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Key Points

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  1. Most solid organ injuries can and should be managed nonoperatively.

  2. Laparotomy is still indicated for hemodynamic instability or peritonitis.

  3. Diaphragmatic injuries, once diagnosed, are often associated with thoracic and abdominal injuries, and should be explored and repaired from the abdomen.

  4. Splenorrhaphy remains the surgery of choice for unstable patients with splenic injury.

  5. Angioembolization may supplant operation for hemodynamically stable patients with persistent hemorrhage.

  6. Exploration for liver injury is rarely necessary, though some patients may require later interventional procedures for complications.

  7. Gastric injury is uncommon, though it may occur more often in children than in adults, and usually occurs along the greater curvature.

  8. The management of pancreatic ductal injury remains controversial: nonoperative, resection, or drainage.

  9. The duodenum is more exposed and more prone to injury in pediatric patients.

  10. Intestinal injuries are best diagnosed on physical examination, and therapeutic delay of less than 24 hours only mildly increases morbidity.

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Although trauma remains the leading cause of mortality among children, emergency abdominal operations are infrequently required. The typical surgeon caring for injured children can expect to perform 1 or fewer emergency abdominal operations per year. This infrequency may diminish the experience of most surgeons and increases the utility of a chapter such as this.

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History of Operative Management

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With the publication of the United States War Manual in 1918, operative management of abdominal injuries became the treatment of choice and resulted in a marked decrease in mortality rate. With the report from Toronto of a series of children with the signs and symptoms of splenic injury who did not require operation, the era of nonoperative management began more than 30 years ago. The widespread use of computerized tomography (CT) has increased the number of abdominal injuries diagnosed. Many severe solid-organ injuries, previously thought to require laparotomy, have also been found to resolve nonoperatively. Despite this, every surgeon who cares for children should be facile with the skills needed for prompt laparotomy in the management of injured children. Completion of training courses, such as the Advanced Trauma Operative Management (ATOM) course® (TM ACS) may help surgeons acquire and retain operative trauma skills.

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Indications for Operative Management

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The primary indications for laparotomy in injured children include hemodynamic instability despite adequate volume resuscitation, peritoneal findings, pneumoperitoneum, and evisceration. While the presence of an abdominal gunshot or stab wound penetrating the peritoneum has traditionally been managed with laparotomy, this has recently been called into question in adults. In a stable child, select stab and gunshot wounds to the abdomen may be managed expectantly in a center experienced in this strategy. In a hemodynamically stable patient, it may be difficult to differentiate an intestinal injury that requires repair from one that will heal without intervention, leading to exploration.

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The large majority of solid-organ injuries in children do not require operation and many pediatric centers have reported operative rates ...

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