**5. Complications associated with operative management of abdominal trauma**

Both of the penetrating and blunt abdominal traumas can be managed with operative approach. The main indicators for an operation are hemodynamic instability and evidence of peritonitis. Penetrating abdominal trauma especially those caused by bullets should be treated operatively. Like non-operative approach most patients undergoing operative management recover smoothly without complications. However, in certain instances complications develop. Notably, to avoid the occurrence of these complications, the management should be performed holistically via five steps namely: (1) preoperative interaction with and evaluation of the patient, (2) choice and planning of the operation, (3) execution of the operation, (4) formulating of the correct diagnosis, and (5) post-operative and long-term care. Certain actions should be performed at each of these steps in order to avoid the occurrence of complications. Shown in **Table 10** are some the tasks to perform in order to favor good operative outcome for abdominal trauma patients. Failure to perform one or more of these tasks at any of these steps increases risks of complications. The principle complications to associate with operative management of abdominal trauma are listed in **Table 11**.

#### **5.1 Hypothermia, coagulopathy and metabolic acidosis**

Hypothermia, coagulopathy and metabolic acidosis form the triad of complications associated with operative management of abdominal trauma. These complications are associated with higher morbidity and mortality. Opening abdominal cavity and prolonged operation for abdominal organs leads to loss of temperature via evaporation. The reduced temperature reduces the rate of blood clotting and coagulation catalytic enzymes. Thus, impaired blood clotting and coagulation process leads to excessive bleeding which eventually results into hypovolemic shock. Hypo-perfusion leads to anaerobic respiration with the release of lactic acid which is the hallmark of metabolic acidosis.

#### **5.2 Hypovolemic shock**

Hypovolemic shock is the common complication to associate with operative management of traumatic abdominal patient. The association between hypovolemic shock and operative management of abdominal trauma can be explained in several ways for instance: (1) the fact that, most abdominal organs are highly vascularized; injuries to either organ can cause severe bleeding and shock. Surgery on abdominal organs such as liver, spleen is a problematic as there can often be a large amount of blood loss


#### **Table 10.**

*Some of tasks to perform in order to maximize the operative outcome for abdominal trauma patient.*

associated with operations, and increase the morbidity and mortality, (2) in case of prolonged operation more fluids evaporate and this compound hypovolemia state, and (3) fluid loss into the interstium as result of inflammation also take place during surgery and complexes hypovolemic state.

Like any other type of shock, hypovolemic shock leads to tissue hypoperfusion, followed by deprivation of nutrients and oxygen to tissues and provoke anaerobic respiration with the release of lactic acid as hallmark of metabolic acidosis. The cellular damage provoked by insufficient delivery of oxygen and substrates induces the formation and releases of damage associated molecular patterns (DAMPs, also called danger signals) and inflammatory mediators which further compromise tissue hypo-perfusion. Typically body's responses to any kind of shock are too complex, and


**Table 11.**

*Examples of complications to associate with operative management of abdominal trauma.*

can be useful and dangerous. Stimulation of dramatic network of inflammatory mediators by innate immune system is the most dangerous responses to occur after shock. These inflammatory responses contribute to the progression of shock, development of multiple organs injury, multiple organs dysfunction and multiple organs failure and finally death.

#### **5.3 Infectious complications**

Infections remain the most dreaded complications in surgical practice. Typically infection refers to the presence of microorganisms in a normal sterile site with subclinical or symptomatic. In surgical practice infections associated with operative management can be described in terms of cleanliness of surgery performed. The type and incidence of infections include: (1) clean surgery (≤ 5%), (2) clean -contaminated surgery (5–15%), (3) contaminated surgery (10–25%), and (4) dirty surgery (30– 80%). Operation to penetrating abdominal injury is an example of dirty surgery. Operative management for an abdominal trauma and infections are frequently associated. The major determinants for infectious complications include: (1) the infecting organisms, (2) patient and his disease, (3) environments, equipments and medical personnel, and (4) conduct of an operation. To better understanding these determinants, the following formulas can be used to describe the relations ship between certain variables.

$$\text{Inflections and their severity } \alpha \frac{the\ dose \ (number\ of\ information)\ times\ virulence}{immunity\ of\ the\ patient} \quad \text{(2)}$$

$$\text{Or\ infections and its complexities\ } \alpha \frac{micropiology \ times\ equivalence}{amotopy\ times\ immunology} \qquad \text{(3)}$$

Given the significance of these expressions in terms of understanding infectious complications associated with abdominal trauma and operative management deserves comments. Firstly, for any infection to occur the pathogen and host must encounter each other. It is clear that, Infections and their severity is directly proportional to dose and virulence of microbes but inversely proportional to immunity of the patient.

Factors which increase numerator and reduce the denominator of this expression increase the burden of infections. Among traumatic abdominal patients, factors that are likely to increase numerator include: penetrating abdominal injury (open wounds), use of contaminated instruments, and spillage of abdominal contents into the peritoneal cavity, whereas factors that can reduce denominator include any conditions which can reduce immunity such as HIV/AIDS, immunosuppressive drugs, undernutrition etc. Otherwise second expression also indicates that, increased microbiology and epidemiology and impaired anatomy and immunology also increase the burden of infections. Further, emphasis for understanding these expressions can be made by using spleenectomy as an example. Spleen has significant immunological functions; overwhelming infectious complications caused by encapsulated bacteria (e.g., *H. influenzae*, *S. pneumoniae*, *and N. meningitidis*) [5] have been reported after spleenectomy.

#### **5.4 Sepsis and septic shock**

Sepsis and septic shock is dangerous bomb which kill human body cells. The hall mark of sepsis is presence of clinical evidence of infection plus systemic response to infection. Various mechanisms can lead to infections which may further progress to sepsis and septic shock. Contamination by penetrating injuries, hematogenous spread, local inoculation, and iatrogenic introduction of microbes into the sterile site are examples of portal of entry for microbes which result into infections. If infections are not recognized and treated promptly further progression to sepsis and septic shock develop. Septic shock can be in two forms namely warm phase, and cold phase. Warm phase is marked by higher peripheral circulation as the compensatory mechanism. This phase is transient and failure to treat the patient with an appropriate therapy leads to un-compensatory shock (cold phase). The dangerous outcome of septic shock include: low flow state (volume reduction), tissue injury, pump failure and more infections.

The cause of death for septic shock patient is multiple organs failure. Evidence has shown that, failure of four body systems leads to death 100%. Only possible way for avoiding this tragedy to happen is to avoid the occurrence of infections and in case infections have occurred early institution of appropriate therapy (with antimicrobial agents, remove the source of infections and supportive care such as oxygen and fluids to correct circulation and respiratory compromise) would favor the rescue to the patient.
