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Canadian Climate Guy is a personal Blog related to climate science, climate news as well as related subjects and viewpoints.
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The science on climate is anything but settled, even though the proponents of Anthropogenic Global Warming (AGW) say otherwise, and the Main Stream Media reporting to the contrary.
After years of personal research and exploration into the subject of Manmade (anthropogenic) Global Warming, or what is now referred to as "Climate Change", it became very obvious to me that the science of climate change was very unsettled and that our understanding of such a complex and chaotic system as the planets climate is still very much in its infancy.
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|This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unverifiable material may be challenged and removed. (August 2008)
|Charles Stross
| File:Charles Stross 2005.JPG
Charles Stross at Worldcon 2005 in Glasgow
| 18 October 1964
Leeds, England
|Writer, former Programmer and Pharmacist
|Writing period
|Science fiction, fantasy, horror
|Official website
Charles David George "Charlie" Stross (born Leeds, 18 October 1964) is a writer based in Edinburgh, Scotland. His works range from science fiction and Lovecraftian horror to fantasy.
Stross is sometimes regarded as being part of a new generation of British science fiction writers who specialise in hard science fiction and space opera. His contemporaries include Alastair Reynolds, Ken MacLeod, Liz Williams and Richard Morgan. Obvious inspirations include Vernor Vinge, Neal Stephenson, William Gibson, and Bruce Sterling, among other cyberpunk and postcyberpunk writers as well as older figures such as H. P. Lovecraft, Roger Zelazny and Robert A. Heinlein.
In the 1970s and 1980s, Stross published some role-playing game articles for Advanced Dungeons & Dragons in the White Dwarf magazine. Some of his creatures, such as the death knight, githyanki (borrowed from George R. R. Martin's book, Dying of the Light), githzerai, and slaad (a chaotic race notable for their rigid caste system) were later published in the Fiend Folio monster compendium.
His first published short story, "The Boys", appeared in Interzone in 1987. His first novel, Singularity Sky was published by Ace Books in 2003 and was nominated for the Hugo Award. A collection of his short stories, Toast: And Other Rusted Futures appeared in 2002. Subsequent short stories have been nominated for the Hugo Award, Nebula Award, and other awards. His novella "The Concrete Jungle" (available online) won the Hugo award for its category in 2005. His novel Accelerando (also available online) won the 2006 Locus Award for best science fiction novel, was a finalist for the John W. Campbell Memorial Award for the year's best science fiction novel, and was on the final ballot for the Hugo Award in the best novel category. Glasshouse won the 2007 Prometheus Award and was on the final ballot for the Hugo Award in the best novel category. His novella Missile Gap (likewise available online) won the 2007 Locus Award for best novella and most recently he was awarded the Edward E. Smith Memorial Award or Skylark at Boskone 2008.
In addition to working as a writer of fiction he has worked as a technical author, freelance journalist, programmer, and pharmacist at different times. He holds degrees in Pharmacy and Computer Science.
Rogue Farm, an animated film based on his 2003 short story of the same title, debuted in August 2004.
He was one of the Guests of Honour at Orbital 2008 the British National Science Fiction convention (Eastercon) in March 2008.
He is the Author Guest of Honour at the Maryland Regional Science Fiction Convention (Balticon) in May 2009.
Non-Fiction Edit
- The Web Architect's Handbook, published 1996, ISBN 0-201-87735-X
Stand Alone WorksEdit
- Scratch Monkey, unpublished, 1993
- A Colder War, published 2000
- Toast: And Other Rusted Futures, published 2002, ISBN 1-58715-413-7 (short story collection)
- Accelerando, published 2005, ISBN 0-441-01284-1 (2006 Hugo Award nominee for Best Novel)
- Glasshouse, published 2006, ISBN 0-441-01403-8 (set in the same universe as Accelerando; 2007 Hugo Award nominee for Best Novel)
- Missile Gap, published 2007, ISBN 1-59606-058-1 (novella)
- Halting State, published 2007, ISBN 978-0-441-01498-9 (2008 Hugo Award nominee for Best Novel)
- Saturn's Children, published 2008, ISBN 0-441-01594-8
Eschaton series Edit
This series is "a post-singularity space opera."
- Singularity Sky, published 2003, ISBN 0-441-01072-5 (2004 Hugo Award nominee for Best Novel)
- Iron Sunrise, published 2004, ISBN 1-84149-335-X (2005 Hugo Award nominee for Best Novel)
The "Bob Howard - Laundry" series Edit
This series is "cross-genre... combining aspects of science fiction, information technology (with a subtle nod to the BOFH), Lovecraftian horror, and the classic British spy thriller."
- The Atrocity Archives, published 2004, ISBN 1-930846-25-8 (contains the Hugo Award-winning novella "The Concrete Jungle")
- The Jennifer Morgue, published 2006, ISBN 1-930846-44-4 (also contains the extra story "Pimpf")
- "Down on the Farm", published 2008.
Merchant Princes series Edit
The Merchant Princes is a series in which some humans have a hereditary ability to travel between parallel Earths, that have differing levels of technology. This series is science fiction, even though it was originally marketed by the publisher as fantasy.
The first three books were collectively nominated for and won the Sidewise Award for Alternate History in 2007.
- The Family Trade, published 2004, ISBN 0-7653-0929-7
- The Hidden Family, published 2005, ISBN 0-7653-1347-2
- The Clan Corporate, published 2006, ISBN 0-7653-0930-0
- The Merchants' War, published 2007, ISBN 0-7653-1671-4
- The Revolution Business, forthcoming April 2009[1]
- The Trade of Queens, forthcoming 2010
Omnibus titles Edit
The Science Fiction Book Club has published omnibus editions that combine two books, without new material.
- Timelike Diplomacy, published 2004, combines Singularity Sky & Iron Sunrise
- On Her Majesty's Occult Service, published 2007, combines The Atrocity Archives & The Jennifer Morgue
References Edit
- ↑ Incidentally…, Charles Stross's blog, 23 August 2008
External linksEdit
|Sister project
|Wikiquote has a collection of quotations related to: Charles Stross
- Official Homepage and blog
- Template:Isfdb name
- The Family Trade has been coded by StoryCode
- A FAQ, mainly listing his published novels. The descriptions for the series came from this.
- Golden Gryphon Press official sites for The Atrocity Archives & The Jennifer Morgue
- Accelerando The complete text of Stross' novel, released as a free ebook under a Creative Commons license.
- "A Colder War" is available online at Infinity Plus
- Charles Stross's online fiction at Free Speculative Fiction Online
- Glasshouse in Librusec library.
- Life's a Game and Then you Die, regarding the future of online games.
- "The High Frontier, Redux", an article on the harsh realities of the future of space travel and colonization of the solar system and beyond.
- Interview conducted by Lou Anders at Infinity Plus
- Interview conducted by Nick Gevers at Science Fiction Weekly (2003)
- Interview extract from an interview in Locus (2003)
- Interview conducted by Martin Empson for Socialist Review, full text here. (2005)
- Mini Inverview conducted by John Joseph Adams for SCI FI WIRE (2006)
- Interview moderated by Cory Doctorow at The Well (2003)
- Interview conducted by Roger Deforest (2006)
|Stross, Charles
|Stross, Charlie
|Science fiction writer
|18 October 1964
|Leeds, England
de:Charles Stross fr:Charles Stross it:Charles Stross nl:Charles Stross ja:チャールズ・ストロス pl:Charles Stross sk:Charles Stross fi:Charles Stross uk:Чарльз Штросс


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- Anonimo
- Canada, Gruppo misto, 18-24
- Nomade principiante
- 3 Recensioni
The lady at the hostel was really nice.
- Anonimo
- Australia, Femmina, 18-24
- Nomade principiante
- 2 Recensioni
I'm so glad I decided to stay here! Initially, it looked a little far from the city centre on google maps, which deterred me at first, but the location is in fact a short 2-3 minute walk to the trap stop. Tucked away in a charming, hilly residential area, it's quiet and peaceful. Nice, clean rooms and facilities. Would definitely stay again!
Applicazioni di Hostelworld per cellulare
Prenota dove vuoi e quando vuoi con le nuove app per dispositivi mobili di Hostelworld.


text:
This week we opened our Pre-Loved Clothing Store (which is yet to be named). It was off to a slow start, but that was fortunate, armed with no experience under my belt but with loads of advice given by a beautiful lady from the 'Newlife Uniting Church- Op Shop' I was able to conduct business without too much worry.
I am going for a bit of a 'Boutique/Shabby Chic' look, arranging clothes according to colour and not size. With loads of quality clothes and shoes from the locals, we hope to attract customers from far and wide. The prices are very reasonable and comparable to most Op Shops. Actually in these first few weeks prices are set very low to attract as many customers as possible.
Pre-Loved Clothing StoreUnfortunately it looks like we may not be able to do a Grand Opening, however we will endeavour to have lots of 'Sale' days where we can give away many items at bargain prices.
This venture serves as a wonderful fundraiser for HART and I'm so glad that we can put the resources donated to us to good use.
If you're on the Gold Coast or just passing through, drop in and have a chat, and a look. Also, we'd never say no to any donation of clothing, shoes or other quality items.
I look forward to meeting you sometime soon.
Sharron Bain
Executive Officer
Hart Australasia Ltd


text:
Pineapple-Mint Coleslaw
Be the first to review
READY IN: 40mins
2Mrs Pie
Recipe by Mrs Pie
This is one of my favorite versions of coleslaw. Inspired by Vietnamese Coleslaw, I added pineapple and substituted ponzu sauce for the fish sauce.
See Discussion:
Ingredients Nutrition
- 2 garlic cloves, minced
- 2 tablespoons sugar
- 3 teaspoons rice wine vinegar or 3 teaspoons mirin
- 3 tablespoons lime juice
- 3 tablespoons ponzu sauce
- 2 tablespoons vegetable oil
- black pepper
- 1 small green cabbage, shredded
- 8 stalks of fresh mint, stalks removed and leaves chopped coarsely (reserve a few leaves for garnish)
- 1 (20 ounce) can pineapple chunks, drain juice for other use, slice chunks into smaller chunks (or use pineapple tidbits)
Directions See How It's Made
- Whisk together first 7 ingredients in a small bowl or 1-cup measuring glass, and set aside for half an hour.
- While dressing is melding, combine remaining ingredients in a large glass mixing bowl.
- When dressing is ready, pour dressing over salad ingredients and gently mix.
- Add salt and pepper to taste, if necessary.
- Garnish with reserved mint leaves and serve. Coleslaw may be refrigerated overnight (seal bowl with plastic wrap).


text:
8327 Cherokee Trail
Crossville, TN 38572
Beds: 2
Baths: 3
Sq. Ft.: 4,000
Listing #998461
Lake Front 4000 Sq Ft Home, located on larger lot with extensive interior features. Instant Hot Water at Kitchen sink, large cabinets include oversized pantry. Endless Storage, several bonus rooms, Full Finished Basement with additional living quarters, Outdoor living on both levels, open floor plan, three car garage, Cement driveway, dock on the water, irrigation system.
Property Features
Location Information
County: Cumberland County - 34
Latitude: 35.876308
Longitude: -85.073346
Subdivision: Eastlake Plat 5
Directions: Highway 101 (Lantana Rd) south to LEFT on Dunbar Road, follow into Lake Tansi, turn RIGHT across from Dollar General onto Cherokee Trail follow around to 8327 on LEFT, Sign in the yard
Interior Features
Rooms: Addl Living Quarter, Basement Rec Room, Den/Study, Extra Storage, Family Room, Great Room, Laundry/Utility, Mstr Bdrm Main Level, Workshop
Master Bedroom Dimensions: 12.5X15.5
Has Dining Room: yes
Dining Room Description: Eat-in Kitchen, Kitchen/Dining Rm Co
Living Room Dimensions: 16X18
Kitchen Dimensions: 18 X 15
Heating: Central
Fuel: Electric, Gas (Natural)
Cooling: Central Cooling
Appliances: Dishwasher, Microwave, Range/Oven, Refrigerator
Basement Description: Finished, Plumbed, Walkout
Has Basement: yes
Exterior Features
Style: Contemporary
Type: Basement Ranch
Construction: Masonry, Other
Exterior: Deck, Porch - Covered
Parking Description: 3 Car Garage
Has Garage: yes
Garage Spaces: 3
Lot Description: Lakefront
Lot Size in Acres: 0
Additional Information
Property Type: SFR
Year Built: 2000
APN: 149f A 012.00
Status: Active
Features: Cathedral Ceiling, Island in Kitchen, Pantry, Walk-in Closets, Walk-in Shower
Tax Amount: 1, 042.9
$ per month
Year Fixed. % Interest Rate.
|Principal + Interest:
|Monthly Tax:
|Monthly Insurance:
Based on a fully amortized fixed rate loan. Ask your agent for the tax rates in your area. Insurance estimate is based on an average cost, your final premium cost will be determined by the type of coverage you select. This program only provides an estimate.
Seller's Representative:
Star Realty
Star Realty
© 2017 Knoxville Area Association of REALTORS®. All rights reserved.
The data relating to real estate for sale on this website comes in part from the Internet Data Exchange (IDX) program of the Knoxville Area Association of REALTORS® (KAAR). IDX information is provided exclusively for consumers' personal, non-commercial use, and may not be used for any purpose other than to identify prospective properties consumers may be interested in purchasing. All Information Is Deemed Reliable But Is Not Guaranteed Accurate.
KAAR data last updated at August 22, 2017 2:09 PM ET
Real Estate IDX Powered by iHomefinder


text:
For whatever reason you want to switch away from Squarespace, here are the best Squarespace alternatives for building websites and online stores. Continue reading… Squarespace Alternatives 2017
WP Engine Review 2017
In this WP Engine Review, I will cover everything I know about WPE to help you decide if their hosting is best for your WordPress site. Continue reading… WP Engine Review 2017
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Emmy Awards
Public Media Connect was recognized with five regional Emmy Awards and 14 nominations.
The Vietnam War
A Film by Ken Burns & Lynn Novick; premieres Sunday September 17, 2017 at 8/7c
ThinkTV's weekly arts series
Sundays @ 5:30pm on ThinkTV16
PBS Kids 24/7
Watch your favorite PBS Kids shows on-air and online anytime, anywhere.
Watch the live stream on ThinkTV.org, Monday through Friday at 6:00 PM EST and the live stream of PBS NewsHour Weekend on Saturdays & Sundays at 5:00 PM EST.
PBS Food
Find recipes and more!


text:
100% Organic Spirulina 500mg Vegetarian Tablets
$ 16.00 – (100 count)
$ 36.00 – (250 count)
- Certified 100% Organic Spirulina
- Contains no film coating
- Small, easy-to-swallow tablet
- Provides an all-natural source of key nutrients and essential fatty acids
- Perfect for vegans and vegetarians seeking a bioavailable source of vitamin B-12
- Provides broad antioxidant support
- 500 milligrams per tablet
SUGGESTED USE: Take 6 tablets daily with food.
About our Organic Spirulina
Our spirulina contains NO artificial colors, flavors or preservatives; no wheat, gluten, milk, eggs, peanuts, tree nuts, soy, crustacean shellfish or fish. Suitable for vegans.
One of the world's best "super foods", spirulina is a source of important nutrients. Spirulina is nature's answer to providing an easy-to-utilize supplement that is purely food based. Beta-carotene, B vitamins, iron, essential fatty acids and protein are all packed into each serving of this green "super food".
Our Spirulina supplier uses a vegetarian source of Nitrogen and Phosphorous for their Organic Spirulina cultivation. Spirulina can come from a variety of sources; we chose the superior source – certified organic under 3 major organic standards:
- USDA NOP (United States Department of Agriculture, National Organic Program)
- Naturland Organic Standards (Naturland, Germany) under 'Processing standards for the production of microalgae and microalgae products'.
- IFOAM (International Federation for Organic Agriculture Movement) standards
- OCIA (Organic Crop Improvement Association) — one of the world's oldest, largest and most trusted leader in the Organic Certification Industry


text: View Full Chapter Figures Only Tables Only Videos Only Print Share Email Send Email Your Name (required) ! Example: John Doe Email Address (required) ! Please enter a valid sender email address. Example: email@example.com CC Me Recipient Email Address (required) ! Separate multiple email address with semi-colons (up to 5). Subject Subject for your email. Message (Maximum characters: 1,000) Please enter your name Please enter your email address Please enter a valid recipient email address. Example:email@example.com Submit Cancel Thank you! Your email has been sent to: The recipient(s) will receive an email message that includes a link to the selected article. Recipients may need to check their spam filters or confirm that the address is safe. Return to: Send Another Email An error has occurred sending your email(s). Please try again later or contact an administrator at firstname.lastname@example.com. Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Stoffan A, Mooney DP. Stoffan A, Mooney D.P. Stoffan, Alex, and David P. Mooney.Abdominal Trauma. In: Ziegler MM, Azizkhan RG, Allmen D, Weber TR. Ziegler M.M., Azizkhan R.G., Allmen D, Weber T.R. Eds. Moritz M. Ziegler, et al.eds. Operative Pediatric Surgery, Second Edition New York, NY: McGraw-Hill; 2014. http://accesssurgery.mhmedical.com/content.aspx?bookid=959§ionid=53539653. Accessed August 23, 2017. MLA Citation Stoffan A, Mooney DP. Stoffan A, Mooney D.P. Stoffan, Alex, and David P. Mooney.. "Abdominal Trauma." Operative Pediatric Surgery, Second Edition Ziegler MM, Azizkhan RG, Allmen D, Weber TR. Ziegler M.M., Azizkhan R.G., Allmen D, Weber T.R. Eds. Moritz M. Ziegler, et al. New York, NY: McGraw-Hill, 2014, http://accesssurgery.mhmedical.com/content.aspx?bookid=959§ionid=53539653. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Chapter 81: Abdominal Trauma Alex Stoffan; David P. Mooney + Key Points Print Section ++ ++ Most solid organ injuries can and should be managed nonoperatively. Laparotomy is still indicated for hemodynamic instability or peritonitis. Diaphragmatic injuries, once diagnosed, are often associated with thoracic and abdominal injuries, and should be explored and repaired from the abdomen. Splenorrhaphy remains the surgery of choice for unstable patients with splenic injury. Angioembolization may supplant operation for hemodynamically stable patients with persistent hemorrhage. Exploration for liver injury is rarely necessary, though some patients may require later interventional procedures for complications. Gastric injury is uncommon, though it may occur more often in children than in adults, and usually occurs along the greater curvature. The management of pancreatic ductal injury remains controversial: nonoperative, resection, or drainage. The duodenum is more exposed and more prone to injury in pediatric patients. Intestinal injuries are best diagnosed on physical examination, and therapeutic delay of less than 24 hours only mildly increases morbidity. ++ Although trauma remains the leading cause of mortality among children, emergency abdominal operations are infrequently required. The typical surgeon caring for injured children can expect to perform 1 or fewer emergency abdominal operations per year. This infrequency may diminish the experience of most surgeons and increases the utility of a chapter such as this. + History of Operative Management Print Section ++ ++ With the publication of the United States War Manual in 1918, operative management of abdominal injuries became the treatment of choice and resulted in a marked decrease in mortality rate. With the report from Toronto of a series of children with the signs and symptoms of splenic injury who did not require operation, the era of nonoperative management began more than 30 years ago. The widespread use of computerized tomography (CT) has increased the number of abdominal injuries diagnosed. Many severe solid-organ injuries, previously thought to require laparotomy, have also been found to resolve nonoperatively. Despite this, every surgeon who cares for children should be facile with the skills needed for prompt laparotomy in the management of injured children. Completion of training courses, such as the Advanced Trauma Operative Management (ATOM) course® (TM ACS) may help surgeons acquire and retain operative trauma skills. + Indications for Operative Management Print Section ++ ++ The primary indications for laparotomy in injured children include hemodynamic instability despite adequate volume resuscitation, peritoneal findings, pneumoperitoneum, and evisceration. While the presence of an abdominal gunshot or stab wound penetrating the peritoneum has traditionally been managed with laparotomy, this has recently been called into question in adults. In a stable child, select stab and gunshot wounds to the abdomen may be managed expectantly in a center experienced in this strategy. In a hemodynamically stable patient, it may be difficult to differentiate an intestinal injury that requires repair from one that will heal without intervention, leading to exploration. ++ The large majority of solid-organ injuries in children do not require operation and many pediatric centers have reported operative rates of 1% or less. The majority of children with a hollow viscus injury requiring operation may be diagnosed by physical examination. CT of the abdomen and pelvis with intravenous, but without enteral contrast, is the diagnostic study of choice to evaluate the abdomen in injured children, although concerns over radiation exposure in children have led to attempts to limit this modality. Diagnostic peritoneal lavage is rarely indicated in children and its ability to locate peritoneal blood has been supplanted by the focused abdominal sonography for trauma (FAST) examination. While the FAST examination appears to be inadequately sensitive in detecting solid-organ injury, it may be helpful to determine the presence or absence of peritoneal and/or pericardial fluid. + Preparations for Laparotomy Print Section ++ ++ If the patient is hemodynamically unstable, preoperative preparations will need to be expedited, but not so much as to jeopardize patient safety. The use of a preoperative checklist has been shown to improve patient mortality and decrease complications. The rapid completion of a checklist may help ensure that the patient has adequate large-caliber vascular access, has blood available, and has received any indicated antibiotics, that necessary equipment is available, and that the correct patient is having the correct procedure. The expenditure of 60 to 90 seconds to complete this process may give long-term dividends. If time allows, an arterial line as well as a Foley catheter and nasogastric tube should be inserted, though these may be placed once control of hemorrhage has been achieved and resuscitation is underway. Central venous lines are rarely helpful in this situation and should be reserved for the occasion when no other access, including by the cut-down or intraossesous route, can be achieved. The use of a warming blanket and warmed resuscitation fluids will help to prevent hypothermia. Tetanus prophylaxis should be considered. ++ Laparoscopy may be indicated as an initial maneuver under certain conditions: a hemodynamically stable patient with physical examination findings concerning for hollow viscus injury. A thorough laparoscopic exploration may avoid laparotomy, especially when it is possible to demonstrate that the peritoneum has not been violated in penetrating trauma. ++ The child is placed supine on the operating table and the skin is prepped from the suprasternal notch to the middle thigh level. A vertical midline incision provides excellent exposure to all quadrants of the abdomen. In children younger than 5 years of age, a transverse supraumbilical incision is an alternative, but the midline approach is the best option where speed is a critical factor. In dire circumstances, the skin may be prepped and the surgical field draped as the patient is being induced for the procedure. The surgeon should be prepared to incise the skin immediately should the patient become hypotensive if peripheral vascular resistance is diminished by the anesthetic agents used. ++ Upon opening the peritoneum, the surgeon may be greeted with massive intraperitoneal bleeding. This may be decreased by compression of the infradiaphragmatic aorta at the hiatus with a small Richardson retractor, a sponge stick, or manual compression, while the 4 quadrants of the abdomen are packed. After they are packed, the vascular compression may then be released. Once the patient has been resuscitated, systematic exploration of each quadrant, with the presumed bleeding quadrant carefully unpacked last, allows the demonstration of the injury while maintaining hemodynamic stability. A retroperitoneal hematoma should be left undisturbed unless it is found to be expanding or overlies the duodenum and pancreas. If the bleeding is controlled with packing and the patient is hypothermic, coagulopathic, or acidotic, the abdominal wall should be expeditiously covered. This may be done using a variety of techniques including the zipper, the Bogota bag, or towels covered with adhesive plastic wraps. The patient should then receive additional resuscitation and stabilization prior to reexploration and completion of injury repair in 12 to 36 hours. + Diaphragm Injury Print Section ++ ++ Diaphragmatic tears from a blunt mechanism may be difficult to diagnose, and their diagnosis and management are often delayed. Injuries of the left hemidiaphragm are more often diagnosed, possibly secondary to the protective effect of the liver. Diagnosis is suggested by distortion of the diaphragm on chest radiograph and may be confirmed by ultrasonography. Tears that result from a penetrating injury are more evident on exploration, and the diaphragm should be carefully inspected in any patient undergoing exploration for a penetrating upper abdominal or thoracic injury. During repair of diaphragmatic injury, an inspection should be performed for any associated abdominal or thoracic injuries (Fig. 81-1). Repair of diaphragmatic tears should be done by a transabdominal approach to inspect for any associated intra-abdominal injuries. Either a transverse upper abdominal or subcostal incision is preferred. The diaphragm is exposed and inspected by pulling the stomach and spleen downward on the left and the liver downward on the right. The edges of the diaphragmatic tear are débrided and the tear closed with an interrupted nonabsorbable suture. Pledgets or U-stitches may be used to reinforce the diaphragmatic edges as necessary (Fig. 81-2). Buttressing the repair with a layer of absorbable patch material may help decrease the recurrence rate. Including the nearby costal cartilage in the closure may reinforce lateral diaphragmatic tears. In the absence of any associated pulmonary injury, a pneumothorax may be evacuated by the placement of a soft, rubber catheter through the defect, which may be removed during sustained positive-pressure peak inspiration as the final closure suture is secured (Fig. 81-3). Associated pulmonary injuries when hemostatic may be treated by tube thoracostomy, placed prior to diaphragmatic repair. ++ Figure 81-1 The upper quadrant and the diaphragmatic surfaces are inspected by pulling the liver down on the right and the stomach and spleen down on the left. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-2 A laceration in the diaphragm is débrided and then closed with permanent suture. A simple, mattress, or pericostal suturing technique is used. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-3 To reestablish a vacuum in the pleural cavity, the diaphragm laceration is closed around a rubber catheter. A positive inspiration is combined with catheter aspiration followed by catheter removal as the last suture is tied securing an airtight closure. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Spleen Injury Print Section ++ ++ The large majority of splenic injuries resolve with nonoperative management. Splenic injuries that cause hemodynamic instability despite resuscitation and lead to laparotomy are likely to be massive with hilar vascular disruption. Ongoing hemorrhage in hemodynamically stable patients is more likely to be from trabecular arterial injuries. ++ In general, splenic bleeding is best controlled initially by packing all 4 abdominal quadrants, followed by careful exploration of each to rule out associated significant injury, finishing with the left upper quadrant. Access to the vascular pedicle of the spleen is best obtained by division of the greater omentum at its attachment to the colon and retraction of the stomach and omentum superiorly (Fig. 81-4). This maneuver allows the splenic artery and vein to be controlled where they separate from the superior–posterior aspect of the pancreas, prior to mobilizing the spleen. The spleen is then mobilized by division of its 3 avascular attachments: the splenocolic, splenorenal, and lateral ligaments (Fig. 81-5). ++ Figure 81-4 Entering the lesser sac to gain control of the splenic artery and vein is done by incising the gastrocolic omentum adjacent to its attachment to the transverse colon. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-5 By dividing the splenocolic, splenorenal, and the lateral ligaments, the spleen is mobilized out of the left upper quadrant. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ The majority of splenic injuries requiring laparotomy may be addressed by splenorrhaphy. Splenic immune function may be preserved if one-third or more of the splenic tissue remains viable. A variety of techniques are available to achieve this end, and the proper technique will depend upon the specific injury encountered. For a simple, peripherally based laceration, horizontal mattress sutures of a large absorbable material on an atraumatic needle may be placed across the defect. Teflon pledgets may be used to prevent tearing of the splenic capsule (Fig. 81-6A, B, and C). Alternatively, a simple laceration may be approximated with deep figure-of-eight sutures to close the parenchymal deep space with capsular simple sutures in between. Omentum may be incorporated into the simple sutures to improve hemostasis (Fig. 81-6D, E, and F). An injury of the lower splenic pole may be repaired using horizontal "through-and-through" mattress sutures of large absorbable material on an atraumatic needle. Incorporation of the omentum or the use of Teflon pledgets may help to support the splenic capsule (Fig. 81-6G, H, and I). Historically, a technique is described that uses a spinal needle to introduce long longitudinal sutures through the splenic parenchyma. The sutures are placed in a horizontal mattress fashion, approximating the splenic parenchyma (Fig. 81-6J, K, and L). A chromic "ladder" may be constructed and wrapped around the greater curvature of the spleen (Fig. 81-6M and N). Tying the chromic ladder ends together across the hilum compresses the splenic parenchyma and may prevent further bleeding. Topical hemostatic agents may be used when the capsule of the spleen has been torn from an extensive area of the surface. The spleen may then be wrapped in an absorbable mesh, compressing bleeding parenchyma (Fig. 81-6O and P). The mesh may be used to help compress other parenchymal defects with or without hemostatic agents. ++ Figure 81-6 A, B, C. For a simple peripheral splenic laceration, splenorrhaphy is done with horizontal mattress sutures with or without using pledgets. D, E, F. Figure-of-eight sutures placed deeply into the splenic parenchyma will effectively approximate the sides of a peripheral splenic laceration. A portion of greater omentum can be incorporated into the ties. G, H, I. A lower-pole splenic laceration can be controlled with through-and-through horizontal mattress sutures, which may include omentum as a seal over the raw surface. J, K, L. A spinal needle is introduced across a splenic laceration. Cauterization aids hemostasis, and the needle serves as a suture passage guide for mattress sutures, which when tied, will approximate the wound edge. M, N. A chromic "ladder" may be constructed and wrapped around the curvature of the spleen and tied in front of or behind the splenic hilum, thus compressing the splenic parenchyma. O, P. The spleen is enwrapped in an absorbable mesh to compress or "tamponade" the bleeding parenchyma. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Significant damage to one portion of the spleen may preclude repair. Under this situation, ligation of the involved segmental vessels and excision of the damaged, and now ischemic, tissue should be performed (Fig. 81-7). The resultant splenic edge may then be approximated with horizontal sutures and covered with omentum as demonstrated previously. ++ Figure 81-7 Damaged portion of the spleen not repairable. Segmented resection can be safely done following the selective ligation of splenic artery and vein branches, and the cut splenic surface is managed as depicted in Fig. 81-6G, H, and I. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ In unstable children, especially with multiple other significant injuries, who may not tolerate the time necessary to perform splenorrhaphy, splenectomy remains the procedure of choice. The spleen is mobilized by the above techniques and the splenic vessels are exposed through the lesser sac. The splenic artery and vein are ligated separately with large nonabsorbable sutures. The short gastric vessels must be ligated carefully or divided using tissue-sealing devices to prevent postoperative bleeding. + Selected Readings Print Section Selected Readings+ +Bonnard A, Zamakhshary M, Wales PW Outcomes and management of rectal injuries in children. Pediatr Surg Int 2007;23(11):1071–1076.CrossRef [PubMed: 17710420] + +Canty TG Sr, Weinman D Treatment of pancreatic disruption in children by an endoscopically placed stent. The Fifth International Conference on Pediatric Trauma. Beaver Creek, CO, June, 2000.+ +Christiano JG, Tummers M, Kennedy A Clinical significance of isolated intraperitoneal fluid on computerized tomography in pediatric blunt abdominal trauma. J Pediatr Surg 2009;44(6):1242–1248.CrossRef [PubMed: 19524748] + +Civit CJ Imaging children with abdominal trauma. Am J Roentgenol 2009;192(5):1179–1189.CrossRef+ +Gaines BA Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma 2009;67(2 Suppl):S135–S139.CrossRef [PubMed: 19667846] + +Gaines BA, Rutkoski JD The role of laparoscopy in pediatric trauma. Semin Pediatr Surg 2010;19(4):300–303.CrossRef [PubMed: 20889087] + +Kiankhooy A, Sartorelli KH, Vane DW, et al Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma 2010;68(3):526–531.CrossRef [PubMed: 20220415] + +Letton RW, Worrell V, Tuggle DW, et al Delay in diagnosis and treatment of blunt intestinal perforation does not adversely affect prognosis in the pediatric trauma patient. J Trauma 2010;68(4):790–795.CrossRef [PubMed: 20386275] + +Lynn KN, Werder GM, Callaghan RM, et al Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol 2009;39(9):904–916.CrossRef [PubMed: 19639310] + +Malek MM, Shah SR, Kane TD Video. Laparoscopic splenic-preserving distal pancreatectomy for trauma in a child. Surg Endosc 2010;24(10):2623.CrossRef [PubMed: 20177912] + +Paris C, Brindamour M, Ouimet A, et al Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision. J Pediatr Surg 2010;45(5):921–924.CrossRef [PubMed: 20438927] + +Stylianos S Liver injuries and damage control. Semin Pediatr Surg 2001;10(1):23–25.CrossRef [PubMed: 11172568] + +Walker ML The damage control laparotomy. J Natl Med Assoc 1995;87:119. [PubMed: 7897683] + Liver Injury Print Section ++ ++ Liver injury is less common than splenic injury and its anatomy is far more complex. An understanding of the varying hepatic vascular anatomy is necessary to manage these injuries properly. The arterial supply of the liver is from 2 sources: systemic and portal. The venous drainage is via 3 main hepatic veins and some short veins draining the posterior surface of the liver directly into the vena cava. The right hepatic vein is most frequently injured in blunt trauma. Liver injury results from blunt or penetrating trauma to the right upper quadrant or lower right chest. An intravenous contrast-enhanced CT scan confirms the diagnosis. Abdominal distension and hypovolemia are cardinal signs that laparotomy is imminent. However, both may be missing in children with significant hepatic injury. ++ Emergent laparotomy for liver injuries in children is increasingly uncommon, and is reserved for patients who remain hemodynamically unstable despite aggressive resuscitation. Later percutaneous or endoscopic interventional procedures for complications of liver injury, such as biliary leak, are more common. ++ In children requiring urgent laparotomy for a liver injury, preparations should be made for possible sternotomy or inguinal incision to allow the passage of an intracaval shunt. As large hemorrhage must be presumed, adequate vascular access and immediately available blood products are necessary. A generous midline incision provides excellent exposure and allows a sternal extension as necessary. Blood loss may be decreased by a variety of maneuvers, including packing. Once significant hemorrhage has been controlled, a more careful exploration for the source of bleeding and any associated injuries may be conducted. In unstable patients, complex injuries are best approached by hemorrhage control and closure, resuscitation to correct hypothermia and coagulopathy, and then, once stable, arteriography and embolization. Intricate biliary repairs and biliary-enteric bypasses are performed much less often than previously and are best reserved for when the patient is stable. Clearly nonviable tissue should be resected, but marginal tissue may prove viable on re-exploration. + Tract Injuries Print Section ++ ++ Tract injuries are the result of penetrating injuries. Hemorrhage from these lesions typically stops spontaneously, or may be aided by manual compression of nearby liver parenchyma. This may be assisted by the use of hemostatic agents applied into the tract prior to compression. If compression does not lead to hemostasis, the wound should be opened and bleeding points isolated and ligated (Fig. 81-8). Closure of the ends of the tract may lead to hepatic rupture if there is ongoing bleeding within the tract. ++ Figure 81-8 A liver puncture tract injury. A. Compression of the parenchyma overlying the tract is often effective in achieving hemostasis. B. The tract has been opened, the bleeding points have been directly visualized, and suture ligatures control bleeding. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Lacerations Print Section ++ ++ Hemorrhage from hepatic lacerations typically stops spontaneously. The surface of actively bleeding lacerations should be gently held with compression with the addition of hemostatic agents as needed. If not successful, then the laceration may be explored by using the finger-fracture technique to identify specific bleeding points and severed biliary radicals that are ligated. Deep suture ligation of the laceration without exploration is not recommended because of the risk of injury to biliary structures. Autotransfusion is useful if bowel injury is absent. If hemorrhage continues, the use of the Pringle maneuver may be useful to enable improved visualization of the laceration, and it may aid in determining the source of the hemorrhage (Fig. 81-9). If the liver hemorrhage slows in response to the Pringle maneuver, then the hemorrhage is more likely from a portal vein or hepatic artery source. If it does not decrease, then it is more likely from the hepatic veins or the retrohepatic vena cava. The maneuver may be maintained for several minutes to aid in dissection. If a dramatic decrease in hemorrhage is obtained through the maneuver, ligation of the hepatic artery as close to the liver as possible may achieve hemostasis. An alternate technique for the control of bleeding from a liver laceration is through the use of packing placed between the diaphragm and against the inferior surface of the liver (Fig. 81-10). After hemostasis has been achieved, the laceration should be filled with omentum and sutured to the capsule with absorbable material. Large drains should be placed above and below the laceration in the event of a biliary leak (Fig. 81-11). ++ Figure 81-9 Pringle maneuver by which the hepatic portal structures are compressed between the surgeon's thumb and index finger to temporarily occlude the hepatic artery and portal vein. Placement of an atraumatic vascular clamp can be used to replace the compressing fingers. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-10 An alternate technique to control liver laceration bleeding is to place packs behind the liver between the liver and diaphragm and against the inferior surface of the liver. A. The packs are in place and compress the laceration. B. Penrose drains are placed into the laceration and they are exited laterally, providing an ongoing assessment of the amount of bleeding. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-11 The omentum stuffed into a laceration is an effective hemostatic agent. Regional drains will help quantify ongoing blood loss. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Perihepatic Venous Injury Print Section ++ ++ Voluminous dark venous bleeding that persists despite the Pringle maneuver, or that worsens with manipulation, raises the suspicion of a perihepatic venous injury. The correct surgical approach to these injuries remains controversial and the mortality rate for any approach is high. ++ One approach involves the placement of an atrial caval shunt. Dissection is carried around the inferior vena cava above the renal veins and a tourniquet is loosely placed. The abdominal incision is carried up through the sternum and dissection is carried out through the lowest posterior-medial aspect of the pericardium. The inferior vena cava is isolated within the lowest portion of the pericardium and a second tourniquet is loosely placed around it at that level. A pursestring suture is placed in the right-atrial appendage and a multiply fenestrated shunt is passed down through the atrium and inferior vena cava and the tourniquets secured (Fig. 81-12). A modified chest tube may be used for this purpose as may an endotracheal tube, depending upon the patient's size. The top of the tube may be used as a route for large volume infusion. In combination with the Pringle maneuver, this will decrease, but not eliminate hemorrhage. The liver is then rotated medially and direct vascular repair is performed. ++ Figure 81-12 Placement of an atriocaval shunt. A firm multifenestrated, large-bore plastic tube is inserted through a right-atrial appendage purse-string suture and tourniquets are secured around the vena cava just above the diaphragm and above the renal veins. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ An alternate approach is to pack the right upper quadrant of the abdomen until visible hemostasis is obtained and closing. The patient is then resuscitated and any coagulopathy and acidosis corrected. From 24 to 72 hours later, the patient is returned to the operating room and the packs carefully removed. If bleeding is again encountered, the packing is replaced. This sequence may be repeated and, if suture repair of the vena cava or hepatic vein are necessary, it is conducted in a more controlled fashion. + Stomach Injury Print Section ++ ++ Injury to the stomach is more common in children than in adults. Perforation of the stomach may occur because of blunt abdominal trauma, such as in the lap belt injury complex, or iatrogenic factors, such as forceful nasogastric tube insertion. Typically, a plain abdominal radiograph shows free air and an abnormal position of the nasogastric tube. ++ Rupture of the stomach occurs along the greater curvature in the region of the fundus. If this injury is discovered, a careful exploration should be performed to exclude other injuries. Elevation of the left lobe of the liver with a retractor allows exposure of the stomach from the esophagus to the duodenum. The gastrocolic ligament is divided and the lesser sac is entered to inspect the posterior surface of the stomach and pancreas. The edges of a gastric perforation are debrided to viable tissue and approximated in 2 layers. A nasogastric tube should be placed (Fig. 81-13). ++ Figure 81-13 A gastric injury. A. Typical anterior wall greater curvature blow out injury. B. A 2-layer closure is preferred after débridement of devitalized tissue. C. Postoperatively, a nasogastric tube is left in place. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Pancreatic Injury Print Section ++ ++ The pancreas may be injured through a variety of means, but blunt trauma from a handle bar, a punch, or compression by the lap belt during a motor vehicle crash are the usual mechanisms of injury. Signs of pancreatic injury may be subtle. Plain radiographs of the abdomen are likely to be normal. Patients often present with increasing epigastric discomfort hours after a seemingly minor event or occult intentional injury. Serum amylase may be normal initially, only to rise significantly over the following hours. Abdominal CT scan with intravenous contrast is typically diagnostic, but initial CT scan findings, prior to significant retroperitoneal inflammation, may be subtle. ++ The management of pancreatic injuries remains controversial, as many resolve without operation. Nonoperative management has been practiced successfully even for children with proven ductal injury. Prompt endoscopic retrograde cholangiopancreatography with laparotomy and distal pancreatectomy has been shown to shorten the length of stay in children with suspected ductal injury in a small number of patients. However, patients with distal ductal injuries have been also managed successfully with external or delayed internal drainage of resultant pancreatic pseudocysts, sparing many children laparotomy. One report describes the successful management of pancreatic ductal injuries through the use of an endoscopically placed pancreatic ductal stent. On occasion, the diagnosis of ductal injury is delayed for several days, and surrounding inflammation may make resection more difficult. The presence of bile staining, gastrointestinal contents, or air in the retroperitoneum indicate associated intestinal injury. ++ The entire abdomen should be prepped and draped. A broad transverse upper abdominal incision should be used in younger children and a vertical midline incision in older children. Mobilization and inspection of the upper abdominal contents should be performed to rule out associated injuries. This should include a wide Kocher maneuver and inspection of the entire gland (Fig. 81-14). The lateral attachments of the second portion of the duodenum are divided and the duodenum is retracted medially, exposing the vena cava and the head of the pancreas, which is palpated. The gastrocolic omentum is divided and the anterior surface of the pancreas is inspected after the stomach is retracted superiorly. ++ Figure 81-14 Exposure to assess the injured pancreas. A. A Kocher maneuver is done, incising the peritoneum along the lateral duodenal wall. Medial retraction will expose the pancreatic head as well as the retroduodenal vena cava. B. After division of the gastrocolic ligament and superior retraction of the stomach and inferior traction on the colon, the anterior surface of the pancreas is exposed. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Distal Pancreatic Ductal Injury Print Section ++ ++ Pancreatic ductal lacerations distal to the superior mesenteric artery and vein may be treated by distal pancreatectomy with splenic preservation. The gastrocolic and splenocolic ligaments are divided. The stomach is retracted upward and the colon downward. The inferior border of the pancreas is separated from the retroperitoneal tissues by blunt dissection from the superior mesenteric vein to the splenic hilum (Fig. 81-15). ++ Figure 81-15 Distal pancreatic ductal injury to the left of the mesenteric vessels. A. The inferior border of the pancreas is separated by blunt dissection from the retroperitoneum. B. A spleen-preserving distal pancreatectomy is done by careful ligation, if clinically feasible, of the multiple branches of the splenic artery and vein to the pancreas. C. The proximal pancreatic parenchyma is closed with mattress sutures after the initial ligation of the end of the main pancreatic duct with a nonabsorbable suture. Drains are placed in the pancreatic bed. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Distal pancreatic tributaries of the splenic artery and vein are then carefully identified, ligated, and divided. In certain patients, the time required for this meticulous dissection may not be available, or the splenic artery and vein may be injured. In these situations, the splenic artery and vein may be ligated and divided as they depart the posterior–superior surface of the pancreas. ++ The pancreas is divided proximal to the injury and the main pancreatic duct is ligated with nonabsorbable suture. The parenchyma is closed with mattress sutures and external drains are placed. The spleen should then be inspected at the completion of the pancreatic resection to ensure its viability based upon the short gastric vessels. If not, a splenectomy is performed. + Proximal Pancreatic Ductal Injury Print Section ++ ++ An injury to the pancreatic duct proximal to the superior mesenteric artery and vein is a difficult problem, and its repair is fraught with complications, including anastomotic stenosis, pancreatic fistulae and possible pancreatic insufficiency after extensive resection. Operation should be reserved for those patients in whom other measures are deemed insufficient, and resection should be avoided at initial operation, whereas extensive simple drainage is a viable alternative. ++ If operation is necessary, an attempt should be made to preserve the distal pancreatic segment with a Roux-en-Y pancreaticojejunostomy. The proximal severed end of the pancreatic duct is carefully identified, and then ligated with nonabsorbable suture. The proximal parenchyma is oversewn with mattress sutures. A Roux loop of jejunum is then fashioned (Fig. 81-16). The open end of the distal jejunal limb is closed and an end-to-side pancreaticojejunostomy is performed with a posterior row of 3-0 silk sutures to approximate the pancreatic capsule to the jejunal serosa. The posterior wall of the duct is then anastomosed to the jejunal mucosa with interrupted 5-0 prolene sutures and the anastomosis is stented using a shortened 5-French feeding tube, which is tacked to the jejunal mucosa by using an absorbable suture. The ductal anastomosis is then completed. An anterior row of Lembert sutures is used to bury the pancreas into the jejunum and the creation of the Roux loop is completed. The area is covered with omentum and drained well. ++ Figure 81-16 Repair of a proximal pancreatic ductal injury. A. A Roux-en-Y pancreaticojejunostomy is done using an intraductal stent. B. A second row of Lembert sutures buries the pancreas into the side of the jejunum and the Roux-en-Y connection is completed. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Combined Duodenal, Common Bile Duct, and Major Pancreatic Duct Injury Print Section ++ ++ This is a devastating injury that can be fatal if treated with drainage alone; it requires aggressive management. The repair performed will depend on the specific injuries encountered, as well as on the stability of the patient. In the rare situation that a patient suffers extensive duodenal and pancreatic injuries yet is able to tolerate a protracted operation, and the surgical team is experienced in the procedure, a pancreatic–duodenal resection with immediate reconstruction can be considered. An alternative to extensive resection includes exclusion of the pylorus with a pursestring of large nonabsorbable suture material, primary duodenal repair, and loop gastrojejunostomy with extensive external regional drainage. ++ In either instance, a generous Kocher maneuver is performed and careful inspection of the duodenum and pancreas is performed to adequately assess the anterior and posterior surfaces of each structure. The gastrocolic ligament is then divided and the pancreas is exposed through the lesser sac to inspect the front of the gland. If resection is chosen, the common bile duct is identified. A plane is developed between the neck of the pancreas and the anterior aspect of the portal and superior mesenteric vessels by finger dissection. The inferior border of the pancreas is dissected free and the pancreas is rotated cephalad. Tributaries from the splenic artery and vein to the pancreas are ligated and divided. Two noncrushing intestinal clamps are then placed, and the pancreas is divided between them. The first part of the duodenum is preserved if possible, and the distal duodenum is divided. A noncrushing bulldog clamp is placed on the common bile duct and it is divided distal to the clamp. Finally, a cholecystectomy is performed. The third and fourth portions of the duodenum are mobilized and the jejunum is divided distal to the ligament of Treitz. The arterial and venous branches to the uncinate process are divided and the specimen is then removed. The completed reconstruction is with an end-to-side pancreaticojejunostomy, end-to-side choledochojejunostomy, and an antecolic duodenojejunostomy (Fig. 81-17). The biliary and pancreatic anastomoses are performed as stated previously with interrupted 5-0 prolene interrupted sutures to the jejunal mucosa, stented to minimize anastomotic stenosis. ++ Figure 81-17 Management of a combined duodenal, common bile duct, and major pancreatic duct injury. Reconstruction is completed with a pancreaticojejunostomy, end-to-side choledochojejunostomy, and an antecolic duodenojejunostomy. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Duodenum Injury Print Section ++ ++ Duodenal Hematoma ++ Children have weaker abdominal muscles, a wider costal arch, and a narrow anteroposterior diameter. Consequently, the duodenum lies in a more exposed position and is prone to injury in abdominal trauma. Intramural duodenal hematoma can result from a direct blow to the epigastrium, such as a bicycle handlebar, which compresses the duodenum against the spine. Symptoms are those of proximal intestinal obstruction. The diagnosis may be suspected on physical examination and, although CT scan is helpful, the diagnosis is best confirmed by upper gastrointestinal series or ultrasonography. The management is nonoperative as the hematoma resolves over 2 to 3 weeks. If a large duodenal hematoma is encountered during laparotomy, it should be evacuated (Fig. 81-18). The serosa is incised and the clot gently removed. The submucosa is usually intact and any obvious bleeding points on it are carefully cauterized. The serosa with attached muscularis is then reapproximated with interrupted 4-0 sutures. ++ Figure 81-18 Evacuation of a duodenal hematoma found at laparotomy. A. A serosal incision is made and the clot is pulled or sucked out of its intramural location. B. The seromuscular area is then reapproximated. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Duodenal Laceration/Perforation ++ Most full-thickness duodenal lacerations can be closed primarily. A Kocher maneuver should be performed to carefully inspect for any associated injuries. Extensive injuries may require exclusion of the pylorus to protect the duodenal repair, or may be addressed using a "patch" of jejunum using either a Roux-en-Y limb or a loop of jejunum (Fig. 81-19). Breakdown of a duodenal repair with uncontrolled leakage of duodenal contents may be devastating, and any repair with an increased risk of breakdown should be drained both internally and extensively. Longitudinal or oblique tears are closed in the direction of the injury to prevent narrowing of the duodenal lumen. Mucosal approximation is imperative and is accomplished by a vertical mattress suture in 1 layer (Fig. 81-19). A complete transection is repaired with a primary end-to-end anastomosis using a 2-layer closure, with care taken to ensure that the bile and pancreatic ducts are not involved. ++ Figure 81-19 Repair of a duodenal laceration. A. Mucosal approximation is critical, and the use of a 1-layer vertical mattress suture is an effective technique. B. A Roux-en-Y loop of jejunum is used to form a duodenojejunostomy and to restore gastrointestinal continuity. C. A loop of jejunum can also be used as a patch duodenojejunostomy either for luminal continuity or for reinforcing coverage. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Jejunoileal Injuries Print Section ++ ++ Injury to the small intestine can result from penetrating injuries, or may follow even mild blunt trauma. Children involved in motor vehicle collisions who are restrained solely by a lap seat belt may suffer the lap belt complex of injuries, which includes abdominal-wall ecchymosis, lumbar spine injury, and intra-abdominal injury. While the majority of patients with intestinal injury have signs of peritoneal irritation on presentation, the diagnosis may prove difficult, especially in children with a brain injury. Free air is commonly not seen on initial plain radiographs and is present only 25% of the time on initial abdominal CT scan, which may reveal free peritoneal fluid without solid-organ injury. Demonstration of intestinal injury mandates prompt laparotomy, as mortality increases with a delay in operative management of more than 24 hours. ++ Laparotomy is performed as described earlier. Perforations from blunt mechanisms typically occur in the antimesenteric border of the bowel and are most common near the 2 fixed points of the bowel: the ligament of Treitz and the cecum. Serosal injuries should be repaired or, when extensive, the injured segment of intestine resected. The majority of injuries may be repaired primarily, or resected and a primary anastomosis performed without the creation of an intestinal stoma (Figs. 81-20 and 81-21). In patients with multiple intestinal perforations amid otherwise viable bowel, such as from a shotgun blast, the perforations may be rapidly approximated using a skin-stapling device. ++ Figure 81-20 Penetrating intestinal injuries or blunt blowout injuries are débrided (A) and primarily closed transversely, typically in 2 layers. B. With a loss of mesentery, resection and anastomosis is more typically done. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-21 Following multiple intestinal perforations, intervening short bridges of intestinal wall are best excised and débrided, and wall reconstruction is incorporated into a single repair. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Mesenteric Injury: Mesenteric Hematoma Print Section ++ ++ A mesenteric hematoma is a common finding in blunt abdominal trauma. A hematoma should not be opened unless it is expanding, which may indicate significant vascular injury. If a hematoma is opened, bleeding vessels should be ligated and the adjacent bowel inspected to assess viability (Fig. 81-22). If the bowel viability is questionable, a resection and primary anastomosis is performed (Fig. 81-23). ++ Figure 81-22 If a mesenteric hematoma is expanding, it should be opened, evacuated, and the bleeding vessels ligated or coagulated. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Figure 81-23 If following a mesenteric injury, there is compromise of the circulation to the bowel, a segmental resection (A) should be done followed by primary end-to-end anastomosis (B). Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Colon Print Section ++ ++ Colonic injuries are uncommon in children and are usually the result of penetrating trauma. Primary repair is appropriate for most colonic injuries, even with peritoneal contamination, and diverting colostomy is rarely necessary. Small puncture wounds are closed with interrupted Lembert sutures. For larger wounds, the edges are débrided and the perforation is closed in 2 layers in a transverse direction. For more extensive injuries with a devitalized segment of bowel, a colon resection and primary anastomosis is done. + Rectum Print Section ++ ++ Penetrating rectal trauma most commonly results from child abuse, but may occur from falling on posts or other sharp objects. The diagnosis may be suspected on physical examination, but may require examination under anesthesia and proctoscopy to adequately determine the depth of injury. Full-thickness rectal injuries require diversion of the fecal stream with a proximal colostomy, although this has been questioned. A layered closure of the rectal wall is done and the retrorectal space anterior to the coccyx is drained. Associated vaginal tears are repaired primarily in layers. Significant rectal injuries commonly involve the anal sphincter mechanism, and a careful evaluation and repair of the sphincter mechanism is performed at the initial operation. + Acknowledgments Print Section ++ ++ The authors thank Dr. Martin Eichelberger for his extensive contributions to previous editions of this chapter.


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