In India 75-80% of Blunt trauma abdomen cases occur due to road traffic accidents. It is followed by pedestrian accidents, abdominal blows, fall from heights and sports injuries [1]. This ever-expanding epidemic targeting the young and productive generations is likely to take a heavy burden on the quality of life and socio- economic growth of the region. The fatality rate due to road traffic accidents in India is highest in the world and it is reported to be 20 times more than that reported in developed countries [2]. As per literature, blunt trauma injuries are more common in males than in females [3]. In a study by Mohammad A Gad et al., significantly more males as compared to females were involved in abdominal trauma (87.1% vs12.9%) [4]. Similarly, the incidence ratio of male to female reported by Lone et al., was 4.4: 1 among abdominal trauma patients [5]. Young males, aged 20 to 30 years are reported to be the most frequent victims [6]. The abdomen is prone to injury as there is minimal bony protection for underlying organs.
In the early sixties, investigation for blunt injury abdomen was mainly needle paracentesis. In 1965, Root et al., introduced diagnostic peritoneal lavage. In 1978, Bivins BA concluded clinical evolution alone would have missed 59 % injuries in blunt trauma patients [7]. In 1979 Roger Sherman detailed the most complete historical perspective of splenic injury [8]. In 1989, Howdieshell concluded that closed DPL is faster, safer and equally accurate as open DPL [9].
The small and large bowel is commonly affected in penetrating trauma. However, they are less frequently affected than solid organs like the spleen and the liver in blunt trauma. Diagnostic modalities evolved in diagnosis of abdominal injuries include diagnostic peritoneal Lavage, focused abdominal sonography for trauma (FAST) and computerized tomographic scan which was introduced in 1981. Now, MRI is also being used. Advanced imaging techniques like spiral CT scan and MRI have made early detection of blunt abdominal injuries. The first step in management of blunt trauma abdomen is resuscitation. The aim of resuscitation is to correct and maintain oxygenation and tissue perfusion. The surgical approach involves control of hemorrhage, limitation of contamination and restoration of continuity. The concept of damage control is based on the realization that patients with hypothermia, acidosis and coagulopathy are in metabolic exhaustion and have a high risk of death. The final objective of surgical intervention remains unaltered, but the emphasis on timing has changed in damage control. Surgical techniques are performed to minimize the metabolic insult rather than merely restoring anatomical continuity. [10]
Liver is the most common solid organ to be involved in the blunt trauma of the abdomen, despite being protected by the rib cage. The anatomical location of the liver, its size and the large surface area of the upper abdomen and trunk are the factors leading to the high proportion of liver injuries seen in abdominal trauma. The liver is snuggled tightly under the diaphragm and thus a compressive force directed at the upper abdomen can result in a crush injury to the liver due to the uncompromising nature of the liver capsule. [11]
Only the liver is injured, in 35-45% of patients of blunt trauma abdomen [12]. Hepatic injuries are associated with high mortalities., but it is very difficult to prognosticate for individual patients. Mortality is often determined by numerous factors including the nature of the hepatic injury itself, grade of hepatic injury, associated injuries incurred, practices and experiences of the treating institution and the physiological characteristics of the patients themselves [13]. Overall mortality from liver injuries is estimated to range from 10-17% [14].The mortality rate for liver injuries managed conservatively ranges from 0 to 0.4% in recent reports [15]. A retrospective study of Blunt trauma liver has shown an overall mortality rate of 9.4%, with 3.7% caused by the liver injury itself. [16]
Rosemary et al., studied 699 patients with complex blunt hepatic injuries in which 65 % were treated non-operatively. Overall 87 patients developed hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary – venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), who required multimodality treatment (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy,24; and laparoscopy, 4).
They concluded that non-operative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury.
Spleen is the most commonly injured organ in blunt trauma in children. Management of blunt splenic injury has undergone significant evolution over the past two decades from operative to conservative management [17].The overall mortality rate from splenic injury has remained 6–7% or higher in many series over the past 20 years, Management has evolved from splenectomy for all traumatic injuries to splenic salvage and nonoperative management in selected patients. The trend toward splenic salvage evolved after the identification of lifelong risk for overwhelming postsplenectomy infection (OPSI) [18, 19]. Nonoperative management has now replaced splenorrhaphy as the most common method of splenic salvage. In addition, as only the most severe splenic injuries are taken to the operating room, splenectomy is performed far more frequently than splenorrhaphy today. Some series suggest that nonoperative management(NOM) success rates can be improved with adjuncts such as transcatheter embolization (TAE). [20, 21]
The historical view of “delayed splenic rupture” likely represented delayed recognition of a splenic injury and bleeding, rather than rupture later in the patients’ course. True delayed rupture of the spleen, with a normal CT scan or diagnostic peritoneal lavage (DPL) on admission, has an incidence of less than 1%. [22, 23, 24]
The majority of blunt splenic injuries are due to motor vehicle collisions and falls [25]. Since the force required to injure the spleen is considerable, associated injuries are common; especially rib fracture, head injury, long bone fractures, spinal column injuries and pelvic fractures. Lower left rib fractures (ribs 10–12) due to direct trauma to the area are associated with splenic laceration in 20–25% of adults. Splenic enlargement can occur with infectious diseases, such as mononucleosis or malaria, and may decrease the amount of kinetic energy required to injure the spleen, resulting in injury to the pathologically enlarged spleen with relatively minor trauma or even spontaneous rupture of the spleen.
USG FAST Evaluation of the left upper quadrant can detect hemoperitoneum associated with possible splenic injury. With multiple views, the FAST exam has been shown to have 80–85% sensitivity for detecting hemoperitoneum. Since this exam can be done in the trauma evaluation area, by the surgeon, it acts as an extension of the physical exam. In patients with normal hemodynamic status without indication for immediate operation for other injuries, CT remains the diagnostic test of choice for blunt abdominal injury. It is both sensitive and specific for solid organ injury.
Pancreatic injury is relatively uncommon, occurring in 0.2–2 % of all trauma patients and 3–12 % of patients with abdominal injury [26].Pancreatic injury occurs predominantly in males (68–90 % male) and in the young (mean age 27–35 years) [27]. Outside of the United States, blunt trauma is the cause of the majority of pancreatic injuries [28]. In blunt injury, the pancreas is most commonly injured by crushing force applied to the upper abdomen resulting in compression of the pancreas against the lumbar vertebral column with crush injury or transection in the region of the pancreatic neck. Blunt force to the right side of the abdomen may cause combined duodenal and pancreatic injuries as these structures are compressed against the vertebral column.
The AAST grading scheme and the scheme devised by Lucas are most commonly used in the literature [29]. In both grading schemes, injury grade is primarily determined by the presence or absence of main pancreatic ductal injury and the anatomic location of the injury within the gland.
Furthermore, delays in diagnosis of pancreatic injury are associated with higher rates of complications [30, 31].The difficulty in diagnosis of blunt pancreatic injury is illustrated by the series reported by Wisner et al., [32] , in which the time from injury to operation was 6–24 h in 23 % and greater than 24 h in 19 % of patients suffering blunt pancreatic injuries. Isolated blunt pancreatic injuries may especially provide a diagnostic challenge. Patton et al., [33] showed that in patients with delayed diagnosis of pancreatic injuries, the mean delay in diagnosis was 3.8 days with an unfavourable outcome in 60 % of these patients. The importance of early diagnosis and management of pancreatic injury are further demonstrated by the series reported by Lin et al., [34].In this report, Grade III injuries treated within 12 h had a complication rate of 58 % compared to 80 % for those operated on more than 24 h after injury. In addition, all five deaths in this group occurred in the group operated on more than 24 h after injury.
Kidney is the third most frequently injured organ in abdominal trauma after the spleen and liver [35]. In the last 30 years, the treatment strategy of renal trauma has changed from operative management (OM) to nonoperative management (NOM) [36].Several studies showed improving outcomes when NOM was applied in blunt trauma and, therefore, conservative management gained an increasing popularity among trauma surgeons. [37]
Immediate surgical management of injuries with life-threatening haemorrhage is widely accepted; however, when this clear-cut indication is lacking, several differences in management strategies emerge from the literature [38]. A successful conservative management for blunt low-grade renal injury (renal contusions and minor lacerations) is well documented with a low complication rate [39]. The conservative management of blunt renal trauma was first proposed in the 1940s. Since then the benefits of this approach have become increasingly apparent with reductions in nephrectomy rate, complications, and hospital stay all being reported. This has resulted in a paradigm shift towards managing increasingly severe blunt renal trauma with a conservative approach. [40]
The widespread availability of CT allows clinicians to be much more informed about the injuries they are treating, while the ability to use ureteric stenting, percutaneous drainage, and embolization within a conservative approach has increased the range of injuries to which conservative management can be applied. [41]
Four‐phase CT of the abdomen and pelvis with non‐contrast, arterial‐, nephrographic‐, and pyelographic‐phase images is generally considered the ‘gold standard’ initial imaging method in renal trauma. [42]
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