Trauma Laparotomy

Trauma Laparotomy (Crash Laparotomy)

David Ray Velez, MD

Table of Contents

Operative Sequence

Access and Exposure
Temporary Bleeding Control
Exploration
Decision (Definitive Repair vs. Damage Control)

Operative Sequence

Position: Supine with Arms Extended

Prepare from the “Chin to Knees”

Operative Sequence

  • Step 1. Access and Exposure
  • Step 2. Temporary Bleeding Control
  • Step 3. Exploration
  • Step 4. Decision (Definitive Repair vs. Damage Control)
  • Based Upon the Sequence Outlined in “Top Knife” by Hirshberg and Mattox

Access and Exposure

Standard Incision: Long Midline Incision from Xiphoid to Pubis

  • Consider Smaller Incisions (Upper Midline, Lower Midline, etc.) If the Patient is Not Crashing and Time Allows or There are Indications of Specific Injury
  • Major Pitfall: Iatrogenic Injury to Left Liver, Bowel, or Bladder

Other Incisions

  • Extend Incision Superiorly/Inferiorly to Enter Virgin Territory
  • Chevron Incision (“Bilateral Subcostal”, “Double Kocher”, “Rooftop”)
  • Mercedes Incision
  • *Used to Avoid Scarring if Necessary but May Limit Exposure in Other Areas – Generally Only Considered in Select Circumstances

Enter Rapidly but in a Controlled Manner and Eviscerate the Bowel Early

Incisions: (A) Midline, (B) Chevron, (C) Mercedes

Temporary Bleeding Control

Approach

  • Blunt Trauma: Begin with Empiric Packing
  • Penetrating Trauma: Begin by Directly Approaching the Bleeding
    • *Some Recommend Empiric Packing in All Trauma Cases

Packing

  • Pack Early – Packing Relies on the Ability to Form Clot and is Less Effective Once Coagulopathy Develops
  • Techniques:
    • “From Within” – Pack Laparotomy Pads into a Cavity Applying Outward Pressure
    • “From Without” – Create a Sandwich to Reapproximate Disrupted Tissue Planes
  • Empiric Packing Sites:
    • Over and Under the Liver
    • Over and Under the Spleen
    • Along the Right Paracolic Gutter
    • Along the Left Paracolic Gutter
    • In the Pelvis

Rapid Supraceliac Control (If Exsanguinating)

  • Clamping the Distal Thoracic Aorta Through the Abdomen
    • Avoids the Thick Fibrous Attachments as the Abdominal Aorta Passes Thorough Diaphragm
  • Step 1. Divide the Gastrohepatic Ligament
    • Normally Avascular but Watch for a Replaced Left Hepatic Artery
  • Step 2. Reflect the Stomach/Esophagus to the Left to Visualize the Aorta
    • May Require Division of the Diaphragmatic Crura
  • Step 3. Bluntly Dissect the Aorta
  • Step 4. Occlude the Aorta
    • Options:
      • Manual Compress Against the Spine
      • Aortic Root Compressor/T-Bar Against the Spine
      • Aortic Vascular Clamp – Consider Umbilical Tape to Hold Up

Other Options for Rapid Control of the Supraceliac Aorta

  • Left Anterolateral Thoracotomy with Thoracic Aortic Control
  • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Supraceliac Control of the Aorta

Exploration

Explore Once Bleeding is Temporarily Controlled

Order of Exploration

  • Step 1. Inframesocolic Exploration
  • Step 2. Supramesocolic Exploration
  • Step 3. Lesser Sac Exploration
  • Step 4. Retroperitoneum Exploration
  • *Some Report Different Orders of Exploration – Exact Order is Not as Important as Making Sure to Preform it the Same Way Every Time and to Not Miss Any Injuries

Inframesocolic Exploration

  • Lift the Transverse Colon Cranially
  • Run the Bowel from the Ligament of Treitz to the Rectum
    • Transverse Colon and Hepatic/Splenic Flexures are Notorious for Missed Injury
  • Inspect the Bladder and Pelvis

Supramesocolic Exploration

  • Pull the Transverse Colon Caudally
  • Inspect from Patient Right-to-Left
  • First: Examine the Liver, Gallbladder, and Right Kidney
  • Second: Examine the Anterior Stomach and Duodenum
  • Third: Examine the Spleen and Left Kidney
  • Additionally Examine the Bilateral Diaphragms

Lesser Sac Exploration

  • Bluntly Dissect Through the Gastrocolic Ligament/Greater Omentum to Enter the Lesser Sac
    • The Left Side is Generally Less Vascular
  • Examine the Posterior Stomach and Pancreas

Retroperitoneum Exploration

  • Keep Retroperitoneal Exploration Targeted and Limited
  • Indications for Exploration:
    • Zone I (Central): Mandatory Exploration
    • Zone II (Lateral):
      • Penetrating: Selective Exploration
      • Blunt: Explore Only if Expanding, Pulsatile, or with Active Hemorrhage
    • Zone III (Pelvis):
      • Penetrating: Mandatory Exploration
      • Blunt: Explore Only if Expanding, Pulsatile, or with Active Hemorrhage
  • Clinical Suspicion Based on Missile Trajectory or Presence of Hematoma
  • Maneuvers:
  • There is Significant Overlap with Maneuvers and They Should be Tailored to the Individual Patient

Retroperitoneal Zones

Maneuvers to Access the Retroperitoneum: 1. Mattox, 2. Cephalad Transverse Mesocolon Reflection, 3. Kocher*, 4. “Extended” Kocher*, 5. “Super-Extended” Kocher*, *#3-5 Together Compose the Cattell-Braasch Maneuver

Decision (Definitive Repair vs. Damage Control)

Damage Control Definition: Surgery to Stabilize with Delayed Definitive Repair

Goals of Damage Control

Indications for a Damage Control Procedure

  • Severe Physiologic Insult
    • Acidosis (pH < 7.2)
    • Base Deficit > 14-15
    • Lactate > 5
    • Temp < 34-35
    • Coagulopathy (Clinical Evidence or INR > 1.5)
    • Intraoperative Ventricular Arrhythmia
  • High Blood Loss
    • Unable to Control Bleeding by Conventional Methods
    • Blood Loss > 4 L
    • Blood Transfusion > 10 U
  • Injury Pattern
    • 5 Different Injury Patterns
    • Difficult to Assess Major Venous Injury
    • Massive Hemorrhage from the Pancreatic Head
    • Major Liver or Pancreaticoduodenal Injury with Hemodynamic Instability
    • Pancreaticoduodenal Devascularization or Massive Disruption with Involvement of Ampulla or Distal CBD
  • Need for Staged Reconstruction
    • Need to Reassess Bowel Viability
    • Unable to Close Abdominal Wall Without Tension
    • Signs of Abdominal Compartment Syndrome While Attempting Closure

The Exact Indications are Controversial and Continually Evolving

Damage Control Phases

  • DC-0: Preoperative
  • DC-I: Initial Operation
  • DC-II: Resuscitation
  • DC-III: Definitive Repair
  • DC-IV: Delayed Soft Tissue Reconstruction (If Needed)