with Dr. Roser Termes
Background Trauma remains a major health problem worldwide and, in many countries, it continues to increase. Globally, road traffic injuries are the leading cause of death between the ages of 18 and 29, while, in the United States, trauma is the leading cause of death in young adults and accounts for 10% of all deaths among men and women. Around 45 million people globally suffer moderate to severe disability every year due to trauma. According to the World Health Organization (WHO) trauma is expected to become the third leading cause of disability worldwide by 2030. Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems. Abdominal injuries, in particular, constitute a significant source of morbimortality in traumatic patients, with up to 15% of all accidents presenting an abdominal injury. The mechanism of injury, injury forces, location of injury, and hemodynamic status of the patient determine the priority and best method of abdominal and pelvic assessment. Of all traumatic abdominal injuries, 75 to 90% of patients with a gunshot wound, 25 to 35% with a stab wound, and 15 to 20% of patients with a blunt trauma will require an emergency laparotomy. What is an emergency laparotomy? The emergency laparotomy, also known as trauma laparotomy, is an emergent procedure performed to treat or control traumatic abdominopelvic injuries. It has some essential parts: – Rapid entry – Adequate (large) incision – Control of massive hemorrhage by: – Packing – Direct control – Proximal + distal control (= source control) – Identification of injuries – Control of contamination – Reconstruction (if possible) Indications – Blunt abdominal trauma with hypotension, with a positive FAST (Focused Assessment with Sonography for Trauma) or clinical evidence of intraperitoneal bleeding, or without another source of bleeding. – Hypotension with an abdominal wound that penetrates the anterior fascia. – Gunshot wounds that traverse the peritoneal cavity. – Evisceration. – Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma. – Peritonitis. – Free air, retroperitoneal air, or rupture of the hemidiaphragm. – Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma. – Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers, or bile from diagnostic peritoneal lavage, or aspiration of 10 cc or more of blood in hemodynamically abnormal patients. Damage control vs. definitive treatment It is important to appreciate the difference between abdominal surgery as part of the resuscitation process and the definitive surgical treatment for abdominal trauma.
Surgical resuscitation includes the “damage control” technique and implies only that the surgical procedure is necessary to save the patient’s life by stopping bleeding and preventing further contamination or injury but is restricted due to the patient’s physiological derangement.
By contrast, definitive surgical treatment implies that the physiological state of the patient allows for the definitive surgical repair to take place. Technique All patients undergoing a laparotomy for abdominal trauma should be explored through a long midline incision, made from the xiphoid to the pubis. It is also essential to be able to extend the incision if needed, so patients must have both thorax and abdomen prepared and draped to allow access to the thorax, abdomen and groins if required.
Once the abdomen is opened, remove as much blood as possible into a receiver (a sucker may not be enough), eviscerate the small bowel and perform a quick exploration to ascertain if there is an obvious site of large-volume bleeding (where packing is not efficient). Massive hemoperitoneum must be controlled before continuing further with the procedure.
Then an absorptive packing with large dry unfolded abdominal swabs must be performed following a clockwise direction: 1.- Under the left diaphragm. 2.- In the left paracolic gutter. 3.- In the pelvis. 4.- In the right paracolic gutter. 5.- Into the subhepatic pouch. 6.- Above and lateral to the liver. 7.- Directly to any other bleeding area (knowing that packing does not control arterial bleeding).
After allowing the anesthetist to achieve a correct blood pressure and other vital parameters, the abdominal packs must be removed, one at a time, beginning at the region least likely to be the site of bleeding.
In the left upper quadrant, if the spleen seems to be the site of bleeding, a decision needs to be made on whether it should be preserved or removed. Bleeding may be temporarily controlled by placing a vascular clamp across the splenic hilum. In the right upper quadrant, injuries to the liver are assessed. It is recommended to dissect the gastrohepatic ligament to place a vessel loop across the portal triad. – If there is a hepatic hemorrhage and it can be controlled with simple compression, it is most probably venous and may be managed with therapeutic liver packing. – If the bleeding does not cease, a Pringle maneuver should be performed, as the suspicion is an arterial or portal injury. Hepatorrhaphy is then carried out to control intrahepatic vessels, alone or with packing. – If this maneuver fails to control the bleeding, the most likely source are the hepatic veins or the inferior vena cava. If so, compression against the posterior abdominal wall and diaphragm can be successful, and packing should also be performed. An important issue to bear in mind is that lesions must be dealt with in order of lethality: 1.- Injuries to major blood vessels. 2.- Major hemorrhage from a solid abdominal viscera. 3.- Bleeding from mesentery and hollow organs. 4.- Retroperitoneal bleeding. 5.- Contamination. Closure of the abdomen After the procedure, we must adequately prepare for closure. This preparation includes: – Evaluation of the adequacy of hemostasis and/or the need for packing. If a definitive packing may be used, swab packs must be placed flat against the organ and they should exert sufficient force on the organ to tamponade the bleeding. – Abundant lavage and removal of debris in the peritoneal cavity and wound. – Placing drains if required.
The choice between primary or delayed closure is based on five principles: 1.- The stability of the patient. 2.- The amount of blood loss. 3.- The volume of intravenous fluid administered. 4.- The degree of intraperitoneal and wound contamination. 5.- The nutritional status and possible intercurrent diseases.
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