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Abdominal Trauma Revisited DAVID V. FELICIANO, M.D.

Clinical Professor of Surgery, University of Maryland School of Medicine/Shock Trauma Center, Baltimore, Maryland; Battersby Professor of Surgery, Indianapolis, Indiana; and Chief Emeritus, Division of General Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

History of Abdominal Trauma

Epidemiology of Trauma

5.1 million deaths from injuries around the world each year. More than 2/3 T of these occur in males, and more than 50 per cent HERE ARE APPROXIMATELY

occur in males 10 to 24 years of age. Norton and Kobusingye have noted that data from the World Health Organization document that trauma causes 6 per cent of all deaths in high-income countries.1 By contrast, deaths from injuries account for 11 to 12 per cent of all deaths in low-income countries in Southeast Asia and “in the Americas.” In the United States, there are 150,000 deaths from injuries each year or 54.4 injury deaths for 100,000 population. There are 400 injury deaths per day, and trauma continues to be the most common cause of death for Americans aged 1 to 44 years.2 Of interest, firearms continue to be the second leading cause of trauma deaths in the United States after motor vehicle crashes with an average of 32,300 deaths per year.3–5

Presidential Address 85th Meeting, Southeastern Surgical Congress Nashville, Tennessee February 25–28, 2017. Address correspondence and reprint requests to David V. Feliciano, M.D., 640 S. River Landing Road, Edgewater, Maryland 21037. E-mail: [email protected].

The Edwin Smith Papyrus, the oldest surgical treatise in world history, describes 48 patients and is thought to date from 3000 to 2500 BC or 1600 BC.6 The patients were mainly victims of trauma, and some of the surgical techniques described included stitching, cauterization, nasal packing, application of splints, reduction of fractures, etc. There is, however, no mention of abdominal trauma in the treatise. Early comments on the management of patients with abdominal trauma were made by some of the most prominent individuals in the history of medicine—namely, Hippocrates, Celsus, and Galen. Hippocrates (460–370 BC) noted that eviscerated omentum through an abdominal wound “mortifies imperatively” in the Corpus Hippocraticum.7 Celsus (25 BC–50 AD), a nobleman in Rome, recommended repairing wounds of the eviscerated colon (but not the small intestine). He then described returning the bowel to the abdomen and closing the wound in the abdominal wall in layers.7, 8 Both Galen of Pergamum (129 AD–199 AD) and Albucasis (936–1013) of Spain described the importance of enlarging abdominal wounds when eviscerated bowel could not be easily returned to the peritoneal cavity before repair of the abdominal

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wall. Guy de Chauliac (1300–1369) of Avignon, France, repeated the principles described previously in Inventorium Seu Collectorium Cyrugie written in 1363 and printed as a text in 1478.9 He, too, recommended suture repair of the eviscerated perforated colon and emphasized that “nothing is more dangerous for the intestine than the contact with air.”7 Approximately 50 years later, Jerome of Bruynswyke (England) repeated this advice in old English, as follows: “If that the wounde of the belly is not grete inowgh, then shall ye make it greater…than shall you take out proply the guttes, and sow it thereafter as it is needful with a skinner’s nedyll.”10, 11 Jean Baudens (1804–1857), a French military surgeon, is credited with the diagnostic maneuver of introducing a finger or a small sponge through an abdominal wound during the Crimean War. When no blood, feces, or bubble of gas was present, he advised against laparotomy.12 Also, Baudens was reported to have performed laparotomies with enterorrhaphies in two victims of abdominal gunshot wounds during the French Algerian War in 1830, and one survived.13 In the United States during the first half of the 19th century, laparotomy was not performed for victims of abdominal trauma except for isolated cases.14 And, it is surprising how little impact the introduction of general anesthesia had on this conservative approach. In particular, the contributions of Crawford W. Long, MD, Jefferson, Georgia, Horace Wells, DDS, Hartford, CT., and William T.G. Morton, DDS, Boston, MA, from 1842 to 1846 did not lead to a more aggressive approach to abdominal wounds during the Civil War. Although there had been one report of a successful laparotomy for a blunt rupture of the bladder in 1849, Shaftan has reminded all about the Civil War data reported by George Alexander Otis.15, 16 He documented an 82 per cent mortality in 3690 soldiers with penetrating abdominal wounds presumably treated conservatively during this conflict.15, 16 Conservative (nonoperative) management of penetrating abdominal gunshot wounds was challenged in the United States after the death of James A. Garfield, the 20th president. Garfield was wounded in the right lower posterior thorax in an assassination attempt by Charles J. Guiteau in Washington, DC, on July 2, 1881.17 After 79 days of finger probing of the wound by a number of renowned surgeons and failure of the president to improve, Garfield died on September 19, 1881. At autopsy, Garfield was noted to have a fracture of the first lumbar vertebra, a possible missed pancreatic injury, a ruptured splenic artery aneurysm, and an intraabdominal abscess.17 J. Marion Sims (1813–1883), described by eminent surgical historian Ira M. Rutkow as “perhaps the first great American gynecologist,” was one of the strongest critics of the

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nonoperative management of President Garfield.18, 19 A later article continued to advocate an operative approach to penetrating abdominal wounds.13 It was William T. Bull (1849–1909), a prominent surgeon in New York, who is credited with performing the first formal laparotomy on a patient with a gunshot wound of the abdomen in the United States.15, 20 The patient was a 22-year-old man with a 0.32-caliber gunshot wound approximately 1.5 inches left lateral and inferior to the navel. The patient was brought to the Chambers Street Hospital in New York City on November 2, 1884, and underwent a laparotomy 17 hours later on November 3, 1884. Bull performed four repairs of five perforations of small bowel, including operative techniques such as transverse closure and converting two adjacent perforations into one oblique repair. In addition, he repaired a perforation of the sigmoid colon, removed all free intestinal content, and swabbed the pelvis with a 2.5 per cent solution of carbolic acid. The patient then developed a subfascial abscess on the sixth postoperative day. The midline “heavy silk sutures” were removed except superiorly, and the open incision was “stuffed with carbolized compresses.” After the open incision slowly granulated, “a large number of skin-grafts were applied on two occasions.” The patient was discharged on the 58th postoperative day. The oral report of this case by Bull at the New York Surgical Society on January 27, 1885, and the publication 18 days later in the New York Medical Journal evidently stimulated great interest in treating future victims of penetrating abdominal wounds in the United States with exploratory laparotomy. Excellent reviews of this new approach were then published by two other surgeons in New York City— Stephen Smith, MD, one of the founders of the Bellevue Hospital Medical College, on January 2, 1886, and by Frederic S. Dennis, later to be President of the American Surgical Association in 1895, on March 6, 1886.18, 21, 22 William T. Bull reported his second successful laparotomy for a patient with a gunshot wound to the abdomen at the New York Surgical Society on October 11, 1886.23 A through-and-through wound of the small bowel, a second wound of the sigmoid colon, and two wounds of the sigmoid mesentery were repaired. On the sixth postoperative day, the patient had a partial dehiscence of the superior aspect of the midline incision. This area was allowed to granulate, and skin grafts were eventually used to cover the defect. Loria has noted that these case reports helped to convince American surgeons of the benefits of laparotomy for patients with penetrating abdominal wounds.11 In addition, he described the symposium on penetrating abdominal gunshot wounds held at the meeting of the American Surgical Association in May

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1887. This “concluded with the consensus of opinion in favor of the operative treatment, even in those cases in which the diagnosis of injury to important intraperitoneal structures was in doubt.” Further review articles over the ensuing 30 years emphasized the benefits of an aggressive operative approach and documented continued refinements in operative technique.24, 25 An aggressive operative approach to victims of abdominal trauma persisted to the 1960s for those with stab wounds, to the 1970s for those with blunt trauma, and to the 1990s for those with gunshot wounds. The reason for a change in philosophy was related to the development of trauma centers in the United States where large amounts of data on trauma victims were collected and analyzed during the decades listed. Over time, it became obvious that an aggressive (mandatory) operative approach to all victims of penetrating (through the peritoneum) anterior abdominal stab wounds resulted in a 25 to 40 per cent nontherapeutic laparotomy rate.26–28 The figures for victims of blunt abdominal trauma were similar,29–31 whereas those for victims of penetrating wounds of the flank or back were 70 to 85 per cent32–37 and for gunshot wounds of the abdomen were 15 to 27 per cent.38–42 Classical Indications for Laparotomy

The classical indications for laparotomy after abdominal trauma are listed in Table 1.43–47 Diagnosis of Abdominal Trauma

A diagnosis of peritonitis on physical examination is compromised when one of the following is present: 1) patient is intoxicated48; 2) patient has taken illicit drugs; or 3) patient has associated injuries to the brain, spinal cord, thoracolumbar spine, lower ribs, or pelvis. In such patients, when serial physical examinations will not be useful, the currently available diagnostic options are as follows: 1) diagnostic peritoneal tap/ lavage, 2) surgeon-performed ultrasound examination (FAST), 3) contrast-enhanced CT of the abdomen and pelvis, and 4) diagnostic laparoscopy.

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David V. Feliciano

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Multisystem Blunt Trauma/Hemodynamically Unstable

In such a patient with a compromised abdominal examination, a surgeon-performed FAST will rule out pericardial tamponade and determine whether intraabdominal fluid (blood) is present.49–51 In the older series by Rozycki et al.,52 there was a 100 per cent sensitivity and 100 per cent specificity of surgeonperformed ultrasound in determining whether intraperitoneal bleeding was the cause of hypotension in patients with multisystem blunt injuries. When no ultrasound machine is available or the results of the surgeon-performed ultrasound examination are equivocal, a diagnostic peritoneal tap/lavage is performed. Multisystem Blunt Trauma/Hemodynamically Stable

A stable patient with a compromised abdominal examination and a positive FAST, negative FAST, and/or hematuria should undergo contrast-enhanced abdominopelvic CT to determine the presence and magnitude of any injuries. Penetrating Abdominal Trauma/Hemodynamically Unstable/Multiple Truncal and Extremity Wounds

It is usually true that patients with multiple wounds have hypotension related to one of the wounds. In the absence of external bleeding from an extremity, an expanded surgeon-performed ultrasound will confirm whether the hypotension is caused by pericardial tamponade, intrapleural hemorrhage, or intraperitoneal hemorrhage. As in patients with possible blunt abdominal trauma, a diagnostic peritoneal tap/ lavage is performed when the FAST cannot be performed or the results are equivocal. Possible Penetrating Thoracoabdominal Trauma/ Hemodynamically Stable

A stab or gunshot wound in the thoracoabdomen (nipple to costal margin from midline to anterior axillary line) will penetrate the diaphragm and abdomen 15 per cent and >45 per cent of the time, respectively.53

TABLE 1. Classical Indications for Laparotomy after Abdominal Trauma43, 44 Penetrating or blunt abdominal trauma with hypotension (and positive FAST or diagnostic peritoneal lavage with blunt trauma) d Peritonitis on initial or subsequent physical examination d Evisceration of bowel and in some centers, omentum (controversial45–47) d Bleeding from stomach, rectum, or genitourinary tract after penetrating trauma d X-ray or CT demonstrates free air, retroperitoneal air, or rupture of the hemidiaphragm after blunt trauma d Contrast-enhanced CT demonstrates rupture of gastrointestinal tract, rupture of intraperitoneal bladder, or severe (AAST OIS Grade V) visceral parenchymal injury after blunt or penetrating trauma d

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In the absence of peritonitis or evisceration, a surgeonperformed ultrasound demonstrating intraperitoneal fluid (blood) documents that the hemidiaphragm and, possibly, intraabdominal viscera have been injured. A “negative” surgeon-performed ultrasound will not be helpful, however, as little intraperitoneal blood can be expected from the usual stab or gunshot wound of the hemidiaphragm. Certain centers will perform a contrast-enhanced CT of the abdomen as the next study after a negative surgeon-performed ultrasound. This would be useful with a possible right thoracoabdominal wound because intravenous contrast would be expected to demonstrate an injury to the liver. On the left side, a triple-contrast CT would be necessary to demonstrate any injury to the stomach, transverse colon, or splenic flexure. There is, however, an aversion of some radiology departments to the labor and timing-intensive nature of triple-contrast CT studies. So, some trauma centers will perform diagnostic laparoscopy with a 30° laparoscope under general anesthesia in the operating room instead. On the left side, an even simpler diagnostic approach is to review the patient’s serial chest X-rays after insertion of a thoracostomy tube for a lower left thoracic penetrating wound. Before discharge of the patient, these X-rays always show a persistent abnormal appearance of the left hemidiaphragm if an injury has been missed.54 This is presumably due to the early herniation of a portion of the omentum from negative intrapleural pressure. Penetrating Anterior Stab Wound/Hemodynamically Stable

A stab wound to the anterior abdomen (costal margins to inguinal ligaments between anterior axillary lines) penetrates the peritoneal cavity 25 to 33 per cent of the time. Many patients with documented (passage of Q-tip, positive local wound exploration, or positive surgeon-performed ultrasound) or presumed peritoneal penetration do not have peritonitis or evisceration. Serial physical examinations over 24 hours rather than other diagnostic tests have continued to be the most popular approach as patients with continuing hemorrhage or gastrointestinal contamination are almost always symptomatic within 6 to 12 hours. Diagnostic peritoneal lavage has an accuracy of 88 to 92 per cent in the early diagnosis of patients with injuries requiring repair, with the compromised accuracy mainly because of false-positive studies.55 There is, however, little enthusiasm for this technique in modern trauma centers. Surgeon-performed ultrasound can only document penetration of the peritoneal cavity as noted previously, but not visceral injury. In addition, in busy urban trauma centers around the world, it is impractical and not cost effective to perform diagnostic laparoscopy in so many patients.

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Penetrating Flank or Back Trauma/Hemodynamically Stable

A stab or gunshot wound to the flank (sixth intercostal space to iliac crest between anterior and posterior axillary lines) or back (tips of scapulae to iliac crests posterior to posterior axillary lines) may penetrate the visceral-vascular area of the retroperitoneum or the peritoneal cavity. Most patients with such wounds do not have peritonitis or evisceration. Serial physical examinations continue to be a popular diagnostic approach, and patients with visceral injuries will almost always develop symptoms or signs within 18 hours.56 Double (intravenous and upper gastrointestinal) or triple (add rectal) contrast CT remains the most commonly used diagnostic test in patients with penetrating wounds to the flank or back. With an accuracy >95 per cent when performed properly, this study rapidly answers the question of whether operative intervention is indicated.34, 57 Operative Management Resuscitation

There are multiple guidelines for predicting which operative patients will likely require massive transfusion and, possibly, a “damage control” operation.58–61 Measurement of the initial base deficit is predictive of outcome in patients with blunt or penetrating abdominal trauma as well.62, 63 “Damage control resuscitation” with fixed ratios of red blood cells, plasma, and platelets has been confirmed to have a beneficial impact on survival and on achieving hemostasis in the The PRospective Observational Multicenter Major Trauma Transfusion and Pragmatic Randomized Optimal Platelet and Plasma Ratios studies, respectively, in recent years.64, 65 Yet, there has been an even more recent evolution to “goal-directed hemostatic resuscitation” based on thromboelastography (Haemonetics Corp., Niles, IN) or rotational thromboelastometry (TEM International, GM6H, Munich, Germany).66, 67 General Principles

Once the surgeon has been updated on the patient’s hemodynamic status and status of resuscitation before operation, a second- or third-generation cephalosporin antibiotic is administered intravenously. The surgeon must then decide on the positioning of the patient. It has always been the author’s preference to position the patient’s upper extremities at the patient’s sides for the following reasons: 1) easy application of self-retaining retractors to the operating table; 2) space for any team members holding retractors in the right or left upper quadrants; and 3) ready access

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to perform an anterolateral thoracotomy or median sternotomy during the emergency laparotomy. The one other consideration in positioning is whether to place the pelvis and lower extremities in the lithotomy position should an injury to the rectum be known or suspected. Preparation and draping of the patient should extend from the chin to the bilateral knees and encompass all of the anterolateral trunk and thighs. This allows for extension of the midline exploratory laparotomy into a median sternotomy if needed. In addition, it allows for access to the groins for distal/proximal vascular control of an injury to the external iliac artery/vein or for retrieval of an autogenous saphenous vein graft. Finally, all of the standard maneuvers to prevent, decrease, or reverse hypothermia are instituted before the incision and maintained throughout the emergency operation.68 Hepatic Trauma

With a blood supply of 1500 mL/min, control of hemorrhage is the obvious priority when operating on a patient with an American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) Grade III, IV, or V hepatic injury. And, as befits the largest organ in the body, there are at least 11 different operative techniques that can be used to attain hepatic hemostasis—compression, topical agent, suture hepatorrhaphy (minor or extensive), hepatotomy with selective vascular ligation, resectional debridement with selective vascular ligation, absorbable mesh compression, formal resection, selective hepatic artery ligation, intrahepatic balloon tamponade, and perihepatic packing. Any AAST Hepatic OIS Grade III (