Trauma Laporotomy / Exploration

Goals
1. Haemostasis
2. Stop contamination
3. Identify injuries.
4. Restore organ function.
These may not be achievable in the first laparotomy.

Preparation
NG Suction


1. Midline incision.

2. Stop the bleeding
- first priority.
- initially by packing the abdomen.

Generally 1.5hrs, or 5-10units of blood without resuscitation, before serious & potentially non-reversible hypothermia, hypoperfusion and coagulopathy occur.
- how long delay to surgery?
- rapidly assess whether pt will tolerate definitive repair
- or whether the laparotomy should be abbreviated for damage control.

Scoop out blood and clot with hands and pads.
- then immediately tightly pack all quadrands and gutters with pads to tamponade all potential bleeding sites.
- suction at this time is worthless.

Now allow the anaesthetist to transfuse and catch up.
Either:
i) the packing will work, and the bleeding will stop.
ii) or the bleeding will continue.
- if so, there is a large venous or ongoing arterial bleed not well tamponaded.
- typically this will be arterial bleeding requiring surgical control.
- typically you will be able to tell the site, eg the iliac artery; ignore everything else and concentrate here.

3. If the Packing Has Worked
- remove packs slowly from areas not apparently injured first
--> but if there is still active bleeding address that area first.
- this will allow you to move the viscera around later.
- look at the pads: how much blood?
- look at the area: is it bleeding?
- examine for retroperitoneal haematomas
Do this by inspecting quadrants in serial fashion

4. Exploring the Abdomen
Explore systematically
1. Start with looking for contamination
- run bowel from GO jx to Ligament of Treitz and down to terminal ileum.
- then over colon.
--> oversew or staple control of leaks; definitive repair unnecessary until patient stabilized and abdomen assessed.
2. Then examine entire abdomen in a systematic fashion, e.g. clockwise
- liver and hemidiaphragm in RUQ; divide suspensory hepatic ligaments if required
- diaphragmatic injuries can be missed posteriorly if not specifically looked for.
- kocher maneuvre if haematoma or bile staining at 2nd part of duodenum
- mobilization of ligament of treitz for 3rd and 4th parts of duodenum
- left upper quadrant, spleen, tail of pancreas, enter into lesser sac if required.
3. Lower quadrants for retroperiteonal haematomas
- (fear large vessel injury; see below)
- examine bladder, ?pelvic haematoma
Run all of bowel a second time, looking more closely for mesenteric haematomas, contusions

Repair vs Damage Control
On second run through, fix all bowel holes and bladder injuries if stable
Criteria for truncating surgery:
- acidosis, hypothermia, coagulopathy
- pH <7.1 and body temp <34 are indications that laparotomy should be ceased
- common injuries needing damage control include major vascular injury, high-grade hepatic injuries, pelvic fractures.
But do not leave operating room if active bleeding needs control.

5. Haematomas & Other Bruises
See retroperitoneal notes

6. Damage Control
See notes

7. Specific Issues
Aortic Injury
Bowel Injury
Hepatic Injury
Pancreaticoduodenal Injury

Splenic Injury


Jeromes Notes


The trauma laparotomy

GA. Supine. Catheter. NG tube.

Prep from neck to thigh with towel over perineum. Drape.

Midline laparotomy from Xiphisternum to pubis.

Scalpel incision down to pre-peritoneal fat in three strokes.

Bluntly enter peritoneum with finger above umbilicus.

Divide linea alba with Mayo scissors protecting the underlying

Divide and tie the falciform ligament

Eviserate the small bowel

Scoop and suck out blood and clots

In blunt trauma, pack empirically:

Pack feeling for blunt injuries to the solid organs:

   Packs above the liver: pull the liver down with the left hand and place pack over it with the right. Pack below the liver and right paracolic gutter

   Pull the spleen down with left hand and place pack above. Place a pack medial to spleen

   Pack the left paracolic gutter and then the pelvis.

Examine the mesentery of the eviscerated bowel and compress any bleeding points manually or with assistants fingers.

In penetrating trauma, eviscerate and go straight for the bleeding structure.

Temporary Control of lacerated bowel with non-crushing bowel clamp

If the patient continues to exsanguinations  - make a hole in pars flaccida of lesser omentum and manually compress the aorta against the spine

Once haemorrhage and contamination control has been achieved allow time for resuscitation, coagulopathy correction and re-warming.

Perform a laparotomy

Explore infra-mesocolic compartment

Run the SB from ligament of Treitz to ileocaecal junction.

Examine the colon down to the rectum.

Any spillage is controlled temporarily with suture.

Look at the bladder, uterus and ovaries

Explore the supra-mesocolic compartment

Liver, GB and right kidney

Inspect from COJ to second part of duodenum.

Do Kocher maneuver and divide ligament of Treitz in all patients

Inspect the left kidney and spleen

Examine carefully the diaphragm

Explore lesser sac

Hold apart the stomach and transverse colon and make window to the left of the midline to look at the posterior wall of stomach and pancreas.

See also retroperitoneal notes


Cameron
Deitch E.A (Ed). Tools of the Trade & Rules of the Road.