What is the management for a 20-year-old male with blunt abdominal trauma and operative findings of a transected duodenum (part 3) and massive hemoperitoneum?

Management of Transected Duodenum (Part 3) with Massive Hemoperitoneum

This patient requires immediate damage control laparotomy without delay—every 3 minutes of delay increases mortality by 1%, and the combination of a transected duodenum with massive hemoperitoneum in an unstable patient mandates abbreviated surgery focused on hemorrhage control, contamination control, and temporary closure. 1

Immediate Surgical Priorities

Hemorrhage Control First

• Control the massive hemoperitoneum immediately through packing, direct pressure, and identification of bleeding sources before addressing the duodenal injury 1
• Massive transfusion protocol should be activated immediately, as delayed laparotomy increases 24-hour mortality by a factor of 1.5 for every 10-minute delay 1
• The presence of massive hemoperitoneum with hemodynamic instability is an absolute indication for immediate laparotomy per European, German, and American guidelines 1

Damage Control Surgery Approach

Given the operative findings of transected duodenum with massive hemoperitoneum, this patient requires damage control surgery with the following sequence: 1

• Abbreviated initial operation focusing on:

  • Rapid hemorrhage control through packing and ligation of bleeding vessels 1
  • Contamination control of the transected duodenum 1
  • Temporary abdominal closure with planned return to OR 1

• For the transected duodenum (D3), damage control options include: 1

  • Staple off both ends of the transected duodenum if tissue quality is poor
  • Pyloric exclusion with gastric decompression and external biliary drainage
  • Temporary tube duodenostomy for drainage
  • Avoid definitive reconstruction during initial damage control operation 1

Criteria for Damage Control Surgery

This patient meets multiple criteria mandating abbreviated laparotomy: 1

• Hemorrhagic shock with massive hemoperitoneum
• Complex duodenal injury requiring time-consuming repair
• Anticipated physiologic derangement (acidosis pH <7.2, hypothermia <34°C, coagulopathy) 1
• Need for deferred intestinal anastomosis 1

Definitive Management (Staged Approach)

After Initial Resuscitation (24-48 hours)

Once the patient is physiologically optimized in ICU with correction of acidosis, hypothermia, and coagulopathy, return to OR for definitive repair: 1

For transected D3 (third portion of duodenum): 1, 2

• Primary repair with single-layer closure if tissue edges are viable and there is minimal tissue loss
• Resection with primary duodenoduodenostomy if the gap is small (<2 cm) and tension-free anastomosis is possible 2
• Roux-en-Y duodenojejunostomy if there is significant tissue loss or the gap is too large for primary anastomosis 1
• Ensure adequate drainage with closed suction drains placed near the repair 3, 4

Pancreatic Assessment

• Carefully inspect the pancreatic head and body for associated injury, as duodenal injuries frequently involve the pancreas 3, 4
• If pancreatic duct injury is identified, manage with appropriate drainage; pancreaticoduodenectomy is reserved only for combined devastating injuries to both duodenum and pancreatic head 3, 4

Critical Pitfalls to Avoid

• Never attempt definitive duodenal reconstruction during the initial damage control operation in a hemodynamically unstable patient with massive hemoperitoneum—this increases mortality significantly 1
• Do not perform pancreaticoduodenectomy unless there is complete destruction of both the duodenum and pancreatic head; this is indicated in <3% of cases and carries extremely high morbidity in the emergency setting 1, 3, 4
• Avoid delayed laparotomy—patients with delayed surgery (>24 hours) have fourfold increased mortality compared to immediate operation 1
• Do not close the abdomen primarily if there is concern for abdominal compartment syndrome, ongoing bleeding, or need for second-look operation 1

Postoperative Management

Nutritional Support

• Initiate total parenteral nutrition early, as duodenal injuries require prolonged bowel rest (typically 7-14 days) 5
• Nasogastric decompression should be maintained until bowel function returns 3, 5

Monitoring for Complications

• Duodenal leak occurs in 25-50% of grade 3 injuries and requires aggressive drainage 2
• Serial imaging and clinical assessment for abscess, fistula formation, or ongoing bleeding 2
• Consider repeat laparotomy if clinical deterioration occurs or source control is inadequate 1