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Trauma Laparotomy

Emergency Medicine
Surgery
Military Medicine
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Introduction

Trauma to the contents of the abdominal cavity is largely classified into two groups:
  • penetrating trauma
  • blunt trauma.
Trauma laparotomy is a versatile procedure that allows for rapid access to all regions of the abdominal cavity. Trauma laparotomy must be performed in a systematic way to avoid delays or missing injuries. The goal of trauma laparotomy is to identify and treat injuries that threaten the patient’s life and treat them as quickly as possible.
Supporting the patient before, during, and after the surgery is just as important as the surgery itself. Hemorrhage control is the first goal of trauma laparotomy as uncontrolled hemorrhage can kill the patient quickly. Contamination, from external or enteral sources, is addressed only after hemorrhage control is achieved. In unstable patients, trauma laparotomy can be performed in stages, using techniques for temporary closure of the abdominal cavity between stages to allow for patient stabilization in the intensive care unit.

Indications

In combat situations, trauma laparotomy is indicated for any patient with penetrating abdominal trauma and hemodynamic instability. There is no role for cross-sectional imaging (CT or MRI) in a hemodynamically unstable patient with abdominal trauma. If a patient with penetrating trauma is not hemodynamically unstable and ultrasound is available, a Focused Assessment with Sonography for Trauma (FAST) exam may help guide decision making. If there is free fluid in any of the regions evaluated by FAST ultrasound, trauma laparotomy is recommended. If ultrasound is not available or the FAST ultrasound is negative, a secondary survey should be performed, evaluating the patient for any of the following: evisceration, signs of peritonitis, profuse bleeding out of the patient’s mouth, rectum, or penetrating injury. If any of these are present, proceed with trauma laparotomy. If none of these criteria are met, the patient should be resuscitated, broad spectrum antibiotics should be initiated, and cross-sectional imaging and supportive care should be pursued.
In patients with blunt abdominal trauma who are hemodynamically unstable, a FAST ultrasound should be performed, and trauma laparotomy is indicated if free fluid is seen. If FAST ultrasound is not available, a diagnostic peritoneal lavage (DPL) may be attempted. If DPL is positive, consider operative exploration. If the FAST ultrasound or diagnostic peritoneal lavage are negative, the patient should be resuscitated and assessed for other causes of shock. If no other source of shock is identified and the patient remains hemodynamically unstable, especially if the patient has abdominal distention, profuse bleeding from their mouth or rectum, or signs of peritonitis, consider performing a trauma laparotomy. As with penetrating trauma, if the patient becomes hemodynamically unstable at any point in time, reassess again to see if the patient meets criteria for trauma laparotomy.

Equipment

A trauma laparotomy kit pre-packed with essential tools should be available at all times to minimize delays in operative intervention. In addition to the equipment used to enter the abdomen, numerous clamps, laparotomy pads, and instruments for vascular repair should be available to assist in achieving hemostasis. Wide retractors (for example a Deaver retractor) are helpful to keep the abdominal wall out of the way. If available, handheld gastrointestinal staplers and staple loads are helpful to quickly ligate and divide structures. Vascular clamps or vessel loops are useful to temporize bleeding before definitive repair can be done. Vessel loops can be improvised with rubber bands. Most injuries identified in trauma laparotomy can be addressed with polyglactin (0 to 4-0), silk (0 to 4-0), or polypropylene (0 to 6-0). It is also important to ensure the anesthesia team has sufficient equipment, IV fluids, medications and blood bank products to resuscitate the patient. This includes rapid transfusing and IV fluid warming equipment.

Decision-Making

Given that the primary goal of the trauma laparotomy is to save the life of the patient, it is essential to state that the first step is to stop bleeding (which can lead to hemorrhagic shock and death) and then to control contamination from enteral injuries (which can lead to septic shock and death). Then it is equally important to recognize that the bleeding trauma patient can quickly develop the “triad of death” – hypothermia, acidosis, and coagulopathy. Once the triad of death has begun, it is almost certain that continued efforts to definitively repair all traumatic injuries will end in exsanguination and death. Hence the philosophy of “damage control” surgery has developed. In damage control surgery, the surgeon’s objectives in chronologic order are to:
  1. Establish temporary bleeding control – through packing, ligating, shunting
  2. Establish temporary contamination control – through rapid oversewing or clamping of enteral injuries or bowel resection without anastomosis
  3. Assess with anesthesia team if the patient is stable enough to continue onto definitive repair of injuries
    • If not, temporary abdominal closure and transfer to ICU for stabilization (re-warming, correction of acidosis with resuscitation, and correction of coagulopathy with transfusion of blood products), with plan to return to OR in 24-48 hours
    • If so, proceed to definitive repair and then closure
  4. Definitive repair of vascular injuries – vessel repair, anastomosis, or bypass
  5. Definitive repair of contamination – enteral repair, anastomosis, or creation of stoma
  6. Abdominal closure

Preparation

Before inducing anesthesia, the patient should be appropriately positioned and prepped, large bore IV access should be obtained, a foley catheter should be placed, prophylactic antibiotics administered, and steps should be taken to avoid hypothermia as this contributes to coagulopathy. The patient should be exposed and placed supine with arms out at 90 degrees.
The patient is then prepped from the chin to the knees with an iodine-based solution, extending as far laterally as possible. This provides access to the entire abdomen as well as the groin, which allows for distal vascular control if needed. Exposure of the thigh allows for harvesting of the saphenous vein if needed for vascular grafting. In a hemodynamically unstable or exsanguinating patient, preparation and intubation may occur simultaneously. Once anesthesia is induced, especially if the patient is intubated, the patient may experience a quick drop in blood pressure or even cardiac arrest. Proceed with the trauma laparotomy and resuscitate as needed.

Steps

To open, a No. 10 scalpel provides fast access into the subcutaneous tissue with a few strokes of the blade. If available, electrocautery allows for quick division of the subcutaneous tissue down to the fascia. Once the fascia is identified it is opened with a scalpel or scissors. The surgeon’s finger is then inserted and used as a guide to extend the fascial incision with either cautery or scissors. A clamp is used to grab and elevate the peritoneum so it may be opened with a knife or scissors in a similar fashion. The incision is usually made from the xiphoid process to the symphysis pubis, going around the umbilicus.
Once the peritoneal cavity is entered, pooled blood or clots should be removed to improve visualization. The small bowel should be eviscerated by sweeping in a circular motion from the left upper quadrant down to the left and right lower quadrants and finally up to the right upper quadrant. All four abdominal quadrants should be tightly packed with laparotomy pads in a systemic fashion in order to tamponade bleeding. If the omentum or the small bowel are bleeding, quickly clamp all mayor bleeding areas and proceed with inspection of the four quadrants. If packing results in temporary control of hemorrhage further exploration may be paused to allow for the patient to be resuscitated. If there is ongoing hemorrhage, the aorta should be compressed above the level of the celiac axis. The supraceliac aorta is accessed by incising the gastrohepatic ligament and retracting the liver to the right, exposing the esophagus and aorta.
The aorta is cleared anteriorly and posteriorly to allow for placement of a vascular clamp. Alternatively, for rapid control, a sponge stick or the surgeon’s fingers may be used to compress the aorta. Once massive hemorrhage is controlled the surgeon should proceed with a systematic inspection all four quadrants, prioritizing any quadrant showing signs of bleeding. If there is bleeding from the spleen, it should be mobilized medially, and a clamp placed across the hilum. Splenectomy should be deferred until later during the operation. Bleeding from the liver can often be controlled by compression of the parenchyma laterally, superiorly and inferiorly using packs.
If there is ongoing bleeding, a Pringle maneuver should be performed by placing a finger through the foramen of Winslow and pinching the portal triad. This can then be replaced with a clamp or a vessel loop to free the surgeon’s hand. Injuries to the hepatic veins or retrohepatic IVC are challenging to control and are associated with extremely high mortality. In order to control hemorrhage and provide exposure, total hepatic isolation may be attempted; these cases are almost uniformly fatal.
At this time, all intraperitoneal sources of bleeding should be controlled. Attention is then turned to the retroperitoneum to evaluate for hematoma. The decision to explore depends on the type of injury and the anatomic location.
The retroperitoneum can be categorized into three anatomic zones.
Zone 1 hematomas represent bleeding from the aorta or inferior vena cava and can be identified by lifting the transverse colon up and down to look at the region. Zone 1 hematomas caused by penetrating injuries should always be explored. The aorta can be quickly cross clamped by opening the lesser omentum and retracting the stomach and duodenum to the left. This should expose the right crus of the diaphragm which overlies the supraceliac aorta, which can be compressed against the spine with one or two fingers and then clamped as described above. Once the supraceliac aorta is clamped, the retroperitoneum should be exposed using a medial visceral rotation maneuver.
This also allows for management of Zone 2 hematomas (largely representing major vascular injuries related to the kidneys), which should also be explored in penetrating trauma.
When coming from the right, perform a 3-step procedure:
  • first a Kocher maneuver
  • followed by release of the hepatic flexure, the ascending colon along the paracolic gutter
  • and finally the avascular plane between the root of the mesentery and the peritoneum.
This is called a Cattell-Braasch maneuver and exposes the inferior vena cava, right renal pedicle, right iliac artery and vein, ureter, head of the pancreas, duodenum, and posterior aspect of the right colon. At this point the inferior vena cava can be temporary occluded with direct anterior compression using a rolled sponge clamped in ring forceps.
The left retroperitoneum can be exposed using a Mattox maneuver. Supraceliac control of the aorta should be obtained prior to performing a Mattox maneuver. The splenorenal ligament should be divided and the descending and sigmoid colon should be mobilized along the paracolic gutter. These structures are rotated medially, taking care to avoid traction injuries to the left kidney and spleen. Continue mobilizing the spleen, and colon medially until you have managed to expose the aorta, left renal pedicle, left iliac artery and vein, ureter, tail of the pancreas, and posterior aspect of the left colon.
Zone 3 hematomas are associated with complex pelvic fractures and can also result from penetrating trauma. Zone 3 hematomas from penetrating injury are generally explored, as in the case of Zones 1 and 2. Cross-clamping the aorta at the bifurcation is advisable for inflow control before opening a hematoma where arterial injury is suspected. Blunt injury to Zone 3 is often venous in nature and is typically more amenable to preperitoneal packing to tamponade venous bleeding or angiography rather than direct surgical repair. To do this, it is ideal to make a new 10-cm midline incision created just above the pubis, preferably separate from the laparotomy incision, to ensure packing is placed extraperitoneally.
The anterior fascia is incised, taking care to keep the peritoneum intact. The bladder is retracted to either side and three packs are placed on each side: one laterally at the sacroiliac joint, one anterior to the middle pelvic brim, and one posterior and lateral to the pubis. The space is usually already dissected out by the hematoma. The decision to explore hematomas in Zone 3 directly depends on access to angioembolization or orthopedic intervention.
At this point, all mayor sources of bleeding should be, at least temporarily, controlled. Enteral injuries can be primarily repaired if they encompass less than 50% of the bowel circumference and the mesentery is viable, otherwise resection should be considered. Resected ends can sometimes be left on discontinuity if a second-look laparotomy is anticipated once the patient is optimized.
Rectal or anal injuries are best managed in the emergency setting with ostomy creation for diversion. Large splenic lacerations usually warrant splenectomy, which can be done by tying or stapling the structures of the splenic hilum taking care of avoiding a pancreatic injury. The stomach has a robust blood supply and can often be primarily repaired, although a partial gastrectomy can be performed if needed. Any injuries to the anterior wall of the stomach should raise suspicion of a posterior wall injury that may need repair. Injuries to the biliary tract and pancreas are addressed in a separate section. Bleeding from most blunt hepatic injuries is venous and can be managed expectantly, leaving it tightly packed for 48 hours to allow for tamponade.
Small and medium penetrating liver injuries usually respond to pressure and topical hemostatic agents. Large liver injuries can be managed with electrocautery or suture closure. At times, a vessel deep to the injury is the culprit and fracturing the hepatic parenchyma with the finger is necessary to identify and ligate the bleeding vessel. An omental patch can also be used to repair hepatic injuries. Removing a severely injured section of the liver is sometimes necessary. As mentioned early, the Pringle maneuver aids in controlling inflow to liver, minimizing bleeding while definitive repair is undertaken. While the effects of long clamp times are unclear, most patients can tolerate longer than an hour. Injuries to the kidneys are best approached after securing control of the renal artery and vein.
Small and medium kidney injuries can be managed with partial resection and repair by primary closure of the capsule or with a peritoneal patch. If the renal vein is injured between the inferior vena cava and the gonadal vein, it can be ligated as the gonadal vein can drain the kidney in most patients (provided it is intact).
Arterial or venous injuries may be repaired primarily or with an interposition graft. Ultimately, if the kidney or its vessels are severely injured, nephrectomy may be warranted. Vascular injuries may be treated with ligation, primary repair, vein patch, interposition grafting or temporary shunting. The celiac artery and internal iliac arteries may be ligated with low risk of morbidity. Ligation of the common iliac artery or external iliac artery is possible but is associated with high rates of amputation.
A femoral-femoral bypass is also an option if reconstruction is difficult. Injuries of the aorta or the inferior vena cava may require primary repair or interposition grafting and should be performed as soon as the injury is identified. The infrarenal vena cava may be ligated in critical situations.
It is important to note that ligation of the infrarenal IVC, the external iliac vein or the common iliac vein may result in significant lower extremity edema and compartment syndrome and fasciotomy should be considered. The portal vein should be repaired when possible, with ligation used only as a last resort as this leads to significant intestinal edema. The superior mesenteric artery and vein should be repaired to preserve circulation of the small bowel.
Once all structures are repaired, the abdominal cavity should be irrigated to minimize sources of contamination. At this point, it may be necessary to consider temporary abdominal closure. There are no current definitive guidelines for temporary abdominal closure. It should be considered in cases where significant tissue edema is anticipated, to mitigate the risk of abdominal compartment syndrome (from ischemia-reperfusion injury or just a large burden of injuries).
If the bowel has been left in discontinuity or if there is an injury that is at a high risk of needing further intervention, the abdomen should be left open. Finally, if the anesthesia team is struggling to appropriately resuscitate the patient and life-threatening bleeding has been controlled, the patient should be transferred to intensive care for further resuscitation, rewarming, and correction of coagulopathy, with delayed re-exploration and definitive repair.
Methods of temporary abdominal closure include reapproximation of the skin with running suture, the use of commercial negative-pressure systems (for example: KCI Abthera), or homemade vacuum pack systems. The later consists of subfascial sterile drapes or the bag from intravenous fluids. This is covered by overlying drains, sterile towels and an occlusive, adherent plastic dressing such as Ioban. Definitive abdominal closure should be performed in the standard fashion. In patients for whom primary closure is not possible, component separation techniques or bridging mesh may be used.

Complications

Given trauma laparotomy is performed during in extremis scenarios, mortality is high. Unless performed in a systematic manner, injuries can be missed. Tying vascular structures can cause ischemia of organs that may not be immediately evident. Primarily repaired enteral structures can leak, typically 3-5 days post-operatively, and can cause intraabdominal abscesses. Mesenteric defects created during the surgery can put the patient at risk of an internal hernia. As mentioned before, ischemia-reperfusion injury can put the patient at risk of abdominal compartment syndrome. Prolonged ischemia times can cause irreversible damage to structures, even after re-perfusion, which can cause acute kidney or liver failure if the blood supply to these organs was clamped. All patients who underwent a splenectomy are at an increased risk of infections from encapsulated organisms and should receive appropriate vaccinations. Fascial dehiscence and evisceration may occur and are associated with high morbidity and mortality. Enterocutaneous or enteroatmospheric fistulae are also possible.