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Acs0706 Operative Exposure Of Abdominal Injuries And Closure Of The Abdomen
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Acs0706 Operative Exposure Of Abdominal Injuries And Closure Of The Abdomen


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  • 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 1 6 OPERATIVE EXPOSURE OF ABDOMINAL INJURIES AND CLOSURE OF THE ABDOMEN Erwin R.Thal, M.D., F.A.C.S., and Terence O’Keeffe, M.B., Ch.B., F.R.C.S.Ed. Over the past two decades, the advent of nonoperative manage- All areas of the body that are not included in the skin prepara- ment techniques for many solid-organ injuries has led to a signifi- tion should be covered so as to prevent excessive heat loss, and cant shift in the care of patients who have sustained abdominal warming devices should be placed if available. Sterile draping trauma. The ever-improving accuracy of diagnostic modalities should be placed so as to allow access to all potential injuries. If (computed tomography in particular) has also contributed to this the patient is in extremis and in danger of expiring, however, shift.1-4 Today, fewer patients require operative intervention for patient preparation should be limited to a rapid skin cleansing and treatment of abdominal injuries.Those who do require such inter- surgery should commence immediately. vention make up a select group who continue to pose a significant challenge to surgeons. In our view, these patients are best managed by following a standardized operative approach, the aim of which is Incision and Initial Exploration to diagnose, prioritize, and treat the injuries in an expeditious fash- CHOICE OF INCISION ion so that the patient is not kept in the operating room any longer than necessary [see Figure 1]. Such an approach optimizes patient A midline celiotomy is the incision of choice. Its advantages are care by minimizing the risk of missed injuries and ensuring a rapid that it allows rapid and easy access to the abdominal cavity, with and efficient response by the members of the surgical team. good exposure of the majority of the intra-abdominal organs and Naturally, every patient’s care should be individualized as neces- structures, and that it can be extended into a median sternotomy if sary. In general, however, a standardized operative approach, com- necessary. Its main disadvantage is that it may not provide adequate plemented by a solid knowledge of a variety of exposures and tech- exposure of injuries in the deep recesses of the upper quadrants. niques, should allow the surgeon to deal with virtually any abdom- Patients with previous midline incisions pose a challenge to the inal injury. In this chapter, we outline our recommended approach surgeon. If at all possible, an attempt should be made to enter the to operative intervention in patients with abdominal trauma. abdomen above or below the previous incision, in an area less like- ly to have adhesions. If this is not possible, an alternative incision, such as a chevron (bilateral subcostal) incision, should be consid- Patient Preparation ered. A chevron incision provides entry into the abdomen while The key to success in this setting is advance preparation aimed avoiding any viscera that are adherent to the undersurface of the at covering all eventualities. Such preparation involves both the previous laparotomy scar. However, this incision takes more time, environment and the patient. The room should be warmed to does not provide ideal exposure, and is associated with a higher ensure that the patient does not lose too much heat and become morbidity; accordingly, it should be considered only when the cir- hypothermic. The instruments should be open on the back table, cumstances are dire. Paramedian, subcostal, retroperitoneal, and and specific instruments should be available when specific injuries flank incisions are not recommended, for much the same reasons. are anticipated (e.g., a vascular set should be available when a vas- INITIAL EXPLORATION cular injury is suspected). A sufficient number of laparotomy pads should be on hand, and a retracting device with which the surgi- Once the peritoneal cavity has been entered, initial exploration cal team is familiar should be employed. Cell saver systems and proceeds in an orderly fashion so as to minimize hemorrhage and rapid infusion systems can be useful adjuncts; if desired and avail- contamination, prevent iatrogenic injury, and facilitate the expedi- able, they should be requested in advance.5 tious identification of injuries. The intestines are eviscerated, and Patient preparation begins with the insertion of a nasogastric or gross blood is rapidly evacuated. Laparotomy pads are then rapid- orogastric tube and a Foley catheter. Invasive monitoring lines ly placed in all four quadrants to pack the abdomen; the right may have to be placed, and resuscitation should continue as the upper quadrant is packed first, then the left upper quadrant, and patient is being prepared. A broad-spectrum antibiotic should be finally the lower two quadrants. Care should be taken not to tear administered intravenously before the initial incision is made. the falciform ligament or the fibrous capsule of the liver during When the patient is correctly positioned on the operating table, this maneuver. Blood pressure may drop when the abdomen is skin preparation should extend from the sternal notch superiorly decompressed. Anesthesia should be given the opportunity to to include the anterior thorax.Thus, no further preparation will be catch up with resuscitation efforts at this point. required if a thoracic injury is identified or vascular control in the Once hemodynamic stability has been achieved, the intraperi- thorax is necessary. Thoracostomy, if required, can also be per- toneal portion of the exploration is begun. In cases of blunt trau- formed without the drapes being changed. Inferiorly, skin prepa- ma, the temporary packs (except for those around the solid vis- ration should extend to the upper anterior thighs so that the prox- cera) may now be carefully removed and any remaining blood imal saphenous veins are available if a vascular reconstruction is evacuated. In cases of penetrating trauma, it is often easier initial- required and so that distal vascular control can be achieved with- ly to address the site of ongoing hemorrhage via a direct approach. out undue delay. Vascular injuries are controlled manually until proximal and distal
  • 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 2 Patient has sustained abdominal trauma for which operative exposure is warranted Prepare abdomen, as well as chest and upper thighs. Perform midline celiotomy. Only hemorrhage is present Hemorrhage and contamination are Only contamination is present present Pack abdomen. Control contamination. Control bleeding and contamination. Allow anesthesia to catch up. Allow anesthesia to catch up if necessary. Bleeding persists Bleeding ceases Reevaluate patient and continue efforts to control bleeding. Treat any coagulopathies. Perform systematic evaluation of abdomen. Bleeding persists Bleeding ceases No additional exposure Additional exposure is is required required Pack abdomen. Perform Kocher maneuver. Perform left or right medial visceral rotation, as indicated. Patient is physiologically unstable Patient is physiologically stable Perform definitive repair of injuries. Close abdomen. Perform damage-control procedure. Leave abdomen open. Figure 1 Algorithm outlines the approach to initial operative exposure in abdominal trauma patients. control can be achieved. Mesenteric bleeding sites are clamped. be examined, and particular care must be taken not to miss an Solid organs are initially packed as for blunt trauma, then treated injury at the mesenteric border. Careful consideration should also with directed repair. In either scenario, bleeding that remains be given to the possibility of mesenteric vascular injuries, which uncontrolled by packing requires immediate attention. may be manifested as mesenteric hematomas. The enteric viscera are then examined in an orderly fashion. Next, the colon is inspected from the cecum to the rectum. If The anterior aspect of the stomach is inspected from the esopha- injuries are present or missile tracts are noted in proximity to a gogastric junction down to the pylorus. If an injury is present or is portion of the ascending or descending colon, the retroperitoneal strongly suspected on the basis of the mechanism of injury or the portion of the colon is inspected by incising the white line of Toldt presence of a hematoma or soilage, the posterior aspect of the (the retroperitoneal reflection) so as to allow access to the poste- stomach is examined by opening the gastrocolic omentum; this rior surface of the colon. Finally, the laparotomy pads around the measure also permits examination of the anterior surface of the solid organs are removed, one organ at a time, to permit inspec- body of the pancreas. The exploration then continues distally tion for hemorrhage or injury. along the course of the GI tract. If duodenal or pancreatic injury Once the peritoneal survey is complete, the retroperitoneum is is a possibility, the duodenum is mobilized fully by means of a inspected for potential injuries. Retroperitoneal hematomas are Kocher maneuver.The duodenojejunal junction at the ligament of classified on an anatomic basis: zone 1 is the central area, bound- Treitz is then inspected, and the small intestine is inspected all the ed laterally by the kidneys and extending from the diaphragmatic way to the ileocecal valve. Both sides of the small intestine must hiatus to the bifurcation of the vena cava and the aorta; zone 2
  • 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 3 comprises the lateral area of the retroperitoneum, from the kidneys the necessary repairs. The repairs themselves are described in laterally to the paracolic gutters; and zone 3 is the pelvic portion [see greater detail elsewhere [see 7:7 Injuries to the Liver, Biliary Tract, Figure 2].Whether exploration is warranted for a retroperitoneal Spleen, and Diaphragm; 7:8 Injuries to the Stomach, Small Bowel, hematoma depends on the mechanism of injury and the location of Colon, and Rectum; 7:9 Injuries to the Pancreas and Duodenum; 7:10 the hematoma [see Priorities in Management, Repair of Retroperi- Injuries to the Great Vessels of the Abdomen; and 7:11 Injuries to the toneal Injuries, below,and 7:10 Injuries to the GreatV essels of the Abdo- Urogenital Tract]. men]. A careful evaluation is performed to identify possible occult AORTA AND BRANCHES injuries to organs (e.g., the pancreas, the duodenum, the retroperi- toneal colon, the kidneys, and vascular structures). Control of the aorta can be gained at several different levels, The initial exploration concludes with a brief pelvic survey depending on the site of injury. The supraceliac aorta can be aimed at excluding injuries to the rectum or the distal urogenital exposed by incising the gastrohepatic ligament, retracting the left hemiliver laterally and cephalad, and retracting the stomach cau- tract (including the bladder). At the end of the operation, this ini- dally. The esophagus and periesophageal fat pad are then mobi- tial inspection should be repeated, following the same sequence, to lized laterally to permit identification of the abdominal aorta at the confirm that no injuries have been missed. diaphragmatic hiatus, at which point the aorta can be encircled, clamped, or compressed. This exposure allows control of the Operative Exposure aorta, but it is inadequate in terms of providing vascular access for definitive repair. Better exposure of the supraceliac aorta and its To expose the various organs that may be injured in patients branches can be obtained by means of a left medial visceral rota- who have sustained abdominal trauma, the surgeon must be famil- tion [see Figure 3]. To perform this maneuver, the splenorenal lig- iar with a number of different techniques. In what follows, we ament is mobilized with a combination of sharp and blunt dissec- detail the operative exposures that enable the surgeon to perform tion. The left peritoneal reflection is incised from the splenocolic flexure down the paracolic gutter to the level of the distal sigmoid colon. The left-side viscera are then gently mobilized to the mid- line (mostly with blunt dissection) in a plane anterior to Gerota’s fascia.This technique allows exploration of the entire length of the abdominal aorta, the origin of the celiac axis, the origin of the superior mesenteric artery, the left iliac system, and the origin of the right common iliac artery. In addition, it facilitates control of 1 the left renal vascular pedicle before exploration of a left-side zone 2 retroperitoneal hematoma. Alternatively, a variation on the stan- dard left medial visceral rotation (the Mattox maneuver6) may be 2 2 employed, in which the left kidney is also included in the organs that are rotated (the plane being anterior only to the muscles of the posterior abdominal wall).This variant may afford better access to the origin of the left renal artery. If the injury is more distal, the aorta may be approached in a transperitoneal fashion. The small intestine is retracted to the right, the transverse colon is retracted cephalad, and the descend- ing colon is retracted laterally. The peritoneum is then incised directly over the aorta, and the third and fourth portions of the duodenum are mobilized cephalad.The proximal limit of this dis- section extends to the left renal vein, which may be divided if nec- essary to provide more cephalad access to the aorta. If ligation of the left renal vein is called for, it should be done at a point where 3 the gonadal vein will be left intact to drain the kidney. A more lim- ited dissection may suffice to expose the distal infrarenal aorta. Depending on the injury, distal control may or may not be required. Control may be achieved at the level of the distal infrarenal aorta, above the bifurcation. Once again, if the patient is in extremis, formal dissection may be curtailed and proximal control achieved either by manually compressing the aorta against the spine at the level of the esopha- gogastric junction or by using an aortic occluder [see 7:10 Injuries to the Great Vessels of the Abdomen]. VENA CAVA AND BRANCHES Access to the suprahepatic inferior vena cava can be gained only by either incising the central tendon of the diaphragm or by per- forming a median sternotomy and opening the pericardium. The Figure 2 Shown are the anatomic zones of the retroperitoneum: infrahepatic inferior vena cava is exposed by performing a right zone 1 (central), zone 2 (flank), and zone 3 (pelvic). medial visceral rotation (the Cattell-Braasch maneuver) [see Figure
  • 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 4 Figure 3 Left medial visceral rota- tion is performed to provide expo- sure of the entire length of the abdominal aorta, the left renal vas- culature, the origins of the mesen- teric arteries, and the common iliac bifurcation. 4]. The right colon is mobilized by taking down the hepatic flex- step is challenging and may have to be performed partly by palpa- ure and then incising the right peritoneal reflection along the para- tion, with care taken not to injure the inferior vena cava, the hepat- colic gutter.The colon is once again reflected medially toward the ic veins, or the phrenic vessels [see 7:7 Injuries to the Liver, Biliary aorta in a plane anterior to Gerota’s fascia with careful blunt dis- Tract, Spleen, and Diaphragm]. section. If additional exposure is necessary, the inferior margin of SPLEEN the peritoneal incision may be extended to the root of the mesen- tery—and even beyond, if the inferior mesenteric vein is sacrificed. The spleen can be mobilized into the midline by dividing the This exposure permits visualization of both the aorta below the phrenicosplenic and splenorenal ligaments with a mixture of sharp origin of the superior mesenteric artery and the vena cava below and blunt dissection. In cases where the spleen has been injured the third portion of the duodenum. Exposure of the portion of the by blunt trauma, these ligaments often are already disrupted, and vena cava directly below the liver alone can be achieved by per- this disruption facilitates the dissection. The splenocolic ligament forming a Kocher manuever [see Figure 5] with medial mobiliza- often contains sizeable blood vessels that must be controlled, and tion of the duodenum and the head of the pancreas. the gastrosplenic ligament contains the short gastric arteries. Once the spleen is mobilized into the midline, control of the vascular LIVER pedicle can be achieved, the splenic injury can be assessed, and Mobilization of the liver begins with division of the round liga- splenorraphy or splenectomy can be performed as appropriate [see ment (ligamentum teres), followed by takedown of the falciform 7:7 Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm and ligament (to prevent iatrogenic trauma to the liver capsule during 5:25 Splenectomy]. exposure and identification of other intraperitoneal injuries). This PANCREAS mobilization may be extended as far cephalad as is necessary. Further mobilization can be achieved by incising the left triangu- Intraoperative evidence of a central hematoma, peripancreatic lar ligament, with care taken not to injure the suprahepatic inferi- edema, or bile staining in the retroperitoneum or the lesser sac rais- or vena cava at the diaphragmatic hiatus during the dissection. es the possibility of pancreatic injury.The contents of the lesser sac When visualization of the right hemiliver is required, the falciform can be visualized by performing a direct inspection through the ligament should be incised to its most superior extent, and the gastrohepatic ligament or by dividing the ligament. Alternatively, right triangular ligament should then be carefully divided. This access can be gained by dividing and ligating two or three gas-
  • 5. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 5 troepiploic arcades of the gastrocolic ligament. If it proves neces- DUODENUM, BILIARY TRACT, AND SMALL INTESTINE sary to explore the pancreas, the stomach is separated from the Exposure of the posterior surface of the duodenum is transverse colon by completing the division of the gastrocolic lig- achieved by means of a Kocher maneuver [see Pancreas, above, ament, and a Kocher maneuver is performed to reflect all portions and Figure 5].This technique is also used when injury to the dis- of the duodenum medially, along with the head of the pancreas. tal extrahepatic biliary system is suspected. The proximal extra- The peritoneum lateral to the duodenum is incised, and careful hepatic biliary tree is visualized by using a Kocher maneuver in blunt dissection is employed to mobilize the duodenal loop from conjunction with local exploration of the porta hepatis. In the common bile duct superiorly to the superior mesenteric vein patients with injuries to the distal duodenum or the proximal inferiorly. This mobilization allows inspection of the anterior and jejunum, division of the ligament of Treitz may also be neces- posterior surfaces of the head of the pancreas, as well as the unci- sary for accurate identification of the site of injury. Because of nate process. If injury to the body or tail of the pancreas is suspect- the mobility of the small intestine, injuries to this structure gen- ed, the splenorenal and splenocolic ligaments are incised. At this erally are readily identified and repaired without additional point, the spleen and then the pancreas can be mobilized medial- mobilization. ly to a position near the level of the superior mesenteric vessels, and the anterior and posterior aspects of the body and tail of the COLON AND RECTUM pancreas can be examined [see 7:9 Injuries to the Pancreas and Evidence of staining, pneumatosis, or hematoma in proximity Duodenum]. to a portion of the ascending or descending colon, particularly in the setting of related injuries or missile tracts, should prompt a full KIDNEYS evaluation of the colon. Because the colon is a partially retroperi- Operative exposure of the kidneys starts with either a left or a toneal structure, the retroperitoneal reflection must be incised to right medial visceral rotation, depending on which kidney is allow inspection of the posterior surface of the colon. Sometimes, involved. The renal vascular pedicle should be controlled before rectal injuries are not accessible via an intraperitoneal approach; in any hematoma in Gerota’s fascia is opened [see 7:11 Injuries to the this situation, consideration should be given to a diverting colosto- Urogenital Tract]. Repair of the kidney may be facilitated by mobi- my and presacral drainage [see 7:8 Injuries to the Stomach, Small lizing the organ out of Gerota’s fascia and retracting it medially. Bowel, Colon, and Rectum].7,8 Figure 4 Right medial visceral rotation is performed to provide exposure of the infe- rior vena cava, the infrarenal abdominal aorta and iliac vessels, and the right reno- vascular pedicle.
  • 6. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 6 Hepatoduodenal Ligament Common Duct Node Pancreas Superior Mesenteric Renal Artery Veins Duodenum Inferior Vena Cava Figure 5 The Kocher maneuver reflects the duodenum and the pancreatic head Gonadal Aorta from the retroperitoneum, allowing Vessels access to the infrahepatic inferior vena cava as well as to the distal common bile duct, the duodenum, and the pancreatic head. Priorities in Management be placed. Injuries to the proximal abdominal aorta often necessi- tate that the vessel be controlled in the chest to permit repair. CONTROL OF HEMORRHAGE In patients who have sustained parenchymal injuries to solid In the event that the patient remains hemodynamically unstable viscera, control of the vascular inflow is crucial as both a diagnos- because of persistent uncontrolled hemorrhage, the primary focus tic and a therapeutic maneuver. Gaining control of the splenic of the initial exploration is control of bleeding. As noted (see hilum effectively arrests further splenic hemorrhage. Similarly, use above), the approach to hemorrhage control differs depending on of the Pringle maneuver [see 7:7 Injuries to the Liver, Biliary Tract, whether the patient sustained blunt trauma or penetrating trauma. Spleen, and Diaphragm] to control the vessels in the porta hepatis In cases of blunt trauma with bleeding from a solid organ, the first (the hepatic artery and the portal vein) helps determine the source thing that should be done is to attempt repeat packing of the spe- of perihepatic hemorrhage. This maneuver is initially performed cific bleeding site with a sufficient number of laparotomy pads. by digitally compressing the portal structures; if digital compres- This is an important skill to master and can be effective as a tem- sion causes the hemorrhage to diminish, the surgeon’s hand is porizing measure until either more definitive vascular control can replaced with an atraumatic vascular clamp or a Rumel tourni- be achieved or coagulopathy can be corrected. In cases of pene- quet. Although the Pringle maneuver can be maintained for at trating trauma, bleeding is more effectively managed by means of least 30 to 45 minutes without causing permanent liver damage, either vascular control just proximal and distal to the site of injury the clamp or tourniquet should be removed as soon as is feasible. or direct control at the bleeding site. In the vast majority of cases of liver trauma—aside from those When significant hemorrhage is anticipated, control of the involving an injury to the retrohepatic vena cava—the use of the injured vessel should be obtained by the operative techniques dis- Pringle maneuver, combined with perihepatic packing, should cussed previously [see Operative Exposure, above]. Given the pos- arrest hemorrhage. sibility of exsanguinating hemorrhage, the surgeon must be pre- In patients who have sustained injuries to the retrohepatic vena pared to gain proximal aortic control at the diaphragmatic hiatus cava, it may be necessary to gain vascular control by performing or even within the chest via a left lateral thoracotomy. For immedi- hepatic exclusion before definitive repair can be attempted [see 7:7 ate control, the aorta can be manually compressed at the hiatus; a Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm]. Hepatic padded Richardson retractor, an aortic compressor, or an assis- exclusion may be achieved by means of either atriocaval shunting tant’s hand can then take over this function to allow the surgeon to (which is rarely if ever used9,10) or occlusion of the inferior vena continue the exploration. If a need for prolonged proximal aortic cava both above and below the liver.The latter may lead to signif- control is anticipated, an atraumatic aortic vascular clamp should icant hemodynamic instability, particularly in volume-depleted
  • 7. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 7 REPAIR OF DAMAGED OR DEVITALIZED BOWEL patients; however, it may reasonably be considered in patients whose volume status is adequate. Complete hepatic exclusion Once vascular injuries have been addressed, the next priority is involves both (1) atriocaval shunting or clamping of both the infra- to repair any enteric injuries [see 7:8 Injuries to the Stomach, Small hepatic and the suprahepatic inferior vena cava and (2) control of Bowel,Colon,and Rectum]. Because the stomach is a large and well- hepatic arterial and portal venous inflow.11 In general, injuries to vascularized organ, gastric injuries are usually amenable to prima- the retrohepatic vena cava are best dealt with by means of dam- ry repair. Injuries to the small intestine that involve less than 50% age-control procedures. of bowel circumference after debridement of devitalized edges can Hepatic parenchymal hemorrhage can be challenging, and any be repaired with either a single-layer or a two-layer closure; single- of a number of techniques may be used to control it, depending layer closure, being less likely to compromise the lumen of the on the location, type, and degree of bleeding. These techniques bowel, is generally preferred. In cases involving multiple enterot- range from simple electrocauterization and parenchymal suturing omies in close proximity or a large area of devitalized tissue, a seg- to argon beam cauterization, direct vessel ligation, hepatotomy, mental enterectomy with primary anastomosis is preferable. The and even resection [see 7:7 Injuries to the Liver, Biliary Tract, Spleen, anastomosis may be either hand-sewn or stapled; the latter tends and Diaphragm].12,13 In difficult cases, it may be advisable to per- to be more expeditious but less cost-effective. form an abbreviated laparotomy, pack the liver extensively, and Solitary injuries to the colon that do not necessitate resection transport the patient to the angiography suite, where selective after debridement and are not associated with multiple transfu- embolization can be performed; the patient can then be transport- sions or significant gross contamination are managed by means of ed to the ICU, undergo warming, and have any coagulopathy cor- primary closure. Large or multiple injuries to the right colon are rected before returning to the OR to have the packs removed. best managed with a right hemicolectomy followed by an imme- Mesenteric bleeding can usually be controlled with manual com- diate ileocolic anastomosis. Similar injuries to the left colon are pression of the vessel followed by suture ligation. Retroperitoneal generally treated with resection and proximal diversion.The distal hematomas are often harbingers of vascular injury, and proximal limb may be exteriorized as a mucous fistula, or, if inadequate and distal vascular control should be obtained before exploration bowel length renders diversion impossible, a Hartmann procedure is initiated [see 7:10 Injuries to the GreatVessels of the Abdomen].Typi- may be performed. 14-16 cally, bleeding from injured hollow viscera is minor and can be REPAIR OF RETROPERITONEAL INJURIES controlled by repairing the injury; on occasion, however, tempo- rary hemostatic suturing or stapling may be required. Once all injuries within the peritoneal cavity have been addressed, the next priority is to inspect the retroperitoneum once CONTROL OF CONTAMINATION more, paying particular attention to the possibility of hematoma Once hemorrhage has been controlled, the next priority is to expansion. The decision whether to explore a retroperitoneal control contamination. All gross spillage should be removed hematoma is based on the mechanism of injury and on the zone from the abdomen with suction and laparotomy pads, and fur- in which the injury is located. All zone 1 hematomas should be ther contamination should be prevented by temporarily closing explored regardless of the injury mechanism: they signal possible small enterotomies with Babcock clamps (or, alternatively, with aortic, vena caval, duodenal, or pancreatic injury. Zone 2 and 3 a continuous suture or skin staples). When multiple enteroto- hematomas should be explored in cases of penetrating trauma but mies are present, suture closure is preferred (to ensure that mul- not, as a rule, in cases of blunt trauma (with the exception of tiple clamps are not present in the operative field). If the injuries expanding zone 2 hematomas). are in close proximity, the preferred method of controlling Before a retroperitoneal hematoma is opened, proximal vascu- intestinal spillage is to apply atraumatic bowel clamps at both the lar control should be obtained so that hemorrhage will be mini- proximal and the distal end of the injury site. Alternatively, if the mized once the effect of the tamponade has been lost. Injuries to injured segment will have to be resected, rapid control of further retroperitoneal organs (e.g., the kidneys, the pancreas, and the spillage can be obtained by firing a GI stapler at each end of the adrenal glands) are treated by means of debridement or resection, injured segment. with drainage as indicated. Vascular injuries are repaired as dis- cussed previously [see Repair of Vascular Injuries, above, and 7:10 REPAIR OF VASCULAR INJURIES Injuries to the Great Vessels of the Abdomen]. Once intestinal contamination has been dealt with, the next pri- ority is definitive vascular repair [see 7:10 Injuries to the Great Vessels of the Abdomen]. If proximal and distal control of the injured ves- Closure sel has not already been obtained, it is obtained at this point. The GENERAL TECHNIQUE extent of the vascular injury is determined, dead or devitalized tis- sue is carefully debrided, and vessel continuity is reestablished if Once the abdominal exploration has been completed, the possible. If the injury is not amenable to primary repair and the abdomen is copiously irrigated with an isotonic crystalloid solu- vessel cannot be ligated, autogenous tissue should be obtained tion. The closure method employed is typically determined on the (usually from the proximal greater saphenous vein) and used for basis of five main considerations: (1) the degree of blood loss, (2) either patch angioplasty or interposition grafting. If no suitable the volume of resuscitation fluid received, (3) the degree of conta- autogenous venous tissue is available, synthetic material may be mination, (4) the patient’s perceived nutritional status, and (5) the considered as an alternative vascular conduit. For aortic or iliac patient’s hemodynamic stability. In cases that necessitate an abbre- arterial injuries, primary ligation with subsequent extra-anatomic viated or damage-control procedure, the speed with which the clo- bypass is an acceptable alternative. In cases in which an abbreviat- sure can be performed may be the most important factor. Provided ed laparotomy is necessary, vascular shunting may serve as a sub- that the risk of subsequent abdominal compartment syndrome stitute for definitive repair until hypothermia, coagulopathy, and (ACS) is considered to be low, every effort should be made to close acidosis are corrected. the fascia. Fascial closure is usually accomplished with a continu-
  • 8. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 8 a b Capstan Up Capstan Down 2 cm Fat Muscle Omentum Peritoneum Figure 6 Retention sutures may be used to bolster fascial closure in wounds at high risk for break- down. (a) Sutures are placed in the subfascial plane. (b) The defect is approximated, and the sutures are tied over skin bridges. ous absorbable or nonabsorbable monofilament suture, though it abbreviated or damage-control procedure is indicated. It may be may also be accomplished with interrupted sutures.The rate of fas- necessary to perform a rapid abdominal closure—with the provi- cial dehiscence is essentially the same for the two techniques; how- so that further exploration, as well as definitive repair of injuries ever, the extent of dehiscence is more limited when closure is done that have been temporarily controlled, will be required. The deci- with interrupted sutures.17,18 With either technique, it is important sion to perform a damage-control procedure should be made at an not to place excessive tension on the fascial tissues. early stage, before the so-called lethal triad (hypothermia, acidosis In cases where there is a specific reason to be concerned about and coagulopathy) has had time to develop. Damage control has possible dehiscence (e.g., in patients who are malnourished or undoubtedly led to improved survival for trauma patients, but it obese or are receiving steroid therapy), large monofilament sutures has also led to an increase in the number of patients whose may be placed at intervals within the standard closure to serve as abdomens are left open.19 retention sutures. They may be tied over bolsters created from a red rubber catheter or over plastic skin bridges [see Figure 6]. If TEMPORARY ABDOMINAL CLOSURE rapid closure is required, the abdomen may be closed with four or When a damage-control procedure is required, it is often most five retention sutures of this type that are placed through the expedient to perform a rapid temporary abdominal closure, then abdominal wall and just above the peritoneum. These sutures to transport the patient to the intensive care unit. This measure must be checked daily and should be loosened if there is evidence may also be necessary in patients whose abdomens cannot be that they are cutting through the abdominal skin as a consequence closed because of intestinal and organ edema caused by intraop- of edema creating increased tension on the wound. erative fluid resuscitation.The simplest form of temporary abdom- SKIN CLOSURE inal closure is the use of towel clips to close only the skin [see Figure 7], in conjunction with the application of a bioocclusive dressing If the patient has minor injuries without evidence of enteric con- to control fluid loss and contamination. This closure, however, tamination, the skin may be closed primarily. Stapled closure is leaves the patient still at risk for subsequent ACS. most expeditious, but suture closure is also acceptable. A degree of clinical judgment is required in assessing a wound’s suitability for The first temporary abdominal dressing described was the so- closure. If the skin is closed primarily, it should be inspected daily, called Bogotá bag—that is, an empty intravenous fluid bag that and the wound should be opened without delay if there is concern was cut in half and sewn to the wound edges. This dressing can about subsequent infection. Alternatively, primary delayed closure still be used in circumstances where no other equipment is avail- may be performed by leaving the wound open, packed with moist able.The so-called vacuum pack technique involves the placement gauze. If the wound shows no evidence of infection when examined of a sterile plastic drape over the bowel contents and under the fas- after 3 to 5 days, it may be closed with Steri-Strips or with inter- cia, followed by insertion of two or more suction drains, over rupted sutures that are placed (without being tied) during the orig- which sterile towels or open laparotomy pads may be placed. To inal operation. If intraperitoneal contamination has occurred, minimize heat loss and insensible fluid loss, an adherent bioocclu- either primary delayed closure should be performed or the wound sive dressing is placed over the entire dressing and the abdominal should be packed and left to heal by secondary intention. wall, with the drains attached to suction. Several commercial devices are now available that can be used to facilitate temporary ABBREVIATED OR DAMAGE-CONTROL LAPAROTOMY closure of the open abdomen; these include the VAC Abdominal If a patient remains unstable after surgical bleeding and contam- Dressing System (Kinetic Concepts Inc., San Antonio,Texas) and ination have been controlled or is cold and coagulopathic, an the Wittmann Patch (Star Surgical, Burlington,Wisconsin).20,21
  • 9. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 9 MANAGEMENT OF THE OPEN ABDOMEN Patient has open abdomen after operative Once the patient’s physiologic status has stabilized, he or she exploration for abdominal injury should be returned to the OR for reexploration and definitive repair of any remaining injuries [see Figure 8], preferably within 48 hours Place temporary abdominal dressing at initial operation. after the first operation. At this juncture, the abdomen should be Return to OR in 24–48 hr, depending on assessed for the feasibility of closure. In some patients, the fascial patient’s condition. edges cannot be approximated, because of edema; in others, reap- proximation may cause a significant rise in intra-abdominal pres- sure, as evidenced by a rise in pulmonary inspiratory pressures.These patients are at risk for ACS, and their abdomens should be left open. At this point, if temporary abdominal coverage continues to be Abdomen can Abdomen cannot be closed be closed required, a temporary abdominal dressing should be placed that Wash out abdomen. attempts to prevent fascial retraction and the associated increased Place fascial retention device, use risk of nonclosure of the abdomen. Options include dynamic vacuum-assisted closure, or repeat retention sutures, the Suture Tension Adjustment Reel (STAR) original dressing. (WoundTEK, Inc., Newport, Rhode Island), the Wittmann Patch, Return to OR every 24–48 hr; wash nonabsorbable mesh, fascial zippers, and the VAC Abdominal out abdomen and reevaluate for Dressing System.20-25 Once the dressing is placed, it should be feasibility of closure. Abdomen can Abdomen cannot be closed be closed Attempt partial fascial closure. Return to OR every 24–48 hr; wash out abdomen. (Alternatively, this may be done at the bedside in the ICU if Perform definitive necessary.) abdominal closure. If abdomen cannot be closed by 10–14 days after operation, consider alternative closure methods. Figure 8 Algorithm outlines the approach to the open abdomen in a patient with abdominal injuries. examined every 24 to 48 hours, depending on the degree of cont- amination; this is often best done in the OR, but it may also be done in the ICU if the patient remains unstable. At every subse- quent procedure, the fascia should be assessed for the possibility of closure. Partial closure of the incision (i.e., closure of the cepha- lad and caudad portions) should be considered, even if full closure cannot be accomplished. In approximately 50% of patients, clo- sure of the fascia is not possible; however, there is some evidence to suggest that this figure may be lowered by employing some of the devices now commercially available.20,26,27 ABDOMINAL COMPARTMENT SYNDROME Patients who undergo fascial closure are at risk for ACS as a consequence of ongoing resuscitation efforts and associated bowel and organ edema. ACS is defined as intra-abdominal hypertension greater than 25 mm Hg in conjunction with dysfunction of one or more organ systems (e.g., pulmonary, renal, or cardiac). 28,29 Intra- abdominal pressure is determined indirectly by measuring bladder pressure. Bladder pressure can be measured by using an arterial transducer at the level of the symphysis pubis that is connected to the urinary catheter after 30 to 50 ml of sterile water has been introduced. Alternatively, an idea of the intra-abdominal pressure can be gained by raising the Foley tubing above the bed after instil- lation of the water, then measuring the column.30 A rising trend in pressure can be as significant as a single elevated measurement. Figure 7 Shown is a “quick out” closure with surgical Patients who have undergone a long operation, have been the towel clips. object of vigorous resuscitation efforts, or who have sustained mul-
  • 10. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 10 a b Split-Thickness Skin Graft Mesh Mesh Granulation Tissue Omentum Relaxing Incision Tissue Bridge Figure 9 Mesh may be used for temporary or permanent abdominal closure in patients at risk for increased abdominal pressure. (a) Mesh is sutured into the fascial plane, then covered with a split- thickness skin graft. (b) The abdominal defect is closed with mesh. tiple injuries should be monitored closely for the development of Abdominal fascial defects may also be closed with sheets of ACS. If the diagnostic criteria for ACS are met, prompt abdomi- nonincorporable synthetic material (e.g., Gore-Tex; W. L. Gore nal decompression is indicated. On occasion, this measure may and Associates, Inc., Newark, Delaware). The advantages of these have to be carried out at the bedside in the ICU. nonabsorbable materials are that they do not react with tissue and Occasionally, ACS develops in patients who have a temporary that they are associated with a low incidence of complications abdominal dressing in place (so-called tertiary ACS). Accordingly, (e.g., fistula formation). The disadvantages are that they are it is mandatory to continue to monitor intra-abdominal pressure expensive and that they must ultimately be removed unless the in these patients.29 skin can be closed over them to prevent contamination. Another option for achieving primary closure of the abdomen is CLOSURE OF THE OPEN ABDOMEN component separation of the rectus sheath. The external oblique It is important to close the abdomen as early as possible: an aponeurosis is incised and mobilized, along with the rectus sheath, open abdomen carries an increased risk of desiccation of the to bring the fascia to the midline. Defects as wide as 14 to 20 cm can intestines and subsequent fistula formation. In certain patients, be bridged in this fashion, but recurrent hernia rates remain high.31 however, despite aggressive efforts to close the fascia, it proves Several biosynthetic materials are now available to be used for impossible to accomplish primary closure, even after many days bridging abdominal fascial defects. One such material is Surgisis and repeated procedures.There are several techniques that may be (Cook Biotech Inc., West Lafayette, Indiana), a porcine submuco- employed to obtain final closure in this situation. sal matrix that can provide scaffolding for the ingrowth of fibrous The simplest method is to allow granulation tissue to form over tissue while supporting abdominal contents and permitting skin the omentum and the exposed intestines and later, when there is closure.32 Another is AlloDerm (LifeCell Corp., Branchburg, New a good clean granulation bed with no evidence of infection, to place Jersey), a denatured human cadaveric product that can be used in a split-thickness skin graft. Alternatively, a piece of absorbable a similar fashion to replace denuded fascia or to bridge the fascial mesh may be placed; this helps facilitate dressing changes, pro- gap in cases where primary closure cannot be accomplished.33,34 At vides a modicum of protection to the intestines, and serves to con- present, long-term follow-up data are lacking for both products, trol evisceration [see Figure 9]. A skin graft can then be placed in and their use is further limited by their very high cost. the same fashion, once a granulation bed has developed. Morbidity is very high in these patients; subsequent complica- Another option is to employ relaxing incisions, either to allow a tions range from prolonged ventilator dependence to enteric fistu- skin-only closure or to allow the skin to be closed over absorbable las to massive ventral hernias.35,36 Major ventral hernias represent mesh. Open skin wounds should be left open to heal by secondary a significant technical challenge and should not be repaired until intention. Unfortunately, the use of relaxing incisions will not pre- the patient’s recovery from injury is complete and his or her nutri- vent the formation of large ventral hernias, which will have to be tional and general status has returned to normal.This may take as repaired at a later date. long as 12 months from the time of the initial trauma.
  • 11. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 6 ABDOMINAL EXPOSURE AND CLOSURE — 11 References 1. Malhotta AK, Fabian TC, Crou MA, et al: Blunt 14. Tzovaras G, Hatzitheofilou C: New trends in the assisted fascial closure for patients with abdomi- hepatic injury: a paradigm shift from operative to management of colonic trauma. Injury 36:1011, nal trauma. J Trauma 57:1082, 2004 non-operative management in the 1990’s. Ann 2005 27. Kaplan M: Negative pressure wound therapy in Surg 231:804, 2000 15. Nelson R, Singer M: Primary repair for penetrat- the management of abdominal compartment syn- 2. Sharma OP, Oswanski MF, Singer D: Role of ing colon injuries. Cochrane Database Syst Rev drome. Ostomy Wound Management 50(11A repeated computerized tomography in nonopera- (3):CD002247, 2003 suppl):20S, 2004 tive management of solid organ trauma. Am Surg 16. Herr MW, Gagliano RA: Historical perspective 28. Balogh Z, McKinley BA, Holcomb JB, et al: Both 71:244, 2005 and current management of colonic and intraperi- primary and secondary abdominal compartment 3. Fata P, Robinson L, Fakhry SM: A survey of toneal rectal trauma. Curr Surg 62:187, 2005 syndrome can be predicted early and are harbin- EAST member practices in blunt splenic injury: a 17. Ceydeli A, Rucinski J, Wise L: Finding the best gers of multiple organ failure. J Trauma 54:848, description of current trends and opportunities abdominal closure: an evidence-based review of 2003 for improvement. J Trauma 59:836, 2005 the literature. Curr Surg 62:220, 2005 29. Sugrue M: Abdominal compartment syndrome. 4. Fernandez L, McKenney MG, McKenney ML, et 18. Carlson MA: Acute wound failure. Surg Clin Curr Opin Crit Care 11:333, 2005 al: Ultrasound in blunt abdominal trauma. J North Am 77:607, 1997 30. Iberti TJ, Lieber CE, Benjamin E: Determination Trauma 45:841, 1998 19. Nicholas JM, Rix EP, Easley KA, et al: Changing of intra-abdominal pressure using a transurethral 5. Jurkovich GJ, Moore EE, Medina G: Autotrans- patterns in the management of penetrating bladder catheter: clinical validation of the tech- fusion in trauma: a pragmatic analysis. Am J Surg abdominal trauma: the more things change, the nique. Anesthesiology 70:47, 1989 148:782, 1984 more they stay the same. J Trauma 55:1095, 2003 31. de Vries Reilingh TS, van Goor H, Rosman C, et 6. Mattox KL, McCollum WB, Beall AC, et al: 20. Suliburk JW, Ware DN, Balogh Z, et al: Vacuum- al: “Components separation technique” for the Management of penetrating injuries of the assisted wound closure achieves early fascial clo- repair of large abdominal wall hernias. J Am Coll suprarenal aorta. J Trauma 15: 808, 1975 Surg 196:32, 2003 sure of open abdomens after severe trauma. J 7. Weinberg JA, Fabian TC, Magnotti LJ, et al: Trauma 55:1155, 2003 32. Pu LL; Plastic Surgery Educational Foundation Penetrating rectal trauma: management by DATA Committee: Small intestinal submucosa 21. Cipolla J, Stawicki SP, Hoff WS, et al: A proposed anatomic distinction improves outcome. J Trauma (Surgisis) as a bioactive prosthetic material for algorithm for managing the open abdomen. Am 60:508, 2006 repair of abdominal wall fascial defect. Plast Surg 71:202, 2005 8. Gonzalez RP, Falimirski ME, Holevar MR: The Reconstr Surg 115:2127, 2005 22. Koniaris LG, Hendrickson RJ, Drugas G, et al: role of presacral drainage in the management of 33. Scott BG,Welsh FJ, Pham HQ, et al: Early aggres- Dynamic retention: a technique for closure of the penetrating rectal injuries. J Trauma 45:656, 1998 sive closure of the open abdomen. J Trauma complex abdomen in critically ill patients. Arch 9. Kudsk KA, Sheldon GF, Lim RC Jr: Atrial-caval 60:17, 2006 Surg 136:1359, 2001 shunting (ACS) after trauma. J Trauma 22:81, 1982 34. Kolker AR, Brown DJ, Redstone JS, et al: 23. McKenney MG, Nir I, Fee T, et al: A simple Multilayer reconstruction of abdominal wall 10. Rovito PF: Atrial caval shunting in blunt hepatic device for closure of fasciotomy wounds. Am J defects with acellular dermal allograft (AlloDerm) vascular injury. Ann Surg 205:318, 1987 Surg 172:275, 1996 and component separation. Ann Plast Surg 55:36, 11. Klein SR, Baumgartner FJ, Bongard FS: 24. Howdieshell TR, Proctor CD, Sternberg E, et al: 2005 Contemporary management strategy for major Temporary abdominal closure followed by defini- 35. Barker DE, Kaufman HJ, Smith LA, et al: inferior vena caval injuries. J Trauma 37:35, 1994 tive abdominal wall reconstruction of the open Vacuum pack technique of temporary abdominal 12. Walker ML:The operative and nonoperative man- abdomen. Am J Surg 188:301, 2004 closure: a 7-year experience with 112 patients. J agement of blunt liver injury. J Natl Med Assoc 25. Bose SM, Kalra M, Sandhu NP: Open manage- Trauma 48:201, 2000 86:29, 1994 ment of septic abdomen by Marlex mesh zipper. 36. Miller RS, Morris JA Jr, Diaz JJ Jr, et al: 13. Parks RW, Chrysos E, Diamond T: Management Aust NZ J Surg 61:385, 1991 Complications after 344 damage-control open of liver trauma. Br J Surg 86:1121, 1999 26. Stone PA, Hass SM, Flaherty SK, et al: Vacuum- celiotomies. J Trauma 59:1365, 2005 Recommended Reading Blaisdell FW, Trunkey DD: Abdominal Trauma. Mattox KL: Complications of Trauma. Churchill Living- and Practice, 2nd ed. Williams & Wilkins, Baltimore, Thieme Medical Publishers, New York, 1993 stone, New York, 1994 1996 Donovan AJ: Trauma Surgery. Mosby–Year Book Co, Mattox KL, Feliciano DV, Moore EE: Trauma, 4th ed. St Louis, 1994 Appleton & Lange, Stamford, Connecticut, 1998 Greenfield LJ: Complications in Surgery and Trauma. Maull KI, Rodriguez A, Wiles CE: Complications in Acknowledgments JB Lippincott Co, Grand Rapids, Michigan, 1990 Trauma and Critical Care. WB Saunders Co, Figures 2 and 5 Susan Brust, C.M.I. Hirshberg A, Mattox KL:Top Knife:The Art and Craft Philadelphia, 1996 Figures 3 and 4 Carol Donner. of Trauma Surgery. tfm publishing Ltd, Harley, Thal ER, Weigelt JA, Carrico CJ: Operative Trauma Figures 6, 7, and 9 Tom Moore. Adapted from Shropshire, United Kingdom, 2005 Management: An Atlas, 2nd ed. McGraw-Hill, New Operative Trauma Management: An Atlas, by C. J. Ivatury RR, Cayten CG: The Textbook of Penetrating York, 2002 Carrico, E. R. Thal, and J. A. Weigelt. Appleton & Trauma. Williams & Wilkins, Baltimore, 1996 Wilson RF, Walt AJ: Management of Trauma: Pitfalls Lange, Stamford, Connecticut, 1998.