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
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.
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
- typically this will be arterial bleeding requiring surgical
- 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
- 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
1. Start with looking for contamination
- run bowel from GO jx to Ligament of Treitz and down to terminal
- 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.
- 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
- mobilization of ligament of treitz for 3rd and 4th parts of
- 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
Repair vs Damage Control
On second run through, fix all bowel holes and bladder injuries if
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.