Category Archives: Abdomen

How To: Manage Rectus Sheath Hematomas

Although not strictly traumatic, rectus sheath hematomas frequently come to the attention of trauma professionals. In some cases, they may be due to vigorous physical activity or blunt impact. They may also occur spontaneously, especially in patients who are anticoagulated.

This is not a very common condition, accounting for only 1-2% of patients who present with acute abdominal pain.  The common etiology of rectus hematomas is either a tear of the major blood supply (superior and inferior epigastric arteries) or a tear of the muscle itself with bleeding from smaller vessels. The loose attachment of the inferior epigastric  and the fixed perforating  muscular branches make injury in the lower half of the muscle more common.

These hematomas are frequently self-limiting problems. The rectus sheath provides containment for the hematoma, and as pressure rises, bleeding slows and stops. However, if the hematoma is able to escape posteriorly, it can result in life-threatening bleeding.

Presentation generally consists of abrupt onset of focal abdominal pain, and an abdominal wall mass. The pain can be rather intense, making it difficult to determine if it is intraperitoneal or in the body wall. Tip: ask the patient to tense their abdominal wall muscles, then palpate the area. If the tenderness increases, then it is more likely due to an abdominal wall source. Tensing the muscles will shield sources inside the peritoneal cavity, decreasing tenderness to palpation.

Diagnosis may be made by physical exam, but not always. The hematoma may be seen using ultrasound, but the gold standard is the contrast-enhanced CT. Contrast is essential to determine if active extravasation is occurring.

Ultrasound

CT scan with contrast showing extravasation

Patients who are hemodynamically stable and do not have active extravasation may be treated conservatively. However, a significant number of patients will require at least one unit of blood. Be prepared and send a type and crossmatch. Conservative management includes ice packs for pain relief, direct pressure (sand bags), and reversal of anticoagulation if possible. Stable patients with extravasation on CT should be evaluated by angiography and embolized if a bleeding vessel can be identified.

Unstable patients must be resuscitated promptly with fluid and blood so they can be taken to the angiography suite. Operative exploration is extremely unsatisfying and should be avoided, since it is difficult to find the bleeding vessels in the midst of a huge hematoma. 

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Stab To The Abdomen: The WTA Algorithm

I’ve spent the last week discussing the hypothetical case of a young patient with a stab to the abdomen. I worked through some of the thought processes regarding physical exam, imaging, and choices for management. Fortuitously, it would seem, The Journal of Trauma published an algorithm on this very topic from the Western Trauma Association (WTA).

The WTA Algorithm Committee reviewed existing data to start the process of developing this algorithm. As could be expected, very little high quality data was available. So the final algorithm is a synthesis of existing lesser quality studies, expert opinion from the committee members, and commentary from the membership.

Here are some of the highlights:

  • Unstable patients go straight to the operating room (A)
  • Patients who cannot be examined (unconscious, head injured, intoxicated) should be evaluated for peritoneal penetration with local wound exploration, ultrasound, CT, or laparoscopy. If positive or equivocal, proceed to exploration. (B)
  • Patients who can be examined should be managed by location of the stab. Flank injuries are lower risk and should be scanned. Anterior stabs can be evaluated using observation, local would exploration, or CT scan,
  • Positive results generally proceed to laparotomy. The algorithm states that laparaoscopy “may be performed in select stable patients by a highly skilled surgeon experienced in minimally invasive surgical techniques.”

As with any algorithm or practice guideline, nothing is etched in stone. These tools are good for about 90% of the clinical situations you will encounter. If you end up off the beaten path, you will need to use your best judgment to provide best treatment for your patient. Just remember to document your rationale, because you may very well have to justify it to your peers.

Click the diagram below to see a full size version.

Reference: Evaluation and management of abdominal stab wounds:
A Western Trauma Association critical decisions algorithm. J Trauma 85(5):1007-1015, 2018.

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What Would You Do? A Teensy Weensy Stab To The Abdomen – Part 4

We’ve gotten the young man with the teensy weensy stab to the abdomen with a bit of omental evisceration to the operating room. Now what should we do? We’ve already decided that he needs an exploration because of the known penetration. How should we go about it?

There are two choices: diagnostic laparoscopy vs laparotomy. Which is better? Let’s talk about laparoscopy first. This tool has been around now for over 25 years. There has been variable acceptance for use in trauma during that time because it tends to take more time and may have a higher rate of missed injury. Both factors have major implications in patients who have active bleeding and small injuries, respectively.

On the plus side, a truly negative (nontherapeutic) exploration tends to be more benign, with rapid recovery, faster time to discharge, and potentially fewer complications when evaluated with a scope. But on the minus side, small injuries can be notoriously difficult to find. What does that small wisp of blood mean? This is not nearly as clear as the meaning of other colors (green, brown). The decision to open can be difficult, particularly for surgeons who perform a high number of laparoscopies in the non-trauma portion of their practice.

Trauma laparotomy is traditionally a large operation with a generous incision and meticulous exploration. This can lead to significant postop pain and morbidity, particularly when no significant pathology is found. Unfortunately, the literature appears to be quite polarized. The surgeon is either pro-laparoscopy, or pro-big incision, and tends to brace their preferred procedure almost exclusively.

But there is a middle ground, and that is what I would choose in a case like this. The surgeon must consider the likelihood of reliably finding the size of internal injury based on his or her assessment of the external wound, as well as the probability that the exploration would be non-therapeutic. So in this case, I would worry that a bowel injury could be only a few millimeters in size and might be missed using only the laparoscope. But I also think that there is a good chance there may not be an injury at all, so I would not be inclined to start with a huge incision.

My choice is to perform a “mini-laparotomy”, making an incision just large enough to explore all of the bowel and visualize the retroperitoneum. I can generally do this through an incision large enough to get my palm into the abdomen, about 6cm. I am confident that I can easily find all injuries, and make the incision larger if warranted. Postoperative pain is better, and discharge if no injuries were found can happen in 1-2 days.

Unfortunately, I can’t find any papers that examine this middle ground between laparoscopy and full laparotomy. But I’ll keep looking! How would you have managed this case? Comment or tweet, please!

In my next post, I’ll review the official algorithm for evaluating stabs to the abdomen recently published by the western Trauma Trauma Association.

References: 

  1. The role of laparoscopy in management of stable patients with
    penetrating abdominal trauma and organ evisceration. J Trauma 81(2):307-311, 2016.
  2. Diagnostic Laparoscopy for Trauma: How Not to Miss Injuries. J Laparoscopic Adv Surg Tech 28(5):506-513, 2018.
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What Would You Do? Teensy Weensy Stab To The Abdomen – Part 3

In my last post, I described the plight of a young man who had sustained a stab to the abdomen. It appeared that a very tiny bit of omentum was hanging out of the wound. What to do?

I listed three options:

  • Local wound exploration
  • CT scan of the abdomen
  • Proceed to the operating room

So let’s work through these. First, local wound exploration (LWE).

LWE is a diagnostic procedure to determine if a sharp wound has actually or potentially penetrated a vital area. It is usually performed in the neck to determine if the platysma has been violated, or in the abdomen top check for peritoneal violation. In this case, you would use it if you just couldn’t believe that the bit of odd fat was actually omentum, or if you were unsure what you were looking at. You could also grab it (gently) and give it a little tug. If more comes out, you’ve made your diagnosis. Fortunately, this is rarely necessary because omentum has a very distinctive appearance. You know it when you see it.

What about probing the wound? One of my mentors, John Weigelt, used to ask, “Michael, does your finger / q-tip / instrument have an eyeball on the end of it?” His point was that probing is like so many other medical tests: diagnostic if positive, but unsettling if it’s not. What happens if the wound does penetrate, but you can’t find the path that the knife/bullet took? You can only call that indeterminate. I suppose you could take an approach that includes probing first, then proceeding to full LWE if that is negative.

I’ll describe the proper technique for local wound exploration in a later post.

And what about CT scan? This is another unsatisfying test, because it is very likely to be negative with small wounds. The fascial defect in this case will be very small, and can easily be missed on the scan. Not recommended.

Given all this discussion, my vote is to proceed to the operating room. I know this is omentum, and I know that there is a good likelihood that there will be an injury that needs repair. So let’s go get it done.  But what procedure should I do, and how should I do it? That’s the subject for my next post.

As always, please leave comments below or tweet them out!

 

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What Would You Do? Teensy Weensy Stab To The Abdomen – Part 2

Yesterday, I presented the case of a young man with a teensy weensy little stab to his abdomen, just above the umbilicus. There was a tiny bit of oddly colored fat that was visible in the wound. So now what should we do?

The first thing is to figure out what that bit of fat is. It doesn’t have the normal large pebbling and color of subcutaneous fat. Therefore, it must be a small piece of omentum protruding from the wound.

And what is the significance of that? This question has been addressed by papers with low numbers of subjects since the 1980s. It really depends on what country you are located in. Do you have readily available OR resources? Are there pressures to minimize hospital stays (US)?

One of the earliest papers originated from Parkland Hospital in Dallas TX. They reviewed 115 cases of omental evisceration over a 4 year period, and found that “serious” abdominal injuries were found in 75% of them. All went to laparotomy, and injuries to not one, but two organs were noted in about half of the positive cases. There was a 7% complication rate with negative laparotomy,

Contrast this with a study from Kingston, Jamaica where 66 patients with abdominal stabs and omental evisceration were treated. Of these, 14 were treated with observation because they had a normal abdominal exam. All were treated successfully without operation. But note the ratio here: 14/66 = 21%, which is the same as the negative laparotomy in the Parkland study (25%). So this study implies that if the patient can be watched and does not develop symptoms, the negative lap may be avoided.

Unfortunately, in many countries there are pressures to get people out of the hospital as soon as possible. Since small bowel content is relatively benign (at first), patients may not become symptomatic for several days. It would probably be difficult to convince your hospital to keep patients laying around for serial exams for days on end. Not to mention the logistical problems of doing good serial exams.

So most trauma professionals will be compelled to do something. And what should we do? Here are some possibilities. Pick your poison, and I’ll give you my choice tomorrow.

  • Local wound exploration
  • CT scan of the abdomen
  • Proceed to the operating room

As before, leave a comment to let me know what you would do. Or tweet it out!

References:

  1. Significance of omental evisceration in abdominal stab wounds. Am J Surg 152(6):670-673, 1986.
  2. Non-operative management of stab wounds to the abdomen with omental evisceration. J Royal Col Surg Edin 41(4):239-240, 1996.
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