Trauma laparotomy

Risk prediction

See 'frailty' under 'periop medicine' for NSQIP/NELA

Goals

Arrest haemorrhage
Control contamination
Minimise operative time in the unstable patient
Aim for quick transfer to ICU for physiological correction

Principles

Rapid entry, large incision
Control of bleeding
Identify injuries
Control contamination
Consider reconstruction

Causes of spontaneous intra-abdominal haemorrhage

Vascular
- Ruptured AAA
- Ruptured arterial visceral aneurysm
- Intra-peritoneal rupture of varices associated with portal hypertension
- Spontaneous rupture of iliac vein
Gynaecological
- Ruptured ectopic
- Spontaneous rupture of the pregnant uterus with placenta percreta
- Post-partum ovarian artery rupture
- Spontaneous ovarian haemorrhage
Pancreatitis
- Erosion of an adjacent vessel
Liver
- Rupture of hepatic tumours
Spleen
- Spontaneous rupture
Adrenal
- Spontaneous haemorrhage
Kidney
- Spontaneous rupture - normal kidney or secondary to tumour
Anticoagulation
- Spontaneous retroperitoneal, intra-peritoneal or abdominal wall bleeding
Unrecognised or denied trauma
Miscellaneous
- Acute rupture cholecystitis
- Mediolytic arteritis of an omental artery
- Polyarteritis nodosa

Indications for damage control techniques as opposed to primary repair

Haemodynamic instability
Temperature <35 degrees
Metabolic instability
- pH <7.2
- BE >5
- Lactate >5
Coagulopathy
- PT >16 seconds
- PTT >60 seconds
Surgical factors
- Complex life-threatening injury
- Time-consuming procedure anticipated
- Multi-system injury requiring management
Environment
- MTP
- Operative time >60 mins
- Multiple casualties
- Limited resources

Preparation

Warm theatre
Cell saver
Headlight
Good assistant
Available:
- Large packs
- Fixed retraction
- 2x suckers
- Major general tray
- Vascular tray
- Haemostatic agents
- Staplers and sutures
Discuss prepping prior to induction with anaesthetist

Technique

Positioning

If just abdomen, supine with arms in (allows easy placement of retractors and access for median sternotomy)
If left anterolateral thoracotomy may be required, elevate left chest 30 degrees, and left arm out
Prep and drape from chin to knees, allowing from retrieval of greater saphenous vein from groin and thigh if needed
Warming: increase room temperature, turn up heating on anaesthesia machine, cover head and extremities with Bair hugger, warming for saline and blood)

Entry

Often delay until blood products are available in OT - opening can release tamponade somewhat and increase bleeding. Depends if stable or not.
One big cut in the midline
- First cut through skin, second down to fascia, third through fascia
Poke your index finger through the weak point in the peritoneum, which is just superior to umbilicus
Extend cut up and down with scissors

If major bleeding/blood is found

Consider enlarging original incision
Lift out the small bowel completely, quickly (sweep from LUQ down to pelvis then out onto skin in RUQ)
Evacuate the blood as fast as possible (scoop it out into a kidney dish)
- If hypotension is worsened due to release of tamponade, apply pressure to aorta at base of diaphragm until anaesthetist catches up
Quickly review for solid organ injury
Pack the four quadrants tightly (see below)
If bleeding not controlled, supra-coeliac pressure/clamp
Systematic assessment
- Unpack, suck and re-pack each quadrant consecutively
- Perform definitive haemostasis when needed

Packing - remember most common sources of bleeding in blunt trauma are liver, spleen, mesentery

Eviscerate bowel early
Liver - right posterior, right lateral, left posterior, left anterior, right anterior
Right paracolic
Spleen - above and medial
Left paracolic
Pelvis
Root of small bowel mesentery

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
    - '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!

Classify bleeding

Minor trouble (easily fixable)
Major trouble (not easily rectified because of complexity or inaccessibility
- Temporise
- HOLD the operation
- Alert team and anaesthetist
- Get more product
- Get senior help
- Additional exposure and mobilisation

Then, decide whether to bail out or conduct definitive repair

Indications for bail out:
- Combined major vascular and hollow visceral injuries
- Penetrating injury to the 'surgical soul'
- High-grade liver injury
- Pelvic fracture with expanding pelvic haematoma
- Injuries requiring surgery in other cavities

Contain and protect bowel with definitive/temporary abdominal closure

Decision to bail out should come early, long before the 'lethal triad' is in play
- Intra-operative clues of 'hostile physiology':
  - Oedema of bowel mucosa
  - Midgut distension
  - Dusky serosal surfaces
  - Tissues cold to touch
  - Non-compliant swollen abdominal wall
  - Diffuse oozing from surgical incisions

Relook laparotomy

Planned
- Return once the patient is stabilised, rather than any specific time period
- Remove packs and count
- Confirm bleeding stopped
- Repeat check for contamination and injuries
- Re-assess any borderline tissues
- Restore GIT continuity, convert damage control techniques to definitive
- Close fascia if possible