The operative approach to abdominal injuries

The indications for and techniques of the trauma

laparotomy

MOHD JOHARI BIN MOHD SHAFUWAN

BM14110073
 DIAGNOSTIC PERITONEAL LAVAGE (DPL)

Indications for DPL in blunt trauma:

1. Hypotension with evidence of abdominal injury
2. Multiple injuries and unexplained shock
3. Potential abdominal injury in patients who are unconscious, intoxicated, or paraplegic
4. Equivocal physical findings in patients who have sustained high-energy forces to the torso
5. Potential abdominal injury in patients who will undergo prolonged general anesthesia for another injury, making
continued reevaluation of the abdomen impractical or impossible
 DIAGNOSTIC PERITONEAL LAVAGE (DPL)

In stab wounds:
1. For immediate diagnosis of hemoperitoneum
2. Determination of intraperitoneal organ injury, and detection of isolated diaphragm injury.
 CONTRAINDICATIONS OF DPL

Absolute :
1. Peritonitis
2. Injured diaphragm
3. Extraluminal air by x-ray
4. Significant intraabdominal injury by CT scan
5. Intraperitoneal perforation of the bladder by cystography
Relative :
1. Previous abdominal operations (because of adhesions)
2. Morbid obesity
3. Gravid Uterus
4. Advanced cirrhosis (because of portal hypertension and the risk of bleeding)
5. Preexisting coagulopathy
 DIAGNOSTIC PERITONEAL LAVAGE (DPL)

Preferred sites for DPL

1. Standard adult :Infraumbilical midline
2. Standard pediatric: Infraumbilical midline
3. 2nd &3rd trimester pregnancy :Suprauterine
4. Midline scarring :Left lower quadrant
5. Pelvic fracture: Supraumbilical
 EVALUATION OF DPL
Fluid is sent for: cell count, amylase, alk phos, presence of bile
Index Positive value
Aspirate Blood >10 mL
Fluid Enteric content
Lavage RBC > 100,000/mL
WBC > 500/mL
Amylase >175 U/dL
Alk Phos > 3 IU
Bile Confirmed
Negative RBC < 50,000/mL
WBC < 100/mL
Amylase < 75 U/dL
 Complications of DPL: Perforation of small bowel, mesentery, bladder and retroperitoneal vascular structures.

Limitation: offers no information about status of retroperitoneal organs nor allow determination of which organ
has been injured.
 LAPAROTOMY

Laparotomy is the most common operation performed for truncal trauma.

It consist of a methodical sequence of steps that enable surgeon to gain access to abdominal injuries, and identify
and address them.
It has two essential roles : diagnostic and therapeutic.
There are two modes of laparotomy for trauma, which are Explorative Laparotomy or Crash Laparotomy
corresponding to the two major indications; Peritonitis or Bleeding.
 1) EXPLORATIVE LAPAROTOMY

The first mode is abdominal exploration in a hemodynamically stable patient with a tender abdomen.
Operation proceeds along the lines of an explorative laparotomy for an acute abdominal condition such as hollow
organ perforation (urgent but not hectic since there is no danger of imminent death)
When operating for peritonitis in stable patient, focus is on reconstructing the anatomy.
 2) CRASH LAPAROTOMY

Dramatic mode, in a patient in shock with intra-abdominal hemorrhage.

Focus is on rapid control of hemorrhage and preservation of the patients physiology.
Anatomical integrity is less important, and sometimes temporarily sacrificed to prevent an irreversible
physiological insult.
 A trauma laparotomy is a life-saving measure and should not exceed 30-45 minutes.
Mechanism of injury have to be analyzed.
Penetrating injuries often limited to trajectory of low-velocity projectiles.
In blunt injury, the mechanism are crushing, deceleration and shearing.
INDICATIONS FOR LAPAROTOMY
INDICATIONS FOR LAPAROTOMY BLUNT TRAUMA

1. Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)

2. Free air
3. Diaphragmatic rupture
4. Peritonitis
5. Positive CT
INDICATIONS FOR LAPAROTOMY
PENETRATING TRAUMA
1. Hemodynamically abnormal
2. Peritonitis
3. Evisceration
4. Positive DPL, FAST, or CT
5. Violation of peritoneum
 Whenever laparotomy is indicated for abdominal trauma, three principles prevail, in order
of importance :
1) Stop the bleeding
2) Limit Contamination
3) Reconstruct whenever possible and/or reasonable.
 TECHNIQUES & MANEUVERS
1. Gaining Access to the Peritoneal Cavity and
Exposure
Through a long midline incision
A bold xipho-pubic skin incision skirting the umbilicus is rapidly
followed by sharp division of the subcutaneous fat down to the fascia.

Upper midline incision. Incision

deepened through subcuteneous tissue
to expose linea alba
- The surgeon than gains the midline by identifying the
decussating fibers of the anterior rectus sheath.
- Sharply divide the linea alba with a scalpel exposes the
preperitoneal fat throughout the entire length of incision.

Linea alba is divided to reveal

preperitoneal fat.
- In most patients, the peritoneum just cranial to the umbilical, is very thin or has a defect and is covered by scant
preperitoneal fat. Poking a finger through this area is the quickiest way to enter the peritoneal cavity.
- The hole is then enlarged by incising both the peritoneum and overlying preperitoneal fat together to the full
extent of the incision using Mayo Scissors.
 Dividing the falciform ligament between clamps provide
access to right upper quadrant and completes the incision.

Abdominal incision is completed

to reveal intra-abdominal organs.
 When gaining access to the peritoneal cavity, the major pitfall is iatrogenic injury.
The left lateral lobe of liver, transverse colon, and bladder are at risk in upper, middle and lower parts
of incision, respectively.
In patient with pelvic fracture, limiting the incison to upper abdomen avoids entering a retroperitoneal
hematoma that may extend into preperitoneal space.
In patient with previous laparotomy scars surgeon can either re-enter through the old scar or carrying the
skin incision beyond previous scar.
 Complete evisceration of the small bowel immediately on entering the peritoneal cavity is a key maneuver that
provides access to the abdominal cavity.
Gathering all loops outside the abdomen and always to the patients right is a pivotal step in organizing the
peritoneal cavity into a convenient workspace.
2.Achieving Temporary Hemostasis
- Achieved with empirical packing.
- After rapidly eviscerating the bowel and evacuating the blood from the
peritoneal cavity using open laparotomy pads and suction, pack the abdomen
without attempting to precisely identify the injuries (empirical packing).
- Several laparotomy pads are placed above and below liver, spleen, paracolic
gutters and pelvis. (common source of bleeding : spleen, liver, small bowel
mesentry)
3.Exploring the Peritoneal Cavity
- Pulling transverse colon cranially enables surgeon to run the gut from ligament of Treitz to the rectum (inspect
both bowel and mesentry)
- Inframesocolic compartment exploration - Inspection of bladder and female reproductive organs.
- Pulling tranverse colon caudad allows surgeon to explore supramesocolic compartment.
- Palpate liver followed by gallbladder, right kidney, anterior stomach, proximal duodenum, spleen and left kidney.
4.Medial Visceral Rotations
- Mattox maneuver and Cattell-Braasch maneuver (Based on principle of lifting intraperitoneal viscera off the
posterior abdominal wall and rolling them medially to expose the midline retroperitoneal structure)

Mattox :
gain access to
suprarenal aorta

Cattell-Braasch :
Access entire
inframesocolic
(or infrarenal)
retroperitoneum.
5.Approach to Intra-Abdominal Bleeding
Bleeding from liver injuries stops either with packing or electrocoagulation.
Complex bleeding, surgeon must achieve temporary hemostasis.
Stocks of blood products
6.Choosing an Operative Profile
Definitive repair of the injuries with formal abdominal closure or a rapid bailout using damage control techniques
and temporary abdominal closure.
7. Abdominal Closure
- Temporary closure : Provide rapid atraumatic containment of the abdominal viscera, protect the bowel, and spare
the fascia for definitive closure. Use of vacuum pack
- Closure using non-absorable suture material in either continuous or interrupted sutures.
- Standard approach is to place sutures about 1cm from the edge of the incised linea alba, maintaining a distance of
1cm between successive bites.