Laparotomy for Abdominal Injury in Traffic Accidents

Transcription

1 Qasim O. Al-Qasabi, FRCS; Mohammed K. Alam, MS, FRCS (Ed); Arun K. Tyagi, FRCS; Abdulla Al-Kraida, FRCS; Mohammed I. Al-Sebayel, FRCS From the Departments of Surgery, Riyadh Central Hospital (Drs. Al-Qasabi, Alam, Tyagi, and Al-Kraida), College of Medicine, King Saud University (Dr. Al-Qasabi, Alam, Al-Kraida, and Al-Sebayel), and King Khalid University Hospital (Dr. Tyagi), Riyadh. Address reprint requests and correspondence to Dr. Al-Qasabi: Department of Surgery (37), College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia. Accepted for publication 25 April This retrospective study presents an analysis of 178 road traffic accident victims on whom laparotomy was indicated. They accounted for 3.8% of total road traffic accident patients admitted to Riyadh Central Hospital during a 2-year period. One hundred seventy-two underwent surgery; the remaining six died in the admissions area before surgery. Male patients outnumbered female patients by a ratio of 8:1. Saudis comprised 56% of the victims. Diagnostic peritoneal lavage yielded an accuracy of 98% with no complications. Spleen (70 patients) and liver (69 patients) were the two most common injured organs. Overall mortality among the operated cases was 20.9%. Mortality appeared to be directly related to the extent of injury to other systems involved. QO Al-Qasabi, MK Alam, AK Tyagi, A Al-Kraida, MI Al-Sebayel, Laparotomy for Abdominal Injury in Traffic Accidents. 1989; 9(1): Accidental trauma is one of the leading causes of death worldwide for all the age groups, but among the younger age group this is the number one killer. Road traffic accidents, a major cause of trauma, accounted for 50% of all accidental deaths in the United States in In Saudi Arabia, the number of automobiles has increased tremendously, accompanied by an increase in the number of traffic accidents. 2 However, only a few reports have been published on the pattern of injury among road traffic accident victims. 3 The purpose of this retrospective study is to review the records of road traffic accident victims who underwent laparotomy, with special reference to diagnostic procedures used, operative findings, and factors that affected mortality. Patients and Methods The records of 178 patients who needed laparotomy were culled from those of 4701 road traffic accident victims admitted to Riyadh Central Hospital from September 1985 to August 1987 ( H). The patients were first evaluated in the accident and emergency department by the surgical resident and specialist on duty. After initial resuscitation and evaluation by clinical examination and/or diagnostic peritoneal lavage, those suspected of blunt abdominal injury were admitted. Patients with multisystem injury were admitted to a special multiple trauma unit where concerned specialties participated in patient management. Laparotomy was indicated in 178 patients based on positive diagnostic peritoneal lavage or frank symptoms and signs of intra-abdominal injury. Six patients died in the admissions area before surgery; hence, 172 patients underwent laparotomy. Patients with only kidney or urinary bladder injury were admitted under the urology service and were not included in this study.

2 Patient Profile Results One hundred seventy-eight of 4701 (3.8%) patients required laparotomy, of whom six died before surgery; 158 patients (89%) were male, 56% being Saudis. The ages ranged from 8 months to 77 years, the mean age being 26.7 years. Approximately one in four patients was a child under 15 years of age (Table 1). The mechanisms of injury are shown in Table 2. Table 1. Age distribution among 178 cases of blunt abdominal trauma needing laparotomy. Age group (y) No. of patients (%) (27) (20) (22) (12) ( 7) (12) Table 2. Mechanism of injury among road traffic accident victims with blunt abdominal trauma in comparison to Cox's series. Mechanism of injury Present study No. (%) Cox's series 1 % only Pedestrian 31 (17.4) 9 Driver 59 (33.2) 26 Passenger 88 (49.4) 43 Motorcycle 0 12 Other 0 0 Total 178 (100) 100 Diagnostic Peritoneal Lavage Diagnostic peritoneal lavage was performed on 165 patients. Percutaneous technique through the infraumbilical region was used in 157 patients; information about technique was not available for the remaining eight cases. Indications for diagnostic peritoneal lavage were (1) equivocal abdominal signs, (2) multisystem injury, and (3) unconsciousness. Patients with minor intra-abdominal injury that did not require any surgical procedure for hemostasis were considered as false-positives. Large retroperitoneal hematoma communicating to peritoneum without any visceral injury was considered as a true-positive result. Two false-positive and one false-negative results were recorded. The patient who had a false-negative lavage developed features of peritonitis. On laparotomy he was found to have a small-bowel perforation. Overall accuracy of this procedure was 98.2%. No complications due to this procedure were recorded. No microscopic or biochemical tests were carried out on returning lavage fluid. Operative Findings and Surgical Procedure The majority of patients were operated through a midline incision. Distribution of abdominal organ injury and surgical procedures among the operated patients is shown in Table 3. Spleen (70 patients) and liver (69 patients) were the most commonly injured organs. Among the patients with liver injury, 32 patients had liver laceration as the only intra-abdominal injury. Associated Injuries Seventy-eight patients (45%) had only abdominal injury. Head injury of various degrees was the most common (77 patients, 45%) associated injury, followed by limb fractures (60 patients, 35%), spine and pelvic fractures (43 patients, 25%), and chest injuries (34 patients, 20%).

3 Mortality Six patients died in the admission area before surgery. Among the operated patients, six died intraoperatively (Table 4), and 30 died postoperatively. Overall mortality among the operated cases was 21%. Extensive liver injury with associated abdominal injury has been the most difficult traumatic problem to manage. Eighteen patients (26%) from the liver injury group died in this study, but none of them had isolated liver organ injury. The factors that were found to be of significant prognostic value for final outcome are shown in Table 5. Mortality appeared to be directly related to the extent of injury to other systems involved (Figure 1). Table 3. Distribution of abdominal organ injury and surgical procedures among 172 operated patients. Viscera injured No. of patients (%) Surgical procedures (No.) Spleen 70 (40.7) Splenectomy (59) Splenorrhaphy (11) Liver 69 (40.1) Suture (66) Left lobectomy ( 1) Packing ( 2) Retroperitoneal hematoma No exploration (51) 55 (32.0) Exploration ( 4) Mesentery 19 (11.0) Suture (12) Resection of bowel ( 7) Small intestine 13 ( 7.5) Suture ( 3) Resection (10) Large intestine 1 ( 0.6) Serosal suture ( 1) Biliary tract 4 ( 2.3) Cholecystectomy ( 3) Repair common bile duct with drain ( 1) Pancreas 2 ( 1.2) Drainage ( 2) Duodenal ulcer perforation 1 ( 0.6) Simple repair Contusion of stomach 1 ( 0.6) Serosal suture Kidney 3 ( 1.7) Nephrectomy ( 2) Suture ( 1) Urinary bladder and urethral injury 3 ( 1.7) Repair and suprapubic cystostomy ( 3) ( 1) ( 1) Table 4. Details of injury among patients who died intraoperatively. Patient, age (y), sex 1,20,M 2,24,M 3,34,M 4,11,F Site of injury Abdomen Chest Head Limb Pelvis and spine Liver and spleen tear, mesenteric tear, small bowel rupture, retroperitoneal hematoma Liver tear, inferior vena cava tear Inferior vena cava tear, liver tear Liver tear, retroperitoneal hematoma Fractured ribs, hemothorax Fractured lumbar spine Hemothorax Fractured femur, clavicle, forearm bones Fractured ribs, hemopneumothorax Severe with fractured parietal bone Fractured left tibia, fibula Fractured pelvis, lumbar spine

4 Patient, age (y), sex 5,40,M 6,5,M Site of injury Abdomen Chest Head Limb Pelvis and spine Liver tear, mesenteric tear, bile duct, tear of head of pancreas Inferior vena cava tear, retroperitoneal hematoma Severe Fractured pubic rami and acetabulum Fractured ribs Fractured forearm bones Discussion Road traffic accident patients requiring laparotomy accounted for only 3.8% of the total number of road traffic accident victims admitted. This is a low figure as compared to Cox's 1 series in which 12.9% required laparotomy. This difference could be due to several factors. One of the main factors may be that Cox's study was carried out in a major regional trauma center which might be receiving only major trauma cases from smaller centers. The present study includes all types of trauma patients received at this general hospital, resulting in a higher admission rate of relatively minor trauma. The other factors may be a high proportion of victims of motorcycle accidents in Cox's series, which invariably cause more severe injury. There was no case of motocycle accident in this series. Table 5. Distribution of significant factors affecting mortality among operated patients. Factors Total patients Systolic blood pressure Deaths No. (%) < 100 mm Hg (45.4) > 100 mm Hg (12.5) No. of blood transfusions < 5 units (15.3) > 5 units (39.0) Head injury Present (32.0) Absent (11.7) Chest injury Present (31.4) Absent (18.2) Significance Ρ = P = P = P = Figure 1. Mortality rate (%) among road traffic accident victims according to their extent of injury. Males greatly outnumbered females (8:1) in this study. This finding is similar to that of Grant et al 3 reported

5 from this country. All the female victims in this series were passengers. There was a higher percentage of pedestrian victims as compared to Cox's series. 1 The majority of trauma victims had associated injuries; hence, the diagnosis of internal abdominal injury poses a serious problem. The accuracy of clinical diagnosis in such situations has been estimated to vary from 48% to 84%. 4-6 With the introduction of diagnostic peritoneal lavage, diagnostic accuracy has improved to 99%, 7 with a very low complication rate. 7,8 In this study, the diagnostic accuracy was 98%. Contrary to Cox's experience, 1 infraumbilical incision was used in the present series without any complications. Federle et al 9 recommend CT scan for the diagnosis of blunt abdominal injury. They claim an overall accuracy of 100% with this procedure. In this series, CT scan was not used, as the procedure is time-consuming for a patient who urgently needs surgery. Diagnostic peritoneal lavage, when properly done, is more convenient and has a proved high diagnostic accuracy. The high prevalence of spleen and liver injury in the present series agrees with most other reported series. 1,3 Unlike the management of splenic injury, hepatic injury presents a difficult management problem. Hemorrhage remains the major cause of death in patients with extensive hepatic injury. 10 Although 80% to 85% of liver injuries can be managed by simple techniques such as compression, topical application of a hemostatic agent, or direct suture, 11 a much smaller proportion of extensive liver injuries demand a greater expertise to carry out such procedures as hepatic artery ligations, 1 selective hepatic artery ligation, 12 lobectomy, 13 or hepatotomy 11 to control bleeding. When such expertise is not available, abdominal packing may be a life-saving procedure. In the present study, abdominal packing was used on two patients where sutures failed to arrest hemorrhage. Both patients survived. This procedure has been recommended as a life-saving procedure in selected patients by other authors. 11 Overall mortality among the operated cases was 21%. This is better than Cox's series, 1 but Grant et al 3 reported a 14% mortality among blunt abdominal injuries. Lower mortality in his series of blunt abdominal injury patients may be due to inclusion of such injuries as falls and sports and domestic accidents. These accidents produce a less severe injury than do road traffic accidents. We conclude on the basis of this study that diagnostic peritoneal lavage is the most useful diagnostic tool due to its low cost, availability, and proved high diagnostic accuracy. It should be used whenever indicated. Factors such as refractory hypotension, associated head injury, and voluminous blood loss and transfusion indicate a poor prognosis. The high rate of involvement of pedestrians and children in road traffic accidents can be reduced by public education. Acknowledgment We wish to thank Mr. Mohammed Mansha for typing the manuscript and for expert secretarial assistance. References 1. Cox EF. Blunt abdominal trauma: a 5-year analysis of 870 patients requiring celiotomy. Ann Surg 1984;199(4): Mufti ΜΗ, Koushki PA, Ali JA. Road traffic accident mortality in Riyadh, Saudi Arabia. Ann Saudi Med 1986;6(4): Grant C, Al-Salem A, Al-Mulhim AM, et al. The patterns of abdominal injuries from a district hospital in Saudi Arabia. Saudi Med J 1987;8(5): Engrav LH, Benjamin CI, Strate RG, Perry JF Jr. Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1975;15(10): Olsen WR, Redman HC, Hildreth DH. Abdominal paracentesis and peritoneal lavage in blunt abdominal trauma. J Trauma 1971;11: Perry JF Jr, DeMeules JE, Root HD. Diagnostic peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 1970;131: Perry JF Jr, Strate RG. Diagnostic peritoneal lavage in blunt abdominal trauma: indications and results. Surgery 1972;71: Gomez GA, Alvarez R, Plasencia G, et al. Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment. J Trauma 1987;27(1): Federle MP, Crass RA, Jeffrey RB, Trunkey DD. Computed tomography in blunt abdominal trauma. Arch Surg 1982;117(5): Elerding SC, Aragon GE, Moore EE. Fatal hepatic hemorrhage after trauma. Am J Surg 1979;138(6):883-8.

6 11. Feliciano DV, Mattox KL, Jordan GL Jr. Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal. J Trauma 1981:21(4): Flint LM Jr, Polk HC Jr. Selective hepatic artery ligation: limitations and failures. J Trauma 1979;19(5): Donovan AJ, Michaelian MJ, Yellin AE. Anatomical hepatic lobectomy in trauma to the liver. Surgery 1973;73: