CASE REPORTS OF UNCOMMON ABDOMINAL TRAUMA

DR.E.KAUSHIK KUMARDEPT.OF GENERAL SURGERYSTANLEY MEDICAL COLLEGE

குறள் 393:  கண்ணுடை�யர் என்பவர் கற்ற�ோர்முகத்திரண்டு

புண்ணுடை�யர் கல்லோ தவர்

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CASE 1 BLUNT INJURY ABDOMEN CAUSING

PANCREATIC TRANSECTION

The pancreas-relatively protected position high in the retroperitoneum,

Many blunt pancreatic injuries are not immediately recognized

Consequently end up causing higher morbidity and mortality rates than observed in injuries to other intraperitoneal organs

Penetrating abdominal trauma frequently causes pancreatic injury

Even physical visualization and examination of the pancreas in the operating room may miss an isolated ductal injury to the pancreas

A delayed diagnosis of pancreatic injury, mild or severe, is easy to diagnose but becomes a major therapeutic challenge to the surgical team and a potentially disastrous situation for the patient.

To consider a pancreatic injury, a trauma that occurred from a significant force is usually required. 

Case profile 22 year male suffered a blunt injury

abdomen-Had no external injuries Primary Health care had pain abdomen in epigastrium and back next day Admitted and evaluated and diagnosed as Blunt Injury Abdomen with retroperitoneal haematoma

? Pancreatic Injury

Taken up for exploratory laparotomy Findings

› Minimal hemoperitoneum› Transection of pancreas at the level of

neck and body with duct disruption› All other organs- Normal

Procedure done› Primary repair of pancreatic duct over a

stent and pancreatic anastamosis and drain of pancreatic bed with Feeding Jejunostomy

Patient was referred for post op care Tachypnoea,tachycardia,intermittent

fever Conservatively managed Uneventful Post-operative imaging-satisfactory Discharged on 15th POD

Approximately 20-30% of all patients with penetrating traumas

10% in blunt traumas The proximity of the larger vessels (eg,

portal vein), the abdominal aorta, and the inferior vena cava (IVC) to the pancreatic head increases the risk of exsanguinating hemorrhage accompanying pancreatic penetrating injury

Work-up Amylase detected in diagnostic

peritoneal lavage (DPL) fluid is much more sensitive and specific for pancreatic injury

CT scans provide the best overall method for diagnosis and recognition of a pancreatic injury-Retroperitoneal hematoma, retroperitoneal fluid, free abdominal fluid, and pancreatic edema

Management Conservative

› Stable hemodynamics and CT scans showing no evidence of pancreatic parenchymal fracture, parenchymal hematoma, parenchymal edema, fluid in the lesser sac, or retroperitoneal hematoma may be observed but should not be considered to be cleared for pancreatic injury for at least 72 hours

Damage-control techniques Operative repair Resection Factors

› Hypothermia› Dilutional coagulopathy› Other fatal or near-fatal injuries 

Conclusion Pancreatic injury can be frighteningly symptom

free early in the postinjury time frame and even silent in many cases

Symptoms of injury to other structures commonly mask or supersede that of pancreatic injury, both early and late in the hospital course

A high degree of clinical awareness is necessary to ensure that pancreatic injuries are not overlooked or missed, either early in the course of trauma or later in the ICU when the patient is not clinically improving as expected

Case 2 PENETRATING TRAUMA WITH GASTRIC EVISCERATION AND PERFORATION

A 26 year male brought to emergency room by 108 people

No specific reliable history Stomach eviscerated in epigastrium Patient under alcohol intoxication There was a laceration over his scalp.

On examination GCS – 12/15 (E 3 V 4 M 5). PR- 112/min. BP- 100/60mmHg. Stomach eviscerated with bluish hue. Rest of abdomen-flat,tenderness not

elicitable. No guarding/rigidity. BS +. No other extremity injuries or spinal injury

Patient resuscitated initially with iv fluids

Coagulation profile assessed and blood taken for cross matching

Shifted to Operating room for exploratory laparotomy.

Findings Stab injury in epigastrium causing

perforation of body of stomach in anterior and posterior wall.

Omental contusion + Hemoperitoneum about 50 ml. No other bowel or solid organ injury. No diaphragmatic injury.

Procedure done: Omental patch closure with feeding jejunostomy.

Post Op: Uneventful and discharged on POD 7.

Follow up : normal

Penetrating trauma causing Gastric evisceration is less than 2 %

Absolute indication of Laparotomy Associated major vessel/organ injury to

be searched Damage control/definitive repair

Conclusion Aware about uncommon injuries Proper clinical evaluation serially Communication within and between

the surgical and allied teams Treatment individualised