Lésions Abdominales et Mécanismes

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Questions and Answers

Quel mécanisme est principalement responsable des lésions par écrasement sur les organes internes?

Augmentation de la pression intra-abdominale

Cisaillement dû à une décélération rapide

Fragmentation causée par une arme à feu

Force appliquée antéro-postérieure ou latérale (correct)

Quel segment du foie est surtout concerné par le mécanisme de cisaillement?

Segment VI

Segment VIII

Segment II

Segment IV (correct)

Quelles lésions caractéristiques sont à prévoir lors d'une plaie par arme à feu de gros calibre?

Lésions uniques et localisées

Lésions sévères avec éclatement (correct)

Lésions uniquement cutanées

Lésions superficielles sans complications

Quel mécanisme provoque des hémorragies sévères dues à l'arrachement?

Cisaillement en cas de décélération Signup and view all the answers

Quel aspect du phénomène d'éclatement se produit lors d'une augmentation rapide de la pression intra-abdominale?

Effet blast sur les organes Signup and view all the answers

Quel est l'âge moyen des adultes jeunes affectés par les lésions abdominales?

27 ans Signup and view all the answers

Quelle est la première cause des lésions abdominales chez les adultes jeunesses?

Accidents de véhicules à deux roues Signup and view all the answers

Quel pourcentage de traitement opératoire est observé au BF?

90 à 100% Signup and view all the answers

Quels segments du foie sont les plus fréquemment associés aux lésions selon la classification de Moore?

Type I Signup and view all the answers

Quelle est la mortalité associée aux formes les plus graves parmi les lésions abdominales?

80% Signup and view all the answers

Quels nerfs sont responsables de l'innervation du foie?

Nerfs sympathiques et parasympathiques Signup and view all the answers

Comment Claude Couinaud a-t-il segmenté le foie?

En 8 segments Signup and view all the answers

Quelle est la composition du peso heparique du foie?

1500g Signup and view all the answers

Quel secteur du foie gauche est irrigué par la branche latérale G ?

Secteur latéral gauche Signup and view all the answers

Quelle fonction n'est pas liée aux responsabilités du foie ?

Synthèse des vitamines Signup and view all the answers

Les segments V et VIII appartiennent à quel secteur du foie ?

Secteur paramédian droit Signup and view all the answers

Quel est le pourcentage des contusions parmi les circonstances de survenue des traumatismes du foie ?

70 % Signup and view all the answers

Quel segment est compris dans le secteur latéral droit ?

Segment VII Signup and view all the answers

Quel est un mécanisme de survenue des traumatismes du foie par plaies ?

Plaies par arme blanche Signup and view all the answers

Quel segment représente le secteur latéral gauche du foie ?

Segment II Signup and view all the answers

Quelle est la triade fatale du polytraumatisé ?

Hypothermie - acidose - coagulopathie Signup and view all the answers

Qu'est-ce qu'un traumatisme hépatique?

Une lésion avec ou sans rupture de la paroi. Signup and view all the answers

Quel pourcentage des traumatismes abdominaux sont des traumatismes hépatiques?

Entre 11,8% et 14,2%. Signup and view all the answers

Quel type de traumatisme cause davantage de mortalité dans les contusions abdominales?

Traumatismes à haute vélocité. Signup and view all the answers

Quels sont les mécanismes lésionnels des traumatismes hépatiques?

Traumatismes pénétrants et à haute vélocité. Signup and view all the answers

Quel est un des critères du traitement non opératoire des traumatisme hépatiques?

Stabiliser le patient sans opération. Signup and view all the answers

Quelle est l'épidémiologie des traumatismes hépatiques chez les victimes d'accidents de la route?

44,1% pour les accidents de la route. Signup and view all the answers

Quelles sont les modalités du traitement opératoire des traumatismes hépatiques?

Intervention chirurgicale selon les facteurs de gravité. Signup and view all the answers

Quel est le premier problème majeur en chirurgie abdominale lié au foie?

Les traumatismes hépatique. Signup and view all the answers

Quels signes fonctionnels dominent lors d’un traumatisme hépatique de grade II de Moore?

Douleur vive Signup and view all the answers

Quelle complication est redoutée chez la femme enceinte après un traumatisme?

Rupture utérine Signup and view all the answers

Quel examen morphologique est considéré comme le 'gold standard' pour évaluer un traumatisme hépatique?

Tomodensitométrie (TDM) Signup and view all the answers

Quel est le traitement principal pour éviter l’évolution vers des complications lors d’un traumatisme hépatique?

Réanimation Signup and view all the answers

Dans quel cas un hématome intrahépatique est dit disséquant?

En cas de lésion majeure des vaisseaux Signup and view all the answers

Quel facteur physiologique est évalué via le Score de Glasgow dans des situations traumatiques?

État de conscience Signup and view all the answers

Quel est un signe d'hémobilie post-traumatique?

Ictère Signup and view all the answers

Quel est un signe objectif lors de l'inspection physique d’un traumatisme hépatique?

Ecchymoses Signup and view all the answers

Quelle est une complication potentielle d’une laparoscopie lors de traumas hépatiques?

Embolie graisseuse Signup and view all the answers

Quel symptôme est exagéré dans la forme clinique d'un hématome sous-capsulaire?

Fièvre Signup and view all the answers

Une douleur au niveau de l’ombilic est souvent indicative de quel type d’examen?

Palpation abdominale Signup and view all the answers

Quel signe pourrait indiquer une hémorragie active au cours d'un examen TDM?

Extravasation du PDC Signup and view all the answers

Quelle approche est cruciale dans la phase pré-hospitalière des soins en cas de traumatisme?

Mise en condition rapide Signup and view all the answers

Dans quel contexte doit-on suspecter un polytraumatisé?

Choc résistant à la réanimation Signup and view all the answers

Study Notes

Introduction and Objectives

The presentation is on traumatic liver injuries.
The presenters are OUEDRAOGO Judion and TRAORE Lionel, both of whom are in the DES II Chirurgie Générale program.
The supervisor is Pr Adama SANOU.
The objectives are to define hepatic traumas, classify liver traumas, cite criteria for non-operative treatment, describe operative treatment modalities, and cite operative indications for a hepatic trauma.

Plan

Introduction and General Information: Definitions and interests, Epidemiology, Reminders, Circumstances and mechanisms of lesions, Classifications
Clinical Study: Type of description: Hepatic trauma grade II of MOORE, Clinical forms
Explorations Paraclinics: Biological and morphological examinations
Treatment: Pre-hospital and in-hospital phases, Non-operative and Operative treatments
Conclusion

Introduction

Major issue in abdominal surgery
High-velocity or penetrating trauma
Ranges from simple hematoma to severe hemorrhage
Management has evolved in the last 30 years
Can present difficult treatment challenges
Severe prognosis, 1st cause of mortality in abdominal contusion (20-25%)

General Information

Definition: Any hepatic trauma, with or without parietal discontinuity.
Frequency: Hepatic trauma observed in 11.8% to 14.2% of abdominal trauma cases and 3.03% of abdominal emergencies in BF.
Interests: AVP: first cause (44.1%), CBV(26.4%).

General Information - 2.

Diagnostic approaches (DC): History-taking and clinical examination.
Imaging: CT scan is the preferred modality
Evaluation of injury severity through classification
Treatment: Dependent on hemodynamic stability and peritoneal signs.
Prognosis: Remains serious, mortality rate: 23.5% (2011) to 4.3% (2016)

General Information - 3.

Epidemiology: Young adult males (average age of 27 years)
Common cause: AVP (motor vehicle accidents), often 2-wheeled
Common injury types: Moore Type II and Type I
Treatment pattern differences: 80% treated without intervention in Europe, versus 10% in BF.
High mortality rates: 80% in severe cases
Associated hemorrhage and other organ damage is critical.

Anatomical Reminders

Liver: largest gland in the body, weighing 1500g (approximately).
Location: Extending from the right upper quadrant (RUQ) to the left upper quadrant (LUQ), below the diaphragm.
Anatomy details: 3 surfaces, 3 edges and 2 extremities.
Structure: Right extremity is voluminous and rounded, left extremity is flattened and tapered..

Anatomical reminders - 2

Liver fixation: details on the right and left diaphragmatic recesses, the falciform ligament, the coronary ligament, the round ligament, and the ligaments related to the inferior vena cava,
Liver relationships: details on the relationships between the liver and surrounding structures, such as the diaphragm, lungs, heart, pericardium, and the various abdominal organs and tissues.

Anatomical details- 3

Relevant anatomical segments details:
Right lateral segment: divided into segments VI and VII
Right medial segment: composed of segments V and VIII
Left lateral segment: single segment II
Left medial segment: divided into segments III and IV
Overall, eight segments in total

Physiological Reminders

Liver functions: Glycogen storage, protein synthesis (albumin), lipid synthesis and breakdown, detoxification, hormone metabolism, biliary, ureogenic and hematologic functions.

Fatal Triad of Polytrauma

Hypothermia, acidosis, coagulopathy.

Circumstances and Mechanisms

Contusions (70%): Vehicle accidents (AVP 72%), falls from height (12.09%), occupational accidents, sports injuries, others.
Injuries (30%): Gunshot wounds, knife wounds, others types.

Mechanism of Contusions

Crushing: Anterior-posterior or lateral force on the abdominal wall, injuring organs tightly anchored by peritoneal attachments
Shearing: Sudden deceleration causing tearing at liver attachment sites
Rupturing: Rapid and significant increase in intra-abdominal pressure (blast effect)
Piercing: direct penetration from sharp objects, injuries are usually concentrated.

Mechanism of Injuries

Penetrating Injuries (e.g., stab wounds): Usually localized damage; less associated visceral injury.
Gunshot Wounds: Vary depending on caliber; small caliber injuries can mimic stab wounds, high caliber injuries can cause extensive damage and rupture.

Classification of Liver Injuries

Moore classification (detailed breakdown of grades).
Mirvis Classification (breakdown of grades).

Clinical Study

Patient history/interrogatory, General symptoms, specific symptoms, detailed physical examination .

Clinical Examination

• Inspection: Ecchymoses, abrasions, entrance wounds. • Palpation: Abdominal guarding, rigidity, tenderness, umbilicus tenderness, cutaneous hyperesthesia. • Percussion: normal sounds. • Auscultation: normal or auscultatory silence. • Pelvic examinations

Clinical Forms

Subcapsular hematoma: Sharp pain, respiratory distress, fever, jaundice, pallor, enlarged liver dullness, intolerable pain
Intrahepatic hematoma: Primary or secondary (unsatisfactory hemostasis), small or dissecting (severe VX injury extending to parenchyma with signs of substantial liver distress)
Post-traumatic hemobilia: Blood in the bile ducts, often a pathological communication between blood vessels and bile ducts that leads to a triad of Sandbloom (pain, jaundice, hemorrhage).
Biliary and VBP injuries: Commonly found with liver injuries; often along with damage to other organs.
Polytrauma patient cases, pediatric, pregnant patients

Biological and Morphological examinations

Lab tests (blood tests): Complete blood count (including hemoglobin and hematocrit), coagulation tests, liver function tests (enzymes), blood chemistry.
Imaging studies (e.g. ultrasound, CT scan and MRI): Evaluation of the severity and extent of internal injury (liver parenchyma, blood vessel, other abdominal organs), to detect the presence of hemoperitoneum, and for the assessment of the appropriateness of surgical approach, in cases where surgical intervention is necessary.

Treatment - Pre-hospital Phase

Rapid and effective (ABCDE)
Establishing adequate respiration
Volume replacement (if necessary)
Initial stabilization of fractures

Treatment - Pre-hospital

Criteria to consider
Kinetic elements:Vehicle ejection or passenger fatalities, entrapment time length exceeding twenty minutes, falls from heights over six meters, and a high degree motor vehicle accident speed (>80 km/h for cars and >40 km/h for motorbikes).
Physiological elements:The Glasgow Coma Scale score below 13; systolic blood pressure less than 90 mm Hg, oxygen saturation under 90%, heart rate below 10 or above 29; burns over more than 15% body surface area; and neurological deficit or paralysis.

Initial Management and Resuscitation

Assessment of airway, breathing, and circulation in a stepwise manner
Peripheral vasoactive or intravenous fluids replacement
Supplemental oxygen and ongoing assessment of ventilation and perfusion are essential
Monitoring of vital signs in a stepwise manner
Group blood for the patient as well as obtaining blood tests:Complete Blood Count (CBC), liver function tests, and coagulation tests.

Initial Management and Resuscitation-2

For polytrauma: a fully multidisciplinary care approach.

Treatment - In-hospital phases- Medical (non-operative)

Stable hemodynamic profile
Blood supply availability and sufficient blood volume.
Absence of injury to hollow organs and the brain.
Close observation and monitoring capability.
Access to ultrasonography, computed tomography (CT) imaging, and angiography with embolization capabilities.
Availability of immediate laparotomy capabilities if required
Hemoperitoneum volume less than 500 mL.

Treatment - In-hospital phase- Medical (non-operative)-2

In-hospital monitoring, care, and assessments.

Treatment - Specific (nonoperative)

Arterial angiography with embolization: Use of interventional radiology to control bleeding in critical medical conditions

Treatment – In-hospital phase - Medical (non-operative)-3

Complications: Compartment syndrome, abdominal hypertension, organ failures (respiratory, cardiovascular, kidney, or neurological)

Treatment- In-hospital phases: Operative Treatment

Urgent laparotomy: for unstable patients despite initial resuscitation.
Wide surgical field, access to the thorax and abdomen (e.g., via Scarpa's fascia).
Approach to the liver through a midline incision, possibly extending to a sternotomy or transverse incision (RUQ/RUQ).

Treatment -Operative -2.

Damage Control Laparotomy: a shortened surgical procedure focusing on initial stabilization, rather than complete repair. It features a technique known as "packing." Materials such as wound protectors and temporary hemostasis are used to create a form of "packing."
Hemostatic Techniques: temporary hemostasis techniques used before definitive closure; these techniques may include ligation or compression techniques.

Treatment- Operative -3

• Primary Hemostasis: Opening the peritoneum, draining the hemoperitoneum, thoroughly examining the entire abdomen for associated injuries, without directly accessing the liver, and cautiously removing any clotting around the liver, while avoiding the damaged area.

Definitive repair/fixation of lesions and hemostasis: sutures in the liver using large stitches to secure the bleeding areas. It is important to avoid damaging surrounding tissue and blood vessels during the surgical procedure.
If necessary, larger fragments of omentum may be used as dressings which are usually sutured to the liver to enhance hemostasis • Resections and other operations: If necessary, some sections of the liver may have to be surgically removed (resected)

Treatment- Operative -4

Pringle maneuver: A method of controlling liver blood flow by clamping blood vessels related to the liver Techniques such as compression and clamping are used during the procedure for the most effective hemostasis, but the surgeon must pay attention to time constraints, and the preservation of the liver vessels and surrounding organs during the surgical procedure
Further operations: techniques for clamping vessels in the quadrupla clamping technique are used

Treatment- Operative -5

Packing procedure: Employing large pads to compress the bleeding region; using the correct placement of such pads to minimize the risk of further injuries
Definitive repair/fixation of lesions and hemostasis: stitches/ sutures to hold the bleeding areas together (to stop the bleeding)

Treatment - Operative -6

Suturing Techniques.
Resections: Procedures used to remove injured tissue sections (e.g., in a partial liver resection).
High-major liver resections: carry a significant mortality risk (up to 50%).

Indications for Operative Treatment - Moderate Liver Injury

Type I MIRVIS: No edge approximation; avoid sutures; early non-operative treatment favored.
Type II MIRVIS: Hematoma that is not ruptured; if no rupture detected, further observation such as CT scan and ultrasound are required; if a laceration/rupture is detected, surgical intervention will involve selective edge trimming and tissue removal. A more permanent method of stopping the oozing/bleeding is the ligature procedure.

Indications for Operative Treatment - Severe Liver Injury

Type III MIRVIS: Deep laceration/rupture; surgical repair necessary
Type III MIRVIS - fractures, complete surgical tissue removal as well as stopping blood bleeding.
Type III MIRVIS - if a complete injury to the liver is observed; this requires more extensive surgical intervention (e.g., major hepatectomy) for long gaps to ensure the liver tissue is adequately repaired; however, due to the damage, a higher fatality rate must be anticipated.
Type IV MIRVIS: large-sized lesions in two lobes; stabilization and further repair.

Indications for Operative Treatment- Severe Liver Injury - 2

Central Hematoma : Small size, no surgery; large size and/or dissecting, surgical intervention required, with ligation of vessels after a diagnostic imaging approach such a CT scan or angiography
Postoperative Complications: Potential complications that demand surgical intervention based on patient response, as well as the condition of the patient.

Closure and Drainage

Stopping bleeding in a simple way (no clamping; no severe collapse):
Closing the wound in steps + large drainage of the affected liver region to remove any residual fluid or blood.
Additional drainage if needed.
Complication Avoidance: preventing significant problems, including abdominal compartment syndrome, is a critical aspect of management.

Special Considerations (TOF, penetrating wounds)

Need for early recognition; often misdiagnosed because of lack of shock or other signs of widespread injury; early recognition of the need for further surgery
Laparotomy as a strategy may not always be successful in these cases, and alternative procedures such as the "Pringle's maneuver" may be required.
Utilization of a Blake Moore tube: It is important to note that this particular method is frequently employed in the management of penetrating abdominal wounds.
Further interventions may be needed.

Complications Postoperative

Common complications: Abdominal issues (opening up, blockage, peritonitis, subphrenic abscesses, parietal suppurations), decubitus issues (breathing and urination infections, skin breakdown, blood clots), pulmonary embolism, acute kidney failure, and sepsis.
Specific liver complications: Continued bleeding, new hematomas forming at the site of injury (secondary to initial injury or due to complications), liver necrosis (if blood vessels were clamped), bile leaks (fistula).
Other possible complications :abdominal compartment syndrome, visceral failure (lung, heart, kidneys, brain), sepsis.

Conclusion

Traumatic hepatic injuries (TH) primarily associated with acute vascular accidents (AVP).
Diagnosis depends on clinical exam and CT, particularly with stable patients.
Management is often conservative(80% nonoperative), but mortality remains high.

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Description

Ce quiz explore les divers mécanismes responsables des lésions abdominales, en se concentrant sur les points clés tels que les lésions par écrasement et par arme à feu. Il aborde également les statistiques cliniques concernant ces blessures, y compris l'innervation du foie et les classifications de Moore. Testez vos connaissances sur ce sujet vital.