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Hello, everyone and welcome to our first event this week. Uh We have Rebecca joining us about and talking to us about abdominal trauma. As always, put your questions in the chat and we will get through them, put your answers in the chat. We'll get through those two. Your feedback form will come to you in an hour's time at the end of this uh session. And once you've completed it, your feedback, your attendance certificate will be on your medical account. Ok. So please put your questions in. We want loads and loads of questions and please fill out the feedback because I will be passing that on to Rebecca. All right. So without any further ado, I'm gonna hand it over to Rebecca now. Ok. Thank you, Rebecca. Thank you. Thank you. So for the introduction. Um Hi, everyone. I'm uh Rebecca. I'm a consultant surgeon, co mostly colorectal emergency, but also a humanitarian surgeon. I'm originally from Switzerland, but I work in the UK for the last six years. Um I also work for MSF uh and I'm part of a team for the David Not Foundation. Uh The David Not Foundation is a foundation that has a course, it's called H course, Hostile Environment Surgical Training um where we teach um surgeons all over the world um in trauma and conflict surgery. Um So that's uh that sign II and I, they allowed me to use some of the pictures we use for our teaching for the H course. And you will see always that sign in the right corner and if the picture is from the David NOTT Foundation. Um so today, um I will uh I will talk about abdominal trauma. It's um mostly about assessment, diagnostic and treatment, but it should be more like an overview of how we can deal with uh trauma. It's um I don't wanna go into too much detail in for every injury or potential injury you could have after an abdominal trauma. Uh we will talk about this more like uh like as an overview but not so much into detail, too much. It, it should be more like a guide uh guidelines, how we can address abdominal trauma. Um and what are the potential um treatment options? And I will also talk about mainly about abdomen, also about closure or open abdomen because I think that's a really important part um of a abdominal trauma. It will be different from, it depends where you, which country you live in and uh your hospital. So what's what infrastructure you have in your hospital? So it will be different from hospital to hospital. But let's talk about um assessment of abdominal uh trauma. So like for every trauma, um the first thing we have to do is a primary survey. So it doesn't matter if the patient has a chest trauma mainly or abdominal trauma or brain trauma. Each trauma patient needs a proper assessment from tip to toe. Um And so the primary sur regardless where the main injury is, we need to uh primary assess and resuscitate the patient. Um You probably all know this, it's like uh we learned ABCD E and for major trauma, it's also uh C ABCD E. So because the first thing we need to address if we have a major trauma is the catastrophic hemorrhage. And that's even before we start with the airway breathing circulation, um that sometimes needs to be to be addressed immediately. So that means for example, you have a, a bleeding that needs a compression dressing or you have a uh uh a tourniquet, you have to apply um because of um uh external bleeding. So that's the first thing we need to address. And then of course, I'm not going into too much detail with ABCDE. Um But basically airway, of course, is important to maintain the airway, uh look into the mouth so that the airway is open and the patient can breathe, the c spine belongs to airway as well. So every major trauma, you can assume that there is ac spine injury as well, breathing ventilation. Um Sometimes you need uh to address a chest injury like a chest drain that has to be inserted, that's usually done. Uh when we do b and then important for us, uh for abdominal trauma is circulation with hemorrhage control. And here specifically, I only talk about abdominal hemorrhage. So it can be any bleeding from a vessel in your abdomen. Um And when you do see, sometimes a patient needs an immediate laparotomy, um you may know when you resuscitate the patient, they are like a responder, transient responder and non responder. That means you give the patient fluids and if they respond, they will go back to normal, the heart rate will normalize the BP is coming up. If it's a transient responder, they respond initially to fluid resuscitation but then um become unstable again and then they, they are the non responder. They are not responding to any resuscitation and they usually need something come quite immediately disability. Uh is just a brief examination of the patient's neurological status. Um mainly uh the Glasgow coma scale. You may aware like different answers, eye, verbal motor response and exposure. And that also is important to warn the patient when we talk about diagnostics. Um um there are two main diagnostic, I think are important for abdominal trauma. So I basically talk about abdominal trauma. So I think if you have a fast scan, we probably all know this like an ultrasound. Uh a quick assessment of the abdomen, usually we also have a look at the chest and the heart. But no, I'm not going into this too into detail. But it's basically, if you have a fast scan, if a a quick assessment of the abdomen with an ultrasound, this can be very useful to see if there is any major injury of the liver or the spleen or the bladder, the vessels. And um but it's, it has its limitations so far is not always ideal if it's very much operator dependent, meaning the sonographer experience has a high false negative results. Um So it's not always um reassuring. If you have a negative fast scan, you, you're still not 100% sure. Sometimes if the patient does not have any injury and also it's not very good for detecting bowel injuries, uh diaphragmatic injuries of the or me mesenteric traumas. And if the fluid is less than 200 mils, you won't see it on the fast scan. So it's, it has its limitation, but it's good to uh as a um an assessment next to your clinical judgment. So, but it can't just be used as a, as um on its own. So you always have your, also your hands, you have to feel the abdomen is the abdomen, tender distended. Um Do you see any obvious bruising uh of your abdomen? And that will also help with your uh interpretation of a scan. So, d the other option would be a CT scan and a CT scan, obviously aid is the gold standard. If you have a CT scan available, I am very much aware that there are many places in the world and hospitals where you don't have a CT scan. Um and it's much more difficult. So you have to go much more uh with your clinical judgment and with the observation of, of the patient. But if you have a CT scan and in western countries, we do all have CT scans. This every patient who is stable enough to, to um to go to the CT scanner should have a CT scan. Um And that helps you a lot in the decision making if you a patient needs surgery or not. Um So now we discussed as clinical assessment, primary survey, examination of the patient observations are crucial. I will come to that later on again and then treatment uh diagnostics and now treatment options. Um So we talk about, we will talk about treatment uh of blunt injuries and perforating injuries. They are slightly different how we address these um uh injuries. But just to say most patients, uh the majority of patients can be treated with definitely definitive surgery um for uh with when you do the first laparotomy or laparoscopy. Um So m most patients, you do a laparotomy and you fix the problem and you close the abdomen. That's what we mean with definitive surgery. So that is for most patients. Um but sometimes you have to consider, we call it damage control, which means the patient is really unstable, has had lost a lot of blood. And what we have to do is to basically turn the top off means the patient is bleeding or has a contamination and the septic. So then we basically address just the most life-threatening injuries and and then deal with the definitive surgery later on. So patients who are really hemodynamically unstable due to a massive blood loss, they need damage control surgery. I will talk about damage control surgery because I think even though it's only for a few patients, but if you have one, it's really important to make the right decision or the right indication which patient needs damage control. So why is it important to address um uh or to be aware of damage control? It's because we basically uh we live in a homeostatic uh en uh environment. So our enzymes uh work best in uh in, in, in the perfect environment. Uh that means normal temperature, normal ph. So, so that's how uh the all the our metabolism works. So if you have a massive blood loss, the tissue is not perfused as well as it should be and you have less oxygen in your cells. And if you have less oxygen or a hypoperfusion, that means um you're not producing enough at P um and the patient becomes hypothermic and as a byproduct um is lactate. So that means you, the patient also becomes acidotic. And because of that lower ph um you, you homos static me mechanisms are no longer functioning. Um And therefore, the clotting cascade uh does not work and the patient become also coagulopathic. So, and all these mechanisms are really important because that leads to more hyperperfusion and to less oxy oxygen delivery to the cells. So, in essence, it's the patient becomes hypothermic coagulopathic and uh acidotic. And then you enter, we call it like a AAA tribe of death, uh which is the driving force. Um uh is hemorrhage, the driving force to for the um tribe of death is hemorrhage. And therefore, we basically need to address the hemorrhage. So the main message here is basically uh treat physiology and not the anatomy. So that means we have to stop the bleeding and, and we do a laparotomy, we stop the bleeding. Uh That's uh we, we do that by packing the abdomen. Uh I will talk about that in a minute. So packing the abdomen to stop the immediate major hemorrhage, sometimes we have to clamp a vessel. Uh I will not go into much detail and how to clamp a vessel. It's, it's, it's not always easy. Um We have to control sepsis. That means if you have bowel injury, you basically just staple off the bowel or tie off the bowel if you don't have staplers and try to restore perfusion to for major vessels. Um and, but minimize the operative time as much as possible because the longer the patient is on the table, on the operation table, the more problem you will have. And then usually we're also not closing the abdomen uh completely. Uh But I will talk about that in a minute as well. Um And then the patient goes to our intensive care unit to restore physiology. So we address um we try to make the patient less acidotic uh we transfuse um we make sure the patient is more stable um is warm. We wanna warn the patient. So basically to inverse like all the uh the factors that thrives uh the trial of death. Um and usually after 24 to 48 hours, we can take the patient back to theater and address uh the problem again and perform definitive surgery. Sometimes you need more than one um a relook as we call it. Um But uh if anyone has any question, please, you can put them in the chart. I'm very happy to answer all the questions in uh in between. So now we talk about trauma laparotomy. It's for damage control, but also for every trauma laparotomy. So what is the most important thing is actually we have to eviscerate small bowel followed by packing and so and direct contro uh direct packing controls, hemorrhage. So we, and it's important to do that in a, in a certain way. Usually I start packing the abdomen where I suspect the injury to be. So for example, if I suspect the injury ca uh, like is from the liver, unless you have a bleeding from the liver, then I usually pack first the, uh, the right upper quadrant. If you think it's the spleen, you can pack the, the left upper quadrant. So you can usually start where you suspect a major injury if you don't know it, you just pack all quadrants. That's the most important thing. But you have to take out the small bowel in order to pack. So don't blindly pack the abdomen. So you have to take out the bowel and you have to do it in a control ma manner. Uh but you have to pack uh above and below the liver in order to compress the liver, the right gutter above and medial to the spleen, the left gutter and into the pelvis. So once you, you've packed the abdomen, you have time to breathe and you to stop. And you can also really important is to communicate with the anesthetist. So everything you do, you should communicate with the anesthetist and the commu and the anesthetist will also uh update you on how the patient is doing. Uh because what you do in the in the abdomen can have an immediate effect on, on the patient's physiology. So that's why communication is really important. And so once you pack the abdomen and the patient is a bit more stable, you have time to think and that gives the anesthetist time to resuscitate the patient. And then, um the next thing we do is uh carefully remove the pack. Um and then systematically inspect the abdomen and we will talk about the, the most important areas of injury. Um But I think most important is that you carefully re uh remove the packs and then you can address the immediate uh injuries. Um So for example, if you have a liver injury, you can uh you can um suture the liver or pack the liver or do an omental patch. Um or if you have a spleen injury, you have to assess the spleen and see if you can salvage the spleen or if there is ongoing bleeding. I think uh it's the best and safest thing is to just do a splenectomy. Um And so you can carefully and systematically have a look at all the different organs and areas of the abdomen. Um So the meaning of pack is a compression. Yeah, sorry, I just saw the question about the, the packing. Yes, it's mainly about compression. Exactly. So if you have a a bleeding, for example, let's take the liver. The most important thing to stop the bleeding from the liver immediately is pack the liver. So you pack from above and below. That means you compress the organ and you can stop the bleeding immediately. It is temporary. It's not a definitive treatment, but it will stop the bleeding and it gives the anesthesist time to transfuse address physiology. And it also gives you a little bit time to think what you, what you are gonna gonna do next. So it, it's a very good question. It's about stopping immediate bleeding to basically stop, turn off the tap and stop the patient from dying or bleeding out. Um, so that's mainly damage control, but sometimes we, if, as we talked about it, if it's 90% or more than 90% of all patients don't need like a damage control surgery, they may be stable or they don't have a major hemorrhage. Um And so we talk about, but then we have to differentiate between blunt and penetrating injuries. So, so what is the role of non operative management? There is a role in for non operative management, I think, and you, some patients, they don't need operation, they don't need surgery. And mostly uh most patients who don't need surgery are these patients who have uh the blunt trauma stable patients and patient who had a CT scan which showed there is no injury in your, in their abdomen. It is more difficult if you don't have a CT scanner. So it is then you depend on your clinical judgment and on the patient's uh condition. Um I will go into a bit details in uh like an algorithm for blunt and penetrating injuries in a second. What is the role of diagnostic laparoscopy? I think there is a role if you if laparoscopy is something uh that's available to you. Um for example, if the patient is stable, but you do you have a high suspicion for intraabdominal bleeding or an injury. Um Then I think if the patient is stable enough, you can also just have a look inside and it's very good for diaphragmatic injuries as well because they sometimes don't need a laparotomy. You can just stitch the diaphragmatic injury, uh laparoscopically. So there is uh for a few patients, diagnostic laparoscopy has its indication uh trauma, laparotomy as we talked about it, I think most patients who have a penetrating injuries in their abdomen, they should have a trauma laparotomy. If the patient is completely stable, maybe you could also do a laparoscopy but all unstable patient for sure, they need a laparotomy. So you shouldn't end if you suspect an abdominal trauma. Um So you have a very high success, blunt injuries, they have a high success rate. Um If you just watch and wait, for example, liver lesions, splenic lesions or renal injuries, they usually self-limiting and they stop on its own or if the capsule is still intact, they stop. So there is a high success rate. If the patient is hemodynamically stable, you don't necessarily need uh to operate on these patients. But always keep in mind if a patient had a blunt trauma, um they have there are some point of injuries because of the deceleration and acceleration mechanism of blunt injuries. For example, if an earthquake or the the patient falls from a few stories and they have no obvious penetrating injury, but they had a a blunt injury. So you have this point in the abdomen which are fixed in it um in the abdomen and the other organs are can move. So that means the areas where the the these organs are fixed, they are very prone for injuries. So for example, splenic injuries, ileocecal junction, ligament of troides um or from the hepatic veins. So if you do um laparoscopy, for example, or laparotomy, just always inspect these uh point of injuries as well. But if a patient has signs for peritonism, signs of active bleeding in the abdomen or if you decide to just observe the patient, but then the patient becomes unstable, then you have to do a laparotomy also for blunt injuries. Uh abdominal a hyper, I can see just a question about abdominal hypertension. Ok. So yes, I will talk about uh intraabdominal um pressure uh or compartment. So how do we know if the packing is enough? So basically, it's um if the bleeding stops, if the patient, if you don't, if you stopped the bleeding. So if it's still bleeding, the packing is not enough and sometimes I will not go into much detail because that's is quite um advanced as well. But if, for example, if you can't control the bleeding with packing, then sometimes you have to clamp uh the oum. So there is a supra clamping. Um So there are sometimes situation that packing is not enough. Um But I will now continue to talk about blunt injuries. So we said blunt injuries, you can see this tree or algorithm um if the patient is hemodynamically stable. Um And you think you, you have, you, you quite convinced the patient has no active injury. Um then um and so there is, then you examine the patient and there is no abdominal tenderness, there is no major trauma, there is no wall contusion, any bruising. Um Then you can also sometimes admit the patient, um, uh observe the patient for 12 to 4, 24 hours and with uh repeated exams, if you have a fast scan or a CT scan that's helpful. And if there are any, is there free fluids, um, then you can, uh, and you see some solid organ injury, meaning you see there is um, um a spleen splenic injury, uh uh liver injury, uh and a little bit of free fluids. Then you can also consider non operative management if the patient is stable. The problem is if you have free fluid but no signs for organ injury, then you have to be a bit more suspicious about the free fluids because the free fluid is coming from somewhere else. Um, because it could be an injury to the bowel or the bladder or a mesenteric injury. So sometimes if you have free fluids but no injury to spleen or liver. Then I would um do uh an a diagnostic laparoscopy or a laparotomy. Um If you go back to, if the patient is hemodynamically stable and he's not hemodynamically stable, then if you can a fast scan and ultrasound to see if there is any free fluid, if there is no free fluid, uh or you don't really sure, you're not really sure that is actually any problem from the abdomen. Then you can also see if there maybe there are other reasons why the patient is maybe unstable. So you just for blunt trauma, they can have also a chest injury or uh another reason why the patient is hemodynamically unstable. If there is free fluid and the patient becomes unwell. I think in doubt it's better to have a look inside also for blunt injuries, especially if you don't have a CT scan. Um What about penetrating injuries, penetrating injuries are slightly different? Um I think the indication to explore uh should be much higher um because you can easily miss injuries even if the patient is stable. But basically, if the patient is unstable, if you there's obvious evisceration. So meaning bowel is protruding through an injury, the patient is has uh is perit or you see any blood from the rectum, then the patient obviously needs a laparotomy. If the patient um is completely stable, then I think if you have time, it's good to do maybe a fast scan. Uh some imaging, you could do an X ray to see if there is any free air. Um That's also an option if you see any uh pneumoperitoneum free fluids. Then I think again, you should do an a laparotomy. If it's completely normal and the patient is stable, you could, then if you have, you should uh then you can do a CT scan. Um If possible. Um I think you should have a CT scan. If you don't have a CT scan, you could also, I would always have a look um because it's, if you miss something that can be a, has a worse outcome for the patient. Uh And if there is suspicious on the CT scan for injuries and the patient is unwell, then of course, the patient needs a laparotomy, but I would be even a bit more aggressive than here. Um But if the patient is stable and has a uh has a normal F scan, but you are ha you, you see there is penetrating injury in the abdomen, I would do a diagnostic laparoscopy if it's that something you have uh is available to you. Um So basically this is more like about uh treating algorithms. So the patient comes into your uh hospital had a trauma, you assess the patient, you do some diagnostic, if that's available to you. If you don't have any diagnostics, you have to take your clinical judgment and the observations and then make a decision. If the patient needs a laparotomy, a laparoscopy or if you maybe just wait and watch and if you wait and if you opt out for wait and watch, just be aware, you should constantly examine the patient and observe them because they can, that condition of the patient can quickly change. If the patient is unstable and lost a lot of blood. Consider damage control surgery, meaning quick laparotomy packing of the abdomen, address only the the major injuries control the sepsis, stop the bleeding and then take the patient to ii intensive care if you have um uh a splenic injury. So I will talk about a few specific injuries and I how I think we should uh address them very often in trauma, uh especially in blunt trauma. The majority of patients have uh injuries to the spleen to the liver or the bowel, sometimes mesenteric vessels as well. These are the m the main the the majority of injuries in the abdomen. And of course, if interventional uh treatment is is possible in your hospital, then the majority of patients who have a splenic injury can go under uh can have an embolization, but only if the patient is stable. If the patient is unstable and it's not immediately available for you to have embolization, then you have to take the patient to see to do a laparotomy and perform a splenectomy splenectomy. It's just safer than to risk the patient from bleeding out just always keep in mind after the splenectomy, the patient needs uh vaccinations. Usually we say within the 1st 14 days and splenectomy is something uh which usually if you have a trauma patient, the splenectomy is not very difficult because the bleeding already mobilized the spleen. But what you do is you basically make the spleen a medial structure. So you have to cut uh the spleen or renal uh ligaments and uh just be aware of the short gastric vessels. Um And then basically, you can, if you have a stable cross staple the hilum, but staple it or a tide of close to the hilum, close to the spleen because of the pancreas, the pancreatic tail is very close to the spleen. But I think it's more or less if you have, if the patient is stable and doesn't and has a blunt injury and it's self limiting, you may sometimes don't have to do anything about splenic injury. If there is uh if it's an advanced injury and the patient is stable, you can embolize. But if the patient is unstable, I would perform a splenectomy. Um liver basically, as as I already mentioned, talking about um damage control surgery. Um I think the first thing you can do is basically pack. Um but also sometimes if it's a massive injury, you can also just manual compress the liver, it just stops the, the the main bleeding and then you pack from above and below and usually packing, you can treat the majority of liver injuries and sometimes you have to just leave the pla packs in place and bring the patient back after 48 hours. And then sometimes the the bleeding stops at the mature. You. Interestingly, most injuries stops. If there is still uncontrolled bleeding from the liver, you can also perform a pringle maneuver. So you just cross clamp basically the the vessels and then you can address the bleeding from the liver and you can suture the liver or you can pack at the liver with uh some omentum packing. I for this talk, I can't go into detail exactly how to deal with these injuries. Um But usually I think the main message is if you pack the liver, um and then the maturity of bleeding can be stopped. So that gives you time to restore the patient's physiology. Also get help from maybe another surgeon or even transfer the patient to another hospital where they can deal with also complex liver injuries. This is just to save the patient's life. Um Bile leaks, pancreatic injuries, they can be quite complex and not always easy to treat. And I think for a general surgeon having a bi or a pancreatic injury, I think the main message is, in my opinion, just drain the bile. That's the most important thing you have to drain the bile. So you put one or two drains or three drains in the abdomen and drain the bile and then you have time, you can transfer the patient to a um a unit where they can deal with uh bile leaks or complex pancreatic injuries. You could, if, if the, the tail of the pancreas is affected, including the bile duct or the pancreatic duct, you could, could perform a distal pancreatectomy if that something is in your skill set. But if you have a complex injuries or to the head of the pancreas, I know some units they can do a trauma Whipples. But that's not something I would recommend if you're not familiar with, uh, with this kind of surgery or, um, with the anatomy. Uh, but as long as you put drains in and, and drain that gives you time, um, bowel injuries, um, there are, I think quite, uh, straightforward if you're in a damage control situation where the patient is really unstable and you just need to control the sepsis because of bowel of contamination of the bowel. Then you can just tie off or staple off bowel and leave the stapled end or ligated end in the abdomen and then you come back 24 hours after and then make a decision if you can join the bowel or if you bring out the stoma. I know there are some surgeons who, um, think you should at least perform a stoma immediately, uh, even as almost part of damage control because of the closed loop obstruction. Um, I think it's debatable. Um, but I, in my experience, I never had problems, um, with, uh, close to bowel obstruction. If you take the patient back after 24 hours, you shouldn't wait too long. But if you, uh, uh, just staple off the small bowel and then come back after 24 hours, you have time then to perform a stoma or to join, if possible small injuries you can also repair so you can rate. Um But sometimes if it's more extended, it's safer to just resect that part of the injured bowel and, and then join later on. Let me see if there are other questions, I will answer this maybe later. Um So these are the m the main how you can address or treat injuries of the spleen, the liver, bowel, pancreas bile. Um But after you've treated the patient, you've performed your trauma laparotomy. And then sometimes there is this question, should you close the abdomen or not? Um Because um you, there are some risk factors for uh increased intraabdominal pressure such as if you perform a damage control surgery, they have a high risk for abdominal compartment uh syndrome because of extreme extreme swelling, um aggressive resuscitation. And that means it's just not possible to close the abdomen and also without the risk of uh compartment syndrome. And if you need, if you plan uh if injuries that just requires packing, then you also shouldn't close the abdomen because you have to bring the patient back uh sometimes to remove the packs later on or if you just need a reoperation anyway, because you stapled of bowel, for example, um then you also shouldn't close. And if we talk about um temporary closure, there are a few principles. I think we um what is mo most important is we have to protect the bowel and we want to prevent a compartment syndrome. So uh uh we want to avoid high pressure in the abdomen. But also equally, we wanna uh uh we wanna avoid loss uh of heat and temperature and it has to give the patient certain stability. Um We and really important is to drain uh fluid, especially toxic fluid. We wanna drain uh fluid in the abdomen. Um If possible, we try to prevent retraction of the fascia because that will uh leaves us with a big problem after uh in order to close the abdomen on a on a later stage. But it should be also kind of easy to apply and quickly uh applied. And of course, in some places more important than other places, it should be available and affordable. So I will talk about just a few uh techniques of how we can temporarily close, close uh sorry, uh the abdomen if you have an A zero. um that would be great. I mean, I think Ater is a good choice uh for a temporary closure, it's a negative pressure. It uh sucks out the fluid of the abdomen um and gives you a good control. Um but it's not always available bacteria. Um So uh maybe some of you know, that a pocket bag, it's basically a temporary closure, but without the negative pressure, but you can, it's, it's highly available. It's low cost. You basically just use a sterile IV bag or urine bag and you suture the edge of the back uh to the skin in a running suture. Um But the problem with the Bogota bag is it, it doesn't prevent the fascy tract and it doesn't um, drain the fluid. So I would then if possible also put a drain, uh an abdominal drain in order to drain the fluid. Um Then maybe some of you heard about B Baker Cillins therapy. Um It's basically consists of a non adherent sheet which is placed over the bowel and the peritoneum and then you cover the sheet, uh uh with um moist surgical towels or gauze. And you put two large drains, uh placed on top of the bowels and put a transparent adhesive drape on top of it to maintain a closed seal. And then you attach the drains uh to, for example, the wall suction. Um Yeah, I will be a bit careful with high pressure, uh just between 2050 mg. Uh mercury uh is usually enough. Um And then you change the dressing after 24 to 48 hours and every time, um, when you change the dressing, you can start to close the fascia uh a little bit uh from the top and the bottom and there is skin closure. Uh I think skin closure is, in my opinion, rarely helpful because you basically ha you face still the problem with intraabdominal high pressure. So you kind of like um you can clips or suture the skin, but then you don't really protect the bowel. So sometimes the bowel can ex protrude between the clips or suture, which is quite dangerous in order to um create the fistula. And also you could end up with a intraabdominal uh compartment syndrome. And so that's why I think it's not really helpful. I think for all the, all regardless if you use Aptera or any negative pressure, uh open abdomen treatment, just make sure that the foam is not com comes in direct contact with the bowel. Um because it, that's a risk for fistulation of the uh the bowel. Um So just to summarize the strategies for a la um for a laparotomy closure. So let's say you have a patient and you, you, you uh treat them initially with an open abdomen, then I would always bring them back after 24 or 48 hours and then start to close uh the fascia sometimes if you initially um did not close. Um The, the fascia, you can also uh um put some sutures, some interrupted sutures um to the fascia that helps you later on to close the fascia. But I think if you start to close from the bottom or the top with interrupted figures of face a, just using Bry and just close the fascia slowly and every time you, you can wash out, you can do a bit of alys and, um, and, and just taking the fascia that helps you, um, with a good outcome at the end. Um, if you start to trickle, enter, uh feet, um as soon as the pressure, like the vasopressors um are in uh are off. Um and that helps you as well. Uh ironically with closing the abdomen and then you do that. Sometimes you need um several like rooks and just try to slowly, slowly close the abdomen, try to close the a abdomen by day seven or eight. So after a week, you should have a closed abdomen um because it basically freezes uh everything in place and you, and it requires a hernia on a later stage, a hernia repair on a later stage. So, um even if you sometimes just be a bit aggressive as soon as the bleeding and sepsis is controlled and stopped, um you can actually uh resolve the abdominal pressure also with a bit more aggressive diuresis. So you can use furosemide or uh sometimes even concentrated albumin uh in order to get rid of the fluid and the edema and you risk sometimes a bit of a kidney injury, but that usually resolves um uh on its own, but an open abdomen after seven days and you not manage to close, it can become a huge problem. There are other, I will not go into much detail, but there are strategies how to close an abdomen on a later stage. If you still have, for example, exposed bowel, there are options like you can put a skin graft on it and then close the skin and then do a a hernia repair on a later stage, usually months um several months after. But this can be quite complex and difficult to treat. So that's why I will not go too much into detail with this. So in summary, um I hope that help like as a it is a it was a brief overview like um because it's so complex, abdominal trauma can be from very simple to be very complex. So that's why I can't go into details for each different um injury. Um But I think it should just give you some idea that if you have act scan, use it for every stable patient. Consider damage control surgery for patients who lost a lot of blood or are really really unwell, really unstable. Consider damage control with just packing. Um I think splenectomy, you can be performed as part of damage control, but everything else is really damage controlled sepsis packing and bring the patient back on another day and then continuous reassessment of the patient is important. So once you decide not to operate on a on a patient. Just make sure you constantly reassess the patient to not miss anything. At least for 24 hours. Usually, I would say 48 hours. Um both considered non operative management in blunt injuries because not every patient who has uh had a blunt injury to the abdomen needs an operation. In doubt, I would always recommend to look inside if possible and the patient is stable. You could also do a diagnostic laparoscopy. Um if not a laparotomy and try to close the abdomen within one week. Thank you so much for your attention. Perfect. That was brilliant. So any questions, I think there are some, I don't know which ones you got around to doing though, you can see them in the um on the right hand side here. Perfect. Yes, I can. II think I addressed a few questions already. Um So the the question about blunt trauma in pediatric population, do we need to do a CT scan or reflux by fast watch and wait? Yes. So I think in pediatric, I mean in in if you can uh reliable as assist the patient in a pediatric patient and you quite sure about um no free fluid on the vas scan, the patient is completely stable for blunt trauma. I think in a in a pediatric and in an adult population, you can wait and watch and wait. I think at your at some point if you have a CT scan, then I would rather do a CT scan even in pediatric patients, especially if they have major trauma. I think it's a big judgment really. And when I think it's just the, the risk of having or missing an injury trumps a bit the radiation, uh the risk of radiation e even in a pediatric patient. Yeah, thank you. Does anyone else have any further questions? I know it takes a little while to type them up. So, um and we have the sure so short source. Um I'm not sure what that means. Do you mean? Um Sorry. Uh Mahmoud, do you mean a recording of this? This will be on catch up. What do you mean by short source? The PDF. Uh So your presentation sure. Are you happy for that? Uh or other images that you'd rather not have shared? Rebecca? I maybe could um or we can set it for attendees only so only those that attended could actually see your slides if that um help. Yes. And, and uh I could do a PDF version. I can, I can send a PDF. I'm assuming, can't I? Oh, maybe or if I want to get rid of some pictures maybe first, then I could send it to you and then I send it just to Yeah, I I'm happy. That's fine. Perfect. So, yes, Mahmod will get something sorted. All right. Does anyone have any other questions? I think it's quite handy sometimes to have the slides because then they can, even if they watch the video again, they can actually, they've got the slides, they've got something in writing and then they can add their notes to it. Another question. It, it is if, uh, retro peritoneal bleeding. Yes. So, I actually, that's a very good question. I was, uh, considering, uh, bringing that into my presentation as well, but they can be quite complex the question about retroperitoneal. But um as you may know, the, you can um there are different zones in the abdomen like so 12 and three um retroperitoneal zones. And I think if it's a penetrating injury, you should usually, we recommend to explore um in blunt injuries only if you have an expanding hematoma. If a hematoma is not expanding, I don't necessarily need to explore. It's a bit the question about penetrating injury. Usually we teach that penetrating injury always should be explored. Um But sometimes I agree if the patient is completely stable and nothing is expanding, you can also just watch and wait. They're usually quite self-limiting, especially if it's a, it's a blunt trauma. So the blunt trauma, uh you can basically wait if it's in the pelvis, um it's a bit different um because it's a bit also a risk for ischemia for the legs. So if you, because in the pelvis, it's, if you have a bleeding retroperitoneal bleeding in the pelvis, it's usually not self limiting and it, it, it compromises the blood supply to the legs as well. So then you have to consider um exploring or pack extraperitoneal packing. Wonderful. Did that answer the question? And do we have any other questions? We've got a few more minutes if you have any? Brilliant. Uh Thank you for the answer. Brilliant. Are there any other questions? Please do pop them in the chat. Um If not, then we will say goodbye and giving you a couple more seconds to quickly take. Mhm. Ok. No, I don't think so. I think that is us. I don't see any other questions popping up. So what we'll do, like I said, your feedback form will be in your inbox within the next minute and a half. So please fill it out. I will pass on the feedback to Rebecca as well. Um So please fill it out. Be completely honest. Um There's questions about her talking there in that, please be completely honest about that. Our feedback is is done in such a way that it helps the speaker. It's something that they can that adds to their CV and that kind of thing. So we really want to, you know, as a way of thanking them for spending their time doing this talk, we really want you to fill out the feedback so that we can pass that on. I so that they can either if there's something that they can improve on or something like that, you know, all our speakers are very much wanting to improve and pass on their knowledge. So please fill out your feedback and I will pass all that on to Rebecca. Alright. So without that, that's it, our catch up will be I'll try and get it done uh tomorrow. Um cos then I'm off for Christmas, so I'll try and get it done before tomorrow and uh you can then rewatch. Ok, everyone. So we'll say goodbye to everyone now. Thank you ever so much for joining us. Take care everyone.