Trauma: Crash Laparotomy

Crash Laparotomy

Position & Prep

Operative Sequence

Access & Exposure

Incision: Long Midline from Xiphoid to Pubis
- Major Pitfall: Iatrogenic Injury to Left Liver, Bowel or Bladder
Options to Avoid Scars:
- Extend Incision Superiorly/Inferiorly to Enter Virgin Territory
- Chevron Incision (Bilateral Subcostal, Double Kocher, Rooftop)
- Mercedes Incision
Enter Fast & Eviscerate Bowel Early

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

Approach

Blunt Trauma: Begin with Empirical Packing
Penetrating Trauma: Begin by Directly Attacking the Bleeding
- *Some Recommend Empiric Packing in All Trauma Cases

Packing

Pack Early – Relies on Ability to Form Clot
Technique:
- “From Within” – Packed into a Cavity Applying Outward Pressure
- “From Without” – Create a Sandwich to Reapproximate Disrupted Tissue Planes
Empiric Packing Sites:
- Right Side – Over/Under Liver & Along the Right Gutter
- Left Side – Over/Medial to Spleen & Along the Left Gutter
- Pelvis

Rapid Supraceliac Control (If Exsanguinating)

Approach:
- Divide Gastrohepatic Ligament
  - Normally Avascular
  - Watch for Replaced Left Hepatic Artery
- Reflect Stomach/Esophagus to the Left to Visualize the Aorta
  - May Require Division of the Diaphragmatic Crura
- Bluntly Dissect the Aorta
- Occlude Aorta Using:
  - Manual Compress Against Spine
  - Aortic Root Compressor/T-Bar
  - Aortic Clamp – Consider Umbilical Tape to Hold Up
Clamp Distal Thoracic Aorta Through the Abdomen
- Thick Fibrous Attachments as Abdominal Aorta Passes Thorough Diaphragm
Other Possible Options:
- Thoracotomy with Thoracic Aortic Control
- Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) – Controversial

Supraceliac Control of the Aorta

General Exploration

Once Bleeding Temporarily Controlled
Order of Exploration:
- 1. Inframesocolic
- 2. Supramesocolic
- 3. Lesser Sac
- 4. Retroperitoneum
*Some Report Different Orders of Exploration – Exact Order is Not as Important as Making Sure to Preform it the Same Way Every Time & to Not Miss Any Injuries

Inframesocolic Exploration

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

Supramesocolic Exploration

Pull Transverse Colon Caudally
Inspect from Right-to-Left
- Palpate Liver, Gallbladder & Right Kidney
- Then Stomach & Duodenum
- Finally, Palpate Spleen & Left Kidney

Lesser Sac Exploration

Retroperitoneum Exploration

Maneuvers to Access the Retroperitoneum

Damage Control Definition

Definition: Surgery to Stabilize with Delayed Definitive Repair
Goals:
- Arrest Hemorrhage
- Limit Contamination
- Maintain Blood Flow
- Temporary Abdominal Closure
Operative Time Limited to Minimize Further Hypothermia, Coagulopathy and Acidemia

Damage Control Indications

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

Damage Control Phases