3. Introduction
Trauma is the leading cause of death for Americans
aged 1 to 44 years and the third leading cause of
death overall.
In 2016, deaths from unintentional injury were
responsible for 23% of years of productive life lost
(YPLL)
The estimated total lifetime costs associated with
both fatal and nonfatal injuries amounted to over
$671 billion
3
8. Trauma Biomechanics cont.
(A) Tensile strain—opposite forces stretching along the
same axis.
example- vascular trauma
(B) Shear strain—opposite forces compress or stretch in
opposite direction but not along the same axis.
example- solid organs, vascular, SB
(C) Compressive strain—stress applied to a structure
usually causing simple deformation.
example- solid organs
(D) Overpressure—a compressive force increases the
pressure within the viscus passing the “breaking point” of
the wall.
example- duodenum, diaphragm
8
9. Abdominal Trauma Mechanism
Abdominal organs are vulnerable to trauma because
of no bone protection
direct compressive force can lead to parenchymal
destruction of the liver, spleen, or kidney. Shear
strain at points of attachment can also lacerate these
organs.
Most shear stain injuries occur at point of attachment
.This can occur at the falciform ligament, the hepatic
veins, the splenic hilum, or the ligamentous
attachments between the kidney and diaphragm.
9
10. Mechanism cont.
Most injuries to the small bowel result from shear
stress, typically occurring within 30 cm of the
ligament of Treitz or ileocecal valve or at the site of
adhesions.
overpressure injury- rupture of the diaphragm
Shear injury can also occur at vascular transitions,
leading to intimal disruption, with thrombosis or
complete transection.
10
11. Approach to the Trauma Patient
ATLS protocol
Management depends on pattern of injury,
hemodynamic status of the patient, diagnostic
modalities
11
14. Work up
DPL (96% sensitivity, 98% specificity)
Indicated if imaging not available for:
Blunt abdominal trauma with hemodynamic
instability
Stab wound penetrating the fascia
Multiple trauma with shock of unclear etiology, esp
in pts with unreliable physical exam of abdomen
Rarely, when imaging is available- hypotension +
unclear FAST
Or FAST shows free pelvic fluid without apparent
solid organ injury (ascites)
14
16. DPL cont.
Absolute contraindication- indication for laparotomy
Relative contraindication-
Availability of appropriate imaging
Pelvic fracture
Inability to place urethral catheter
Pregnancy- 2nd or 3rd tms
Previous abdominal surgery
Morbid obesity
16
17. FAST
Advantage: Available, non invasive, cheap, no radiation
exposure.
Disadvantage- cannot detect fluid <250 mL, does not
reliably determine the source of hemorrhage nor grade
solid organ injuries.
Has 62-96% Sensitivity and 94-99.7% Specificity
Comparable efficacy when done at hospitals Vs field (pre-
hospital)
Sorravit et al. Focused Assessment with Sonography for
Trauma : Current Perspectives. Open Access Emergency
Medicine. 2017;9:57-62
17
18. FAST
(Top)Normal and abnormal views of Morison’s pouch. Asterisk indicates intraperitoneal free fluid.
(Bottom)- Normal and abnormal views of the splenorenal recess. Free fluid is seen around the spleen (arrows
18
19. FAST cont.
Normal transverse view; longitudinal view and abnormal
views of the pelvic region. Asterisk indicates intraperitoneal
free fluid.
19
20. CT SCAN
Indications
Equivocal physical examination;
Altered consciousness secondary to acute alcohol
intoxication or use of illicit drugs;
Associated injuries to the brain or spinal cord; and
Associated injuries to lower ribs, thoracolumbar
spine, or pelvis.
gross hematuria, Abdominal tenderness
Unexplained Hct<35%
20
21. CT cont.
High sensitivity (90%-100% ) - except in Bowel
injuries and small penetrating diaphragmatic injuries.
Findings on CT suggestive of hollow viscus injuries:
fat stranding;
hematoma of the mesentery;
extraluminal air;
thickened (>4–5 mm) wall;
abnormal bowel contour; and
free fluid without injury to a solid organ
Can miss upto 4% of patients with documented blunt
rupture of hollow viscus .
21
22. CT cont.
Advantages:
Can reveal other associated injuries- pelvic, thoracic
Determine source of bleeding
Shows retroperitoneal injuries
Important component of grading and nonoperative management of solid
organ injuries.
can differentiate the composition of fluid
Acute haemorrhage- 30-40 HU
Clotted blood- 45-70 HU
Old blood/ seroma- <30 HU
Findings:
1. Hemoperitoneum
2. Subcapsular hematomas
3. Active Bleeding
4. contrast extravasation (i.e., a “blush”)
5. pseudoaneurysms
22
28. Laparoscopy
helpful in avoiding laparotomy in penetrating
thoracoabdominal trauma and a suspected
diaphragmatic injury
Can also be therapeutic
28
33. Trauma Laparotomy
In patients who require emergent laparotomy,
mortality depends on the time from presentation to
hemorrhage control and obtaining or examining
studies should not delay time to incision.
Priorities before incision include
positioning and prepping the patient,
ensuring large-bore intravenous access and Foley
catheter placement,
obtaining blood products,
temperature control of the room and the patient, and
the administration of perioperative antibiotics
33
34. Trauma Laparotomy
Prepping from chin to
knees
Antimicrobial skin
preparation- povidone-
iodine vs chlorhexidine??
In the exsanguinating
patient, sterility remains
desirable but is not
essential.
34
35. Trauma Laparotomy cont.
Incision- classic xiphoid-to-pubis incision is indicated.
The basic steps
Entering the peritoneum,
prompt control of bleeding and contamination,
Complete exploration of the abdominal cavity, and
Repair of identified injuries.
35
36. Hemostasis
The top priority is the temporary control of all
significant bleeding. This can often be achieved by a
combination of packing and direct compression.
Likely sources of bleeding- solid organs, bowel
mesentery, and the great blood vessels.
A blind four-quadrant packing not advocated as the
first step because it is inadequate to tamponade
bleeding, may injure delicate structures (splenic
ligaments, friable or injured mesentery), and masks
ongoing bleeding.
36
37. Trauma Laparotomy cont.
In severe bleeding that is not compressible, consider
temporary aortic compression below the diaphragm
The next step is small bowel evisceration
Facilitates the exposure and exploration of retroperitoneal
hematomas
allows careful evaluation of the right and left colon.
All hematomas due to penetrating trauma mandate
exploration except a stable retrohepatic hematoma.
37
38. Trauma Laparotomy cont.
Stable hematomas due to blunt trauma generally
should not be explored, except paraduodenal
hematomas, and large, expanding or leaking
hematomas.
If central exposure of the infrarenal aorta or inferior
vena cava be required, medial visceral rotation
should be performed.
38
40. Trauma Laparotomy cont.
After bleeding control, the abdominal cavity should
be explored systematically to identify and treat other
injuries and contamination from GI contents are
addressed.
In trauma, the outcomes are equivalent for hand-
sewn versus staple anastomoses.
Comparable outcomes for one-layer versus two-layer
anastomoses, as well as continuous versus
interrupted sutures.
40
41. Abdominal Closure
Closed drains are recommended only in selected
cases, such as complex liver or pancreatic injuries.
Fascial closure should be attempted whenever
possible.
However, for patients at risk of abdominal
compartment syndrome or intra-abdominal
hypertension, temporary closure is acceptable.
41
42. Tips
In penetrating injuries with hemodynamic instability,
avoid venous access in the lower extremities.
In multiple small bowel perforations, identify all
perforations before starting repairs or resections.
Resecting one segment with a single anastomosis
may be safer than multiple intestinal repairs or
resections in close proximity.
Decision to proceed with a damage control
approach should be made before the patient
develops the “lethal triad” of physiologic abnormality
42
44. Damage Control Resuscitation
The primary objective of the damage control approach is
avoid “lethal triad” of trauma—acidosis, coagulopathy,
and hypothermia.
Damage control resuscitation currently includes
simultaneous early transfusion of blood products and
arrest and/or temporization (ie, balloon tamponade and
TIVS) of ongoing hemorrhage in the most challenging
patients.
DCR addresses the early coagulopathy of trauma, avoids
massive crystalloid resuscitation, and leaves the
peritoneal cavity open when a patient approaches
physiologic exhaustion without improvement.
44
45. Indication
Degree of physiologic insult in the pre- or
intraoperative setting
Persistent SBP <90 mm Hg or a successfully
resuscitated cardiac arrest during transport to
hospital
Persistent SBP <90 mm Hg in the preoperative
setting or during operation
Core body temperature <34°C, arterial pH <7.2, or
INR/PT >1.5 times normal (with or without a
concomitant PTT >1.5 times normal) preoperatively
or at the beginning of operation
Clinically observed coagulopathy during operation
45
46. DCS cont.
Estimated blood loss and amount or type of resuscitation
provided
Estimated blood loss >4 L in the operating room
>10 units of PRBCs were administered to the patient in the
preoperative or preoperative and intraoperative settings
Injury pattern identified during operation
An expanding and difficult-to-access pelvic hematoma
A juxtahepatic venous injury
An abdominal vascular injury and at least one major associated
abdominal solid or hollow organ injury
A proximal superior mesenteric artery injury
Devascularization or destruction of the pancreas, duodenum, or
pancreaticoduodenal complex with involvement of the ampulla/
proximal pancreatic duct and/or distal CBD
Multiple blunt or penetrating injuries spanning across more than one
anatomic region or body cavity that
46
47. DCS cont.
General Recommendations
(1) pack injuries to solid organs such as the liver and
kidney,
(2) perform splenectomy as needed,
(3) ligate or shunt major vascular injuries,
(4) over sew or staple off injuries to the intestines,
(5) drain suspected biliary or pancreatic injuries, and
(6) place a temporary abdominal closure.
47
48. DCS
Structure Damage Control method
Abdominal arteries- ligation, balloon tamponade, TIVS (transient
intravascular shunt)
Abdominal Veins ligation, packing
Pancreas packing and draining
Spleen Splenectomy, Bulk ligation of the hilum
Multiple large
perforations of the
bowel
Segmental resection,
Jejunum Jejunectomy
48
49. Temporary Abdominal Wall Closure
The ideal method of TAC
should
prevent evisceration,
actively remove any
infected or toxin-loaded
fluid from the peritoneal
cavity,
minimize the risk of
formation of
enteroatmospheric fistulas,
preserve the fascia and the
abdominal wall domain,
facilitate reoperation, and
help achieve early
definitive closure
49
50. TAC cont.
The “Bogota bag”-
prevents evisceration of
the abdominal contents,
while minimizing the risk of
IAH or ACS.
Disadvantage- does not
allow removal of any
contaminated or toxin and
cytokine-rich intraperitoneal
fluid, and abdominal wall
retraction
50
51. TAC cont.
NPT (negative pressure
therapy)techniques
Advantage of active
removal of contaminated or
toxin-rich peritoneal fluid,
fluid while minimizing
abdominal wall retraction.
51
52. DCS cont.
Transport to the SICU for the second stage of
resuscitation.
Hemodynamics, urine output, and serial lab
parameters such as lactate and base deficit are
followed.
If abdominal wall is closed at the index operation,
monitor bladder pressures, peak airway pressures,
and other physiologic parameters postoperatively for
the potential development of IAH or ACS.
52
53. Reexploration
Once the patient is fully resuscitated, reexploration
with definitive repair can occur.
The exact timing is based largely on the patient’s
response to resuscitation, but a shorter time (<2
days) to the first attempt at definitive closure is
associated with greater odds of successful facial
closure.
53
54. REBOA
Zone 1- distal to the left
subclavian artery to the level
of the diaphragm and is ideal
for abdominal or pelvic
bleeding.
Zone 3- the renal vessels
and above the aortic
bifurcation; describes the
zone of occlusion for pelvic
and perineal bleeding
Zone 2 is the region of
thevisceral and renal
vessels, and REBOA
inflation in this zone should
54
57. DIAPHRAGM
The incidence of traumatic diaphragm injury (TDI )
ranges from less than 1% to 7% after blunt trauma
and from 10% to 15% after penetrating trauma
Three phases of presentation
acute, or during the period of recovery from injury;
latent, following an asymptomatic period; and
obstructive, during which time herniation leads to
cardiovascular compromise or gastrointestinal
obstruction or perforation.
57
58. Chest X-ray
an air–fluid level within a
hollow viscus overlying the
thorax
Coiling supradiaphragmatic
nasogastric tube
abnormality in the contour,
shape, or position (e.g.,
elevation) of the
hemidiaphragm, pleural
effusion or atelectasis, and
mediastinal shift.
58
59. CT
Diaphragmatic
discontinuity,
thickening, elevation, or
segmental
nonrecognition and
intrathoracic herniation
of abdominal viscera
are strong predictors of
blunt diaphragmatic
rupture.
Small penetrating
injuries could be
missed on CT
59
60. Diagnostic Laparoscopy
Excellent modality for evaluating the diaphragm
Although laparoscopy alone is sufficient to rule out a
diaphragm injury, it is unclear which patients should
undergo the procedure.
Almost two thirds of diagnostic laparoscopies in
stable patients with penetrating thoracoabdominal
trauma will fail to reveal diaphragmatic injury.
Repair- single vs. double layer, running suture vs.
horizontal mattress, primary repair vs. mesh repair
60
62. LIVER
Most injuries to the liver do not require operative
intervention
In approximately 80–85% of patients can be
managed by relatively simple surgical techniques,
such as application of local hemostatic agents
(argon beam coagulation, fibrin glue), electro-
coagulation, superficial suturing, or drainage.
The remaining 15–20% of cases require more
complex surgical techniques.
62
64. Nonoperative Management
Is perused in hemodynamically stable patients who do
not have indications for laparotomy
Factors like:
High grade injuries
Large hemoperitoneum
Contrast extravasation
Pseudoaneurysm predict complication or failure of
nonoperative management
Adjuncts to nonoperative management-
Angioembolization and ERCP
64
65. Operative Techniques
Temporary control of liver
bleeding may be achieved
by
finger compression of the
liver wound.
Pringle maneuver
65
66. Pringle maneuver
Ischemic time 30-60 min, esp. if no cirrhosis
If bleeding continues, it must be from retrohepatic IVC
or hepatic veins
66
67. Hemostatic maneuvers
1. Direct Suture
for lacerations less than
3 cm in depth.
Chromic -0- stich with
special blunt “liver”
needle
Avoid tight sutures- to
avoid necrosis
67
68. 2. HEPATOTOMY
careful extension of the
laceration using finger
fracture
bleeding vessels are
identified and controlled
with clips, ligation, or
direct repair.
68
69. 3. Omental packing
used as the primary
technique or in conjunction
with other methods of
hemorrhage control.
Source of macrophage
69
70. 4. Packing
The most widely
used method to
control venous
bleeding
86% survival rate
Removal of packs at
36 to 72 hours
70
71. Other methods
Resection
If massive bleeding/ massive tissue destruction
Major bile leak from proximal main intrahepatic bile duct
Selective Hepatic Artery ligation or
Angioembolization
angioembolization- for
contrast blush on CT
Failure of nonoperative therapy
Postop bleeding after DCS (4 units of RBC in 6 hours or 6
units in 24 hours)
Hepatic Transplant
71
73. Nonoperative Management
Pediatric patients
Severe associated injuries, particularly a TBI
Adequate resources exist for nonoperative
management (angioembolization for grade IV and V)
73
74. Operative Management
Options, based on the extent of the injury and the
physiologic condition of the patient:
splenectomy,
partial splenectomy, or
splenic repair (splenorrhaphy)
Splenectomy is indicated for significant hilar injuries,
pulverized splenic parenchyma, or any >grade II injury
in a patient with coagulopathy or multiple life-
threatening injuries.
74
76. Stomach and Small Intestine
The incidence of gastrointestinal injury following gunshot
wounds and stab wounds that penetrate the peritoneal
cavity are 80% and 30%, respectively.
Hollow viscus injuries present in 1% to 3% of all blunt
trauma patients, with small bowel injuries accounting for
90% of these injuries.
The key to the successful management is prompt
recognition and treatment, thus decreasing the
likelihood of abdominal septic complications, including
anastomotic leaks, fistulas, and intra-abdominal
abscesses.
76
77. OPERATIVE MANAGEMENT
STOMACH
Grade I- suture or
leave alone
Grade II & III- two-
layer repair
Grade IV & V-
Reconstruct with
gastroduodenostom
y or
gastrojejunostomy
77
79. SMALL BOWEL
All hematomas on or
adjacent to the
bowel wall must be
explored.
Small nonexpanding
mesenteric
hematomas away
from the wall of the
bowel should be
reassessed at
intervals throughout
the operation
79
80. Colon and Rectum
Absence of blood on
digital rectal exam does
not rule out injury to the
colon or rectum.
Control of the
hemorrhage takes
precedence over
intestinal spillage.
Explore all paracolic
hematomas due to
penetrating trauma to
exclude underlying injury.
80
81. Colon cont.
Due to the high rates of wound
infection after colonic injury, the
skin should generally be left
open at the initial operation
Degree of fecal contamination
influences the probability of
developing intra-abdominal
abscess, but is not associated
with an increased risk of suture
line failure (anastomotic leaks).
81
82. Rectum
Intraperitoneal rectal injuries
are managed like colon injuries,
the vast majority with primary
repair.
Fecal diversion should be
considered in extraperitoneal
rectal injuries,
Low extraperitoneal rectal
injuries can be managed with
transanal repair, if technically
feasible.
If the injury is destructive, a
defunctioning loop colostomy
should be performed.
82
83. Rectum cont.
The Hartmann’s colostomy should be reserved for patients with
extensive destruction of the rectum.
83
84. Tips
Patients with suspected extraperitoneal rectal injuries should
be placed on the operating table in the lithotomy position for
rigid sigmoidoscopy evaluation and possible transanal repair
of low rectal injuries.
Low rectal injuries may be repaired transanally and high rectal
injuries can be accessed transperitoneally. In midrectal
injuries, the exposure may be difficult. In these cases, a
proximal diverting sigmoid loop colostomy without repair of the
rectal perforation should be considered.
In the presence of associated genitourinary or vascular
injuries, separate the repairs with omentum, in order to reduce
the risk of rectovesical fistula or infection of the vascular graft.
Complex anorectal injuries after open pelvic fractures should
be managed with hemostasis, wound packing, and a sigmoid
colostomy.
84
85. Abdominal Vessels
Patients with gunshot wounds to
the abdomen will have injury to a
named abdominal vessel 20% to
25% of the time
Abdominal vessel injuries
present with;
intraperitoneal hemorrhage;
a contained mesenteric,
retroperitoneal, or portal
hematoma;
thrombosis; or
some combination of these
85
87. OPTIONS FOR MANAGEMENT
1. Nonoperative- an intimal flap or mural hematoma
that is repeat CT angiogram after 48 hours
2. Endovascular
Endostents for intimal flaps, intramural hematomas,
and luminal thromboses in major named abdominal
vessels
Indications-
associated injury to the brain, associated extensive
burns, or early organ failure; laparotomies; delayed
diagnosis; failed operative repair or chronic missed
vessel injury.
3. Operative
87
90. Exposure and Vascular Control
ZONE 1: SUPRAMESOCOLIC REGION
left-sided medial visceral rotation(Mattox Maeuver )
90
91. Left medial visceral rotation
Advantage- extensive
visualization of the entire
abdominal aorta from the
aortic hiatus of the diaphragm
to the aortic bifurcation.
Disadvantage - time required
to complete the maneuver (5–
7 minutes);
risk of injury to the spleen, left
kidney, or posterior left renal
artery
91
93. ZONE 1: INFRAMESOCOLIC REGION
Injuries to the infrarenal
abdominal aorta or
inferior vena cava.
Exposure- right medial
visceral rotation(Cattell-
Brasch Maneuver)
93
95. Zone-3
The proximal common iliac arteries are exposed by
eviscerating the small bowel to the right and dividing the
midline retroperitoneum over the aortic bifurcation.
Deliberate division of right common iliac artery exposure
and repair of an underlying venous injury.
95
96. TO LIGATE
OR
NOT TO LIGATE?
Significant injury to the celiac axis- can be ligated
Injury to the renal artery- ligation + nephrectomy
SMA and EIA- repair, shunt
If ligation needed for CIA or EIA- ipsilateral two-
incision, four-compartment below-knee fasciotomy +
revascularize within 6 hours
IIA- can be ligated
Most veins can be ligated- CIV, EIV, infrarenal IVC,
?SMV,
PV- end-to-end anastomosis, graft, portocaval shunt
96
The next two categories, malignant neoplasm and heart disease, accounted for 14% and 11% of YPLL, respectively.7
Tensile- stretching of vessels along their longitudinal axes- its length and the amount of tissue stain increases. An increase in length that exceeds tensile strngth causes the vessel to break.
The most common example of this injury pattern is blunt duodenal rupture where the closed pylorus and acute angle of the ligament of Treitz create a “pseudo-obstruction.” When a compressive load is applied, the retroperitoneal duodenum is compressed. Because gas cannot adequately escape, high pressures develop and the duodenum ruptures
Injuries involving high energy transfer include auto-pedestrian accidents, motor vehicle collisions in which the car’s change of velocity (ΔV) exceeds 20 mph or in which the patient has been ejected, motorcycle collisions, and falls from heights >20 ft. In fact, for motor vehicle collisions the variables strongly associated with life-threatening injuries, and hence reflective of the magnitude of the mechanism, are death of another occupant in the vehicle, extrication time of >20 minutes, ΔV >20 mph, lack of restraint use, and lateral impact.
As previously described, strain force requires a point of attachment in order to exacerbate a difference in momentum. This can occur at the falciform ligament, the hepatic veins, the splenic hilum, or the ligamentous attachments between the kidney and diaphragm.
Another important example of overpressure injury is rupture of the diaphragm. A large blunt abdominal force, such as the impact of a steering wheel, can cause a temporary deformation of the peritoneal cavity and a concomitant decrease in its volume. The subsequent abrupt increase in peritoneal pressure ruptures the diaphragm.
percutaneous needle insertion into the peritoneal cavity followed by catheter over wire
mini-laparotomy, dissection into abdominal cavity to directly visualize the peritoneum, incise and insert the catheter
Small right hepatic lobe subcapsular hematoma in a 24-year-old male status post MVC with pickup truck (arrow)
large subcapsular and perihepatic hematoma with active contrast extravasation (arrow). Non-contrast narrow window images show acute hyperdense subcapsular and perihepatic hematoma (asterisk). Arterial phase images show a small arterial focus of contrast extravasation (arrow) which enlarges on the portal venous phase (arrow). The density of the extravascular contrast blush on both post contrast phases is the same density as the contrast in the aorta
Computed tomography (CT) findings suggesting of blunt small bowel injury (A) include thickened loops of bowel (white arrow), free fluid within loops of bowel (black arrow), and free air (red arrow).
helpful in avoiding laparotomy in hemodynamically stable patients with possible penetrating thoracoabdominal trauma and a suspected diaphragmatic injury
Criteria- hemodynamically stable, no peritonitis, no evisceration
Prepping from chin to knees: the sterile operative field for trauma provides access to the neck, chest, abdomen, and groins. It allows the surgeon to plan for the unexpected during the procedure, providing access into an adjacent cavity and access to the groins for vein harvest or vascular control.
Antimicrobial skin preparation for trauma surgery remains problematic. Historically, povidone-iodine was the agent of choice, but more recent literature shows povidone-iodine is associated with increased risk of surgical site infections compared to chlorhexidine-based products
5 On the other hand, chlorhexidine-based products commonly contain alcohol, which increases the risk of an OR fire. In an ex vivo model, Jones et al6 demonstrated that after alcohol-based skin preparation, immediate use of electrocautery resulted in flash fires 22% of the time. Even after waiting the manufacturer’s suggested 3 minutes, electrocautery use still caused fires 10% of the time.6 In addition to fire risk, critically injured patients do not have 3 minutes to spare.
3 sweep y
Clamping of the infradiaphragmatic aorta can be facilitated by dividing the left crus of the diaphragm at 2 o’clock, where there are no vessels
SB evisceration- sweeping the hand around the small bowel from the left upper quadrant toward the pelvis, then up the right side, lifting the entire small bowel up onto the right upper abdominal wall, allowing the mesentery to remain in line and not twisted
Mount everst sign
Rapid Control of Supraceliac Aorta. (A) Retraction of lateral segment of left hepatic lobe and division of gastrohepatic omentum (along dotted line). (B) Division of overlying diaphragmatic crural fibers and blunt index finger mobilization of supraceliac aorta; palpation of nasogastric tube and retraction of stomach to left reduces risk of inadvertent injury to stomach/esophagus during this maneuver.
(C) Placement of large, vertically oriented clamp across supraceliac aorta.
In all patients, close postoperative monitoring of intra-abdominal pressures is warranted
Ongoing communication with the anesthesia team is critical during the operation to determine the potential need for damage control.
• The surgeon should consider using a headlamp routinely, especially for unknown injuries or those located in difficult anatomical areas.
• Open the linea alba 2–3 cm above the umbilicus, where the aponeurosis is widest to reduce the risk of entering the rectus sheath.
In penetrating injuries with hemodynamic instability, avoid venous access in the lower extremities, because of the possibility of a proximal injury of the iliac vein or inferior vena cava injuries.
Tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation all play key trigger roles in the acute coagulopathy of trauma shock
If a limited number of enterotomies or colostomies from penetrating wound(s) are encountered, rapid one-layer, full-thickness closures using a continuous 4-0 monofilament suture is appropriate.
ABThera negative pressure system for temporary abdominal closure: A: visceral protective layer, B: fenestrated foam, C: semi-occlusive adhesive d
rape, D: tubing with interface pad, E: pump.
quantifiable markers of shock to guide fluid resuscitation
When possible, a tension-free fascial closure is performed. In cases of ongoing contamination, bleeding requiring repacking, or concern for bowel viability, a temporary closure may be replaced for subsequent reexploration.
Efforts at progressive fascial closure on a daily basis are warranted, since the overall success rate of definitive closure falls dramatically after 1 week
For the purposes of REBOA placement, the aorta is divided into three anatomic zones. Zone 1 spans distal to the left subclavian artery to the level of the diaphragm and is ideal for abdominal or pelvic bleeding. Zone 3 describes the zone of occlusion for pelvic and perineal bleeding and spans the area distal to the renal vessels and above the aortic bifurcation. Zone 2 is the region of the visceral and renal vessels, and REBOA inflation in this zone should be avoided.
It is hypothesized that the left posterolateral diaphragm is the weakest area and thus predisposed to injury.11 It is likely, however, that the liver affords protection to the right hemidiaphragm by mitigating the effects of blunt kinetic energy applied to the abdomen.21 Similarly, penetrating injury to the diaphragm has had a left-sided predilection. This has been suggested, but not proven, to be related to the prevalence of right-handed assailants.
Radiographic evidence include air or an air–fluid level within a hollow viscus overlying the thorax or with the additional “classic” finding of the coiling
supradiaphragmatic nasogastric tube. Suggestive findings include abnormality in the contour, shape, or position (e.g., elevation) of the hemidiaphragm, pleural effusion or atelectasis, and mediastinal shift.
Penetrating diaphragm injuries also present a distinct spectrum of radiographic findings from those in blunt trauma with contiguous injury and transdiaphragmatic trajectory acting as best predictors.
Available data suggest that almost two thirds of diagnostic laparoscopies in stable patients with penetrating thoracoabdominal trauma will fail to reveal diaphragmatic injury.
nonabsorbable monofilament running suture for the repair of traumatic diaphragmatic defects
The index finger of the left hand is placed into the foramen of Winslow (arrow) and the porta hepatis structures are compressed with the thumb (a). The avascular portion of the gastrohepatic ligament (b) may then be divided to allow placement of a noncrushing vascular clamp or Rummel tourniquet (c).
Using a large, special blunt “liver” needle on an absorbable suture, a deep figure-of-eight suture can stop troublesome bleeding. Sutures should be tied loosely, rather than snug and tight, since the liver swells postoperatively, and tight sutures can cause hepatic necrosis.
Gross, large ligatures to the liver may cause liver necrosis and postoperative fever. The injury is unroofed by performing a hepatotomy, with direct ligation of the biliary and vascular structures
careful extension of the laceration using finger fracture or clamping of the hepatic parenchyma as dissection proceeds through the liver. The fracture continues until bleeding vessels are identified and controlled with clips, ligation, or direct repair.
The left side of the omentum is mobilized off of the transverse colon, preserving a vascular pedicle from the right side of the omentum. The sutures attaching the omentum to the liver are loosely applied, so as not to strangulate the omentum.
Perihepatic packing has become the most widely used “bailout” method for damage control of a severe hepatic injury. Packing laparotomy pads around the liver compresses the bleeding wound between the anterior chest wall, diaphragm, and retroperitoneum and stops venous bleeding.
Temporary packing of a bleeding liver is the prime example of damage control. Laparotomy packs are placed above and below a bleeding area in the liver, making a “liver sandwich.” Care is taken not to obstruct the inferior vena cava or to produce too much constriction, leading to liver necrosis.
Angioembolization is an adjunct to the nonoperative management of high-grade splenic injuries, especially in patients with evidence of active extravasation on contrast enhanced CT scan
Bleeding from the splenic parenchyma can be temporarily controlled with digital pressure on the hilum while the spleen is being mobilized. As previously noted, mass clamping of the hilum should be reserved for profoundly hypotensive patients because it increases the risk of damage to the adjacent tail of the pancreas.
The most common sites of persistent postoperative bleeding are the areas near the tail of the pancreas, from the superior pancreatic artery and at the insertion of the short gastric vessels into the stomach
Blunt)Mechanisms postulated for injury to the small intestine to occur include the following:
(1)crushing of bowel against the spine;
(2) shearing of the bowel from its mesentery of a fixed point by sudden deceleration; and
(3) bursting of a “pseudo-closed” loop of bowel due to a sudden increase in intraluminal pressure
Following blunt trauma, small bowel injuries are generally obvious and are often associated with extensive mesenteric bleeding and hematomas. Conversely, in penetrating trauma, especially stab wounds, small bowel injuries may be small and subtle. This is the reason that
colostomy has no role in patients undergoing primary repair of the colon, irrespective of associated injuries, contamination, blood transfusions, or hemodynamic instability. • In destructive injuries requiring resection, the existing evidence supports primary anastomosis.
The selection of a stapled vs. hand-sewn anastomosis is largely a matter of surgeon discretion and has no effect on anastomotic leak.
Primary repair, end colostomy, Primary repair with diverting loop colostomy
A Western Trauma Association observational trial reported leak rates of 3% for right colon wounds, 20% for transverse colon wounds, and 45% for left colon wounds
`The splenic flexure is the most challenging portion of the colon to mobilize.
During its mobilization, caution should be exercised to avoid excessive downward traction of the colon, which may cause avulsion of the splenic capsule and troublesome bleeding.
Perform good debridement of all colon wounds, especially gunshot wounds, before any repair. In destructive injuries, the resection should ensure healthy and well-perfused edges and the anastomosis should be tension-free.
During mobilization of the right or left colon, the ureters should be identified and protected
In managing rectal injuries, routine fecal diversion, presacral drainage, and distal rectal washout do not offer any advantages and may be associated with worse outcomes.
Left Medial Visceral Rotation for Suprarenal Retroperitoneal Hematoma
A. The initial dissection involves division of the congenital adhesions to the sigmoid colon, left line of Toldt, and the lienorenal ligament. With a combination of blunt and sharp dissection, the left colon, left kidney (if desired) and ureter, spleen, tail of the pancreas, and stomach including fundus are mobilized toward the midline.
B. Once the abdominal aorta is palpated on the lumbar vertebrae, the anterior celiac gangia and surrounding lymphatics are dissected away. The abdominal aorta can be cross-clamped with a DeBakey vascular clamp applied from the left lateral position just inferior to the aortic hiatus of the diaphragm. If more proximal aortic control is needed, the left side of the aortic hiatus can be divided at the 2 o’clock position with an electrocautery.
Left Medial Visceral Rotation. (A) Peritoneal incision lateral to descending colon and spleen. (B) Reflection/rotation of abdominal viscera from left to right (medially) in a plane anterior to left kidney leaving kidney in normal anatomic location with exposure of proximal abdominal aorta in base of wound. Dotted line is intended division line of left diaphragmatic crus. (C) Same exposure following division of left diaphragmatic crus and mobilization of left renal vein. (D) Cross-sectional view showing potential retraction injury of spleen and pancreas with this approach. (E) Same exposure but dissection plane is carried posterior to left kidney elevating it out of its bed and
retracting it medially.
Exposure of Subhepatic Inferior Vena Cava and Right Renal Artery Through Right Medial Visceral Rotation (Cattell-Brasch Maneuver). (A) The lateral peritoneal reflection of the ascending colon is incised (from cecum to hepatic flexure). (B) The right colon is reflected medially and anteriorly. (C) The underlying second portion of the duodenum and the head of the pancreas are mobilized with a Kocher maneuver and reflected medially to expose the right kidney and inferior vena cava. The cecum can be reflected superiorly to expose the entire infrarenal vena cava to its bifurcation. (D) Mobilization of the right renal vein exposes the underlying right renal artery.
Exposure of an injury to the right common iliac vein is very difficult. Deliberate division of right common iliac artery between vascular clamps facilitates exposure and repair of an underlying venous injury.
B. Following venous control, the right common iliac artery is reanastomosed
After ligation of the superior mesenteric (or portal) vein, there is immediate swelling and discoloration of the midgut.
SMV ligation-bowel edema
PV ligation- hypervolemia of splanchnic vessels hypovolemia of pt--> need to administer vigorous amount of fluid
Port-caval shunt hepatic encephalopathy
Infrarenal IVC- fasciotomy + fluid + compression wraps of lower extremity + leg elevation
