Traumatic Small Bowel and Mesentery Injuries (SBMI)

Fig. 13.1

Decisional flowchart in traumatic abdominal hollow viscus injuries

The use of abdominal CT scan has resulted in an increase in nonoperative management of solid organ injury. Concomitant simultaneous reduction of use of DPL has lessened the number of exploratory laparotomies in blunt trauma, resulting in a greater risk of delay in diagnosis of bowel perforation. Undetected bowel injuries could progress to sepsis, multiple organ failure, and death.

Fakhry et al. demonstrate, by a retrospective analysis of mortality for intestinal perforation, that the longer is the delay to surgery progressively, the higher is the mortality rate (<8 h mortality 2 %, >24 h mortality 31 %) [13].

In Table 13.1 the AAST scale classification of small bowel injuries is reported.

Table 13.1

Small bowel injury scale from AAST

Grade	Type of injury	Description of injury	AIS-90
I	Hematoma	Contusion or hematoma without devascularization	2
I	Laceration	Partial thickness, no perforation	2
II	Laceration	Laceration <50 % of circumference	3
III	Laceration	Laceration >50 % of circumference without transection	3
IV	Laceration	Transection of the small bowel	4
V	Laceration	Transection of the small bowel with segmental tissue loss	4
V	Vascular	Devascularized segment	4

From www.aast.org

13.4 Treatment

Timing to surgery for isolated SBMI depends on hemodynamic status of trauma victims and accuracy of diagnosis.

Therefore, laparoscopy could have a double role: diagnosis in cases of dilemma on possible SBMI (e.g., stab wound) and treatment, avoiding unnecessary laparotomies. This device is more effective in surgical teams experienced both in laparoscopy and trauma management. Most of all for gastrointestinal injuries, laparoscopy has a low sensitivity [14]. Kawahara and colleagues concluded that by standard protocol for laparoscopic exploration, undetected SBMI can be minimized to zero [15].

When SBMI is identified, it must be treated.

Perforation mandates a segmental resection. Also in case of full-thickness wall injury, even without perforation, resection should be considered.

Hemostasis of mesenteric hemorrhage could be enough, but sometimes, sequential ischemia of tributary tract of small bowel can force the surgeon to perform resection. In cases of multiple jejunal and ileal injuries, conservative treatment becomes difficult to perform, but in any case, digestive function must be compromised.

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