Head, Thoracic, Abdominal, and Vascular Injuries (eBook)

Head, Thoracic,Abdominal, and Vascular Injuries 2
Foreword of the Series Editors 4
Preface 5
Contents 6
1: Traumatic Brain Injury 8
1.1 Introduction 8
1.2 Traumatic Insults 9
1.2.1 Mechanisms of Traumatic Brain Injury: Primary Insult 9
1.2.1.1 Primary Brain Damage 9
Impulsive Loading 9
Impact Loading 9
Static Loading 10
1.2.1.2 Secondary Brain Damage 10
1.2.2 Mechanisms of Traumatic Brain Injury: Secondary Insult 10
1.3 Clinical Assessment of TBI 10
1.3.1 Assessment According to ATLS 11
1.3.1.1 Primary Survey 11
Disability 12
Assessment of Level of Consciousness 12
Assessment of Pupillary Function, Oculocephalic Testing, and Oculovestibular Testing [32] 13
Lateralized Extremity Weakness 14
1.3.1.2 Secondary Survey 14
History 14
Local Status 15
Neurologic Status 15
Risk Factors 15
Radiological Examination 16
1.3.2 Classification of TBIs 16
1.3.3 Outcome After TBI 18
1.3.3.1 Outcome Scales 18
1.3.3.2 Mild (GCS 15–13) TBI: Outcome 18
1.3.3.3 Moderate (GCS 12–9) TBI: Outcome 18
1.3.3.4 Severe (GCS 8–3) TBI: Outcome 19
1.3.4 Predictors of Outcome 19
1.3.4.1 Age 20
1.3.4.2 Admission GCS Score 20
1.3.4.3 Pupils 20
1.3.4.4 Hypotension and Hypoxia 21
1.3.4.5 Intracranial Pressure 21
1.3.4.6 Mechanism of Injury 21
1.3.4.7 Computed Tomography 21
1.3.4.8 Laboratory Parameters 22
1.3.4.9 Combinations of Several Predictive Characteristics 22
1.4 Technical Assessment of TBI 22
1.4.1 Skull Radiography (SR)/Cervical Spine 22
1.4.2 Computed Tomography 23
1.4.2.1 CT-Classification of TBI 24
1.4.2.2 Initial Assessment: Indication for CT Scanning 24
1.4.2.3 Repeated CT Scanning 26
1.4.3 Magnetic Resonance Tomography 26
1.4.3.1 Structural Imaging 26
1.4.3.2 Functional Imaging 26
1.4.3.3 Clearance of the Cervical Spine in Blunt Trauma 27
1.4.4 Cerebral Angiography 27
1.4.4.1 Intra-Arterial Digital Subtraction-Angiography (iaDSA) 27
1.4.4.2 Computed Tomography Angiography 27
1.4.4.3 Magnetic Resonance Angiography (MRA) 27
1.4.4.4 Recommendation 27
1.4.5 Electroencephalography 28
1.4.5.1 Evoked Potentials (EP) 28
1.4.5.2 Electrophysiologic Examination 28
1.4.6 Lumbar Puncture 28
1.4.7 Intracranial Pressure Monitoring 29
1.4.7.1 Indication for Intracranial Pressure Monitoring 29
1.4.7.2 Method 29
1.4.7.3 Complications 29
1.5 Minor Traumatic Brain Injury 29
1.6 Moderate and Severe Traumatic Brain Injury 31
1.7 Traumatic Brain Injury: Neurosurgical Management 31
1.7.1 Standard Procedures 32
1.7.1.1 Standard or Generic (Standard) Head Trauma Craniotomy 32
Anesthesia 32
Positioning 32
Preparing 32
Draping 32
Scalp Incision 33
Craniotomy 34
Dural Opening 34
Dural Closure 35
Bone Flap/Skin Closure 35
1.7.1.2 Burr-Hole Exploration 36
1.7.1.3 Ventriculostomy 36
Frontal Ventriculostomy 37
Parieto-Occipital Ventriculostomy 38
1.7.1.4 Intra/Postoperative Problems/Complications 38
Intraoperative Brain Swelling (IOS) 38
Intraoperative Bleeding 38
Air Embolism [27, 227] 39
1.7.1.5 Postoperative Problems/Complications 39
Postoperative Reaccumulation of Intracranial Hematomas 39
Delayed Traumatic Intracranial Hematomas (DITCH) and Evolving Contusions 39
Postoperative Intracranial Hypertension 40
Posttraumatic Hydrocephalus 40
Surgical 40
Hygroma 40
Chronic Subdural Hematoma 40
Infection 40
Sinking Skin Flap Syndrome (Syndrome of the Trephined) 41
Medical Complications (see Chap. 2) 41
1.7.2 Specific Lesions 41
1.7.2.1 Scalp Injury 41
Diagnostic Procedures 42
Therapy 42
Differential Diagnosis 42
Prognosis/Outcome 42
Surgical Principles 42
Special Remarks 42
1.7.2.2 Skull Fracture (Fig. 1.CT-1a) 42
Diagnostic Procedures 44
Therapy 44
Differential Diagnosis 44
Prognosis/Outcome 45
Surgical Principles 45
Special Remarks 45
1.7.2.2.1 Depressed Skull Fracture (Fig. 1.CT-1b1, b2) 45
Diagnostic Procedures 46
Therapy 46
Differential Diagnosis 47
Prognosis/Outcome 47
Surgical Principles 47
Special Remarks 48
1.7.2.2.2 Fractures of the Skullbase 48
Diagnostic Procedures 49
Therapy 50
Differential Diagnosis 50
Prognosis/Outcome 51
Surgical Principles 51
Special Remarks 53
1.7.2.3 Diffuse Traumatic Brain Injury (DTBI) 53
Diagnostic Procedures 54
Therapy 55
Differential Diagnosis 55
Prognosis/Outcome 55
Surgical Principles 55
Special Remarks (see Sect. 1.1.2.6) 56
1.7.2.4 Acute Epidural Hematoma (AEDH) (Fig. 1.CT-2) 56
Definition 56
Epidemiology/Etiology 56
Clinical Presentation/Symptoms 58
Complications 58
Diagnostic Procedures 58
Therapy 59
Differential Diagnosis 59
Prognosis/Outcome 59
Surgical Principles 59
Special Remarks 62
1.7.2.5 Acute Subdural Hematoma (aSDH) (Fig. 1.CT-3) 62
Diagnostic Procedures 64
Therapy 65
Differential Diagnosis 65
Prognosis/Outcome 65
Surgical Principles 66
Special Remarks 67
1.7.2.6 Chronic Subdural Hematoma (CSDH) (Fig. 1.CT-5) 67
Diagnostic Procedures 68
Therapy 69
Differential Diagnosis 69
Prognosis/Outcome 69
Surgical Principles 69
Special Remarks 71
1.7.2.7 Traumatic Hematomas of the Posterior Fossa (Fig. 1.CT-4) 71
Diagnostic Procedures 72
Differential Diagnosis 73
Prognosis/Outcome 73
Surgical Principles 73
Special Remarks 75
1.7.2.8 Traumatic Intraparenchymal Hemorrhage (Fig. 1.CT-6) 75
Diagnostic Procedures 77
Therapy 77
Differential Diagnosis 78
Prognosis/Outcome 78
Surgical Principles 78
Special Remarks 79
1.7.2.9 Penetrating Brain Injury (PBI) 79
1.7.2.9.1 Stab Wounds to the Head (Fig. 1.CT-8) 79
Diagnostic Procedures 80
Therapy 80
Differential Diagnosis 81
Prognosis/Outcome 81
Surgical Principles 81
Special Remarks 81
1.7.2.9.2 Civilian Gunshot Wounds (GSW) (Fig. 1.CT-9) 81
Diagnostic Procedures 83
Therapy 83
Differential Diagnosis 84
Prognosis/Outcome 84
Surgical Principles 84
Special Remarks 85
Civilian Tangential Gunshot Wound 85
Diagnostic Procedures 86
Therapy 86
Differential Diagnosis 86
Prognosis/Outcome 86
Surgical Principles 86
Special Remarks 86
References 86
2: Intensive Care Treatment Options of Elevated Intracranial Pressure Following Severe Traumatic Brain Injury 99
2.1 Summary 99
2.2 Introduction 100
2.3 Pathophysiologic Basis 101
2.3.1 Local Autodestructive Cascades and Local Secondary Insults 101
2.3.2 Systemic Secondary Insults 102
2.3.2.1 Crucial Points and Pearls 104
2.3.3 Increase in Intracranial Volume and Intracranial Pressure 105
2.3.3.1 Crucial Points and Pearls 106
2.4 Neuromonitoring 106
2.4.1 ICP and Compliance 107
2.4.1.1 Crucial Points and Pearls 110
2.4.2 Jugular Venous Bulb Catheter: SjvO2 and Arterio-Jugular Venous Differences 111
2.4.2.1 Crucial Points and Pearls 114
2.4.3 Microdialysis 114
2.4.3.1 Crucial Points and Pearls 118
2.4.4 Tissue Oxygenation-ptiO2 118
2.4.4.1 Crucial Points and Pearls 119
2.4.5 Analysis of Cerebrospinal Fluid 120
2.4.5.1 Crucial Points and Pearls 120
2.4.6 Electrophysiologic Studies: Electroencephalogram, Sensory Evoked Potential, Cortical Spreading Depression 121
2.4.6.1 EEG and SEP 121
2.4.6.2 CSD (cortical spreading depression) 123
2.4.6.3 Crucial Points and Pearls 123
2.4.7 Assessment of Cerebral Perfusion 123
2.4.7.1 Crucial Points and Pearls 124
2.5 Therapeutic Interventions 124
2.5.1 Crucial Points and Pearls 125
2.5.2 Positioning 125
2.5.2.1 Crucial Points and Pearls 126
2.5.3 Oxygenation 126
2.5.3.1 Crucial Points and Pearls 126
2.5.4 Hyperventilation 127
2.5.4.1 Crucial Points and Pearls 127
2.5.5 Analgesia and Sedation 127
2.5.5.1 Crucial Points and Pearls 128
2.5.6 Optimal Hematocrit and Transfusion Requirements 128
2.5.6.1 Crucial Points and Pearls 129
2.5.7 Optimal Blood Glucose Values 130
2.5.7.1 Crucial Points and Pearls 131
2.5.8 Barbiturate Coma 132
2.5.8.1 Crucial Points and Pearls 132
2.5.9 Temperature, Fever, Hypothermia, Rewarming 133
2.5.9.1 Crucial Points and Pearls 133
2.5.10 Hemodynamic and Volume Management 134
2.5.10.1 Crucial Points and Pearls 134
2.5.11 Osmotherapy: Mannitol, Small Volume Resuscitation, Albumin 135
2.5.11.1 Crucial Points and Pearls 136
2.5.12 Controversial Issues Regarding Treatment Concepts: ROSNER vs. LUND 136
2.5.12.1 Rosner Concept 136
2.5.12.2 Lund Concept 137
2.5.12.3 Crucial Points and Pearls 138
2.5.13 Intraabdominal Compartment 138
2.5.13.1 Crucial Points and Pearls 138
2.5.14 Drainage of Cerebrospinal Fluid 138
2.5.14.1 Crucial Points and Pearls 139
2.5.15 Craniectomy 139
2.5.15.1 Crucial Points and Pearls 139
2.5.16 Corticosteroids 139
2.5.16.1 Crucial Points and Pearls 140
2.5.17 Prophylactic Antiepileptic Therapy 140
2.5.17.1 Crucial Points and Pearls 141
2.6 Treatment Steps 141
2.6.1 Crucial Points and Pearls 142
2.6.2 Controlled Escalation 142
2.6.2.1 Basic Measures 142
2.6.2.2 Step 1 143
2.6.2.3 Step 2 143
2.6.2.4 Step 3 143
2.6.2.5 Crucial Points and Pearls 143
2.6.3 Controlled De-escalation 145
2.6.3.1 Crucial Points and Pearls 146
2.7 Difficult Decision Making 146
2.7.1 Initial GCS 146
2.7.2 First CT Scan Following Severe Trauma and GCS 147
2.7.3 Time Point for Surgery 147
2.7.3.1 Reconstruction of Midfacial Fractures 149
2.7.4 Influence of Different Factors on Morbidity and Mortality 149
2.7.4.1 Crucial Points and Pearls 150
References 150
3: Craniofacial Trauma 159
3.1 Introduction 159
3.2 History 159
3.3 Etiology 159
3.4 Approach to Patient Management 164
3.4.1 Primary Management 164
3.4.2 Secondary Survey 165
3.5 Facial Examination 166
3.5.1 Extraoral 166
3.5.1.1 One Should Note by Only Visually Examining the Patient 166
3.5.1.2 Physical Examination (Noting Steps, Pain, Crepitation, Sensory Disturbance, Surgical Emphysema, Soft Tissue Injuries 166
3.5.2 Intraoral 167
3.5.3 Special Investigations 167
3.6 Mandibular Fractures 171
3.6.1 Classification 171
3.6.2 Symptoms 173
3.6.3 Signs: (Discussed Before, but Summarized Here as Well) 173
3.6.4 Treatment 175
3.6.4.1 Emergency Treatment 175
3.6.4.2 Definitive Treatment 175
3.6.5 Exceptions and Controversies 177
3.6.6 Complications 179
3.7 Midface Fractures 181
3.7.1 Classification 181
3.7.2 Maxillary Fractures 181
3.7.2.1 Symptoms 187
3.7.2.2 Signs 187
Extraoral 187
Intraoral 189
3.7.2.3 Treatment 189
Emergency Treatment 189
Definitive Treatment 191
3.7.2.4 Exceptions and Controversies 192
3.7.2.5 Complications 192
3.7.3 Zygoma and Orbital Wall Fractures 193
3.7.3.1 Zygoma 194
Symptoms and Signs 194
Diagnosis 194
Emergency Treatment 195
Definitive Treatment 195
Exceptions and Controversies 196
3.7.3.2 Orbital Wall 197
Symptoms and Signs 197
Diagnosis 199
3.7.3.2.3 Treatment 199
Complications 199
Exceptions and Controversies 201
3.8 Frontal and Skull Base Fractures 202
3.8.1 Classification 203
3.8.2 Symptoms and Signs 203
3.8.3 Diagnosis 206
3.8.4 Treatment 206
3.8.5 Complications 206
3.8.6 Exceptions and Controversies 206
3.9 Panfacial Fractures 207
3.10 High-Velocity Injuries and Gunshot Wounds 209
3.10.1 Treatment 209
3.10.1.1 Emergency treatment 209
3.10.1.2 Definitive Treatment 213
3.10.2 Complications 213
3.10.3 Exceptions and Controversies 215
3.11 Dental and Dentoalveolar Fractures 216
3.11.1 Dentoalveolar Fracture 216
3.11.2 Luxated Teeth 217
3.11.2.1 Subluxated Teeth 217
3.11.3 Lost Teeth 217
3.11.4 Complications 218
3.12 Soft Tissue Management 218
3.12.1 Tongue 218
3.12.2 Lip 220
3.12.3 Eyelid 221
3.12.4 Mouth Floor 226
3.13 Late Reconstruction 226
References 226
4: Chest Trauma 228
4.1 Thoracic Wall Injuries 228
4.1.1 Rib Fractures 228
4.1.1.1 Epidemiology and Outcomes 228
4.1.1.2 Treatment 228
4.1.2 Flail Chest 229
4.2 Lung Injuries 230
4.2.1 Pulmonary Contusion 230
4.2.1.1 Pathophysiology 230
4.2.1.2 Diagnosis 230
4.2.1.3 Management 230
4.2.1.4 Prognosis 231
4.2.2 Pneumothorax 231
4.2.3 Hemothorax 233
4.2.3.1 Diagnosis of Hemo/Pneumothorax 233
4.2.3.2 Management of Hemo/Pneumothorax 233
4.2.3.3 Technique of Chest Tube Insertion 234
4.2.3.4 Post-Chest Tube Insertion Complications 235
4.2.4 Indications for Emergency Thoracotomy 236
4.2.5 Emergency Operations for Lung Injuries 236
4.2.5.1 Incisions 236
4.2.5.2 Operative Techniques 237
4.2.5.3 Outcomes 240
4.3 Thoracic Aortic Injuries 240
4.3.1 Blunt Thoracic Aortic Injury 240
4.3.1.1 Epidemiology 240
4.3.1.2 Screening and Diagnosis 241
4.3.1.3 Management of Thoracic Aortic Injuries 243
4.3.1.4 Timing of Definitive Repair 243
4.3.1.5 Definitive Management of Aortic Injuries 243
4.3.2 Penetrating Thoracic Aortic Injuries 245
4.4 Cardiac Injuries 246
4.4.1 Blunt Cardiac Injury 246
4.4.1.1 Definition 246
4.4.1.2 Screening and Diagnosis 246
4.4.1.3 Treatment 247
4.4.1.4 Blunt Cardiac Rupture 247
4.4.2 Penetrating Cardiac Injury 247
4.4.2.1 Epidemiology 247
4.4.2.2 Clinical Presentation 248
4.4.2.3 Investigations 248
4.4.2.4 Management 250
4.4.2.5 Operative Management 250
Emergency Room Thoracotomy 250
Operating Room Management 252
4.4.2.6 Outcomes 253
4.4.2.7 Postoperative Evaluation 254
4.6 Esophageal Injuries 256
4.6.1 Epidemiology 256
4.6.2 Diagnosis 256
4.6.3 Management 256
4.6.4 Operative Therapy 256
References 257
5: Diaphragm 261
5.1 Introduction 261
5.2 Trauma Mechanism and Epidemiology 261
5.3 Diagnostic Procedures 261
5.3.1 Penetrating Injury 261
5.3.2 Early Diagnosis in Blunt Injury 262
5.3.3 Late Diagnosis 263
5.4 Therapy 265
5.5 Prognosis 265
References 265
6: Esophageal and Gastric Injuries 267
6.1 Esophageal Injuries 267
6.1.1 Classification 267
6.1.2 Pathophysiology, Diagnosis, and Treatment of Esophageal Injuries 268
6.1.2.1 External Trauma and Iatrogenic Lesions 268
6.1.2.2 Boerhaave’s Syndrome 270
6.1.2.3 Ingestion of Foreign Bodies 273
6.1.2.4 Caustic Injuries 274
6.2 Gastric Injuries 277
References 277
7: Liver 279
7.1 Introduction 279
7.2 Trauma Mechanism and Epidemiology 279
7.3 Diagnostic Procedures 280
7.3.1 Clinical Evaluation 280
7.3.2 Diagnostic Peritoneal Lavage 280
7.3.3 Radiological Evaluation 280
7.4 Therapy 282
7.4.1 Non Operative Therapy 282
7.4.2 Operative Therapy 283
7.4.2.1 Draping 283
7.4.2.2 Initial Actions 283
7.4.2.3 Access to the Liver 283
7.4.2.4 Pringle Maneuver 283
7.4.2.5 Packing 284
7.4.2.6 Selective Resection 284
7.4.2.7 Tubes and Catheters 284
7.4.2.8 Miscellaneous Techniques 285
7.4.2.9 Arterial Injuries 285
7.4.2.10 Venous Injuries 285
7.4.3 Interventional Radiology 285
7.5 Prognosis 285
7.5.1 Mortality Rate 285
7.5.2 Infections and Abscesses 286
7.5.3 Necrosis 286
7.5.4 Bile Leakage 286
7.5.5 Prognosis Depends on Concomitant Injuries 286
7.5.6 Non-Liver Related Complications 286
References 286
8: Splenic Injuries 288
8.1 Introduction 288
8.2 Reasons for Splenic Preservation 288
8.3 Accessory Spleen, Splenosis, and Autotransplantation 289
8.4 Diagnostic Procedures 290
8.5 Grading of Splenic Injuries 290
8.6 Strategies in Splenic Injuries 293
8.6.1 Nonoperative Management 293
8.6.2 Laparoscopy in Splenic Trauma 293
8.6.3 Methods of Splenic Repair 294
8.6.3.1 Parenchymal Suture (Fig. 8.7) 294
8.6.3.2 Use of Adhesives (Fig. 8.8) 295
8.6.3.3 Coagulation Techniques 295
8.6.3.4 Partial Resection 295
8.6.3.5 Mesh Splenorrhaphy 296
8.6.4 Splenectomy 297
8.7 Sequelae to Splenectomy 297
References 298
9: Pancreas, Duodenum, Small Bowel 299
9.1 Introduction 299
9.2 Trauma Mechanism and Epidemiology 299
9.2.1 Small Bowel and Mesentery 299
9.2.2 Duodenum and Pancreas 300
9.3 Diagnostic Procedures 300
9.3.1 Clinical Evaluation 300
9.3.2 Radiological Investigations 301
9.3.3 Grading of Organ Injuries 301
9.4 Therapy 302
9.4.1 Nonoperative Management 302
9.4.2 Operative Management 302
9.4.2.1 Pancreas and Duodenum 302
9.4.2.2 Small Bowel and the Mesentery 304
9.5 Prognosis 304
9.5.1 Pancreas and Duodenum 304
9.5.2 Small Bowel 305
References 305
10: Colorectal Injuries 306
10.1 Introductory Statements 306
10.2 Anatomy 306
10.3 Ethiology 307
10.4 Diagnostic Work-up 308
10.5 Past Medical History 308
10.6 Extended Diagnostic Work-up 308
10.6.1 Ultrasound 308
10.6.2 Laboratory Work-up 308
10.6.3 Conventional X-Ray 308
10.6.4 CT Scan 309
10.6.5 Invasive Diagnostics 309
10.6.5.1 Procto-Rectoscopy 309
10.6.5.2 Peritoneal Lavage 309
10.6.5.3 Laparoscopy 309
10.6.5.4 Explorative Laparotomy 310
10.7 Classification 310
10.8 Therapy 310
10.8.1 Conservative 310
10.9 Operative Therapy 311
10.9.1 Patient Consent 311
10.9.2 Patient Preparation for Surgery 311
10.9.3 Priorities 311
10.9.4 Principles 311
10.9.5 Complications and Results from Literature 313
References 316
11: Abdominal Compartment Syndrome, Abdominal Decompression, and Temporary Abdominal Closure 318
11.1 Intra-Abdominal Hypertension and Abdominal Compartment Syndrome 318
11.1.1 Introduction 318
11.1.2 Definitions 318
11.1.3 Pathophysiological Effects of IAH and ACS 319
11.1.3.1 Cardiovascular System 319
11.1.3.2 Respiratory System 319
11.1.3.3 Renal Implications 320
11.1.3.4 Gastrointestinal Effects 320
11.1.3.5 Central Nervous System 320
11.1.3.6 ACS and Multiple Organ Failure 320
11.1.4 Intra-Abdominal Pressure Measurement Techniques 321
11.1.4.1 Indirect Intra-Vesical Pressure Measurement Via the Bladder 322
11.1.4.2 Indirect IAP Measurement Via the Stomach 322
11.1.5 Identification of Risk Patients and Prevalence of IAH and ACS 323
11.1.6 Prevention of ACS 324
11.1.7 IAP Monitoring 324
11.1.8 Management of IAH and ACS 324
11.1.8.1 Medical Treatment 326
11.1.8.2 Surgical Management of IAH and ACS 326
11.2 Abdominal Decompression and Temporary Abdominal Closure 327
11.2.1 Introduction 327
11.2.2 Pathophysiological Considerations and Complications Related to Open Abdomen 327
11.2.3 Avoidance and Management of Complications Related to the Open Abdomen 327
11.2.4 Methods of Temporary Abdominal Closure Techniques 328
11.2.4.1 Towel Clip Closure/Skin Closure Only 328
11.2.4.2 Bag Silo Closure (Bogota Bag) 329
11.2.4.3 Zipper Technique 329
11.2.4.4 Synthetic Mesh Closure 329
11.2.4.5 Vac Pac Closure 329
11.2.4.6 Abdominal Vacuum-Assisted Closure ( VAS) 330
11.2.4.7 Bogota-VAC 330
11.2.5 Fascial Closure and Abdominal Wall Reconstruction after an Open Abdomen 331
References 331
12: Trauma Laparotomy: Indications, Priorities, and Damage Control 333
12.1 Introduction 333
12.2 Indications and Priorities 333
12.2.1 Adjunctive Measures 335
12.3 Associated Extra-Abdominal Lesions 336
12.4 Patient’s Positioning and the Right Incision 336
12.4.1 Exploration 337
12.4.2 Hematoma 340
12.4.3 Resuscitative Measures 340
12.5 The Indications for Abbreviated Laparotomy – Damage Control Surgery 340
12.5.1 Patient Selection and Primary Operation 341
12.5.2 Physiological Restoration 341
12.5.3 Reoperation 342
12.5.4 Definitive Abdominal Wall Closure 342
References 342
13: Laparoscopic Procedures in Trauma Care 343
13.1 Introduction 343
13.2 Diagnosis with Blunt Abdominal Trauma 343
13.3 Why Laparoscopy? 344
13.4 Selection of Patients 344
13.5 Indications for Laparoscopy 345
13.6 How to Perform Laparoscopy in Trauma 346
13.7 The Risks of Laparoscopy in Trauma 348
References 348
14: Traumatic Injury of the Urogenital System 350
14.1 Introduction 350
14.2 Epidemiology 350
14.3 Trauma Mechanism and Related Urogenital Injuries 350
14.3.1 Kidneys and Ureter 350
14.3.2 Bladder and Urethra 351
14.3.3 Penis, Testicles, and Scrotum 351
14.4 Diagnostic Procedures 351
14.4.1 Clinical Evaluation and Imaging Studies 351
14.4.2 Kidney 352
14.4.3 Ureter 353
14.4.4 Bladder 353
14.4.5 Urethra 353
14.4.6 Penis 353
14.4.7 Testes and Scrotum 354
14.4.8 AAST-Grading Scale of Renal Injury 355
14.4.9 EAU-Classification of Blunt Anterior and Posterior Urethra Trauma [Adapted according to EAU Guidelines 2007] 355
14.5 Therapy 356
14.5.1 Renal and Ureteral Trauma 356
14.5.1.1 OP-Technique 359
Kidney 359
Follow-Up, Outcome, Complications 360
Ureter 361
14.5.2 Bladder Trauma 361
14.5.2.1 Follow-up 362
14.5.3 Posterior Urethral Trauma 362
14.5.4 Anterior Urethral Trauma 364
14.5.5 Penile Trauma 364
14.5.6 Scrotal and Testicular Trauma 364
References 366
15: Abdominal Vascular Injuries 368
15.1 Introduction 368
15.2 Anatomic Location of Injury 369
15.3 Operative Intervention 369
15.3.1 Pre-operative Preparations 369
15.3.2 Exposure and Incisions 370
References 378
16: Vascular Injuries of the Neck 380
16.1 Introduction 380
16.2 Operative Interventions 380
16.2.1 Pre-Operative Preparations 380
16.2.2 Anatomy of the Neck 381
16.2.3 Vascular Anatomy of the Neck 383
16.2.3.1 Carotid Artery 383
16.2.3.2 Jugular Vein 383
16.2.3.3 Vertebral Artery 383
16.2.4 Exposure and Incisions 383
16.2.4.1 Surgical Exposure Carotid Artery and Internal Jugular Vein 383
16.2.4.2 Surgical Exposure Vertebral Artery 384
16.2.5 Surgical Techniques 385
References 390
17: Vascular Injuries of the Lower Extremities 392
17.1 Introduction 392
17.2.1 Pre-Operative Preparations 392
17.2.2 Vascular Anatomy of Lower Extremities 392
17.2.2.1 Common Femoral Artery 392
17.2.2.2 Superficial Femoral Artery 393
17.2.2.3 Profunda Femoris Artery 393
17.2.2.4 Common Femoral Vein 393
17.2.2.5 Superficial Femoral Vein 393
17.2.2.6 Popliteal Artery 393
17.2.2.7 Popliteal Vein 394
17.2.2.8 Tibioperoneal Trunk 394
17.2.2.9 Anterior Tibial Artery 394
17.2.2.10 Posterior Tibial Artery 394
17.2.2.11 Peroneal Artery 394
17.2.3 Adjuncts 395
17.2.4 Lower Extremities Vessels’ Surgical Exposure 395
17.2.4.1 Common Femoral Artery and Vein 395
17.2.4.2 Superficial Femoral Artery and Vein 395
17.2.4.3 Popliteal Artery and Vein 395
17.2.4.4 Tibioperoneal Trunk 396
17.2.4.5 Anterior Tibial Artery 396
17.2.4.6 Posterior Tibial Artery 396
17.2.4.7 Peroneal Artery 396
References 399
18: Vascular Injuries of the Upper Extremities 401
18.1 Introduction 401
18.2 Operative Interventions 401
18.2.1 Pre-Operative Preparations 401
18.2.2 Vascular Anatomy Upper Extremity 402
18.2.2.1 Axillary Artery 402
18.2.2.2 Axillary Vein 402
18.2.2.3 Brachial Artery 402
18.2.2.4 Radial Artery 403
18.2.2.5 Ulnar Artery 403
18.2.2.6 Basilic Vein 403
18.2.2.7 Cephalic Vein 403
18.2.3 Adjuncts 403
18.2.4 Upper Extremities Vessels’ Surgical Exposure 404
18.2.4.1 Surgical Exposure Axillary Artery and Vein 404
18.2.4.2 Surgical Exposure Brachial Artery 404
18.2.4.3 Surgical Exposure of the Ulnar and Radial Arteries 404
18.2.5 Surgical Techniques 404
References 409
Index 410