Trauma Ginjal

TRAUMA GINJALSUB BAGIAN UROLOGI BAGIAN/SMF BEDAH FK UNS/RSUD Dr. MOEWARDI PENDAHULUAN • 10% trauma abdomen  trauma traktus urogenitalis • Trauma urogenitalis  trauma ginjal >>>  5% trauma abdomen • Dewasa muda sekitar 74%, usia tua 15%, dan anak-anak 9% • Sering bersama trauma organ lain (multiorgan trauma). • AS : trauma ginjal bersama hepar (40%), lien (5-7%), pankreas (13%), kolon (7%) dan usus halus / gaster (3%) ETIOLOGI Trauma tumpul (Blunt Injury)  80-85% Mekanisme trauma tumpul ginjal : 1. Trauma langsung pinggang kosta 11 & 12 fraktur  melukai ginjal 2. Trauma tumpul bagian depan abdomen 3. Jatuh terduduk dari ketinggian or vessel thrombosis .AAST Renal Injury Grading Scale Grade* Description of Injury Contusion or non-expanding subcapsular 1 haematoma No laceration 2 Non-expanding peri-renal haematoma Cortical laceration < 1 cm deep without extravasation Cortical laceration < 1 cm without urinary 3 extravasation Laceration: through corticomedullary junction into 4 collecting system Or Vasculary: segmental renal artery or vein injury with contained haematoma. or partial vassel laceration. ETIOLOGI Trauma tembus (penetrating injury) 1. luka tembak (gun shot) . intervensi operatif . 80% luka tembus ginjal  trauma visera intraabdomen . luka tusuk (stab wound) 2. KLASIFIKASI . Fraktur costa bawah 5. Hemodinamik tidak stabil (hipotensi) .DIAGNOSIS 1. Hematoma di regio flank 4. Hematuria (95%) 3. Riwayat trauma 2. abdominal tenderness. lithiasis) should be recorded B A though examination should be made of the thorax. fractured ribs. flank pain. distension or mass. large cysts. and known pre-existing renal abnormalities (ureteropelvic junction obstruction.History and Physical Examination Recommendations Haemodynamic stability should be decided upon admission History should be taken from conscious patient. flank absasions and ecchymoses. witnesses and rescue team personnel with regard to the time and setting of the incident GR B C Past renal surgery. abdomen. flanks and back for penetrating wounds B Findings on physical examination such as haematuria. could indicate possible renal involvement B . until evaluation is complete. It not be clean whether it is due to renal trauma and or associated injuries. However.Laboratory Evaluation Recommendations GR Urine from a patient with suspected renal injury should be inspected grossly and then by dipstick analysis B Serial haematocrit measurement indicates blood loss. B Creatinine measurement could highlight patient who had impaired renal function prior to injury C . PEMERIKSAAN IMEJING GINJAL Dahulu: IVP  skg: CT Scan kontras Jk fasilitas CT Scan (-)  pakai IVP Indikasi: 1. Trauma deselerasi 4. Trauma tembus regio flank / abdomen tdk lihat derajat hematuria 2. Trauma abdomen / flank penderita anak dengan hematuria . Trauma mayor berhubungan trauma intra-abdominal & mikrohematuria 5. Trauma tumpul dewasa dg gross hematuria /mikrohematuria + shock (sistolik < 90 mmHg) 3. although more data is required to suggest this modality university C A CT scan with enchancement of intravenous contrast material is the best imaging study for the diagnosis and staging of renal injuries in haemodynamically stable patients B Unstable patients who require emergency surgical exploration should undergo a one-shot IVP with bolus intravenous unjection of 2mL/kg contrast C Formal IVP/.Imaging Recommendation GR Blunt trauma patients with macroscopic or microscopic haematurial (at least 5rbc/hpf) with hypotention (systolic blood preassure <90mmHg) should undergo radiographic evaluation B Radiographic evaluation is also recommended for all patients with a history of rapid declaration injury and/or significant associated injuries. B All patients with any degree of haematuria after penetrating abdominal or thoracic injury require urgent renal imaging B Ultrasonograpy can be informative during the primary evaluation o polytrauma patients and for the follow-up of recuperating patients. MRI and radiographic scintigraphy are acceptable secondline alternative for imaging renal trauma when CT is not availabel C Angiography can be used for diagnosis and simultaneous selective embolisation of bleeding vessels B . PENGELOLAAN NON OPERATIF • 98% trauma tumpul renal • Penderita hemodinamik stabil & staging (+) & CT Scan (+) • Trauma tembus luka tembak / tusuk  staging hati-hati dg CT Scan  monitor ketat • 55% trauma tusuk & 24% trauma luka tembak  nonoperatif • Trauma derajat III & IV  monitor ketat (serial hematokrit & CT Scan) • perdarahan persisten  angiografi  embolisasi . stable patients should be manage conservatively with bed-rest. stable patients. after complete staging. should be selected expectant management B Indicated for surgical management include Haemodynamic instability Exploration for associated injuries Expanding or pulsatile peri-renal haematoma identified during laparotomy Grade 5 injury Incidental finding of pre-existing renal pathology requiring surgical therapy Renal reconstructing should be attempted in cases with where the primary goal of controlling haemorrhage is B B .Non-operative Management of Renal Injuries Recommendations GR Following grade 1-4 blunt renal trauma. prophylactics antibiotic and continuous of vital signs until haematurial resolves B Following grade 1-3 stab and low-velocity gunshot wounds. perdarahan ginjal yang persisten  hematoma meluas. trauma renal derajat V . denyut. hematom retroperitoneal 2.EKSPLORASI GINJAL INDIKASI ABSOLUT 1. trauma tumpul dg hematom retroperitoneal & kelainan pd ’single shot’ IVP . trauma grade IV dg laserasi pelvis renalis. trauma derajat III & IV dg jar non-vital luas & trauma organ intraperitoneal 3. parenkim ginjal & sistem kolektivus & avulsi UPJ 4. abses perinefrik. urinoma terinfeksi.EKSPLORASI GINJAL • INDIKASI RELATIF 1. & perdarahan 2. Trauma tumpul & tembus ginjal  komplikasi: ekstravasasi urin persisten. Algoritma Pengelolaan Trauma Ginjal . (a)IVP pada trauma tumpul ginjal dengan trauma pada pelvis renalis yang ditunjukkan ekstravasasi kontras (b)Tomogram yang menunjukkan trauma ginjal mengenai kaliks pole bawah . TRAUMA VASKULAR • Trauma vaskular renal (50%)  syok (+)  mortalitas 10-50% • Trauma arteri renalis sulit utk diselamatkan & rekonstruksi • Pembedahan rekonstruksi < 12 jam  >>> diselamatkan  keberhasilan revaskularisasi 10-30%.  ↓ fs ginjal CT Scan ginjal menunjukkan absen komplit kontras pada ginjal kiri oleh karena adanya avulsi komplit pedikel renal . Arteriografi menunjukkan oklusi komplit arteri renalis kiri sekunder akibat trombus Pergerakan ginjal ok deselerasi  peregangan arteri renalis  ruptur intima  trombus . menunjukkan kurangnya perfusi kontras ke ginjal (kiri).TROMBOSIS ARTERI RENALIS  NEFREKTOMI CT Scan ginjal kiri dengan trombosis arteri renalis. simfisis pubis • Kolon transversum  rongga dada (bungkus kasa lembab) • Identifikasi cab a. mesenterika superior smp retroperitoneum perluas keatas dr lig Treitz • V. renalis sin  tanda identifikasi pd renalis  tegel dipasang . mesenterika inf  petunjuk insisi  diseksi hingga ant perm aorta • Diseksi smp sup hingga v. mesenterika pd usus halus • Angkat usus keatas dan ke kanan  retroperitoneum tampak • Insisi vertikal di atas aorta superior dr a.EKSPLORASI & REKONSTRUKSI GINJAL • Insisi midline transabdominal dr proc xiphoideus . parenkim & pd • Rekonstruksi  debridement adekuat: jar mati dibuang  preservasi kapsula renalis utk penutupan ginjal • Ligasi PD parenkim kromik 4/0 • Laserasi sistem kolektivus dijahit scr kedap air (watertight fashion) kromik 4/0. • Inj metilen blue ke pelvis renalis  identifikasi trauma lain & penutupan sistem kolektivus • Tutup kapsula renalis reaproksimasi tepi parenkim  jahitan interrupted Vicryl 3/0 • Jk defek ginjal luas  packing dg agen hemostasis (Avitene. Tissel. lemak perinefrik) .EKSPLORASI & REKONSTRUKSI GINJAL • Kontrol PD (+)  evakuasi hematom retroperitoneal • Insisi fasia Gerota di lateral  ginjal terpapar  evaluasi pelvis renalis. EKSPLORASI & REKONSTRUKSI GINJAL • Segmen pole ginjal tidak vital (+)  parsial nefrektomi (amputasi & penutupan sistem kolektivus)  pakai omentum utk tutup defek pole ginjal jk kapsula renalis (-) • Pasang Penrose drain (drainase retroperitoneum) Suction drain tidak boleh . EKSPLORASI & REKONSTRUKSI GINJAL . EKSPLORASI & REKONSTRUKSI GINJAL . EKSPLORASI & REKONSTRUKSI GINJAL . EKSPLORASI & REKONSTRUKSI GINJAL . EKSPLORASI & REKONSTRUKSI GINJAL . DAMAGE CONTROL • Coburn (2002): keuntungan  ↑ penyelamatan ginjal •  packing dg laparotomy pads  kontrol perdrhn & dibuka kembali dalam 24 jam  eksplorasi & evaluasi luas trauma • mencegah nefrektomi total . vaskular & kombinasi.NEFREKTOMI Indikasi : • Trauma ginjal ekstensif. & koagulasi buruk  renal repair tdk mgkn (fs ginjal kontralateral N) • Nash dkk (1995)  77% nefrektomi (+) ok perdrhn parenkim luas. hemodinamik tidak stabil. suhu tubuh rendah. 23% ok hemodinamik tdk stabil dg ginjal dpt direkonstruksi. . Complication Recommendations Complication following renal trauma require a thorough radiographic evaluation Medical management and minimally invasive technique should be the first choice for the management of complications Renal salvage should be the surgeon’s aim for patients in whom surgical intervention is necessary GR B C C . angiografi & embolisasi • hipertensi arterial . infeksi perinefrik & kehilangan ginjal  Obs ketat & AB tepat • Perdarahan ginjal tertunda (21 hari)  bedrest. hidrasi.KOMPLIKASI • Ekstravasasi urin persisten  urinoma. Individualized radiological investigation 4. Serum determination of renal function Long-term follow-up should be dedicated on a case-bycase basis but should at the very last involve monitoring for renovascular hypertension GR B C C C . Physical examination 2. Repeat imaging is always recommended in cases of fever. Serial blood pressure measurement 5. patients follow-up should involve: 1. flank pain.Post Operative Care and Follow-Up Recommendations Repeat imaging is recommended for all hospitalized patients within 2-4 days of significant renal trauma (although no specific data exists). Urinalysis 3. or falling haematrocrit Nuclear scintigraphy before discharge from the hospital is useful for documenting functional recovery Within 3 month of major renal injury. Patient with associated abdominal injury regardless of the findings of urinalysis 3. direct flank trauma. or all a fall from a height Ultrasonography is the considered a reliable method of screening and monitoring blunt renal injuries by some researchers.Paediatric Renal Trauma Recommendations Indications for radiography evaluation of children suspect of renal trauma include: 1. Patient with normal urinaluses who sustained a rapid deceleration event. but is not universally accepted CT scanning is the imaging study of choice for staging renal injuries Haemodynamic instability and a diagnoses grade 5 injury are absolute indications for surgical GR B B B B . Blund and penetrating trauma patients with any level of haematuria 2. Renal Injury in The Polytrauma Patient Recommendations Polytrauma patients with associated renal injuries should be evaluated on the basic of the most threatening injury GR C In case where surgical intervention is chosen. all associated injuries be evaluated simultaneously C The decision for conservative management should consider all injuries independently C . and. in case of failure. type of injury and the patients’ conditions Hyperselective embolisation may control arterial bleeding during percutaneous procedures GR C C C C . with a stent graft Surgical venous injuries should be managed with venorrhaphy or patch agioplasty The transoanted kidney should be evaluated on the basis of renal function.Percutaneous Renal Procedures Recommendations Latrogenic rupture of the main renal artery should be treated with balloon tamponade. Algorithm for The Management of Paediatric Renal Trauma Paediatric renal trauma Blunt Penetrating UA UA >50 rbc/hpf or deceleration UA <50 rbc/hpf or haemodynamically stable Stable >5 rbc/hpf Unstable Unstable CT Scan Abdominal exploration Abdominal exploration CT Scan Observes Observes Stable Renal exploration IVP NL Observes ABNL Renal exploration Renal exploration IVP NL Observes ABNL Renal exploration . Evaluation of Bunt Renal Trauma in Adults Suspected adult blunt Renal trauma Determine haemodynamic stability Stable Unstable Microscopic haematueria Gross haematueria Renal Imaging Rapid deceleraton Injury or Major associated injuries Grade 1-2 Grade 3-4 Emergency laparotomy One-shot IVP Observation Normal IVP Stable Retroperitoneal haematoma Grade 5 Observation. bed rest. antibiotics Associated injuries requiring laparotomy Renal exploration Pulsatile or expanding Abnormal IVP . Serial Ht. Serial Ht. antibiotics Associated injuries requiring laparotomy Normal IVP Retroperitoneal haematoma Pulsatile or expanding Renal exploration Abnormal IVP .Evaluation of Penetrating Renal Trauma in Adults Suspected adult blunt Renal trauma Determine haemodynamic stability Stable Unstable Emergency laparotomy One-shot IVP Renal Imaging Grade 3 Grade 4-5 Grade 1-2 Observation Stable Observation. bed rest.