdomen are necessary. Initial control of hepatic hemorrhage is achieved with manual compression. If manual compression fails to arrest bleeding, portal triad clamping with the Pringle maneuver may be performed. The Pringle maneuver is application of a noncrushing vascular clamp placed across the structures in the hepatoduodenal ligament, interrupting hepatic arterial and portal venous flow into the liver. The Pringle maneuver may arrest or significantly reduce hepatic hemorrhage, and it helps distinguish bleeding due to hepatic inflow vessels (hepatic artery, portal vein) from bleeding due to outflow vessels (hepatic veins, IVC). Perihepatic packing with laparotomy pads may be applied to manage bleeding from the hepatic injury. Non-viable tissue should be debrided once bleeding is controlled. Hepatic resection is uncommonly needed to treat major hepatic injury.

Question 68

Given a patient with ongoing hepatic bleeding, the resident can describe various surgical techniques to definitively control hepatic hemorrhage.

Answer 68

Perihepatic packing has become a core technique for management of hepatic bleeding. Perihepatic packing may be used as a temporizing measure prior to definitive treatment of the hepatic injury. This maneuver is often used when other abdominal injuries need to be addressed prior to definitive hepatic repair. Perihepatic packing may also be used as a semidefinitive method of hemorrhage control at the first laparotomy with subsequent return to the operating room for pack removal. This maneuver is most useful when packing controls the bleeding and the patient is hemodynamically unstable, hypothermic, coagulopathic or acidotic. Topical hemostatic agents are often used in conjunction with perihepatic packing and electocautery to control bleeding from raw surfaces of the liver. Conventional electrocautery or argon beam coagulation can be used to control mild bleeding from the raw surface that is not controlled using perihepatic packing or topical hemostatic agents. Deeper lacerations of the liver parenchyma can be managed by ligation of the vessels and biliary radicals through the laceration as the bleeding vessels and biliary ducts are encountered. Approximation of the raw liver edges may be used as a primary means to promote hemostasis following division of hepatic parenchyma and parenchymal vessel ligation. This technique should not be used to control major hepatic hemorrhage. An additional technique to definitively control hepatic bleeding uses an absorbable mesh. A lobe of the liver is wrapped with mesh with the mesh attached to the falciform ligament. This technique is useful, with or without packing, when there are multiple superficial lacerations of the liver with active bleeding. This maneuver can be used as an alternative to parenchymal debridement. Parenchymal bleeding from penetrating injury can often be conrolled with tamponade of the bullet track with a Foley catheter.

Question 69

Given a patient with hepatic injury, the resident can describe the common posthepatic injury complications and their management.

Answer 69

The coagulopathy after liver resection is usually the result of hypothermia and inadequate replacement of blood components. In cases of major liver hemorrhage, it is imperative to work with anesthesia to confirm that adequate fresh frozen plasma and platelets are being given along with blood cell replacement. Hyperbilirubinemia is transient and usually peaks in 2 to 3 weeks after major resection. Perihepatic, intrahepatic, and subphrenic abscesses can develop, particularly if significant debridement had been necessary. These abscesses are diagnosed by clinical evidence of sepsis combined with ultrasound or CT scan and often can be treated with percutaneous drainage. Biliary fistulas or bilomas usually resolve spontaneously, and major extrahepatic ductal injuries are rare. For the rare biliary leak or fistula that does not close spontaneously, endoscopic placement of a temporary intrabiliary stent to decrease intrabiliary pressure is recommended. Hemobilia is a rare complication, occurring with intrahepatic bleeding into the bile ducts, and is best diagnosed with angiography. Angiographic embolization is the treatment of choice.

Question 70

Given the patient with blunt hepatic injury, the resident can describe outpatient evaluation and advancement of patient activity.

Answer 70

There are few data to guide the routine care and follow-up of patients who have been managed nonoperatively. There are no clear recommendations for the timing or need for repeat imaging. It is common to avoid strenuous activity for several weeks. Patients with a higher grade injury (grade IV and V) are restricted from strenuous activity for longer periods of time.

Question 71

17-year-old male is brought to the emergency department after a high-speed motor vehicle crash. He is hemodynamically stable and CT scan reveals a grade IV liver laceration. One hour later, he becomes hypotensive with increased abdominal distension. How would you manage this patient?

Answer 71

This patient was initially hemodynamically stable and should be considered for nonoperative management of his liver injury. Grade IV and V liver injuries are associated with a higher failure rate of nonoperative management than lesser grade injuries, and care providers must be keenly attentive to patients with higher grade injuries. Hemodynamic instability is an indication for operative intervention. Affected patients are no longer candidates for observation or angiographic embolization and must undergo exploratory laparotomy to stop the hepatic hemorrhage.

Question 72

A 17-year-old male is brought to the emergency department after a high-speed motor vehicle crash. He is hemodynamically stable and CT scan reveals a grade IV liver laceration. One hour later, he becomes hypotensive with increased abdominal distension. The patient undergoes exploration. Describe the initial maneuvers you would use to stop the hepatic hemorrhage.

Answer 72

* Initial control of hepatic hemorrhage by manual compression * Perihepatic packing is indicated if manual compression controls bleeding * Still unable to control - Pringle maneuver * Bleeding from raw surface - Electrocautery/argon coagulation * Deeper lacerations - ligation of vessels; approximation of raw edges * If bleeding continues, injury could be retro-hepatic or supra-hepatic * Non-viable tissue - debride * Hepatic resection is last resort

Question 73

A blunt trauma patient is found to have a grade III hepatic injury of the right lobe intraoperatively. When manual compression of the injury is applied, bleeding stops. However, hepatic bleeding commences when manual compression is relieved. What surgical techniques can be used to definitively stop the hepatic bleeding?

Answer 73

A topical hemostatic agent can be used by itself or in conjunction with perihepatic packing. Conventional electrocautery or argon beam coagulation can be used to control bleeding from the raw surface of the hepatic injury. This is most effective with minor or mild hepatic bleeding. Deeper hepatic lacerations can be managed by direct ligation of hepatic vessels. Approximation of raw liver edges may also be used. When multiple lacerations or significant injury is present, the technique utilizing absorbable mesh wrap with attachment to the liver can often stop hepatic bleeding without the need for perihepatic packing. Perihepatic packing may be used as semidefinitive management of hepatic injuries, with the caveat that these patients will require a return to the operating room for pack removal.

Question 74

A 14-year-old boy who is riding his bicycle has been hit by an automobile. He is hemodynamically unstable and undergoes emergent exploratory laparotomy. A grade IV injury of the hepatic right lobe is identified with significant active hemorrhage. What structures need to be divided for mobilization of the liver and what vascular structures can be occluded to decrease hepatic inflow?

Answer 74

The liver is mobilized by ligation and division of the falciform ligament and incision of the triangular and coronary ligaments. When mobilizing the triangular and coronary ligaments, care must be taken to avoid injury to the posteriorly located hepatic veins. The hepatoduodenal ligament extends from the porta hepatis to the duodenum and contains the proper hepatic artery, common bile duct, and portal vein, and it can be cross-clamped to decrease blood inflow to the liver. A noncrushing vascular clamp can be placed across the structures in the hepatoduodenal ligament (Pringle maneuver), interrupting hepatic arterial and portal venous flow into the liver.

Question 75

In the setting of severe liver trauma from blunt or penetrating mechanisms, the resident understands and can independently describe - or can demonstrate with minimal assistance - the following steps used to control hemorrhage from the liver:

Answer 75

Rapid access to the peritoneal space through a generous midline incision using the scalpel. Evacuation of hemoperitoneum. Aggressive elevation of the right costal margin using a large Richardson retractor. Manual compression of the liver and the placement of perihepatic packs to compress the liver.

Question 76

You are in the operating room and have just finished packing a shattered liver after blunt trauma. The patient is hemodynamically unstable. Despite packing, there is continued brisk bleeding from the liver. What should be done next?

Answer 76

Ongoing bleeding despite optimal liver packing needs to be categorized as predominately venous or arterial. Perform the Pringle maneuver to determine this.

Question 77

You are in the operating room with a hemodynamically unstable patient who is bleeding from a laceration to the right lobe of the liver from blunt trauma. Despite attempts to control bleeding with perihepatic packing and a Pringle maneuver, brisk venous bleeding continues from deep within the laceration. Describe the details of complete vascular isolation of the liver to control the bleeding as you consider whether resection will be necessary.

Answer 77

Control of the supraceliac aorta is critical prior to vena cava control to prevent cardiac arrest in unstable patients. The infrahepatic IVC can be isolated below or above the renal veins. Options for control include a vascular clamp or an umbilical tape as a Rummel tourniquet. The suprahepatic IVC can be clamped through the abdomen at the diaphragm if bleeding does not obscure access. Otherwise, the IVC must be isolated in the pericardium. The pericardium can be accessed through a median sternotomy or through an incision in the diaphragm slightly to the right of the midline, above the left lobe of the liver.

Question 78

Describe the workup of a patient with abdominal trauma for splenic injury. Determine the need for operative intervention, emergent or delayed, versus nonoperative management.

Answer 78

Advanced Trauma Life Support (ATLS) is a commonly used guideline for evaluation of injured patients. In hemodynamically unstable blunt trauma patients with a positive (identification of intra-abdominal fluid) FAST (focused assessment with sonography for trauma), splenic injury is commonly identified during emergent exploratory laparotomy. In hemodynamically stable patients, computed tomography (CT) imaging with intravenous contrast is used to evaluate for spleen and other solid organ injuries. Nonoperative management is a viable strategy in hemodynamically stable patients without other indications for surgical intervention. Nonoperative management may include the use of angiography with embolization for vascular abnormalities associated with the splenic injury (splenic pseudoaneurysm or blush).

Question 79

Given a patient requiring splenectomy, describe the anatomic location of the spleen and associated anatomic structures, including the splenic vasculature and ligamentous attachments.

Answer 79

The spleen is located in the left costodiaphragmatic recess. Multiple peritoneal reflections (splenophrenic, gastrosplenic, splenorenal, and splenocolic ligaments) support the organ. Short gastric arteries (located off the gastroepiploic and left gastric arteries) are located in the gastrosplenic ligament. The splenic artery and vein are located in the splenorenal ligament. The tail of the pancreas commonly abuts the hilum of the spleen.

Question 80

Given a patient who presents for operative intervention, be able to independently prepare the patient for emergent surgery.

Answer 80

A midline celiotomy is commonly used in emergent surgery for ease of exploration and intervention of the whole abdominal cavity for unstable abdominal trauma.

Question 81

Describe the critical steps for resection of the spleen in a patient undergoing operative intervention.

Answer 81

The superior and lateral attachments are generally taken first. This can also be extended inferiorly to divide the attachments to the colon. Both of these can be done bluntly. Then the spleen is lifted out of its bed using blunt dissection (in similar manner to the Kocher maneuver for the duodenum) to bring the spleen medially into the wound. One's fingers should be between the tail of the pancreas and the anterior surface of the left kidney. The short gastric arteries are divided with care to ensure the gastric wall is not injured. The splenic artery and vein are then identified and ligated. Care should be taken to avoid injury to the pancreatic tail, which is commonly at the splenic hilum or near it. A drain should be placed if concern for pancreatic injury is present.

Question 82

Identify intraoperative and physiologic findings that would determine if operative splenic salvage, including splenorrhaphy and partial splenectomy, is appropriate.

Answer 82

Splenorrhaphy and partial splenectomy, while commonly discussed, are not generally practiced in the emergent setting. They are more often used when an incidental splenic injury with mild bleeding is identified when exploring patient for other injuries. Intervention may involve topical agents (procoagulants), cautery, hemostatic wrap and packing.

Question 83

Review the presentation of early and late postsplenectomy complications of operative and nonoperative management strategies in patients with splenic injuries.

Answer 83

Operative complications include injury to associated organs (gastric wall, pancreatic tail, colon), pancreatic leak, and abscess formation. Nonoperative complications include delayed splenic rupture, splenic abscess formation (with embolization of trunk of splenic artery), and splenic infarction. Splenic function postembolization is not known. Postsplenectomy thrombocytosis and leukocytosis are common findings. The thrombocytosis can lead to thrombosis when associated with myeloproliferative disorder. Overwhelming postsplenectomy sepsis is a rare but high mortality/morbidity condition.

Question 84

Describe the guidelines for overwhelming postsplenectomy infection (OPSI) prophylaxis, including antibiotics and vaccination.

Answer 84

* OPSI generally occurs years after splenectomy. (See Learning Objective 8b for more information.) * Streptococcus pneumoniae is the most common organism (50%-90% of cases). Other common organisms include Haemophilus influenzae and Neisseria meningitidis. * Vaccinations for these agents are recommended within 14 days from splenectomy for H influenzae and N meningitidis and immediately for pneumococcal disease. * Antibiotic therapy is controversial at the present time and is more commonly used in children.

Question 85

In the nonoperative management of splenic injuries, understand the importance of monitoring, serial clinical evaluations, and laboratory studies. Discuss the need for repeated radiographic imaging, specifically angiography.

Answer 85

Nonoperative treatment of splenic injuries often involves periods of serial examinations, laboratory monitoring, bed rest, and bowel rest. This varies between institutions and grade of injury. Repeat imaging also varies among institutions. It ranges from mandatory repeat CT imaging to identify splenic vascular abnormalities (pseudoaneurysms) in higher-grade splenic injuries to repeat imaging based on clinical factors. Indications for angiography with embolization are currently debated among trauma surgeons. Vascular abnormalities (pseudoaneurysm, blush) are commonly accepted indications for use of angiography. High-grade (IV and V) injuries are also commonly evaluated and treated empirically in many centers with angioembolization.

Question 86

Discuss outpatient follow-up of patients who have undergone operative and nonoperative management of splenic injuries. Understand the importance of reevaluation of patient prior to clearance for participation in contact sports.

Answer 86

The majority of nonoperative failures occur in the first 72 hours postinjury. Additional significant failure can occur up to 1 month postinjury. Therefore, patients must understand the signs of bleeding and the importance of returning to the hospital if concerns develop after nonoperative treatment. Return to contact sports is a controversial topic in trauma, especially concerning reimaging of injuries prior to return to such activities, and it varies depending on location and grade of injury.

Question 87

Describe the presentation and management of late complications of splenectomy, specifically mesenteric vein thrombosis and OPSI.

Answer 87

Thrombosis of vessels associated with postsplenectomy thrombocytosis generally occurs with associated myeloproliferative disorders. It is most often treated when the platelet level exceeds 1,000,000/µL and is generally treated with aspirin. The presentation of OPSI is often insidious in nature, with a prodromal state similar to an upper respiratory infection, with rapid physiologic decline in hours. OPSI has a high mortality rate (50%-70%), with survivors often having associate comorbidities.

Question 88

On post-injury day 3, a patient undergoing nonoperative management of an isolated splenic injury (grade 3 with moderate hemoperitoneum) develops increasing abdominal pain along the left flank and slight leukocytosis (white blood count of 13) with shift. How would you evaluate this patient?

Answer 88

Early deterioration. Assess patient, get vitals, get labs. * DDx: re-bleeding, missed hollow viscus injury (4%), unlikely splenic abscess * Mgmt: If unstable, go back to OR * Dx: CT w/ IV contrast can define these injuries * Tx: embolize contained vascular injuries, go to the OR if bowel injury

Question 89

Patients with penetrating abdominal injuries demonstrating hemodynamic instability, peritonitis, or evisceration should get what after the primary/secondary surveys?

Answer 89

exploratory laparotomy

Question 90

In a patient s/p penetrating trauma, what imaging can be obtained during the primary/secondary surveys?

Answer 90

CXR, Abdominal XR, Pelvic XR FAST is limited in value except for pericardial view

Question 91

What is a major purpose of the secondary survey in penetrating trauma?

Answer 91

identification of all wounds - allows the surgeon to anticipate trajectories - can determine which major cavity should be explored first in a hypotensive patient

Question 92

If a patient is stable without peritonitis, what imaging and management can be useful as a next step?

Answer 92

these patients are candidates of nonoperative management, a CT scan can identify further injuries and guide management

Question 93

What procedural technique can be considered in stable patients with penetrating abdominal - specifically abdominal fascial defects and left diaphragm injuries in left thoracoabdominal stab wounds?

Answer 93

laparoscopy can be both diagnostic and therapeutic

Question 94

In a polytrauma patient who is hypotensive, what adjuncts to the primary survey can be obtained to help identify operative candidates?

Answer 94

FAST/DPL that is positive can indicate abdominal source of hypotension - go to OR CXR, abd XR, pelvic XR can be obtained prior to OR to identify concomitant sources of instability

Question 95

In abdominal trauma ex-lap, to what length is the GI tract evaluated?

Answer 95

esophageal hiatus to the intraperitoneal portion of the rectum

Question 96

The Pringle maneuver (clamping the hepatoduodenal ligament) can be used to control some bleeding in liver hemorrhage. What hepatic bleeding source would it miss?

Answer 96

hepatic veins

Question 97

How do you evaluate the body/tail of the pancreas as well as the posterior stomach in an abdominal trauma ex-lap?

Answer 97

open the lesser sac - make an incision in the lesser omentum between the greater curvature of the stomach and the colon

Question 98

In an abdominal trauma ex-lap, how are the head of the pancreas, duodenum, and IVC evaluated?

Answer 98

right medial visceral rotation

Question 99

How is the suprarenal aorta evaluated in an abdominal trauma ex-lap?

Answer 99

left medial visceral rotation

Question 100

How is the aortic bifurcation evaluated in an abdominal trauma ex-lap?

Answer 100

cranial movement of the bowels

Question 101

How is the retroperitoneum assessed in an abdominal trauma ex-lap?

Answer 101

right and left medial visceral rotations

Question 102

In a hypotensive patient on the way to the OR, what is the role of crystalloid resuscitation?

Answer 102

avoid crystalloids and allow for permissive hypotension; too much resuscitation just pushes the blood volume out and replaces it with crystalloids

Question 103

If a trauma patient has suspected cardiac tamponade and is going to the OR, what is the correct order of preparation once the patient arrives?

Answer 103

prep and drape... then induce anesthesia

Question 104

In a trauma ex-lap, how do you control bleeding in the liver?

Answer 104

packing, then Pringle (hepatoduodenal ligament clamp); if this is unsuccessful, the bleeding may be from the retrohepatic IVC or hepatic veins - will either need retrohepatic packing or mobilization

Question 105

In penetrating trauma ex-lap, how are stabs and GSWs causing bowel injuries managed?

Answer 105

* GSWs often cause blast effect, so even if the wound looks small, the bowel has to be debrided back to healthy tissue often requiring resection and re-anastomosis * For stab injuries, lacerations \<50% can be repaired primarily

Question 106

How are infra-peritoneal rectal injuries managed?

Answer 106

temporary diverting colostomy

Question 107

How are expanding retroperitoneal hematomas managed in blunt trauma? Penetrating trauma?

Answer 107

explore

Question 108

How are zone 2 (flank) and zone 3 (pelvis) nonexpanding hematomas managed in blunt trauma patients?

Answer 108

leave alone

Question 109

How should stable retroperitoneal hematomas in penetrating traumas be managed?

Answer 109

exploration

Question 110

What are the two primary goals of a damage control laparotomy?

Answer 110

* control hemorrhage - pack * control contamination - close enterotomies

Question 111

What are the consensus data about when to perform damage control laparotomy?

Answer 111

* Hypothermia (\< 35°C), acidosis (pH \< 7.2), coagulopathy * Combined bowel and vascular injury * Administration of large volume transfusion (\>10 PRBCs) * Need for OR to remove packing or reassess viability of bowel * Inability to close the abdomen without tension or anticipated need for ongoing resuscitation in the ICU with the potential to develop abdominal compartment syndrome

Question 112

What is a type A biliary injury after cholecystectomy?

Answer 112

leakage from ducts of Luschka (minor hepatic ducts) or from the cystic duct

Question 113

What are type B and C biliary injury after cholecystectomy?

Answer 113

* Type B - occlusion/ligation of aberrant R hepatic - can be asymptomatic for years and present w/ cholangitis * Type C - leak of aberrant R hepatic

Question 114

What is a type D biliary injury after cholecystectomy?

Answer 114

Lateral incomplete damage to the common bile duct resulting in a biliary leak

Question 115

What are type E biliary injuries after cholecystectomy?

Answer 115

1. transection \>2 cm from the confluence 2. transection \< 2 cm from the confluence 3. transection at the hilum, confluence intact 4. transection at the confluence, confluence destroyed 5. injury to an aberrant R hepatic duct (type C) plus hilar injury

Question 116

What should you do if you recognize a possible biliary duct injury intraoperatively?

Answer 116

* get IOC if possible... * achieve external drainage and transfer... or... * convert to open and repair

Question 117

When suspecting a biliary injury in a postop patient, what do you do to work this up?

Answer 117

* determine if there is a fluid collection/biliary dilation - RUQ US * if still undefined - CT * determine if it's bile - HIDA * determine site of the leak - ERCP (can treat some) * if needing more thorough anatomical definition - MRCP

Question 118

How do you treat most type A and D biliary injuries postop cholecystectomy?

Answer 118

* percutaneous drain placement once fluid collection is identified * ERCP w/ biliary stent, sphincterotomy if retained stones * if ERCP finds complete disruption (E), do PTCs * removal of perc drains in 3-5 days if output is decreasing * 2 wks - repeat ERCP w/ stent removal if no more leak/asymptomatic/normal LFTs * type D may require repeat HIDA * sphincterotomy if ongoing leak

Question 119

How do you treat most type B and C injuries?

Answer 119

* Type B injuries may need hepaticojejunostomy, or partial liver resection if atrophy is significant * Type C injuries can attempt the standard percutaneous drainage and biliary stent, but may still need hepaticojejunostomy/resection

Question 120

Generally, how do you manage type E injuries?

Answer 120

* If intraop finding - tension-free repair w/ T-tube (\<1 cm or distal) or hepaticojejunostomy if too much tension * If late finding w/ jaundice presentation - US shows dilated intrahepatic ducts, ERCP shows complete obstruction * PTC to delineate proximal ducts and length of injury - drain both sides * if partial occlusion or clip - may be able to dilate/stent * if unable to dilate/stent - do delayed hepaticojejunostomy

Question 121

In a type E injury discovered intraop, what can you do if IOC determines a clip made the injury?

Answer 121

remove the clip, close choledochotomy from IOC w/ 5-0 prolene

Question 122

What are the outcome/postop differences between hepatico-J and primary repair in type E biliary injuries?

Answer 122

* primary repair can be stented if it strictures * primary repair is less complex intraop * fewer early postop complications w/ primary repair * no difference in stricture, health, quality of life

Question 123

Why hepatico-J over hepatico-D?

Answer 123

* hepaticoduodenostomy can create duodenal fistula if there's an anastomotic leak

Question 124

Long-term outcomes for biliary injury?

Answer 124

* 98% stent free * physical/social domains of quality of life are similar for those who undergo successful repair compared to age-matched patients who undergo successful lap chole

Question 125

In a patient with cholecystitis found to have enlarged CBD, CBD stones, or jaundice, what should be done?

Answer 125

ERCP then lap chole if just elevated LFTs or mild dilation, can do IOC

Question 126

What are the 6 steps in the SAGES program for safe cholecystectomy?

Answer 126

1. expose the critical view of safety 2. recognize the possibility of aberrant anatomy 3. make use of IOC or other biliary imaging 4. intraop timeout before clipping ducts 5. recognize danger and alter approach 6. get help if experiencing difficulty

Question 127

What are some maneuvers that can facilitate safe cholecystectomy?

Answer 127

* convert to open * drain a distended gallbladder * top-down cholecystectomy * subtotal cholecystectomy * IOC - can ID injury early * IO-US - can prevent conversion to open

Question 128

When approaching the gallbladder from a top-down method, what gallbladder characteristics can increase the complication rate?

Answer 128

contracted and inflamed gallbladders can be tethered to the hilar structures