Complications and Avoidance of the Complications Associated with Management of Abdominal Trauma

Abstract

Despite decades of dramatic advance in treatment and prevention of trauma, globally trauma continues to be a major public health problem. More than 5 million individuals perish every year as a consequence of injuries. This is responsible for about 9% of the world’s deaths, approximately 1.7 times the number of mortalities that result from HIV/AIDS, tuberculosis and malaria combined. Abdominal trauma continues to be the leading cause of mortality and morbidity in all age groups. A comprehensive management of traumatic abdominal patient with various approaches is of proven value in terms of mitigating the burden associated with abdominal trauma. However, all available approaches used to manage traumatic abdominal patient are potentially associated with development of various complications. Practical to mitigate these complications, various measures should be considered all the time while managing any traumatic abdominal patient. The goal of this chapter is to describe systematic approaches for avoiding the complications associated with management of abdominal trauma. Moreover, it describes the common and some rare complications associated with the management of traumatic abdominal patient.

1. Introduction

Etymologically the term complication originates from (Latin complicationem, past participle; complicare which means to fold together). Various experts of surgery have defined the term complication. Some authors have defined complication as an occurrence which is avoidable. Moreover, other authors have devised criteria of complication in surgical practice; in certain book of neurosurgery complication has been regarded as an occurrence which fulfills three criteria namely, unwanted, unplanned and does not commonly occur. Management of abdominal trauma is complex and remains a problematic in surgical practice due to notable occurrence of numerous complications [1]. Failure to recognize and treat these complications earlier increases the mortality and morbidity. Planning and uniting more efforts to predict and prevent the occurrence of complications associated with management of traumatic abdominal patient is fundamentally essential. The main goal of this chapter is to describe systematic approaches for avoiding the complications associated with management of traumatic abdominal patient. Risk factors leading to the occurrence of complications, commonly occurring complications and some rare complications but with higher potential to cause mortality and morbidity are also described. The contents of this chapter are arranged as follows:

1. Introduction

2. General consideration

3. Risk factors leading to the occurrence of complications associated with the management of abdominal trauma

4. Complications associated with non-operative management of traumatic abdominal patient

5. Complications associated with operative management of traumatic abdominal patient

6. Systematic approaches for avoiding the complications associated with the management of abdominal trauma

7. Discussion

8. Conclusion

9. Future prospectus

2. General consideration

The mortality and morbidity associated with abdominal trauma can be attributed to the disturbance of anatomical and functional integrity of abdominal structures. Based on understanding the anatomy and physiological processes performed by abdominal organs, it is possible to plan and enhance measures designed to avoid the occurrence of the complications associated with the management of abdominal trauma. To achieve such tasks more efforts should be directed to avoiding all possible risk factors leading to the occurrence of abdominal trauma, try as much as possible to avoid the removal of any injured abdominal organ, and ensure as quick as possible to restore functions of any injured abdominal organ.

2.1 Anatomical and functional consideration of abdominal organs

Knowledge of anatomy and physiological processes of abdominal organs is paramount for understanding and avoiding complications which occur secondary to abdominal trauma and those associated with chosen management approach. Abdomen is flexible and dynamic part of the body which lies between diaphragm and pelvis. Abdominal cavity houses all structures that involve in gastrointestinal and genitourinary system. Some abdominal structures are intra-peritoneal while others are retroperitoneal. Shown in Table 1 are the components of abdominal wall and the classification of abdominal organs. The fact that, abdominal organs have minimal bony protection they are frequently injured during trauma event [2]. Like any other injuries following abdominal trauma two responses happen namely: (1) biological adaptation to condition of external stress (injury and starvation), and (2) maintenance of internal constancy. These responses are useful for increasing the chance of survival for traumatic abdominal victim. However, in certain instances these responses can be dangerous; for instance if they occur in uncontrolled manners, in excessive and for prolonged time and when there is removal or failure multiple organs. The primary function of abdominal organs is to maintain homeostatic process. Thus, while managing traumatic abdominal patient, it is crucial to restore the functions of abdominal organs as quick as possible and as well as to avoid the removal of any abdominal organ as much as possible.

Divisions	Components/abdominal organs
Abdominal wall	A) Boundaries of abdominal wall
	Superior: Xiphoid, Costal arch, X II rib	Inferior: Pubis symphisis, inguinal groove, Iliac crest	Lateral: Posterior axillary line
	B) Layers of anterolateral abdominal wall
	Skin Subcutaneous tissues Superficial fatty layer- camper’s fascia Deep membranous layer-Scarpa’s fascia Muscles (external oblique abdominal muscle, internal oblique abdominal muscle and transverse abdominal muscle)		Transversalis fascia Extraperitoneal fat Parietal peritoneum
Intraperitoneal Organs	Liver Spleen Stomach		Small bowel Transverse colon Mesentery
Extraperitoneal organs	Solid and hollow organs	Genito-urinary tract	Blood vesells
	Pancreas (except tail) Suprarenal glands Duodenum Ascending and descending colon Esophagus Rectum	Kidneys Ureters Bladder Urethra	Abdominal aorta Inferior vena cava

Table 1.

Components of abdominal wall and classification of abdominal organs which can assist to make diagnosis.

2.1.1 Liver

Liver is a solid and the largest organ of the body, located in the right upper quadrant of the abdomen under the right lower rib cage against the diaphragm [3]. It receives dual blood via: (1) hepatic arteries which deliver about 20% blood oxygen rich, and (2) portal vein which carries about 80% blood nutrient rich from stomach, intestine, pancreas and spleen via portal vein. Moreover, at rest liver receives about 25% of cardiac output and has the capacity to reserve about 450 ml of blood in healthy person and up to 1 liter for congestive heart failure patient. Liver is the most commonly injured organ during trauma due to its big size and because of its high vascularity, hemorrhage is the most frequent complication to associate with liver injury.

Liver serves as a hub of metabolic processes of which life depends. Eight main metabolic processes taking place in the liver are: (1) bile formation and excretion, (2) carbohydrate metabolism, (3) protein metabolism, (4) fat metabolism, (5) blood coagulation, (6) vitamin metabolism, (7) detoxification and (8) phagocytosis and immunity. It is very unlikely for human being to survive without liver. One of the events which can lead to the loss of liver is severe injury of which hepatectomy would be warranted. In such case liver transplant would be only possible solution. However, liver transplant is too expensive, not available as an emergency treatment and it is associated with other numerous complications. Evidence has shown that liver cells have the capacity to regenerate. This regeneration is mainly achieved with the support of portal blood; because portal blood contains hepatotrophic portal blood factor (HPBF) which supports hepatic cells to regenerate [4]. Given this evidence it is very crucial for the physician to ensure enough portal blood supply to any injured liver. No hepatectomy should be done at all unless there is immediate liver transplant.

2.1.2 Spleen

Spleen is situated in the left upper quadrant of the abdomen. Spleen is encircled superiorly and laterally by diaphragm and left lower rib cage, inferiorly by the colon, medially by stomach and posteriorly by the kidney. Spleen is highly vascularized organ. Spleen also receives dual blood supply via splenic artery and short gastric artery, and it receives about 5% of cardiac output. Though, it seems that, the spleen is protected by ribs and muscular parieties, the spleen is commonly injured during abdominal trauma because, it is friable, and it has suspended ligaments that are attached to an adherent capsule. Thus, even relatively minor trauma can lead to avulsion of splenic substances or tearing of the blood vessels that are present within its suspensory ligaments which result into abundant bleeding.

Spleen has a number of functions in the body including: (1) filtering blood elements and foreign material, (2) production of lymphocytes and antibodies. Human being can survive without spleen indicating that functions that are carried out by the spleen can be performed by other organs elsewhere in the boy. However, it has been confirmed that, loss of spleen is associated with overwhelming infectious complications caused by encapsulated bacteria (e.g., Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis) [5]. The recognition of high rates of infections after spleenectomy led to the shift of paradigm of management of splenic injury from mandatory operative to selective conservative management, and then to non-operative management and splenic artery embolization, etc. Studies have shown that more than 60% of splenic injury can be managed with non-operative approach.

2.1.3 Pancreas

Pancreas is not commonly injured during abdominal trauma [6]. However, greater considerations should be taken while managing any abdominal trauma involving the pancreas because of its intimate relationship with vital vascular structures. While in its transverse course, pancreas passes immediately anterior to inferior vena cava, the aorta, superior mesenteric artery and vein. It also lies anterior or slightly to the splenic artery and vein. The common serious danger for both penetrating and blunt injury to the pancreas is the risk of injury to these great vessels. The pancreas may obscure the site of bleeding and as such extensive mobilization or transection of the pancreas may be required in order to control the bleeding vessel. Early mortality related to pancreatic injury is due to massive hemorrhage whereas late mortality can result from the consequence of infections and multiple organ failure. Moreover, the neglected pancreatic injury may result into complications such as: pseudocysts, fistulas, sepsis and secondary hemorrhage [6].

2.1.4 Gastrointestinal tract (GIT)

The components of gastrointestinal tract (GIT) to consider with regard to abdominal trauma include stomach, small intestine and large intestine. GIT assists in digestion, absorption, assimilation of nutrients, and secretion and excretion of waste products. Absorptive and propulsive actions of GIT are reduced after trauma anywhere in the body. There is profound and prolonged reduction of GIT actions when peritoneal cavity is involved. The disturbed GIT actions leads to the accumulation of fluid within the abdominal cavity causing increased intra-abdominal pressure, abdominal distention and increased risks of aspiration as one of the complications. Moreover, fluid accumulation into the GIT and possibly bleeding causes the reduction of cardiac output. Following this instance the body compensates by transferring adequate blood to vital organs (brain and heart), leaving other organs such as GIT, skin etc. This compensation takes place because brain and heart are vital organs with high metabolic rates and their capacity to store substrates for energy production is very low, as such they need adequate constant blood supply. Reduction of blood supply to GIT causes the development of ischemia which is a common complication to associate with abdominal trauma.

2.1.5 Other abdominal organs

An appreciation of anatomy and functional physiology of other abdominal organs such as kidneys and bladder, blood vessels, nerves, uterus and ovaries (in female) is also important. These organs have substantial functions in various physiological processes including regulation of homeostasis. During abdominal trauma these organs can also be damaged and some of them are hard to treat. Readers are advised to revise anatomy and physiology of these organs.

2.2 Approach to the patient with abdominal trauma

2.2.1 General consideration and primary survey

The patient with abdominal trauma can present with multiple injuries with higher likelihood to compromise functions of vital organs. As such, all traumatic abdominal patients should be managed holistically. Management of traumatic abdominal patient is complex, challenging and typically encompasses all possible interventions to offer to the patient during the course of management. In approaching traumatic abdominal patient the clinician should be prepared to provide various interventions at any of the three phases of trauma care, namely: (1) primary phase that encompasses initial assessment and provision of certain actions to correct any impairment of airway, breathing and circulation, disability and exposure, (2) secondary phase which progresses with resuscitation and full assessment of the patient), and (3) tertiary phase which involves the provision of definitive treatment to specific injuries.

Death is certainly a powerful dependent variable but unwanted one, which is ever seen in all kinds of trauma. All kinds of trauma have the potential to cause death to the victim either directly or by any complications that occur in the trajectory of management. Ideally, in order to avoid such death, the basic principles of advanced and trauma life support (ATLS) protocols are the forefront interventions to offer to any trauma patient and should be started at the scene. The core components of ATLS protocol, namely: (1) Airway management, (2) Breathing, (3) Circulation, (4) Disability or Damage, and (5) Environment/Exposure (ABCDE) are of the first priority [5] in order to secure the functions of vital organs.

2.2.1.1 Airway

The most common cause of death for traumatic patient is asphyxia. To avoid this tragedy to happen an immediate goal of management should be to clear and keep the airway open to ensure adequate ventilation. Shown in Table 2 are the strategies used for recognizing the compromised airway and actions to do as early as possible to ensure adequate ventilation.

Assessment

Important actions to be done as early as possible in order to ensure adequate ventilation

Call the patient; if able to reply appropriately indicates that, airway is patently open. Look in the mouth to ascertain the presence of blood, vomits or broken teeth that may obstruct airway or be aspirated. Perform a quick brief respiratory physical examination: Listen properly to the nature of breathing; the positive noisy breathing indicate upper airway obstructions Auscultate for the breath sounds Check for the presence of: (1) asymmetric chest wall movement, and (2) open wounds or flail segments

Take away the secretions from the airway with suction. Perform chin lift and jaw thrust if there is no evidence of neck injury and position the patient properly, conscious patient should be kept in sit up posture in order to support drainage of secretion by gravity and reduce the risks of aspiration. Insert oral-pharyngeal airway. Remember that unconscious patients are at high risks of airway obstruction and aspiration due to: Loss of tone for the muscles of pharynx, jaw and tongue leads to fallback of the tongue when the patient is kept in supine position causing airway obstruction. These patients also have depressed laryngeal reflexes and do not cough out or swallow. As such secretions worsen their obstructed airway and increase the risks of aspiration. Airway of any traumatic unconscious patient should be secured meticulously; inserting oral airway, putting the patient in coma position and be frequently turned would suffice the control of their airway. Intubating the patient should be done: If airway is not clear If there is bleeding into the pharynx When the patient has aspirated Execute tracheostomy in case upper airway is injured and when intubation is impossible. Execute cricothyroid stab if there is no time for tracheostomy.

Table 2.

Recognition of the compromised airway and the important actions to do as early as possible to ensure adequate ventilation.

2.2.1.2 Breathing

Impaired breathing is a common cause of respiratory failure, perhaps the common cause of death among traumatic patients. Quick recognition and correction of impaired breathing is crucial. Shown in Table 3 are the potential findings indicating impaired breathing and actions to perform in order to correct impaired breathing.

Findings of compromised breathing	Important actions to correct impaired breathing
Cyanosis Tachycardia Unsatisfactory breathing Poor respiratory pattern Paradoxical movement	Oxygen therapy to maintain oxygen saturation between 94 and 98% Intubation Ventilation

Table 3.

Potential findings indicating impaired breathing and actions to perform to correct the impaired breathing.

2.2.1.3 Circulation

Shock secondary to trauma is largely caused by bleeding and perhaps the common cause of circulatory failure and a leading cause of deaths among traumatic patients. The dangerous effect of shock is that all body organs are affected. The hypovolemic shock secondary to bleeding affects all body organs regardless the location of the bleeding. Lack of the capacity to maintain systolic blood pressure at ≥90 mmHg after trauma provokes hypovolemia which is associated with mortality of about 50%. The direct goal of management is to prevent further blood loss and determine the degree of circulatory derangement. Directly identify the site of bleeding, feel central (carotid) and peripheral (radial pulses) and start resuscitative interventions. Shown in Table 4 are signs of shock and prompt stepwise interventions to execute in order to correct hypovolemic shock in primary phase of trauma management. Despite the control of bleeding, the patient may continue to manifest signs and symptoms of shock as consequences of loss of plasma volume into the interstium, and this effect is compounded by injury induced inflammatory responses. The physician should put this into consideration and give maintenance fluids to the patient after resuscitation phase.

Signs of hypovolemic shock

Stepwise interventions to treat hypovolemic shock

Mild hypovolemic (<20% blood volume); Cold and clammy on the face and hands Droplets of sweat on the face and hands Restlessness, anxiety and confusion, Increased capillary refill time Moderate hypovolemic (20–40%blood volume); Above signs plus: Tachycardia Tachypnea Postural changes Oliguria Severe hypovolemic (>40% blood volume); Above signs plus: Hypotension Marked Tachycardia Hemodynamic instability Loss of consciousness

Begin resuscitation with a goal of rapid re-expansion of the circulating intravascular blood volume along with other actions to stop ongoing bleeding. Insert two largest bore intravenous cannulas (preferably 14 gauge in adult) Start volume resuscitation with isotonic saline (take a care to avoid hyperchloremia) or balance salt solution such as ringer’s lactate (take a care to avoid hyperkalemia) Classically infusion of 2–3 L of salt solution should restore normal volume in about 20–30 minutes. Failure of these interventions suggests that shock has not been reversed or persistent blood loss. Evidence of persistent blood loss and declining hemoglobin ≤10 g/dL implies initiation of blood products. Do blood grouping and cross matching. Coagulopathy due to deficient of clotting factors is a common clinical state for the patient resuscitated with crystalloid or banked packed red blood cells. Evidence has shown that early administration of component therapy during massive transfusion (fresh frozen plasma and platelets) appears to improve survival. For severe or prolonged hypovolemia, after restoration of blood volume inotropic support with epinephrine, vasopressin or dopamine may be vital to maintain ventricular performance. Insert urinary catheter to monitor response of resuscitation.

Table 4.

Signs of shock to look for and prompt interventions for correcting hypovolemic shock during the primary phase of trauma management.

2.2.2 History and physical examination

Ascertaining the type of abdominal trauma that has occurred is essential in terms of choosing diagnostic approach, selecting appropriate therapy, and providing potential vital information regarding the prognosis; this task is achieved in secondary survey. Typically, two types of abdominal trauma, namely: blunt and penetrating abdominal injuries have been recognized. In secondary survey assessment, the mechanism of injury, time and place of injury, whether the patient had consumed some substances (e.g. alcohol) and other clinical manifestations implying abdominal organ injuries should be elicited. Clinical presentations of traumatic abdominal patient are diverse and depend on the type of abdominal injury sustained.

2.2.2.1 Clinical presentation for penetrating abdominal injury

Patient with penetrating abdominal injury can present with stab or gunshot wounds. Gunshot wounds are much more difficult injuries to treat. The type of gun used should be determined. The severity associated with gunshot wounds depends on the kinetic energy of the bullet used.

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where KE = kinetic energy, M = mass of the bullet, V = velocity of the bullet, g = gravitational acceleration. As it can be seen KE is directly proportional to mass and squared velocity. As such, multiple visceral damage should be ascertained when the bullet of high velocity or great mass has been used and the exit wound may be noted. Exploratory laparotomy must be performed for all gunshot wounds. Surrounding injury warrants extensive debridement of tissues that have been destroyed by concussive forces. Low velocity bullet mostly remains within the abdominal cavity and sometimes can be handled as knife stab wounds. The fact that, some bullets move in different directions while coursing within the body, multiple organ damage should always be anticipated. Abdominal trauma surgeon should perform meticulous assessment to any bullet wounds to avoid missing an injury.

The patient with penetrating stab wounds can present with diverse entities and they should be assessed thoroughly. Assessment of stab abdominal wounds should be done under local anesthesia. If posterior rectus sheath has been penetrated it is wise to perform laparotomy. It is vital to remember that intact peritoneum may be misleading because the perforated peritoneum retracts with abdominal rigidity. Omental protrusion through the stab wounds warrants laparotomy. The patient may present with knife in the abdomen, which should not be pulled out immediately; it should be removed by surgeon via an operation [5].

2.2.2.2 Clinical presentation for blunt abdominal trauma

The common mechanism of blunt abdominal trauma include: road traffic accident, physical violence. Abdominal pain is usually the presenting complaint of blunt abdominal trauma. The common signs include: abdominal distention, rigidity, and tenderness which implies peritonism. Bowel sounds can be absent and abdomen moves poorly with respiration. Tachycardia, hypotension and other signs of shock are frequently present which infers laparotomy. Other important signs to look for in case of blunt abdominal trauma include: (1) Seat belt sign (diagonal and lower abdominal abrasion) if positive points to bladder, bowel perforation and fracture of lumbar spine, (2) balance sign (immovable mass or immovable area of dullness in the left upper quadrant) its positivity implies splenic sub-capsular or extra-capsular hematoma, (3) Ker’s sign (presence of left shoulder/ neck pain) if positive it is associated with splenic injury, and (4) Cullen’s signs (presence of periumblical ecchymosis) in case it is positive it implies hemorrhage in the peritoneum.

2.2.3 Investigations

History and physical examination findings are essential but most of the time not enough for complete assessment of traumatic abdominal patient. To appreciate thoroughly abdominal organ injuries certain investigations should be performed to compliment the findings of history and physical examination. The available modalities to use for the assessment of traumatic abdominal patient include: computer tomography (CT), focused assessment sonography for trauma (FAST), laparoscopy, diagnostic peritoneal lavage (DPL) and other basic investigations such as complete blood count (CBC). The key points related to these investigations with respect to the management of abdominal trauma are provided in Table 5.

Investigation	Key significant points with respect to abdominal trauma management	Disadvantages
CT	CT is the gold standard investigation to use for assessing stable traumatic abdominal patient Compared to other investigations such as DPL, CT has higher predictive ability for lesions to be operated CT is useful to guide angiographic interventions for determining the source of bleeding CT has a capacity to visualize retroperitoneal space and vertebral column It is useful for assessing genitourinary and renal arteries CT is effective for avoiding needless surgery	The patients must leave emergency department CT can potentially delay laparoscopy or laparotomy There are risks of radiations It is expensive investigation which is not available and affordable for most patients especially in developing countries
Ultrasound; FAST; For blunt; Penetrating; Extended-FAST	Ultrasound has profound advantages for both blunt and penetrating abdominal trauma patient assessment. It is portable, fast and serial examinations can be performed It is non-invasive, safe and no risks of radiations E-FAST has the capacity to detect small amounts of hemoperitoneum with good specificity and can support to determine concurrent injuries located in thorax	Lack of the capacity for imaging solid parenchymal damage and retroperitoneal and diaphragmatic injuries Nature of the patient e.g. obesity, agitated, and gas in the bowel may limit its usability It is user dependent It has no capacity to detect hollow viscus injury
Laparoscopy	Laparoscopy is used for investigational and therapeutic purpose. Laparoscopy is powerful for detecting diaphragmatic injuries It also reduces the rate of nontherapeutic laparotomy. Numerous investigators have reported higher sensitivity and specificity	Complications associated with insertion Missing solid organ, stomach, small bowel injury, retroperitoneal injuries It requires higher level of expertise prior to its use.
DPL	It is useful for triaging unstable patients with uncertain FASTs It can be used when FAST is not available (e.g. in most hospital of developing countries)	Risk of infections (very low) Intraperitoneal injury (low) Failure to perform DPL can lead to unnecessary laparotomy for the patient who is stable and with self-limiting injury
Others; x ray MRI Hematologic investigations	X ray can be used to detect chest injuries MRI can be useful to detect spinal cord injuries Hematological investigations such as complete blood count (CBC)	Increased white blood cells especially neutrophils, and left shift, toxic granulation may indicate bacterial infections

Table 5.

Key points related to stated investigations with respect to the management of abdominal trauma.

3. Risk factors leading to the occurrence of complications associated with management of abdominal trauma

In addition to understanding anatomy, physiology of abdominal organs and the framework of management for traumatic abdominal patient, it is essential to know other risk factors leading to complications associated with the management of abdominal trauma. Recognizing these predisposing factors can support in planning and enhancing designed measures which aim to avoid the occurrence of the complications associated with abdominal trauma.

3.1 Individual and community related risk factors

Certain complications associated with the management of abdominal trauma are highly common because of individual and community influence. The common known fact is that, life is made at home and repaired at the hospital. The violation of this fact is seen for individuals who sustain abdominal trauma for whatever the cause and delay to present to the health facility.

For one or more reason (s) some traumatic abdominal patients do not seek immediate medical care for their injury. Ignorance is among the factors stopping some individuals and communities from seeking immediate medical care after trauma event. This is commonly seen in developing countries. In developing countries there are still remarkable dual management approaches for traumatic patients [7]. Some traumatic abdominal patients are first seen by traditional healers. The traditional healers have insufficient knowledge and capacity to support quick restoration of functions of injured abdominal organs. Due to failure of the treatment started by traditional healers, traumatic abdominal patients are further referred to the health facility in delayed time. However, due to the delay the standard of management is compromised, which is a major factor leading to complications associated with management of abdominal trauma.

Furthermore, all individuals and communities of the World are suspected to maintain peace which is one of the 17 sustainable development goals (SDG) maximally all the time. With the current ambitions of various countries to achieve SDGs, peace (SDGs 16) is highly needed. All 17 SDGs integrate each other. Specifically integrating SDGs 3 (good health and wellbeing) and SDGs 16 (peace and justice) would favor the mitigation of injuries in various communities; in fact one of the targets of SDGs 3 is to halt number of global deaths and injuries from road traffic accident by 2020. However, evidences indicate that, wars, conflicts [8, 9] and road traffic accident continue to affect many individuals and communities in many parts of the world. Inflicting various types of injuries including abdominal injuries is among the common worst outcomes of un-peaceful communities. Intentional abdominal injuries are likely to be penetrating. Evidences have shown that penetrating abdominal injuries are associated with many complications such as infections, bleeding etc. Thus, high incidence of penetrating abdominal trauma in a community associates with occurrence of many complications that occur during its management.

3.2 Weak health system and trauma care system related risk factors

Weak health system of various countries is among the profound factors leading to complications of various diseases or event. Many countries continue to lack strong health system. Weak health system is profoundly found in most of developing countries [9] yet majority of the diseases and events including abdominal trauma happen in these countries. One of the indicators of a weak health system is continuous occurrence of high mortality and morbidity related to trauma ever reported in these counties. Weak health system seemingly marks the negligence of various countries to their populations. For instance, evidence has shown that the spectrum of trauma has increased due to: (1) increased urbanization, (2) use of automobiles, (3) use of firearms. These factors have also led to higher prevalence of abdominal trauma. As of such high prevalence of trauma, one would suspect strong health system (with standard trauma care as component) to be available all the time. However, in many countries this element has been ignored, thus, complications continue to occur among traumatic abdominal patients at any stage of their management.

Likely in developing countries majority of traumatic abdominal patients are still managed at the substandard centers due to weak trauma care system and due to this instance complications develop. Weak trauma care system can be marked by: (1) Inadequate trained trauma care providers to manage abdominal trauma, (2) Lack of pre-hospital services for traumatic abdominal patients, (3) Absence of appropriate referral system for traumatic abdominal patient, (4) lack of inter-professional collaboration while managing traumatic abdominal patient, (5) Negative attitudes of trauma care providers towards traumatic abdominal patients, and (6) Lack of equipments and infrastructure to use while managing traumatic abdominal patients.

3.2.1 Inadequate trained trauma care providers to manage abdominal trauma

Traumatic abdominal patient should be managed by trained health workers whose knowledge is enough to help to make rational decision regarding management approach. As mentioned earlier the main goal of management of traumatic abdominal patient should be to restore the function of abdominal organs as quick as possible. Lack of trained trauma care providers to provide timely interventions at any stage of management reduces the chance of survival and those who survive are likely to remain with permanent disabilities.

3.2.2 Lack of pre-hospital care services for traumatic abdominal patient

For many years trauma has been a neglected epidemic worldwide. The history marks increased mortality and morbidity related to trauma because of such neglect [10]. With the recognition of such neglect in 2000 WHO affirmed the use of prehospital care interventions as one way for mitigating the mortality and morbidity associated with any kind of trauma. However, many countries especially developing countries have not adopted the principles of prehospital care optimally yet majority of trauma cases happen in these countries as such poor outcomes including: deaths, prolonged hospital stay and development of complications are still reported at unacceptable level.

Three levels of deaths associated with trauma have been recognized; level 1 (immediate deaths encompass deaths which occur quickly due to overwhelming injuries, level 2 (intermediate deaths encompass deaths which occur within several hours after trauma event and notably result from treatable conditions) and level 3 (delayed deaths encompass deaths which occur within days or weeks after trauma event). Evidences have shown that most of these deaths can be prevented by providing timely prehospital care interventions. Trauma care provider should know conditions which are likely to kill the patient and appropriate tasks to perform in order to prevent such deaths at any of these levels. Traumatic abdominal patient may die at any of these stages due to lack of prehospital care interventions. Examples of conditions which can cause death to abdominal trauma victim at any of these stages are shown in Table 6.

Level	Likely cause of death	Actions to prevent the occurrence of death
Immediate deaths	Airway obstruction Hypoxia Hemorrhage Abdominal trauma with other severe injury (severe traumatic brain injury, severe cardiac injury)	Immediate aids Immediate ATLS interventions Followed by other standard trauma care interventions
Intermediate deaths	Airway obstruction Hypoxia Hemorrhage	High benefits of prehospital interventions are noted at this level. Timely ATLS interventions can mitigate or stop the cascades of events that lead to deaths or lifelong disability. Followed by other standard trauma care interventions
Delayed deaths	Airway obstruction Hypoxia Hemorrhage Infections Multiple organ failure Abdominal trauma with other injuries (e.g. spinal cord injury, fractures etc.) Other complications	Prehospital intervention can mitigate deaths which occur at this phase by ensuring: Proper wound care Adequate immobilization of fracture Early initiation of other measures which reduce the likelihood for the development of complications Other standard trauma care interventions

Table 6.

Levels of deaths associated with trauma and likely interventions which can prevent the occurrence of such deaths.

3.2.3 Absence of appropriate referral system for traumatic abdominal patient

The transfer of traumatic abdominal patient may encompass transportation from the scene to health facility or inter-facilities transfer. Depending on the severity of abdominal injury, the patient might need management interventions at different levels of trauma centers. To accomplish such task, an appropriate referral system should be available all the time. Lack of appropriate referral system disturbs the standard of management which is among the prominent factors leading to complications and even sometimes death of abdominal trauma victim.

3.2.4 Insufficient inter-professional collaboration while managing traumatic abdominal patient

Insufficient inter-professional collaboration while managing abdominal trauma patient may increase the occurrence of complications due to: lack of proper communication, increased rates of errors, insufficient assessment of the patient etc.

3.2.5 Negative attitudes of traumatic health care providers towards a traumatic abdominal patient

Saving lives and avoidance of the occurrence of complications for traumatic abdominal patients would be achieved if all trauma care providers approach to them with good attitude. Negative attitude of trauma care providers towards a traumatic abdominal patient can be marked by various factors. For instance, neglecting the patient, failure to follow standards of trauma care, abusive language etc. as per observation of an author working in one of developing countries, negative attitudes of health workers towards patients is real fact. As such many innocent traumatic patients (including those with abdominal trauma) continue to die and some survival patients develop numerous complications.

3.2.6 Lack of equipments and infrastructure to use while managing traumatic abdominal patients

The evidence is clear management of any traumatic abdominal patient should be done at standard trauma center which should have adequate equipments and good infrastructures. Lack of standard trauma care is a major factor leading to the occurrence of complications. Evidence has confirmed that, findings of history and physical examination are unreliable for deciding management approach. Many studies have shown that, CT, FAST, and laparoscopy support to make correct decision regarding the management approach to utilize for traumatic abdominal patients. Due to shortage of equipments and infrastructures many traumatic abdominal patients continue to undergo non-therapeutic laparotomy which is ever associated with numerous complications. Markedly, unacceptable shortage of equipments and infrastructures is found in developing countries where most trauma incidence, mortality and morbidity happen.

3.3 Mechanisms of abdominal trauma related risk factors

All mechanisms leading to abdominal trauma have the potential to associate with a certain complications which may occur during the trajectory of management. However, the variability in terms of how dangerous they provoke complications exist. For instance Gunshot as one of the mechanisms of penetrating abdominal injury is associated with many complications [1]. If the bullet of high velocity and large mass was used, many complications develop because of the damage of multiple abdominal organs. Classically, penetrating abdominal trauma is associated with many complications and deaths compared to blunt abdominal trauma. However, in terms of making diagnosis, blunt abdominal trauma poses more challenges to diagnose compared to penetrating abdominal injuries. As such, astute clinician should thoroughly assess all traumatic patients and perform certain investigations in order to remove such confusions, make appropriate diagnosis and institute timely treatment interventions.

3.4 Abdominal trauma with concurrent and multiple injuries related risk factors

Concurrent and multiple injuries profoundly increase the occurrence of complications associated with the management of traumatic abdominal patient. Shown in Table 7 are possible injuries which increase complications associated with management abdominal trauma. In fact evidences have shown that these injuries are the leading cause of deaths among traumatic abdominal patients. The way these injuries cause complications vary from one another. For instance, patient with abdominal trauma together with traumatic brain injury and who are unconscious are at higher risk of aspiration and asphyxia. Unconsciousness impairs the contraction of pharyngeal muscles and muscles of the tongue, thus the tongue fall back when the patient is in supine position, causing airway obstruction that culminate into aspiration and asphyxia. Moreover, injuries to the central respiratory centers may be present and are among the cause of impaired breathing.

Retroperitoneal hemorrhage Tears of the aorta or inferior vena cava Fractured ribs (Lower ribs fractures) Pelvic and vertebrae injury Diaphragmatic injury

Traumatic brain injury Cardiac injury Pulmonary injury Spinal injuries Fracture of extremities

Table 7.

Possible injuries which increase complications associated with management abdominal trauma.

3.5 Treatment approach related risk factors

Classically, in order to lessen complications and burden associated with the management of abdominal trauma, astute clinician should manage any traumatic abdominal patient using principles of medical management. There are five principles of medical management namely: (1) identify and treat the cause, (2) identify and treat complications which have occurred or as they occur, (3) communication, (4) consultation, and (5) continuous management. The causes of abdominal trauma include road traffic accident, assaults, wars etc. It is impossible for the clinician to directly stop the causes of abdominal trauma. However, in the hospital clinician should teach patients, attendants, and community measures designed to stop the occurrence of injuries all the time, but also clinician should teach them other health promotion and preventive measures.

There are numerous complications such as airway obstruction, hypoxia, hemorrhage, infections, and multiple organs failure which are likely to occur during management of traumatic abdominal patient. It is necessary for practitioners caring traumatic abdominal patient to have optimal understanding factors which favor the development of these complications at any stage of management. In broadly speaking three factors can contribute to the occurrence of complications to the hospitalized traumatic abdominal patient. These factors are: (1) Lack of information, incorrect information or confusion in data regarding to choosing, and planning management approach, (2) Incorrect judgment in choosing and planning management approach, and (3) incorrect execution of management approach. Shown in Table 8 are factors and examples of conditions which are likely to increase the occurrence of complications.

Risk factor	Examples of situations leading to complications
I) Lack of information, incorrect information or confusion regarding data in choosing, and planning management approach	A) Incorrect or confused data; Management of wrong patient Management of wrong abdominal organ (operated) Administration of wrong medications, unnecessary blood and fluids B) Complications due to failure to treat other medical conditions; Bleeding disorders Diabetes mellitus Electrolyte imbalance Endocrinopathies Cardiovascular disorders Pulmonary disorders
II) Incorrect judgment in choosing and planning management approach	Failure to start timely ATLS interventions Failure to triage the patients Failure to choose appropriate management approach (non-operative or operative) due to insufficient assessment of the patient Failure to consider and treat other medical conditions Failure to adhere to infection control measures Failure to adhere to World Health Organization surgical checklist (if the patient is to be operated) Misdiagnosis Use and misuse of instruments (urinary catheters, intravenous cannula, ventilators and nasal-gastric tube), use of contaminated instruments Failure or delay to refer the patient at higher trauma centers for continuous management Prolonged hospitalization of traumatic abdominal patient
III) Incorrect execution of management approach	Prolonged operation for traumatic abdominal patient Failure to treat other concurrent injuries Missing injured abdominal organs Excessive retraction of abdominal organs Removing abdominal organ unnecessary Inserting unnecessary drains Creating unnecessary stoma

Table 8.

Factors and examples of conditions leading to complications associated with the management of abdominal trauma within the hospital.

Furthermore, treatment of abdominal trauma should be comprehensive and should be done via multidisplinary approach. Appropriate communication (between the patient and clinician, and between clinicians), consultation and continuous management are highly crucial in terms of mitigating the burden associated with the management of abdominal trauma.

4. Complications associated with non-operative management of abdominal trauma

Many investigators have confirmed profound benefits of Non-Operative Management (NOM) approach for the management of traumatic abdominal patients. The main indicators NOM include: hemodynamic stability of the patient, absence of peritoneal signs and negative findings of certain imaging modalities. Studies have shown that NOM is useful for the management of majority of blunt and few penetrating abdominal injuries. With the use of NOM most patients progress smoothly to complete recovery without complications. However, in certain number of instances complications develop. Shown Table 9 are some of the possible complications to associate with non-operative management of abdominal trauma. There are shortages of literature written on some of these complications; probably because of the fact that, some of these complications develop in delayed phase of management.

Infections	Nosocomial infections Pneumonia Urinary tract infections Peritonitis Sepsis and septic shock Abscess Liver abscess Sub-phrenic abscess
Delayed rupture	Delayed rupture of hematoma Delayed rupture of a sub-capsular hematoma Delayed rupture of pseudoaneursym Delayed Splenic rupture Delayed hepatic rupture
Others	Hematoma formation Hemobilia Biliary stricture formation

Table 9.

Possible complications to associate with non-operative management of abdominal trauma.

4.1 Infectious complications associated with non-operative management of abdominal trauma

4.1.1 General consideration

Both of the useful and dangerous microorganisms have been with human beings for many years. Human body is ever colonized by useful microorganisms so called normal flora. Evidences have shown that these organisms play substantial role in defense mechanism for normal human being. However, due to certain circumstances such as injuries, and compromised immunity these microorganisms escape their usual habitants and reach sterile site of the body which eventually results into infections. Typically infections can be defined as an invasion and destruction of tissues by microorganisms. Various factors influence the occurrence of infections to humans. For hospitalized non-operated traumatic abdominal patients, among the factors which influence infectious complications include: (1) presence of superficial lacerations, (2) missed and unrepaired hollow viscus injuries, (3) Overcrowded wards of which abdominal trauma patients are mixed with other patients who have other surgical conditions, (4) non-adherence to infections control measures, (5) Compromised immune status of the patient, (6) Starvation, (7) shock, and (8) prolonged hospital stay etc. These factors can influence the occurrence of principal infectious complications such as sepsis and septic shock, peritonitis and nosocomial infections for non-operated hospitalized traumatic abdominal patient.

4.1.2 Sepsis and septic shock for non-operated hospitalized traumatic abdominal patient

The initiation and progression of infection process for non-operated abdominal trauma patient occur via several routes. For instance traumatic abdominal patient with superficial wounds are at risk of developing infections due to immediate colonization of their wounds by normal flora. Usually humans mount both local and systemic responses to microorganisms that have escaped their usual habitants. Infections provoke the process of inflammation. Classic features (pain, warmth, redness, swelling and loss of functions) of inflammation may appear as signs for either local or systemic response to infections. Local metabolic effects of infections are due to tissues damage with cells deaths and buildup of proteins rich exudate of leukocyte, immuglobulins, and plasma; these are visible externally as pus.

Untreated or poorly treated local infections may result into catastrophic results that initiate systemic responses. Systemic inflammatory response syndrome (SIRS) is evident clinical when there are two or more of the following findings: (1) fever (oral temperature (>38°C), or hypothermia (< 36°C), (2) tachypnea (> 24 breaths/minutes); (3) tachycardia (heart rate > 100 beats/minute, and (4) leukocytosis (>12,000/μL) and leukopenia (400 < μL). Sepsis should be diagnosed when evidence (results of culture) shows that infections are the responsible cause of SIRS. Sepsis marks the inability of cell to use nutrients.

Untreated or poorly treated sepsis progress to septic shock. Septic shock can be in two forms namely: warm phase, and cold phase. In warm phase, there is increased peripheral circulation in attempt to deliver enough blood to the cells. High temperature marks this phase. 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 (heart) and more infections. The diagnosis of septic shock is made if there is sepsis and hypotension (arterial blood pressure < 90 mmHg systolic or 40 mmHg less than patient’s normal blood pressure) for at least 1 hour regardless of satisfactory fluid resuscitation. Early recognition of septic shock and institution of appropriate therapies can be useful in terms of saving the life of the patient.

4.1.3 Peritonitis

4.1.3.1 Description

Peritonitis is life threatening condition which is associated with abdominal trauma. The association between NOM and peritonitis depends on the fact of missing perforation of hollow viscous organ. “Injuries to the stomach, duodenum, small intestine, and colon are common in penetrating trauma and relatively rare in blunt trauma. Violation of the peritoneum occurs in between 20 and 80% of patients with penetrating trauma, depending on the type of weapon used” [11]. Both of the pillage of abdominal contents and blood into the peritoneal cavity irritates peritoneal membrane. Persistent non-repaired perforation of hollow viscus abdominal organ exacerbates the process of inflammation due to continuous spillage of GIT contents into the peritoneal cavity. Moreover, severity of peritonitis can depend on perforated hollow organ. For instance, when stomach or duodenum has been perforated, the severity is high because of the spillage of contents of low PH and some microorganisms.

4.1.3.2 Clinical manifestation and treatment

The clinical manifestations of peritonitis may include, fever, rigidity, guarding, signs of toxemia and shock etc. Early recognition and institution of treatment approach is lifesaving. Firstly, stabilize the patient; ensure adequate ventilation, breathing and circulation. Administer fluids and antibiotics. Secondary proceed to the repair of perforated viscus organ. And finally provide postoperative and long term care in order to detect and treat any complications which can occur after an operation.

4.2 Hematoma formation

4.2.1 Description

Hematoma formation is a common outcome to occur following abdominal trauma. Hematoma can form within the tissue or outside the tissue due to damage of blood vessels. Blood that has accumulated coagulate and results into hematoma. The association between NOM of abdominal trauma and hematoma formation as a complication lies on the fact of making a wrong decision. Certain imaging modalities can assist to stage hematoma and support to make best choice regarding management approach. Evidence has shown that stage 1 and 2 of hematoma resolve spontaneously in contrast to stage three and above which should be managed via operative approach. Lack of imaging modalities to decide which stage of hematoma the patient has developed is a common factor leading to the use of wrong management approach. When a certain unrepaired blood vessel continues to bleed more blood accumulate and hematoma continue to form. Untreated hematoma may serve as culture medium for microorganisms because accumulated blood lyses and release cellular contents such as iron which is good nutrients of microbes. As such hematoma can be a focus of infections which may turn into sepsis. The use of antibiotic as prophylaxis for infections associated with hematoma seems not to be effective because hematoma does not allow the entrance of antibiotics.

4.2.2 Clinical features

Manifestations of hematoma depend on its location, size and whether it has ruptured or infected by microbes. History of abdominal trauma and left upper quadrant pain and positive balance sign (immovable mass or immovable area of dullness in the left upper quadrant) point to splenic sub-capsular or extra-capsular hematoma. The pain may occur due to big size of hematoma which compresses nerves, capsule and other tissues to result into ischemia. Signs of hemodynamic instability may be present if hematoma has undergone rupture. Moreover, if hematoma has been infected by microorganisms, signs of infections may be apparent; evidence of infections should infer quick interventions because untreated infections may turn into sepsis, septic shock; perhaps death.

4.2.3 Treatment approach

Evacuation is treatment of choice for hematoma. Evacuation of hematoma diminishes successive inflammatory reactions to the initial insult. But also, diminish damage associated molecular patterns (DAMPs) and successive diffuse organ injury. Operating on hematoma is challenging due to risk of bleeding. While managing patient with abdominal hematoma, physician should remember to treat other complications which would have occurred or as they occur. Treatment or prevention of hypovolemic shock and infections is highly needed.

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.

Step	Example of tasks to perform to improve outcome of an operation
I) Preoperative interaction with and assessment of the patient	Firstly, triage the patients and offer ATLS interventions If possible involve patient in the decision making concerning their surgery Ensure that the patient and attendant (family member) understand the goal of operation; tell them the benefits of an operation, and risks and the possible complications to encounter while performing an operation. Tell the patient other alternative treatment approach; the benefits and risk of such approach should be discussed. Obtain informed consent
II) Selection and preparation of the operation	Choose appropriate management approach (non-operative, operative, damage control, embolization, laparoscopy or Each operation should be individualized Involve anesthetic team in planning of the operation. Traumatic abdominal trauma patients are at high risk of aspiration and anesthetic agents can exacerbate such risks. Anesthetic team can plan ahead strategies for minimizing these risks prior to an operation. Start pre-medications Book blood if excessive bleeding is anticipated. Consider and normalize other medical conditions prior to an operation if possible Ensure appropriate temperature in operating room
III) Execution of the operation	Follow infections control measures Follow WHO surgical checklist Avoid the removal and resecting abdominal organs needlessly Ensure optimal communication between all members of the operating team during an operation Avoid prolonged operation
IV) Formulation of the correct diagnosis	To avoid misdiagnosis, surgeon should perform adequate assessment of the patient during preoperative and intraoperative period. Adequate light is highly required
V) Postoperative and long-term care	Meticulous monitor of vital signs and patient recovery from anesthesia should be done properly after an operation. Advice the patient about the appropriate time to resume eating; early resumption should be favored in order to avoid negative nitrogen balance if not possible total parenteral nutrition should be offered to the patient. Ensure long term care to detect delayed complications. When complication happens during intraoperative or postoperative, operating team should support the patient to overcome the burden of such complication.

Table 10.

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

The triad of:	Hypothermia, Coagulopathy Metabolic acidosis
Shock	Hypovolemic shock secondary to: Hemorrhage Evaporation Loss of fluid into the interstium
Infectious complications	Surgical site infections Superficial surgical infections Deep surgical infections, Sepsis and septic shock Secondary peritonitis Nosocomial infections
Others	Fistula formation

Table 11.

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

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 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 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.

$$\text{Infections and their severity}\mathrm{\alpha }\frac{\mathit{\text{the dose}}\left(\mathit{\text{number of infections}}\right)\mathit{\text{times virulence}}}{\mathit{\text{immunity of the patient}}}$$E2

$$\text{Or infections and}\mathrm{its}\text{complications}\mathrm{\alpha }\frac{\mathit{\text{microbiology times epidemilogy}}}{\mathit{\text{anatomy times immunology}}}$$E3

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.

6. Systematic approaches for avoiding the complications associated with management of abdominal trauma

The twentieth and twenty first centuries have been the time of great changes. In medical field remarkable changes have been noted and mainly changes have focused on finding new solutions to old problems. In overall, trauma continues to be a serious global problem of which new solutions are needed. In fact, evidences have confirmed that, trauma is a worldwide epidemic which is ever becoming worse due to many factors for instance: increased unstandardized urbanization in many countries (especially developing countries), increased use of unstandardized automobiles and roads, increased firearms in many communities, unreasonable violence and wars in many parts of the world etc. As mentioned earlier death is certainly a powerful dependent variable but unwanted one which is ever seen in all kinds of trauma. However, mortality and morbidity associated with most of trauma cases can be prevented. Thus, it is wise to direct more efforts to avoiding the occurrence of abdominal trauma and complications which occur during the trajectory of its management.

6.1 The role of individual and community participation in avoiding the occurrence of abdominal trauma and its complications

Historically, curative measures have occupied greater place in all fields of medicine. However, from 1960s–1970s up to now evidences have shown that, curative measures are not enough for optimizing health status of the populations [9, 12, 13]. As such health promotion and preventive measures are of the greater significance in terms of tackling various medical problems. Health promotion and prevention measures focus on avoiding the occurrence of a certain disease or event. The philosophy for optimizing the use health promotion and preventive measures lies on empowering individual and community to participate in all designed actions which aim to stop the occurrence of certain disease or event.

With regard to abdominal trauma which is the persistent old problem to be solved with new solutions various ambitions are to be emphasized. Redesigning and optimizing the strategies which aim to empower individual and communities to stop all factors leading to the occurrence of abdominal trauma is an effective way which can stop all complications related to abdominal trauma. All causes of abdominal trauma and factors that increase the complications associated with it are known and are preventable. Road traffic accidents, physical violence are marked as common cause of abdominal trauma, however, these are preventable. Thus, mentoring individuals and communities to optimize the use of measures designed to prevent trauma is one of the effective ways to reverse the burden caused by abdominal trauma and its complications.

6.2 The role of countries’ health system in avoiding the occurrence of abdominal trauma and its complications

Evidences are clear all countries should opt to maximize health status of their populations. Through health system which is defined as all organizations, people, and actions whose primary intents are to promote or restore or maintain health; countries can optimize health status of their population without leaving any one behind. From 2015 all worlds’ countries opted to achieve sustainable development goals (which are the extension of millennium development goals) by 2030 [14]. With regard to surgical practice, in 2015 global lancet commission on surgery was established upon recognizing the fact that, globally about 5 billion people had no easy access to surgical care services [14, 15]. This commission is in line to support countries to achieve sustainable development goals through ensuring easy access to surgical services at any time.

Intuitively, by looking on the coverage of various countries towards achieving this commission, many are still needed to be done. Worldwide (especially in developing countries) equitable access to affordable surgical services, safe anesthesia remains a serious problem for many surgical patients including those who sustain abdominal trauma. As such poor outcomes are ever reported for these patients. The World is advancing solving old problems with new solutions is an effective and efficient way for mitigating various problems of Worlds’ populations. In the province of abdominal trauma care, scientists have devised various approaches designed to mitigate the burden caused by abdominal trauma. Among those approaches include: (1) use of damage control strategy, (2) use of laparoscopy for therapeutic and diagnostic purpose, (3) use of embolization strategy to control bleeding, (4) reducing the rate of operative management for traumatic abdominal injuries, and (5) enhancing health promotion and preventive measures designed to reduce risk factors leading to the occurrence of trauma. The purpose of this chapter is not describing in details these approaches, only few highlights about the significance of these approaches are shown in Table 12.

Management approach	Some essential aspects related to this approach
Non-operative management	Indications; Hemodynamic stable patient Absence of peritoneal signs (Guarding, rigidity) Complications that can be reduced if this approach is used suitably; Non-therapeutic laparotomy Bleeding (shock) Infections Key remarks; Non operative management has become the most preferred approach to adopt for stable abdominal trauma patients It can be used for both blunt and penetrating abdominal trauma.
Operative management	Indications; Indications for emergency laparotomy following: A) For penetrating abdominal trauma; Hemodynamic instability Peritonism Evisceration Diaphragmatic injury Gastrointestinal hemorrhage Intraperitoneal air Gunshot wounds traversing peritoneum B) For blunt abdominal trauma; Unstable vital signs with strongly suspected abdominal injury Unequivocal peritoneal irritation If there is evidence of pneumoperitoneum If there is evidence of diaphragmatic injury If there are signs of significant gastrointestinal bleeding Hypotension and positive FAST scan or DPL Complications that can be reduced if this approach is used suitably; Infections Bleeding
Laparoscopy	Indications; Stable penetrating abdominal trauma Few stable blunt abdominal injuries Complications that can be reduced if this approach is used suitably; Missing an injury Infections Bleeding Key remarks; Laparoscopy is essential for both therapeutic and diagnostic purpose [16]
Damage control; Strategy	Indications; Damage control surgery is warranted if there is positive findings of: Acidosis: pH ≤ 7.2 Hypothermia: core temperature ≤ 34°C Coagulopathy: transfusion of ≥5000 mL or total fluid infusion ≥1200 mL Injuries that would otherwise require overly time-consuming surgery (> 90 min) Intra-abdominal tissue edema preventing formal closure of the abdominal wall Source: [17]; Complications that can be reduced if this approach is used suitably; Shock Infections Abdominal compartment syndrome Key remarks; Damage control primarily focus on the normalization of: Physiological Biochemical stabilization over the full anatomical repair of all injuries Damage control surgeries are useful for a subcategory of traumatic abdominal patients as such not suitable in all cases. Guiding criteria for damage control management may comprise the mechanism of injury and the degree of physiological derangement
Embolization strategy	Complications that can be reduced if this approach is used suitably; Hypovolemic shock No removal of injured organ Infections
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)	Complications that can be reduced if this approach is used suitably; Hypovolemic shock No removal of injured organ Infections Key remarks; REBOA is essential for the control for enormous hemorrhage It has delivered auspicious results in the trauma victims It is recognized as a slightly invasive and lower risk technique Complications associated to usage of REBOA are infrequent in case used properly

Table 12.

Highlights of some aspects of some available management approaches for abdominal trauma.

These strategies have been of greater significance in terms of reducing the burden of abdominal trauma in some countries. However, some countries have not utilized these measures optimally due to weak health system. As such unacceptable poor outcomes for traumatic abdominal patients are ever noted. Strengthening trauma care system can support to stop the burden of abdominal trauma. The components of standard trauma care system which should be given the first priority include: pre-hospital care services, appropriate referral system for traumatic abdominal patients, adequate infrastructure and equipments, practice goal oriented approaches. Shown in Table 13 are some of the remarks related to these components in terms of avoiding the complications associated with abdominal trauma management.

Component	Some of the remarks related to standard trauma care in terms of avoiding complications associated with abdominal trauma management
Pre-hospital care	Pre-hospital interventions have valuable role in terms of avoiding the complications associated with management of traumatic abdominal patient. Classically prehospital care can support for: Early initiation of ATLS protocol Early transportation of traumatic abdominal patients to the hospital, Enhance communication process among trauma team members caring traumatic abdominal patient.
Practice goal oriented approaches	The primary goal of traumatic management is to prevent deaths The second goal of management is to restore functions of abdominal organs or the whole patient as quick as possible. The third goal is to provide definitive management and to teach the patient health promotion and preventive measures designed to mitigate burden of any trauma and other medical conditions. Astute clinician should optimally practice these goal oriented approaches, in order to support his/her clients and various communities to achieve optimal health status.
Ensure correct management approach to be done at an appropriate trauma center	Correctly choose management approach (Non-operative versus operative). Operative management has been marked to associate with many complications compared to non-operative management. Many countries have issued essential protocol to support abdominal trauma providers to make appropriate decision regarding to whether to operate or not. Availability of equipments such as CT, FAST has advanced abdominal trauma care with best outcomes. However, marked disparities continue to exist between developing and developed countries regarding to the availability of these investigational modalities. Non-therapeutic laparotomies are still being performed and are associated with high morbidity and mortality. To mitigate these tragedies countries should opt to ensure the availability of these investigational modalities in their hospitals (trauma care centers)
Ensure correct execution of management approach	Various complications associated with management of abdominal trauma would be avoided if correct execution of the management approach. To ensure that happen, all traumatic abdominal patients should be managed by appropriate trained medical personnel at standard trauma center in order to provide correct execution of management approaches.
Appropriate monitoring of traumatic abdominal patients	Physiological derangement associated with abdominal trauma happens in dynamic fashion. As such continuous monitoring (vital signs, response to treatment etc.) of the patient is very essential at any stage of management
The role of inter-professional collaboration (IPC) in avoiding the complications associated with management abdominal trauma patients	Inter-professional collaboration is valuable approach to adopt in order to optimize the standard of care for any patient. The emphasis has been made that, “inter-professional collaboration is of global interest for addressing the complex health care needs and improving patient safety in health care” [18]. Inter-professional collaboration (IPC) can support to avoid the complications associated with the management of abdominal trauma as follows: IPC can empower members of trauma team who routinely involve in management of traumatic abdominal patient IPC can close the communication gaps among the team members managing traumatic abdominal patient IPC can favor traumatic abdominal patient to receive comprehensive care IPC can support to minimize days of hospital stay and readmission rates for traumatic abdominal patients as IPC supports to reduce errors during the course of management IPC can promote team mentality IPC can promote centered care to traumatic abdominal patients

Table 13.

Significances of availability of standard care in terms of avoiding the complications associated with abdominal trauma management.

6.3 Approaches for avoiding infectious complications associated with abdominal trauma management

With the advent of antimicrobial agents, various famous of medical fields believed that infectious diseases would soon disappear. However, currently infections are still marked among the contributors leading to mortality and morbidity worldwide. Infections are still marked as dreaded complications to associate with surgical care and cause unacceptable mortality and morbidity among all kinds of surgical patient. The fact that infections continue to infect patients seeking surgical care warrants the continuous search for the strategies and new technology that can prevent their occurrence. The correct use of antiseptics and of antimicrobial prophylaxis can support to reduce infectious complications associated with the management of abdominal trauma. “Prophylactic antibiotics for patients sustaining penetrating abdominal injuries with intestinal contamination have a role for reducing the rate of incisional wound infection subjected to gastrointestinal soiling” [19]. Moreover, in hospitals where infections are a problematic an infection controls committee may design guideline to follow to protect the patients and trauma care providers from spreading infections and prevent the occurrence of infections and their impacts.

In overall, use of various antimicrobial agents have played a significant role in reduction the burden caused by microorganisms. However, resistance, virulence and unavailability of these agents have been reported as factor limiting the usability of some of these agents. As such scientists continue their discoveries in order to discover agents to use for fighting infections. The recent renewed light based technology (air flow of ultraviolet (UV-C) germicidal emitters, open UV-C germicidal lamps, ozone generators, professional disinfection devises based on UVC radiation and ozone, or the combination of technologies) is being given greater consideration in many countries for fighting infections.

The postulated mechanism of which UV-C radiation inactivates a microorganism is by damaging deoxyribonucleic acid (DNA). Examples of microbes that are killed by UVC include: Pseudomonas aeruginosa, Staphylococcal aureus, Methillicin-resistant Staphylococcus aureus (MRSa), Staphylococcus epidermidis, Mycobacterium tuberculosis, Serratia marcescens, Corynebacterium diptheriae, Legionella pneumophilia Adeno virus type III, Coxsackie A2, Influenza etc. Some of these microbes are encountered in traumatic abdominal patients; perhaps some are more resistant to antimicrobials and cause significant mortality among surgical patients. There have been noted success of the use of air disinfection by UVC in surgical rooms and stimulated an expansion of UVC application in hospitals [20]. Evidence indicates that infections continue to be a serious problem in many hospitals. However, there is promising evidence that, light based technology can destroy microorganisms effectively compared to other agents. Shown in Table 14 are advantages of light over alternative disinfectants, biocides, and anti-infectives [20]. Designing and adopting the use light based technology in surgical field would favor the reduction of infectious complications among traumatic abdominal patient, indeed for all patients and people who interact daily with patients.

Light is environmentally approachable and non-polluting Light is comparatively safe and non-toxic Light does not cause unwarranted injury to the material surrounding the biological agent, whether inorganic, organic, or living Light is relatively cheap to produce Light acts speedily, generally within seconds. Light can be pragmatic to human skin, wounds, mucosa, and other locations of contact minus initiating unnecessary injury There have been no reports of microbial cells evolving resistance to light-based anti-infectives

Table 14.

Advantages of light over alternative disinfectants, biocides, and anti-infectives.

7. Discussion

Globally, injuries are increasing and cause significant health problems worldwide. The greater burden of trauma is reported in middle- and low-income countries and approximately 90% of injury-related deaths happen in these countries [21]. This is a painful fact, as there is published evidence that “if injury mortality rates in low- and middle-income countries were reduced to rates in high-income countries, 2,117,500 lives could be saved per year” [22]. All body organs are vulnerable to the impacts of trauma. However, some body regions are more susceptible than others. Abdominal injuries are the most common type of injuries sustained during trauma event. Development of various complications during the course of management has been documented as a major driver leading to mortality and morbidity among traumatic abdominal patients. However, strategies for avoiding the occurrence of these complications have not been described. In this chapter we discussed systematic approaches for avoiding the complications associated with management of traumatic abdominal patient. Moreover, risk factors leading to the occurrence of these complications, and commonly occurring complications and some rare complications but with higher potential to cause mortality and morbidity have been discussed. We defined complication as an occurrence which is avoidable.

In order to avoid complications associated with the management of abdominal trauma, it is crucial to have maximal knowledge of anatomy and physiological processes of abdominal organs. We have highlighted essential points regarding to the anatomy and physiological process of liver, spleen and GIT because they are mostly injured organs during abdominal trauma. Moreover, anatomy of pancreas has been described because of its intimate relationship with vital vascular structures and common serious danger for both penetrating and blunt injury to the pancreas is the risk of injury to these great vessels. As it was asserted pancreas may obscure the site of bleeding and extensive mobilization or transection of the pancreas may be required in order to control the bleeding vessel.

The comprehensive management of abdominal trauma is a major determinant for the survival of abdominal trauma victim. The framework (primary phase, secondary phase and tertiary phase) of trauma management should be applied to the management of abdominal trauma. In principle all trauma patients should be managed by following the accident and trauma life support (ATLS) protocols. These protocols are also of the first priority while managing traumatic abdominal patient. These protocols contain all interventions aimed to prevent deaths. But also, these interventions influence all other steps of the traumatic abdominal management. Most importantly in this chapter we described ATLS interventions to offer to traumatic abdominal patients as shown in Tables 2–4. Evidence has shown that prehospital care services can optimizes ATLS interventions and improves patient outcomes [23]. However, most of the developing countries do not have formal prehospital care. And possibly this contribute to reported unacceptable mortality and morbidity associated with trauma in these countries. More studies are needed in order to determine barriers stopping developing countries to have formal prehospital care services.

Classically, as shown in this chapter there are various complications associated with the management of abdominal trauma and contribute to poor outcomes. Numerous risk factors leading to the occurrence of these complications have been discussed. In broadly speaking, risk factors discussed are: (1) Individual and community related risk factors, (2) Weak health system and trauma care system related risk factors, (3) mechanisms of abdominal trauma related risk factors, (4) Abdominal trauma with concurrent and multiple injuries related risk factors, and (5) treatment approach related risk factors. By closer look at these factors, it appears that most of them are preventable, suggesting that, multiple tiers and more integrative processes are needed in order to avoid the occurrence of complications associated with the management of abdominal trauma.

Apparent of individual and community related risk factors as factors contributing to the occurrence of complications associated with abdominal trauma indicate that more efforts are needed to in order to enhance the prevention strategies at the individual and community level. “Human beings are regarded as rational decision makers whose knowledge informs their actions. The knowledge regarding health promotion and disease prevention is mostly insufficient or not well perceived by many world’s people” [9]. Mentoring and educating various individuals and communities positively about the strategies designed to prevent the occurrence of abdominal trauma and to have peaceful community is an effective way for mitigating all burden associated with abdominal trauma. Such mentorship would bring the best outcomes by changing unhealthy behaviors leading to physical violence and this in turn would leads to the reduction of abdominal trauma and complications associated with its management.

Moreover, in this chapter weak health system is considered among the most profound factors leading to the occurrence of complications associated with the management of abdominal trauma. Weak health system is mainly found in developing countries where a greater burden of trauma is reported. In overall, “to ensure optimal health status of the people in developing countries, we need a strong health system, we shall surely have it if all health concerned stakeholders understand and put into the consideration the fact that achieving optimal good health status is an important and primary goal to be primarily considered in all planned actions” [9]. Strong health system can lead to the fruition of existence of standard trauma care system of which abdominal trauma patients can also profit.

Certain complications develop as consequence of chosen management approach. Numerous investigators have favored the use of non-operative approach for any stable traumatic abdominal patients regardless the types of abdominal injuries sustained. Probably, this is a good approach in developed countries because of the fact that, the decision for using NOM is made with the support of findings of certain advanced imaging modalities. This is contrary to developing countries where there are shortages of imaging modalities. In developing countries the decision for using NOM is mainly based on clinical findings. This is very dangerous because numerous traumatic abdominal patients present with no external features of intra-abdominal organs injuries. Negative abdominal examination findings do not warrant absence intraabdominal injuries. Evidence has shown that, about half of the bleeding in the peritoneal cavity or retroperitoneum manifests itself with few or no symptoms and that about 31% of cases of abdominal trauma deaths occur when there are no external features indicating intraabdominal injuries [24].

As asserted in this chapter, both penetrating and blunt abdominal trauma can be managed either by nonoperative or operative approach. In past it used to be mandatory to perform laparotomy for all Gunshot wounds however; evidence has shown that some Gunshot wound’s patient can be managed nonoperatively [25]. Other main indicators for operation regardless the types of injuries sustained include hemodynamic instability and presence peritonism and positive finding of certain imaging modalities. Studies have confirmed that various imaging modalities can support to detect intraabdominal organs injuries after trauma.

Specifically FAST is essential for assessing blunt abdominal trauma and about 93% sensitive and 99% specificity have been reported [24]. Otherwise CT scan is gold standard investigation for detecting various abdominal organs injuries. According to the study done in Iran of which 100 patients were enrolled and it was confirmed that CT scan has highest sensitivity for detecting various abdominal injuries. Typically the results of CT in detecting various abdominal injuries in this study are as follows: liver (100%) and spleen (86.6%), specificity for detecting retroperitoneal hematoma (100%) and injuries to kidney (93.5%) [26]. Additionally the accuracy of CT images for detecting injuries of spleen, liver, kidney and retroperitoneal hematoma were reported to be 96.1, 94.4, 91.6, and 91.6% respectively. Imaging modalities assist to make rational decision regarding the best management approach for stable blunt abdominal trauma patients. However, despite their potentials in detecting intraabdominal organs injuries they are mostly not available in most hospitals of developing countries [27] possibly because they are too expensive. Thus, in these countries blunt abdominal trauma patients are likely to be managed with wrong approach. This probably leads to poor outcome and the most dangers are likely to happen to those patients who sustain retroperitoneal injuries because without CT scan it is hard to detect these injuries.

Despite decades of dramatic advance in treatment and prevention of trauma, globally trauma continues to be a major public health problem. More than 5 million individuals perish every year as a consequence of injuries. This is responsible for about 9% of the world’s deaths, approximately 1.7 times the number of mortalities that result from HIV/AIDS, tuberculosis and malaria combined. It is not clear why trauma has not been given great priorities in some countries. There has been clear stated target that “by 2020, halve the number of global deaths and injuries from road traffic accidents” [25]. In the context of most developing countries evidence indicates that, this goal has not been achieved. What remains to be understood is that, what caused the failure and which interventions are being taken in order to achieve this missed achievement of targeted goal? This evidence of failure indicates that, if we are in the pace of preventing and ensuring proper management of traumatic patients, we still need multiple tiers of influence of which some of them would be to solve old problems with new solutions. Road traffic accident is responsible for about 75% of blunt abdominal trauma [24]. As such mitigating road traffic accidents would favor the reduction the burden of abdominal trauma. But also, there is a need for designing new ways for avoiding the occurrence of other physical violence leading to injuries. The emphasis should be directed to designing new ways for maintaining optimal peace in many parts of the world.

As the World continues to advance solving old problems with new solutions is an effective and efficient way for mitigating various problems of Worlds’ populations. Scientists have devised various approaches to use in order to mitigate the burden of abdominal trauma. In Table 12 we highlighted essential points of various strategies devised by scientists in order to mitigate the burden of abdominal trauma. Intuitively some of stated strategies require high level of expertise and should be done with support of modern technologies. Thus, there are likely not to be available in most of developing countries. As such unacceptable poor outcomes to traumatic abdominal patients are ever reported. Thus, one would affirm the principles of preventing all factors leading to the occurrence of abdominal trauma as real solutions for avoiding the complications associated with abdominal trauma management in many countries.

More so, in this chapter we described various complications such as shock, sepsis etc. associated with the management of abdominal trauma. Infections were described as dreaded complication to associate with management abdominal trauma. Most importantly, we described strategies for preventing the occurrence of infections. We highly recognized the potential of antimicrobials in terms of mitigating infections however; due to notable resistance, high virulence of some microbes and unavailability of antimicrobial agents in some hospitals as factors limiting effectiveness and usability of antimicrobial agents; We additional described use of light based technology as new way to use for mitigating infections among traumatic abdominal patient. As shown in Table 14 light based technology has substantial advantages over alternative disinfectants, biocides, and anti-infectives. What remains unknown is the safety and how this technology can be used effectively and efficiently to mitigate infections. The greater considerations should be given to developing countries because most of the infectious complications are reported in these countries.

8. Conclusion

In this chapter we discussed various aspects related to complications associated with management of abdominal trauma. The main goal of this chapter has been to describe strategies which can be used to avoid the occurrence of complications associated with the management of abdominal trauma. As real fact abdominal trauma is persisted old problem which must be solved with new solutions. To achieve such task a great deal of emphasis should be dedicated to preventing the occurrence of abdominal trauma. Truly, without stopping the occurrence of abdominal trauma, complications associated with its management will continue to occur. Timely initiation of evidence-based management protocols for abdominal trauma can improve patient outcomes. Evidences have shown that, management of traumatic abdominal patient at standard trauma centers coupled with optimal use of modern technology favors the benefits of decreasing mortality and morbidity associated with abdominal trauma. In fact various countries especially developed countries have endorsed the availability of standard trauma care and modern technology to be used while managing traumatic abdominal patient. Greater disparities exist between developed and developing countries in terms of tackling various cases of trauma. What remains unknown is how to eliminate these disparities? New strategies should be designed in order to eliminate such disparities. All worlds’ countries have adopted the agenda to achieve sustainable development goals by 2030. It has been strongly affirmed that none should be left behind. Putting more efforts in solving abdominal trauma with new solutions is an effective way to use for supporting traumatic abdominal patient to move with others in the journey towards achieving sustainable development goals.

9. Future prospectus

Many publications have affirmed that, majority of trauma cases happen in middle and low income countries. However, data showing specifically epidemiology of trauma per body region are not available in these countries. For instance there is lack of data showing epidemiology of abdominal trauma in developing countries and as real fact it is hard to know extent of the complications associated with the management of abdominal trauma in these countries. Designing a new strategy for collecting trauma data per body region will support to develop new strategies that will be used to mitigate the burden of such certain injuries. Moreover, uses of imaging modalities are highly essential in terms of improving management outcomes for trauma patient. However, there is still shortage of these imaging modalities in most of developing countries probably due to the fact that, these imaging modalities are very expensive. Dealing with companies which manufacture equipments of imaging modalities to ensure cost effectiveness for these equipments will support in terms of availability of these imaging modalities in developing countries and this will be one of the new solutions for solving abdominal trauma plus among others.

One of the targets of SDGs 3 has been to halt number of global deaths and injuries from road traffic accidents. This target was to be achieved by 2020; however, globally a road traffic accident which is the major cause of blunt abdominal trauma continues to happen at unacceptable level. Rethinking on new strategies for achieving this designed target which aim to mitigate global deaths from injuries will support to reduce complications associated with trauma. Moreover, many communities and countries continue to lack peace, which is among the leading cause of abdominal trauma and other injuries. Various authorities from all parts of the world should look for the new ways of maintaining peace and this will reduce suffering caused by physical violence for many people.

Acknowledgments

Firstly, I would like to acknowledge my dear DIANE UMWALI, my parents JOTHAM KAMEGELI AND KESIE NYIRANGEJEJAHO, and my Elder brother GERARD NKUNZURWANDA for their profoundly constructive, supportive and inspiring ideas, and financial support given to me while preparing this chapter. Secondary, I sincerely thank the Government of RWANDA for its profoundly commitments and ambitions towards: (1) achieving sustainable development goals by 2030 and vision 2050, (2) optimizing health status of all Rwandans, (3) empowering the youths, and (4) creating strong communities which love life and development more than any other things etc. Without these commitments this work would have not come into the reality.

Conflict of interest

The author declare no conflict of interest.