No anatomical region or cavity is exempt when addressing injuries sustained when managing multi-trauma patients, especially if the traumatic injury is the result of a blunt mechanism. This cornerstone principle is the paramount rationale for the two-tier, systematic approach for the injured patient. In most settings, the acute care surgeon (a specialist who has expertise in trauma, critical care, and emergency general surgical management) is heavily involved in every aspect of care of the trauma patient. Abdominal trauma, regardless of the mechanism of injury, can present many challenging situations, even for the most well trained and talented surgeon. With the pendulum continuing to move more toward nonoperative/selective management of abdominal trauma due to enhanced diagnostic modalities, the hazards of missed or delayed diagnoses are well known and equally well respected. The unevaluable abdomen in a patient who has an associated closed head injury or substantial intoxication with a depressed sensorium remains a perplexing dilemma, irrespective of an unprecedented myriad of advanced technology designed to detect the sequence of intra-abdominal injury.
In addition, there are special populations (the elderly, immunosuppressed, anticoagulated, morbidly obese, etc.) that pose unique management challenges. While the explosion of laparoscopic intervention has made an indelible imprint on practically every surgical discipline, its impact on trauma management has been mostly diagnostic in the hemodynamically normal patients, as opposed to therapeutic management of the injured patient. With the hemodynamically compromised patient being the prototypical individual who is taken to the operating room for exploration, a laparoscopic approach would be an absolute contraindication in that cohort of patients.
Traumatic injury remains the leading cause of death both in the United States and worldwide, resulting in enormous economic and societal losses. In many regions of the world, there is a significant shortage of surgical specialists and general surgeons. This is particularly problematic given the fact that it is the general surgeon specialist who still provides the bulk of emergency surgical care. Given the fact that there are many regions of the country and the world without established trauma systems, this chapter is as applicable to the general surgeon as it is to the trauma surgeon.
Even though the abdomen remains one of the most critical and vulnerable anatomic regions in blunt trauma, a standard, systematic approach of the entire patient must always be conducted—without exception. An initial assessment of the entire patient is imperative before focusing on the specific anatomical region where there is an obvious traumatic injury. The concept of initial assessment includes the following components: (1) rapid primary survey, (2) resuscitation, (3) detailed secondary survey (evaluation), and (4) reevaluation. Such an assessment is the cornerstone of the Advanced Trauma Life Support (ATLS®) program.1 Integrated into primary and secondary surveys are specific adjuncts. Such adjuncts include the application of electrocardiographic monitoring and the utilization of other monitoring modalities such as arterial blood gas determination, ...