Editing Trauma laparotomy (section)

=== Systematic assessment '''(if penetrating trauma, follow path of missile/knife first)''' ===

* Infracolic compartment
** Start by running small bowel, from ligament of Treitz to TI
*** Commonly missed injury - ligament of Treitz, any injury at mesenteric border of small bowel
*** Repair holes transversely to avoid narrowing the lumen
** Large bowel - especially posterior aspect of transverse mesocolon, and splenic and hepatic flexures, and extraperitoneal rectum, which are notorious for missed injuries
*** Right colon injury - right hemi
*** Left colon is more complicated - colocolostomy can be dangerous due to risk of leak - may be safer to bring out as stoma
** Bladder, female reproductive organs
* Supracolic compartment
** Liver
** GB
** Right kidney
** Oesophagus
*** Simple injuries can be repaired in a single layer
** Stomach
*** Oesophago-gastric junction - common missed injury
*** Beware of injuries high on lesser curve and posterior wall near cardia - very easy to miss them
*** Mobilise greater curve by dividing gastrocolic omentum
** Duodenum
*** Ligament of treitz - site of commonly-missed injury
** Spleen
** Left kidney
** Diaphragm
** Lesser sac (need to poke a hole in greater omentum on its left side where it's less vascular)
* Retroperitoneum (limited exposure, pick which zone you want to explore - see 'zones' below)
** When to explore
*** Penetrating: explore zones 1 and 3, selectively explore zone 2
*** Blunt: explore zones 1 and 2, do not explore zone 3 (unless rapid expansion suggests major vascular injury)
** Techniques
*** Zone 1: left medial visceral rotation (Mattox)
**** Allows exploration of supramesocolic retroperitoneum
**** Consider getting proximal and distal control aorta before entering haematoma
**** Incise left peritoneal reflection to mobilise left colon
**** Incise splenorenal ligament
**** Descending colon mesentery, left kidney and pedicle and ureter, spleen, stomach and pancreatic tail are all mobilised medially
**** ''<nowiki/>'Modified Mattox' leaves the kidney in place to prevent traction injury, but means renal vein can get in the way of aorta''
**** If you cut the left crus at 2 o'clock, you can access the distal thoracic aorta
***
*** Zone 2: 
*** Zone 3: right medial visceral rotation (Cattall-Braasch Maneuvre)
**** Take down hepatic flexure
**** Extended Kocher maneuvre, carried down all the way along the white line of Toldt and then up again towards the midline, allowing you to swing the bowel all the way out of the lower abdomen
**
** Ureteric injury
*** Much lower risk for spreading contamination than bowel injury
*** If you have time for a transected ureter, put in any thin tube and tie it to ureter, then externalise this drain (just leave distal end alone, it won't leak)
*** If you don’t have time, tie it off and get out
*** Don't dissect out the ureters!