Surgeons Rethink Abdominal Trauma Playbook

For decades, the standard approach to managing abdominal trauma, especially for cases involving penetrating injuries, has been to surgically open the abdominal cavity for exploration.

But in recent years, there has been a shift toward selective nonoperative management—particularly for stable patients with solid organ injuries—with advanced imaging, evolving resuscitation methods, and a better understanding of injury mechanisms becoming increasingly important.¹

Today, selective nonoperative management of blunt abdominal trauma is acknowledged as a safe treatment option in many injury patterns for hemodynamically stable patients and considered part of the standard of care.^2,3

“The most exciting emerging trend in abdominal trauma is the increasing use of interventional techniques in trauma care,” said Kylie Zane, MD, an interventional radiologist from The University of Chicago Medicine in Illinois. “Advanced imaging allows us a way to see inside the patient without the scalpel.”

The expanded role of interventional radiology (IR) comes at a time when traumatic injuries are on the rise.⁴ Traumatic injury is the leading cause of death for people younger than 45 years of age in the US and globally, accounting for about 10% of deaths worldwide each year. During the past decade, outcomes have improved due to a number of factors such as better integration of multidisciplinary care, faster access to advanced imaging and interventions, and the increased selective use of nonoperative management.⁵

In abdominal trauma cases, early involvement of IR can significantly improve patient outcomes by enabling timely and effective management of hemorrhage and other injuries. IR techniques, such as angioembolization, stent grafts, and other endovascular procedures, allow for rapid identification and treatment of vascular injuries and solid organ damage, potentially reducing the need for emergency surgery and improving survival rates.

“We call interventional radiologists early—when we think the injury will be difficult to access, be it the abdomen, pelvis, or head and neck,” said trauma surgeon Kenneth L. Wilson, MD, FACS, from The University of Chicago.

Even patients who may require a blood transfusion may be candidates for nonoperative management as long as imaging has found the source of bleeding. According to Dr. Zane, a 20-minute angioembolization procedure in the angiography suite may stop bleeding in patients who once may have needed a major operation.

“We can control internal bleeding through an incision that’s a centimeter long compared to a foot-long laparotomy incision that might have been used historically,” she said. “Trauma surgeons continue to trust us with their patients because they see those results.”

Diagnostic “Game Changer”

Strategies now being widely used in the treatment of solid organ injury are based on the Focused Assessment with Sonography for Trauma (FAST) scan, CT scan diagnosis, and the hemodynamic stability of the patient.⁶ This approach allows surgeons to quickly identify patients with hemodynamic instability and help determine if they need surgical intervention by assessing potential injuries.

Because x-ray and ultrasound machines are smaller and portable, the machines can be deployed to the patient’s bedside for immediate patient evaluation. An advantage of ultrasound is that it can be repeated as the patient progresses without increased radiation exposure, Dr. Wilson said, adding that this is critical in repeated checks for fluid buildup in the abdomen, “It’s a real game changer.”

High-Quality CT Scan as Prerequisite

After the primary and secondary surveys are completed, the hemodynamically stable patient will go to a nearby CT scanner that is typically standardized based on the level of trauma, Dr. Zane explained. In fact, major factors in the increased use of nonoperative management for trauma patients are high-quality CT imaging and the increased availability of interventionalists.

“The prerequisite for all of this is having a surgical ICU setting where trauma patients can be closely monitored to make sure that nonoperative approaches are safe for them,” she said. “The trauma surgeon can request additional imaging or exclude imaging based on what they’re most concerned about.”

In most cases, these imaging modalities provide a comprehensive list of the injuries, allowing for appropriate triage, whether that means a subspecialty surgeon, an interventional radiologist, or a trip to the OR, Dr. Zane noted. The whole sequence of portable imaging takes about 10 minutes.

For hemodynamically stable patients who get a CT scan and do not appear to need emergency surgery, nonoperative management has become the standard of care. For example, rather than a laparotomy, the ACS Trauma Quality Improvement Program Best Practices Guidelines in Imaging, produced in collaboration with the American Society of Emergency Radiology and the American College of Radiology, recommend that surgeons base their initial management decisions on CT scans for selected patients.3

“Twenty-plus years ago, if you had a penetrating injury in the abdomen, you automatically went to the operating room,” Dr. Wilson said. “Now, if that patient is stable, you can get a CT scan, and there are no overt signs of peritonitis or hemodynamic instability, we may be able to get away without operating at all and deploy our interventional radiology team to attempt a nonoperative approach.”

CT scans can help the surgeon identify the source of the hemorrhage. In some cases, the leak may be in a place that’s hard for the surgeon to access but not for the interventional radiologist.

“We can, perhaps, stop the hemorrhage without making an incision at all,” Dr. Wilson said.

But some surgeons think the trend toward nonoperative management of abdominal trauma could be pushing the boundaries too far, said cardiothoracic surgeon Kenneth L. Mattox, MD, FACS, a distinguished service professor in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine in Houston, Texas. He added that this hands-off approach may tend to result in more complications and longer operations.

Some tests, such as the CT scan with intravenous contrast or magnetic resonance imaging, are used even though they do not alter decision-making regarding the patient. “If you cannot write a progress note on why an advanced technology is going to change what you normally were going to do and can do it quicker and maybe cheaper, then that extra technology should not be applied,” Dr. Mattox said.

In most cases, “the patient who has the big, bad acute injury to the abdomen needs the bleeding taken care of, not just watched,” he explained.

IR Offers Alternative to Open Surgery

Many surgeons choose laparoscopy for selected abdominal trauma patients rather than laparotomy because it provides a minimally invasive way not only to visualize the injuries but also to treat them.⁷

The approach often depends on the experience and preferences of the surgeon, Dr. Wilson said. Some surgeons would never perform minimally invasive surgery (MIS), while others are trained at the centers where they do a lot of MIS, such as robotic surgery using a laparoscope.

As trauma surgeons become increasingly familiar with IR techniques, there has been a move toward combined surgical and nonoperative approaches for trauma patients. IR can provide an alternative to what would have been a difficult surgery. For example, consider the patient who had a bullet lodged in their inferior vena cava.

“In close collaboration with our trauma surgeons, we snared the bullet fragments intravenously in the IR suite without having to make an incision,” Dr. Zane said. “We retracted that bullet to the groin, and then our trauma surgeons performed a targeted cut down over the femoral vein and took that bullet out. This saved a massive operation and allowed for a much smaller recovery time for the patient with really good outcomes.”

Hybrid OR

Valuable time is wasted when moving a severely hemorrhaging patient from the trauma resuscitation bay to the OR or angiography suite or for additional radiological imaging.⁸ This extended journey can be fatal for the patient.

In Japan, the hybrid OR system combines a sliding CT scanning system with IR, enabling CT diagnosis and emergency therapeutic interventions without transferring the patient to another examination room. The hybrid OR enables multiple emergency procedures, such as damage control surgery and endovascular intervention, to be conducted after early CT diagnosis. The ability to perform immediate CT diagnosis and rapidly control bleeding without moving the patient has helped improve outcomes for severe trauma patients.⁹

There is growing interest in the hybrid OR approach in the US. At the Ben Taub Hospital in Houston, Texas, for instance, there is a hybrid surgical suite named for Dr. Mattox—the Kenneth L. Mattox, MD Surgical Suite. Although it helps reduce the time spent moving the patient around to get various tests and studies, Dr. Mattox acknowledges that the hybrid OR’s complexity and varied instrumentation can be a challenge.

New Protocols in Damage Control

For years, damage control surgery was the standard response to abdominal trauma patients with life-threatening injuries, with the aim of resuscitating patients so they could have definitive treatment later.¹⁰

“Damage control is meant to immediately control bleeding and contamination, resuscitate in the ICU, and return for repeat operation within 12 to 24 hours for definitive repairs not completed during the initial damage control procedure,” Dr. Wilson said.

Resuscitation protocols are being integrated into planning for the patient, Dr. Zane said. There’s wide recognition in trauma about the importance of balanced resuscitation and balanced transfusion. For example, most trauma surgery departments now have the ability to initiate massive transfusion in the trauma bay, which is crucial for damage control resuscitation for patients experiencing massive hemorrhage and acute traumatic coagulopathy.

“This is an incredible advance compared to what people were doing 10 years ago,” Dr. Zane said.

To manage life-threatening bleeding in abdominal trauma patients, a massive transfusion protocol (MTP) is recommended, according to 2024 damage control resuscitation recommendations from the ACS and American Association for the Surgery of Trauma.¹¹ The MTP aims to provide a rapid and balanced resuscitation of patients with major blood loss, often in a ratio of 1:1:1 (platelets: plasma: packed red blood cells). It aims to interrupt the lethal cycle of acidosis, hypothermia, and coagulopathy that can develop during massive transfusion.

Another new protocol is a resuscitation strategy known as “permissive hypotension,” in which blood pressure is intentionally kept lower than normal in patients with active bleeding, particularly in trauma. This is done to avoid disrupting blood clots and potentially worsening the hemorrhage, which can occur if blood pressure is raised too quickly before bleeding is controlled.

“The word ‘resuscitation’ is often concomitant with raising the blood pressure to pre-injury levels or higher,” Dr. Mattox said. “That’s wrong.”

IR is increasingly used in damage control and, according to one study, should be considered an arm of damage control surgery and not simply as nonoperative management.¹²

There also is a new generation of hemostatic agents and adjuncts used in damage control of abdominal trauma, including bioactive dressings, powders, sealants, and sprayable hemostats.

Dr. Mattox stressed that these new agents and devices have benefits but often are overused and even harmful if surgery is delayed more than 2 days.

Coordination between Trauma Surgeons, Interventionalists

The increasing role of IR in the management of bleeding patients has prompted the need for greater coordination between trauma surgeons and interventionalists, including training trauma teams in IR resuscitation practices.¹²

“There’s been a big and relatively recent shift in the organization and structure of interventional radiology that facilitates this coordination,” Dr. Zane said.

The move started with the creation of an integrated residency pathway a decade ago for IR, leading to more interventional radiologists receiving preliminary training in surgery. Similarly, trauma surgical residents are getting more exposure to MIS techniques through fellowship programs. This experience can involve dedicated training in areas like laparoscopic trauma surgery or mentorship from experienced MIS surgeons.

This cross-training could alleviate the trend toward overspecialization, Dr. Mattox predicted.

“Twenty to 30 years ago, the general surgeon took care of all of the diagnostic workup and was trained to do a number of procedures, including vascular,” he said. Now, general, critical care, and acute care surgeons are all involved in abdominal trauma cases, in addition to specialists in emergency medicine and radiology.

Too often, these physicians work separately, not together, Dr. Mattox said, which may lead to a “lack of patient ownership” and worse outcomes. He suggested that better coordination and collaboration with IR could be achieved if they both answered to the same chief of service.

“It’s the perfect time to promote collaboration between trauma, surgery, and interventional radiology on standards and protocols,” Dr. Zane said, noting that trauma surgeons have voiced concern about a standard 1-hour response time for intervention radiologists when it could be 30 minutes, as an example.

What’s Next?

In addition to the numerous tools and technologies that have already transformed care for the abdominal trauma patient, other significant advances are in the offing.

Artificial intelligence (AI)-assisted trauma imaging and triage tools already leverage computer vision and machine learning to analyze trauma-related images, aiding in the rapid identification of injuries and prioritization of patients for treatment. These tools can help improve workflow efficiency, reduce errors, and enhance patient outcomes.

“There’s a broad use of AI already in radiology,” said Dr. Zane. “Overnight, we have AI running in the background for many of the CT scans we acquire.”

Dr. Mattox said he is intrigued by the potential for AI to guide surgeons through unfamiliar operations, draft the operative report after a case, and augment surgeon decision-making, “Using artificial intelligence, you can get assistance instantaneously.”

Augmented reality could improve the interoperability of abdominal trauma care, Dr. Wilson said. In a complex, multidisciplinary environment like the trauma bay, augmented reality could improve the surgeon’s ability to simultaneously tap different information technologies and software applications to optimize patient care.

Also, surgeons could use augmented reality goggles in the OR to get a real-time consultation with a surgeon in another part of the world. These goggles will be able to interact with the environment, pull up relevant information, or even offer guidance via AI.

Staying Current

Abdominal trauma care is evolving fast, and staying current means rethinking old habits, embracing new tools, and building multidisciplinary agility.

Monitoring performance data and comparing performance to others is one way to stay ahead of the game.

To keep up to date, surgeons should read relevant books and articles and attend conferences, such as the ACS Clinical Congress, Dr. Mattox suggested. “Meeting in the hallway, talking over problems and case management—it really keeps one current.”

Dr. Zane also would like to see more institutional support for hybrid models and interdisciplinary collaboration. “We’re building these relationships so we learn what we can offer each other,” she said. “It’s an exciting time for trauma care.”

Jim McCartney is a freelance writer.

References

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