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The talk is going to be split into three sections. I'm going to be talking about the general approach to the patient with abdominal injury, philosophy of damage control surgery and then talking about specific injuries to the retroperitoneum solid organs and uh management of laparoscopy. Me. The general approach begins with the C A B C D E of assessment where C stands for management of catastrophic hemorrhage like application of tourniquet. A stands for airway management, be reading management, see circulation, the disability assessment of the Glasgow coma school and exposing the patient and performing a full examination. And if we start with, see, you can see from this picture of a patient who was injured from improvised explosive device. There is already a C problem because the patient is bleeding from fragmentation injury through the femoral vessels, even though he has a tourniquet on because they have not applied it properly, but they have put a tourniquet on properly here. So they're taking care of potential catastrophic hemorrhage on this upper limb amputation. They have taken care of the airway by performing intubation. There may be a more internal hemorrhage circulatory problem. You can see the patient has a catheter and there is blood in the capital bag suggesting a renal tract injury. And they are putting in a federal line to gain venous access for transfusion as part of management of circulation. So the C A B C approaches overtaken the ABC approach because in battlefield trauma where most of the bleeding injuries are in the extremities, application of a tourniquet can be life saving. Hence see before ABC. So the question is now in this multiple injured patient, is there an abdominal injury? We now need to work out if there is an abdominal injury or not, we need to understand if the patient is bleeding and how bad we also need to understand. Where is the bleeding coming from? Is it the sources that we've already seen or is it hidden somewhere in the abdomen through the chest? So understanding how bad bleeding is relies on assessment of the physiology of the patient. And even though the BP is okay in this patient, there is severe tachycardia indicating that there is likely to significant and then we also can make a judgment about if there is ongoing bleeding because we can see that recording the trends of BP. Even when it comes up, it's only a partial response blocks back down again. So the trend is very useful as well as the snapshot of the pathology. So having made the determination that this patient is shocked and it's bleeding and is only partially responsible responsive to resuscitation, hold uh vascular fluids. The decision made to activate the massive transfusion policy and to mobilise from the blood bank. And we're doing this because we want to prevent uh further loss of blood due to traumatic coagulopathy, failure of the blood to clot because of gross physiological disturb patient. As sort of coagulopathy, it is very difficult to treat situation. And the principles of this we have been using for the past two decades, consists of early transfusion were born to one ratios of plasma and red blood cells together together with early use of platelets, tranexamic acid, perhaps whole blood. So now we have worked out the patient is bleeding, we have begun are massive transfusion and now we must find out where the patient is bleeding from. And this quest can be undertaken in the E R in the resuscitation bay. Firstly, by thorough physical examination and assessing all the wounds on the patient and working out what the trajectory is of any gunshot wound or fragmentation move is passed into the patient. Secondly, by simple X ray including chest X ray which search for signs of massive hemothorax, all by monitoring chest strain output. And if there is a large amount of bleeding coming out, the chest strain is may be due to an injury in the chest or an injury in the abdomen which has violated the Diovan. It's a simple X ray of the pelvis is useful in working out if there has been a massive pelvic disruption, which may again be the cause of the patient's shock state. And of course, focus sonography of the abdomen where you're not looking for organ damage, that you're just looking for. The presence of blood is very helpful in triaging the taxes as the source of. So by now, just using physical examination, X ray, uh monitoring drainage of chest drains and performing ultrasound scan, the surgeon should have a good understanding of where the patient is breathing from in the torso. In modern trauma practice. Uh At this point, if the patient's observations have settled and the physiology is improving in response to transfusion. Uh some surgeons will take the patient for CT scan because this gives additional value of working out. For instance, here, fragmentation in the kidney be a liver lacerations. But if the patient is not well and not stable, I suspect there is bleeding. Yeah. So I finished talking about the general approach. Now I'm going to talk about damage control surgery in North eat. Firstly, the phrase damage control surgery is not a surgical one. It was invented by the Navy. Uh used to describe the actions that are taken to salvage a ship. It's been put by this at Walmart. And the principal is that if the ship has taken damage, then even if it means sealing off compartments, which crew are in. If that keeps the ship afloat, then you take the action that's required. So for surgery, this means that restoring patient normal physiology outweighs restoring normal anatomy. This means just doing enough surgery to stabilize the patient and no more. In other words, matching the surgery to the physiology of the patient. So the goals of the surgical team, number one, stop meeting, number to stop contamination. Number three, keep the patient warm. And number four to prevent a patient from becoming acidotic. And by this, we will prevent former co argument. Only 10% of patient's uh who need surgery, need damage control surgery. And the textbooks say that patient's who have acidosis, low temperature. Hi prothrombin time. In the words, I iron are performing type and I lactate. This is how you select patient's with damage control surgery. That's what the textbooks say. The only problem is by the time these things have happened, it's probably too late. So actually the best guy for the surgeon is not these blood tests. It is simple physiological observation, art rate, BP. If the patient is shocked and responds poorly to resuscitation, only response partially, then it's a good idea to do damage control. So the damage control surgery or DCs, it has four phases and I'm going to talk about these phases. The first is recognizing that the patient needs damage control surgery. And as I mentioned, this is a decision that should be made based on physical examination, monitoring, physiology and simply investigations in the resuscitation. Secondly, in the operating room, one has to explain to the other partners that we are going to position the patient supine with the cruciform. So the arms straight out uh we prepare the patient drape the patient if anesthesia has not been administered and this is administered once the patient has been prepared and draped in communication as to what the surgical plan is. It's essential doing this face, the laparotomy, the incision extends from the xiphoid process that the super pubic area. The surgeon then takes large abdominal tax, the swabs and position these inside the abdominal cavity uh to uh mop up blood. The surgeon then removes the packs, removing them from the area of least bleeding likelihood uh to the area of most likely leaving if the surgeon can see a bleeding point, uh then all the surgeon has to do at that point is to grass, the bleeding point or two Clampitt apply pressure. The surgeon then speaks in the cysts and says I have temporary control. Uh You can catch up, you can put some more more limits. The patient would see a nest assist content with the trajectory of the patient. The surgeon can then formally expose the bleeding area, get definitive control and arrest of bleeding using or by either removing the organ packing the organ suturing the organ. Once the bleeding is controlled, speak to your knee cyst again. So we have control. Now, do you need any more time to transfuse the patient if not, then the surgeon can proceed to search for any bowel injuries or other injuries that are likely to contaminate the abdomen and to, to the abdomen is then closed using temporary control. So I closure mechanism uh and the patient is then uh sent to the intensive care unit uh for uh continuation of resuscitation at the right time. 24 48 72 hours later, with the right team in place. Patient can then be taken back to theater for re exploration, uh controlled way and definitive surgery to construct uh any uh public cover injury patterns that so now we have spoken about the general approach. We have spoken about damage control surgery and I want to talk about specific injury management. So the first thing I want to talk about is trauma to the rates of peritoneum. And I want you to consider that there are three kinds of retroperitoneal fever, tumor, central hematoma, lateral hematoma tell the the most um threatening to the patient and can be a central hematoma because this is hematoma due to injury of the main vascular structures. Yeah, I think the surgeon finds these hemotomas, they're likely to be large and they must always be explored in the injury repair. And that is because if they are large and they cause the patient to become shocked, they're not going to go away by themselves, they're going to get bigger. Definitively, hemotomas can be central hemotomas can be classified as above the colon above the parents of the reflection of the news in three of the colon. Oh beneath the kona fantastic of these, the more difficult and the more scary is the hematoma which is above the colon, which is getting proximal control of the blood vessels before exploring the hematoma can be difficult. And you could see that in this illustration here, just like for an abdominal aortic aneurysm infrarenal, it is not difficult to get control, proximal control of the hematoma before going into explore it if the hematoma has been the the level of the transverse colon. But if the hematoma is uh in the upper portion of the abdomen, above the, these three, the transverse colon to get proximal control can be difficult because the aorta is not freely available. It lies behind the diaphragmatic brewer and these must be divided before you can get control of the super celiac uh India. For this reason, I often advise surgeon to uh unfamiliar with this anatomy that before they explore the Dema toma, sometimes it is better to open the chest on the left side and to clamp the thoracic aorta because that is a simpler procedure trying to control the super cedar aorta within the active, once we have control of the blood vessels above the central hematoma, uh and this is a example of the uh thoracic aorta clamp from within the chest with the lungs being retracted, uh once we have control then we can explore the, there are two maneuvers which can be used to explore central hemotomas. A rely on moving the viscera from left to the right to the right to the left to expose the aorta or the inferior vena gala reporting. So we can see here, the surgeon is performing a rotation of the viscera from left to right. They make a cut along the lateral border of the attachment of the left, the descending colon and they mobilize the colon from the left and right. And in doing so, exposing Bryant, the aorta, the cardiac vessels. Um and they have a nice view of any potential injuries to that uh exposure of central hematoma due to being a cable injury. The first procedure is to coke arise uh routine. Um uh In other words, to bring the duodenum over to the midline, this incision is continued onto the lateral attachments of the a sending the right colon by doing so you can mobilize that this erupt right to left and you get a lovely view of the whole of the fear of you. This is what it looks like in real life with a duodenum, the uh the colon and the small bowel pushed over, you can see their hematoma in fear of indication. It is important to remember when repairing the inferior vena cava. It does not like clamps. It's very easy to tear using formal clamps. So rather when you are controlling blood flow of the area that you want to repair, control it just with these sponge sticks that is sufficient so that you can see the injury, repair it moving one step forwards. There may be injuries to the branches of the being a caver or the aorta and injuries that occur in this region here around the head of the pancreas, they can be fatal because of the number of very vascular structures. From the injuries to the portal triad can be controlled, clamping approximately dissolute before going into the hematoma. Find out of the portal vein of the pattern. Start with the first step in managing injuries to this area is to suture, what you see bleeding and then to mobilize that you would deem them following a Coca maneuver. So that one can expect the back of it as well as the front. Once you have got the Judean and rotated, it's easy to see. And then it is more amenable to repair this Giardina because straightforward to repair just primary anastomosis if you can't do this because the injury is too ragged, you can't do attention to you with their for the sake maneuver is simply to drain it using by the holy capita by the form of similarly, the pancreas lies next to the duodenum. It can be inspected by expecting it to the lesser sac taking off the mental Ephesians between the place of the average of the stomach and postcode. This is the view through the letter sack of a pancreatic injury. Uh the the body of tail of the pancreas, which is managed by mobilizing the pancreas of it's retro parents Neil attachment. Once it is mobilized, the pancreas can be transected and the distal damaged portion from the. So that is central hematoma. Now, I wish to talk about lateral hematoma. Unlike central hematoma, lateral hematoma, it is up to the surgeon whether they explore it or not, if the hematoma is getting bigger or a patient is shocked that it is best to X book. So the best way to explore the hematoma is by performing uh visual rotation and taking the cone on off. It's retroperitoneal attachments bringing it to them in mind. Then you see the tailor, the surgeon can make a cut on the capsule on the Kuroda's fasher around the kidney and then put their hands into delivery kidney. See if it's uh uh from the front. This kidney looked okay when we mobilized it, we could see at the back of the damage. This is a nine millimeter. Similarly, this kidney here have been injured by gunshot week and it was decided as the patient, a big kidney on the other side to remove it. But some surgeons might instead of just respecting this damaged portion and do a capsule a repair. So we've talked about central and natural. Now, I want to talk about pelvic hematoma and pelvic hematoma. Again, it is sometime depends on what surgeons opinion is that in general, if there is a large pelvic hematoma and the patient is shock, it is better to be explored with the small hematoma. It can just a and the technique that is the most utility in controlling pelvic chemo hemorrhage due to massive pelvic fracture. Uh if you don't have interventional radiology with something called preperitoneal package, an incision is made down to the free peritoneal space. Three large packs are pushed into the free peritoneal space. A positioned around the back of the Pelvis Tampa Nada. This is the ct scan of a patient who had packs put in. Unfortunately, this packs on the wrong space. I'm showing it because the surgeon put them to anterior, they need to be posterior to compress the sacred places. But now we've done retropulsion hematoma. I'm going to talk about Spanich trauma, liver trauma, bowel coma and closing up. I'll make it easy for spleen that's been injured in military circumstances. There's only one operation spleen comes out. It was put in the bucket. Unfortunately, you can't take the liver out if the liver is bleeding. The first thing to do is once you've done your packing is to mobilize the liver, take down into the ligaments and then basically compress the liver in your hands to restore liver, the the shape of the liver. The next step is to perform a pringle maneuver. This is where the surgeon includes the hepatic inflow vessels by this foramen of Windsor. This is a useful technique that can only be applied for 45 minutes maximum advise time so that the surgeon can explore for any obvious bleeding vessels or potentially control any bleeding. But it also allows the surgeon to come up with more exotic ways of controlling pieces such as uh intra Karen Kimmel Paki. So fives time when I was surgeon to see if there's any bleeding vessels to like get them uh to explore the main uh ought to pack the mood. This is an example of a patient who had a gunshot wound to the liver and the tract has been compressed with the surgeon creating in the sector tamponade by using the finger of the glove around a phony capita and inflating this and putting it down the track stop leaving. Unfortunately, such created means are not usually required. Just simple, properly applied packs positioned in the right area that restores liver, uh liver shape and the liver anatomy is actually uh nine times out of 10 given up could well most difficult. So now I just quickly talk about controlling contamination on bowel injury. If the patient is very sick, then there is no need to repair bowel injury. One can simply litigate about either side of the injury in this case using how all ties to isolate the injured segment. Alternatively, one can use stapled uh staplers uh to uh put a bow into this continuity and it is safe but about being the state for up to 72 hours thereafter, the patient must be taken back to theater either and then that's the most is performed or was stolen. Of course, contamination can also come from disruption to the Neuragen. It'll crack with close leakage of urine. Uh If this is because of a, you're a Terek injury and, and your it can be controlled uh simply bypassing a pediatric feeding tube, uh repairing the uniter over. Mhm. At the end of the surgery, if there's any doubt at all, then we need the abdomen open because we do not want the patient to develop abdominal compartment syndrome. We want to make it easier to go back into the abdomen to perform delicate surgery. Uh the next day for the day off and there are of course commercial uh back devices which are very good for uh managing the laparotomy. But also uh OpSite sandwich is a cheap and effective main means of controlling the HLA Prosta me, which I would expect. So this is simply a abdominal pack or drape which has been enveloped with OpSite or other appear a dressing on both sides. It is then placed over the peritoneal contents, then a fluffy cause uh is placed over that and over the top of the fluffy cause our two brains. Further dressing is placed over the brains and OpSite brain dressing on top of that. So, summarizing, I hope you understand that management of abdominal trauma takes place in the context of A C A B C D E and that the surgeon and the resuscitation A and work out how bad the bleeding is and where it is coming from, just from physical examination and simple investigation. And that the right state of mind for operating on these sick patient's is damage control.