Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (64 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Complex pelvic fractures can be some of the most difficult injuries to treat. Initially, they can cause devastating haemorrhage and subsequently may be associated with overwhelming pelvic sepsis and distant multiple organ failure.
For those patients who present with complex pelvic fractures and who are haemodynamically stable, diagnostic studies should be carried out as rapidly as possible, including plain films of the pelvis, CECT and arteriogram. All haemodynamically unstable patients with such pelvic fractures should be taken to the operating theatre as soon as possible, to allow continuing resuscitation including packing.
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The priorities facing the surgeon are to control the pelvic haemorrhage and rule out other intra-abdominal organ injuries with associated haemorrhage. Sometimes it is prudent to perform a rapid laparotomy to rule out additional haemorrhage, but if there is not a strong suspicion of abdominal bleeding, it is best to avoid laparotomy until the pelvic bleeding has been arrested (
Box 13.7
). Extrapelvic packing should be considered.
Box 13.7
Evidence-based guidelines for management of haemorrhage in pelvic fracture: summary of recommendations
Recommendations based on evidence of effectiveness
Patients with evidence of unstable fractures of the pelvis associated with hypotension should be considered for some form of pelvic stabilisation (
Evidence level II
)
Patients with evidence of unstable pelvic fractures who warrant laparotomy should receive external pelvic stabilisation prior to laparotomy incision (
Evidence level II
)
Patients with a major pelvic fracture who have signs of ongoing bleeding after non-pelvic sources of blood loss have been ruled out should be considered for pelvic angiography and possible embolisation (
Evidence level II
)
Patients with major pelvic fractures who are found to have bleeding in the pelvis, which cannot be adequately controlled at laparotomy, should be considered for pelvic angiography and possible embolisation (
Evidence level II
)
Patients with evidence of arterial extravasation of intravenous contrast in the pelvis by computed tomography should be considered for pelvic angiography and possible embolisation (
Evidence level II
)
Patients with hypotension and gross blood in the abdomen or evidence of intestinal perforation warrant emergency laparotomy (
Evidence level II
)
The diagnostic peritoneal tap appears to be the most reliable diagnostic test for this purpose. Urgent laparotomy is warranted for patients who demonstrate signs of continued intra-abdominal bleeding after adequate resuscitation or evidence of intestinal perforation (
Evidence level II
)
Recommendation made where there is no adequate evidence as to the most effective practice
Patients with evidence of unstable fractures of the pelvis not associated with hypotension but who do require a steady and ongoing resuscitation should be considered for some form of external pelvic stabilisation (
Evidence level III
)
Reproduced from DiGiacomo JC, Bonadies JA, Cole FJ et al. Practice Management Guidelines for haemorrhage in pelvic fracture. EAST Practice Management Guidelines Work Group;
http://www.east.org
.
The patient is positioned supine and, if necessary, an external fixator or C-clamp is applied. A 5-cm vertical midline suprapubic incision is made and the fascia anterior to the rectus muscle is exposed. The fascia is divided until the symphysis can be palpated directly (the pre-peritoneal plane has been reached). The fascia is divided in the midline, protecting against urinary bladder damage. From the symphysis the pelvic brim is followed laterally and posterior to the sacroiliac (SI) joint (first bony irregularity felt), first on the side of major bleeding (most often the side of SI joint disruption). The fascia is then dissected away from the pelvic brim as far posteriorly as possible at the level of the pelvic brim. The bladder and rectum are then held to the opposite side while the plane is opened bluntly down to the pelvic floor, avoiding injury to vascular and nerve structures in the area. The space is then packed with vascular or abdominal swabs, starting posteriorly and distal to the tip of the sacrum, and building the packs cranially and anteriorly.
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In an unbroken pelvis with intact pelvic floor, one should be able to accommodate three large abdominal swabs on each side. In severe pelvic fractures, efficient packing might require many more (> 10 packs is not unusual). The number of packs needed is defined by the available space and the appropriate force applied. The outer fascia is closed with a single running suture and the skin is closed. If laparotomy is required, it should follow the packing procedure.
After a damage control laparotomy with extraperitoneal pelvic packing, a temporary abdominal closure is appropriate. As in the abdomen, the packs should be removed after 24–48 hours.
Stabilisation of the pelvis is initially by compression (using a knotted sheet or external fixation). External fixation is used for stabilisation of the anterior pelvis but will fail if the posterior pelvis is unstable. These patients may require plating of the SI joint and are best managed by temporary stabilisation using a pelvic binder, and then assessed by CT and arteriography. Based on location of the injury, colostomy may be required in order to prevent contamination of a perineal wound in the post-injury period. In general, all compound injuries involving the perineum and perianal area should have a diverting colostomy (see also
Chapter 11
).
In patients with associated major perineal injuries, after the initial fixation of the pelvis has been obtained, daily wound examination, debridement and gradual removal of packs should take place. A caveat of pack removal is that the longer they are left in, the greater the risk of pelvic sepsis, and ideally they should be removed within 24–48 hours.
There is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal injury, both blunt and penetrating in nature. Most surgeons who practice SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient, as a contraindication to attempting non-operative management.
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Almost all regard CT as essential, and their preparedness to consider SNOM was related to injury extent, as well as the experience of the surgeon concerned.
In 1990, it was suggested that a number of patients with blunt liver injuries might be candidates for expectant management,
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and in a multicentre study it was found that, in the hands of experienced trauma surgeons, the success with the non-operative approach to liver injuries was greater than 98%.
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Currently, all patients with liver injuries following blunt trauma should be considered candidates for non-operative management, provided that haemodynamic stability can be assured. Unlike the spleen, delayed haemorrhage from the liver is rare. The complications in those patients managed expectantly are frequently related to the biliary system and can usually be managed by endoscopic or interventional techniques. While non-operative management has most frequently been applied to patients with blunt injuries, stable patients with liver injuries as the result of penetrating trauma have also been managed expectantly.
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In children, the success of non-operative management of the spleen is over 90%, but this has not been the experience in adults. Currently, most surgeons will attempt to manage the injured adult spleen with an AAST grade I–III injury non-operatively; the management of grade IV or V injuries remains controversial. Patients over 55 years of age generally do not do as well and splenectomy continues to be recommended (see
Box 13.8
).
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Box 13.8
Practice management guidelines for the non-operative management of blunt injury to the liver and spleen: summary of recommendations
Recommendations based on evidence of effectiveness
There are class II and mostly class III data to suggest that non-operative management of blunt hepatic and/or splenic injury in a haemodynamically stable patient is reasonable (
Evidence level II
)
The severity of hepatic or splenic injury (as suggested by CT grade or degree of haemoperitoneum), neurological status and/or the presence of associated injuries are not contraindications to non-operative management (
Evidence level II
)
Abdominal CT is the most reliable method to identify and assess the severity of injury to the spleen or liver (
Evidence level II
)
Recommendations made where there is no adequate evidence as to the most effective practice
The clinical status of the patient should dictate the frequency of follow-up scans (
Evidence level III
)
Initial CT of the abdomen should be performed with oral and intravenous contrast to facilitate the diagnosis of hollow viscus injuries (
Evidence level III
)
Medical clearance to resume normal activity status should be based on evidence of healing (
Evidence level III
)
Angiographic embolisation is an adjunct in the non-operative management of the haemodynamically stable patient with hepatic and splenic injuries and evidence of ongoing bleeding (
Evidence level III
)
Reproduced from Alonso M, Brathwaite C, Garcia V et al. Practice Management Guidelines Work Group. Blunt liver and spleen injuries: non-operative management;
http://www.east.org/tpg/livspleen
.
In those patients with penetrating injury to the abdomen, who are haemodynamically unstable, have peritonitis or clear signs of abdominal penetration, there is little debate regarding the need for urgent laparotomy. However, in those patients with penetrating injury where the wounds are tangential, it is clear that if these patients are stable, without peritonitis, some patients may not need surgery despite the penetrating nature of the wound.
In a recent study of gunshot wounds managed non-operatively, clinical examination was a key marker, and all failures occurred within 24 hours of admission, setting a minimum required observation period before discharge.
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Laparoscopy may play a role, particularly in the clarification of penetration of the abdominal cavity and of the diaphragm. Current evidence-based guidelines for the management of penetrating trauma are limited, and are perhaps more suited to high-volume centres than those only occasionally dealing with penetrating trauma
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(see
Box 13.9
).
Box 13.9
Selective non-operative management of penetrating injury of the abdomen: summary of recommendations
Strong recommendations
Patients who are haemodynamically unstable or who have diffuse abdominal tenderness should be taken for laparotomy as an emergency (
Evidence level I
)
Patients who are haemodynamically stable with an unreliable clinical examination (i.e. brain injury, spinal cord injury, intoxication or need for sedation or anaesthesia) should have further diagnostic investigations done for intraperitoneal injury or undergo exploratory laparotomy (
Evidence level I
)
Routine laparotomy is not indicated in haemodynamically stable patients and abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centres with surgical expertise (
Evidence level II
)
A routine laparotomy is not indicated in haemodynamically stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs (
Evidence level II
)
Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (
Evidence level II
)
In patients selected for initial non-operative management, abdomino-pelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (
Evidence level II
)
Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations as well as peritoneal penetration (
Evidence level II
)
Recommendations made where there is no adequate evidence as to the most effective practice
Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness (
Evidence level III
)
The vast majority of patients with penetrating abdominal trauma, managed non-operatively, may be discharged after 24 hours observation, in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (
Evidence level III
)
Reproduced from Como JJ, Bokhari F, Chiu WC et al. Practice Management Guidelines Working Group. Penetrating trauma: selective non-operative management. Eastern Association for the Surgery of Trauma. J Trauma 2010; 68(3):721–33. With permission from Lippincott, Williams & Wilkins.