Non operative management of abdominal trauma - a 10 years review

Abstract

Introduction: Due to high rate of operative mortality and morbidity non-operative management of blunt liver and spleen trauma was widely accepted in stable pediatric patients, but the general surgeons were skeptical to adopt it for adults. The current study is analysis of so far largest sample (1071) of hemodynamically stable blunt liver, spleen, kidney and pancreatic trauma patients managed non operatively irrespective of severity of a single /multiple solid organ injury or other associated injuries with high rate of success.

Methods: Experience of 1071 blunt abdominal trauma patients treated by NOM at a tertiary care National Trauma Centre in Oman (from Jan 2001 to Dec 2011) was reviewed, analyzed to determine the indications, methods and results of NOM. Hemodynamic stability along with ultra sound, CT scan and repeated clinical examination were the sheet anchors of NOM. The patients were grouped as (1) managed by NOM successfully, (2) failure of NOM and (3) directly subjected to surgery.

Results: During the 10 year period, 5400 polytrauma patients were evaluated for abdominal trauma of which 1285 had abdominal injuries, the largest sample study till date. Based on initial findings 1071 patients were admitted for NOM. Out of 1071 patients initially selected 963 (89.91%) were managed non operatively, the remaining 108 (10.08%) were subjected to laparotomy due to failure of NOM. Laparotomy was performed on 214(19.98%) patients as they were unstable on admission or had evidence of hollow viscous injury.

Conclusion: NOM for blunt abdominal injuries was found to be highly successful in 89.98% of the patients in our study. Management depended on clinical and hemodynamic stability of the patient. A patient under NOM should be admitted to intensive care / high dependency for at least 48-72 hours for close monitoring of vital signs, repeated clinical examinations and follow up investigations as indicated.

Keywords: Advanced Trauma life Support; Non-operative management; Surgery.

Figure 1

The picture shows severely injured liver.

Figure 2

Severe renal injury with a midline shift, successfully managed non operatively, arrow showing injured kidney.

Figure 3

Shows both liver and splenic injuries indicated by arrows.

Figure 4

Shows all the solid organ injuries with bilateral haemothorax and fractures: A girl aged 6 years had injuries in all the solid organs (a) both kidneys,(b) and (c) bilateral haemothorax (d) liver and spleen, (e) body of pancreas, (f) bilateral acetabular fractures were treated non operatively except bilateral intercostal drains were inserted.

Figure 5

Subserous extravasation of dye causing a fuzzy mesentry is suspicious of mesenteric vascular disruption.

Figure 6

Mesentric vascular injury showing bowel wall necrosis and delayed perforation: Mesenteric injury (1) caused bowel ischemia but bowel wall necrosis and perforation occurred late on third day (2). Such patients have an unexplained high pulse rate.