Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (61 page)
Laparotomy for trauma
In patients who, by any of the diagnostic criteria above, are judged to need a laparotomy for control of their injuries, the timing of laparotomy in relationship to the detection and/or repair of concomitant injuries requires input from an experienced trauma surgeon. Although open to debate, the following scenarios are offered along with a suggested algorithm (
Fig. 13.1
).
Figure 13.1
Management of abdominal injury.
The unstable patient with obvious intra-abdominal haemorrhage should undergo immediate operative intervention. However, if other priorities are also pressing (e.g. major physiological derangement, severe closed head injury or associated pelvic haemorrhage), a ‘damage control’ procedure (abbreviated laparotomy) should be considered to allow management of the patient's physiology or of other life-threatening injuries.
During the laparotomy, however brief, if the patient had an initial Glasgow Coma Scale (GCS) of less than 8/15, it is recommended that intracranial pressure monitoring should take place. The most lethal secondary brain injury is induced by hypotension or hypoxia.
If a widened mediastinum is present, the situation must be assessed and priorities of care selected. In the patient who is unstable because of intra-abdominal pathology, the diagnostic processes for the mediastinum may have to take place
after
the therapeutic laparotomy. Consideration should be given to the use of beta-blockade, and hypotensive resuscitation, until the aorta/great vessels can be properly evaluated.
There are considerable data available to support medical treatment of contained thoracic aortic injuries and to delay repair or endovascular stenting until other injuries are stabilised.
33
In a patient who is unstable with both intra-abdominal haemorrhage and pelvic bleeding, the surgeon must decide which injury is causing the hypotension. If the DPL is grossly positive, or an ultrasound demonstrates a large amount of fluid in Morrison's pouch, laparotomy should be performed promptly. As most fractures of the pelvis bleed extraperitoneally, this bleeding is unlikely to originate in the pelvis. An unstable patient who has signs of bleeding from both pelvis and abdomen should have compression stabilisation of the pelvis, with a knotted sheet (or proprietary device) or external fixation applied immediately, followed by laparotomy and
extraperitoneal
packing, then angiography of the pelvis and embolisation of bleeding arteries. Ultrasound is unreliable for quantifying blood loss in such circumstances and, if the patient is stable enough, CT of both pelvis and abdomen should be carried out. Not only will CT provide significant information regarding the pelvic fractures and source of bleeding (85% will be venous in origin), it will also give information as to possible injury to intra-abdominal organs. Furthermore it may exclude a diaphragmatic rupture, which has a significant association with pelvic fractures. Intrapelvic bleeding is best controlled by angio-embolisation (arterial) or by external fixation (venous), often in association with extraperitoneal pelvic packing.
In stable patients with combined head/chest/abdominal injuries, CT with contrast can rapidly identify injuries that need operative intervention. A study by Wisner et al. described 800 patients who were thought to have potentially correctable injuries to both the head and the abdomen.
34
Only 52 had a head injury requiring craniotomy, 40 required laparotomy, and only three needed both craniotomy and therapeutic laparotomy. These authors lend support to the concept that if patients with combined head/abdominal trauma are
stable
and have a negative ultrasound (or DPL), they can undergo CT of both the head and abdomen. Many patients with head trauma and stable liver/spleen injuries are now being treated non-operatively.
35
With the exception of pelvic fractures, fracture/dislocations and in the presence of vascular impairment, most fractures can be simply splinted while other surgical procedures take place. Open fractures should be irrigated and debrided within 6 hours of the injury, and antibiotics administered. Although there is still considerable debate about the timing of fracture fixation in trauma patients with multiple priorities, those with head and/or pulmonary injuries still benefit from early fracture fixation, provided hypotension and hypoxia can be avoided during the surgery. There is a clear role for damage control orthopaedics as part of a damage control procedure.
If it is decided that the injured patient would benefit from laparotomy, the operation should be approached in an orderly fashion. It is important to recognise the components of the ‘trauma laparotomy’. The vital initial goals are to:
stop the bleeding;
limit contamination;
restore the physiology.
An adequately stocked
warm
operating theatre is essential.
Delay in surgery is the most common cause of unnecessary ongoing bleeding
. In addition to routine equipment, the following should be considered as mandatory equipment:
rapid infusion devices with rapid warming capability (Alton Deane®, Mallincrodt® or Level One®);
patient warming blankets (e.g. Bair Hugger®);
autotransfusion if available.
A long midline abdominal incision is used, one that can be extended superiorly as a sternotomy. The ideal incision is always ‘too big rather than too small’ and should extend from the xiphisternum to the symphysis pubis.
If, upon opening the abdomen, gross blood is encountered, as much as possible is scooped out, using a receiver such as a kidney dish. Suction is ineffective as it is too slow, and the apparatus blocks with clots.The abdomen is packed using layered dry abdominal swabs:
below the left hemidiaphragm;
lateral to the descending colon;
the pelvis;
lateral to the ascending colon;
lateral to the liver;
below the liver;
anterior to the dome of the liver, under the right subcostal margin;
central abdomen.
Additional packs are used to isolate bleeding areas as required.
With blunt injuries, the most likely sources of bleeding are the liver, spleen and mesentery. The solid organs are packed and bleeders in the mesentery are clamped using mosquito forceps. No attempt is made to tie off individual vessels (very time consuming) until all major bleeding has been controlled with clamps. If necessary, a soft bowel clamp can be used across the mesentery to control all mesenteric bleeding.
With penetrating injuries, the liver and retroperitoneal structures, vascular structures and mesentery are all examined.
If packing does not control the bleeding, the blood supply to the organ is isolated using proximal clamping or isolation techniques. If additional assistance is needed for blood pressure control, the abdominal aorta can be manually compressed at the hiatus. When the patient is reasonably stable, the packs are removed systematically, uncovering the most likely injury
last
. Any bleeding sites are then rapidly controlled by clamps, sutures or re-packing as needed.
Gross contamination from the gastrointestinal tract is quickly controlled with sutures or staples.
No further definitive surgery is performed until the anaesthesia team has the patient stabilised and the patient is
warm
(> 35 °C). This may require a period of resuscitation in the intensive care unit (see ‘Damage control laparotomy’ below).
Once there is control of haemorrhage and contamination, a systematic inspection is performed.
In addition to inspecting the liver and spleen, a full trauma laparotomy includes examination of the anterior/posterior stomach wall, the entire large and small bowel (including the duodenum), the diaphragm, the gastrohepatic ligament, the head, body and tail of the pancreas, and any central retroperitoneal haematomas. In order to achieve this, it will be necessary not only to perform a conventional reflection of the duodenum (the Kocher manoeuvre) and to enter the lesser sac, but also to reflect the right and left hemicolon to view the great vessels (right and left medial visceral rotation manoeuvres).
The abdomen is only closed when it is safe to do so (see ‘
Damage control laparotomy
’ and ‘
Abdominal compartment syndrome
’ below).
Since the mid-1980s, there has been a re-emergence of the concept of packing and closing for abdominal injuries with profuse haemorrhage. Further experience with this technique has resulted in its extension to patients with other vascular/intestinal injuries, and new terms such as ‘damage control’ surgery, ‘abbreviated laparotomy’, ‘staged laparotomy’ or ‘planned re-operation’ have emerged.
36
The principle of damage control has been extended beyond the abdomen, to thoracic, extremity and orthopaedic damage control techniques.
37
The concept of damage control has as its objective the avoidance of imposition of additional surgical stress at a moment of physiological frailty. The concept is not new – livers were not infrequently packed 100 years ago. However, the failure to understand the underlying rationale, or deal with the resulting disruption to physiological processes, led to disastrous results. The concept of packing was re-examined, and the technique establishment of intra-abdominal pack tamponade and then completion of the procedure once coagulation has returned to an acceptable level proved to be life-saving. This approach was initially advocated for patients with severe liver injuries, especially those with retrohepatic venous injuries. When properly applied, packs above/below the liver can compress and control venous injuries long enough for the patient's coagulopathy, acidosis and temperature to be corrected.
Often, when the patient is returned to the operating room after packing for liver injuries, the bleeding has already stopped, and irrigation, debridement and formal closure are all that are required. The concept of ‘staging’ applies both to routine and to emergency procedures, and it can apply equally well beyond the abdomen.
This approach has been used for patients with both penetrating and blunt injuries, and it generally includes clamping of major bleeding vessels, packing of bleeding solid-organ injuries and stapling/dividing bowel injuries but
without
initial reconstruction. A variety of temporary methods of closure of the abdomen have been developed (see ‘Temporary abdominal closure’ below), including mesh and other synthetic material, plastic intravenous bags and towel clips. Currently, the ‘vacuum sandwich’ technique is the simplest method of choice. However, it must be remembered that the type of closure is much less important than the recognition of the need to terminate the operation and save the patient.
Patients are selected for a damage control approach if there is:
inability to achieve haemostasis;
proven coagulopathy;
inaccessible major venous injury, e.g. retrohepatic vena cava injury;
anticipated need for a time-consuming procedure (> 90 min);
demand for non-operative control of other injuries, e.g. fractured pelvis;
desire to reassess the intra-abdominal contents (directed relook).
Irrespective of setting, a coagulopathy in the presence of hypothermia is the single most common reason for abortion of a planned procedure or the curtailment of definitive surgery. It is important to abort the surgery
before
the coagulopathy becomes obvious.
Hirshberg and Mattox described three distinct indications for planned re-operation in severely injured patients:
38
avoidance of irreversible physiological insult in a hypothermic coagulopathic patient by rapid termination of the surgical procedure;
inability to obtain direct haemostasis (by ligation, suture or vascular repair), necessitating indirect control of bleeding by packing or balloon tamponade;
massive visceral oedema precluding formal closure of the abdomen or chest.
Garrison et al. described criteria that predicted the need to pack early for severe intra-abdominal haemorrhage:
39
Injury Severity Score (ISS) > 35;
coagulopathy with a prothrombin time > 19 seconds;
hypotension with a systolic blood pressure < 70 mmHg for longer than 70 minutes;
pH < 7.2;
serum lactate > 5 mmol/L;
temperature < 34 °C.
More recently, thromboelastography (TEG) or rotary thromboelastometry (RoTEM) has been regarded as the ‘gold standard’ for assessment of coagulation status, and an
r
time > 12 minutes would mandate damage control surgery.
13
Damage control procedures can be considered under the following stages.
In damage control, the technical aspects of the surgery are dictated by the injury pattern, with the primary objectives as follows.
Arrest bleeding and the resulting (causative) coagulopathy:
Procedures for haemorrhage control include:
repair or ligation of accessible blood vessels;
occlusion of inflow into the bleeding organ (e.g. Pringle's manoeuvre for bleeding liver);
tamponade using wraps or packs;
intravascular shunting;
intraoperative or postoperative embolisation.
Limit contamination and the associated sequelae:
This is achieved by:
ligation or stapling of bowel;
isolation of pancreatic injury;
adequate suction drainage (e.g. with a Blake® drain).
Temporary abdominal closure:
The abdomen is only closed to limit heat and fluid loss and to protect viscera. Closure is usually achieved using the ‘sandwich technique’, first described by Schein et al. in 1986
40
and subsequently popularised by Rotondo et al.
36
A sheet of self-adhesive incise drape (Opsite®, Steridrape® or Ioban®) is placed flat, sticky side up, and an abdominal swab placed upon it. The plastic edges are trimmed, to produce a sheet with membrane on one side and abdominal swab on the other. If extra firmness is required, a surgical drape can be used instead of the swab. It is worth noting that it is unnecessary to make any perforations in the membrane, and to do so may increase subsequent fistula formation.
The membrane is utilised as an on-lay with the margins ‘tucked in’ under the edges of the open sheath, the membrane being in contact with the bowel.
The appreciable drainage of serosanguinous fluid that occurs is best dealt with by placing a pair of drainage tubes (e.g. sump-type nasogastric tubes or closed-system suction drains) through separate stab incisions onto the membrane and utilising continuous low-vacuum suction. This arrangement is covered by an occlusive incise drape applied to the skin, thus providing a closed system.
Other techniques, such as the use of towel clips or the so-called ‘Bogota bag’, are now generally regarded as obsolete. The use of proprietary vacuum suction devices at this stage is not only expensive, but the suction used is often above mean arterial pressure, which increases the risk of subsequent fistula. Such devices should generally only be used at the final stage of closure if definitive closure is not possible.
The timing of the transfer of the patient from the operating theatre to the intensive care unit is critical. Early transfer is cost-effective; premature transfer is counter-productive. In addition, once haemostasis has been properly achieved, it may not be necessary to abort the procedure and it may be possible to proceed to definitive surgery. Conversely, there are some patients with severe head injuries where the coagulopathy is induced by severe irreversible cerebral damage, and further surgical energy is futile.
In the operating theatre, efforts must be started to reverse all the associated adjuncts, such as acidosis, hypothermia and hypoxia, and it may be possible to improve the coagulation status through these methods alone. Adequate time should still be allowed for this, following which reassessment of the abdominal injuries should take place, as it is not infrequent to discover further injuries or ongoing bleeding.
Priorities on reaching the intensive care are:
The restoration of body temperature using:
passive rewarming with warming blankets, warmed fluids, etc.;
active rewarming using lavage of chest or abdomen.
Correction of clotting profiles by blood component repletion. This is best directed by the results of the TEG/RoTEM.
13
Optimisation of oxygen delivery:
volume loading to achieve optimum preload;
haemoglobin optimisation to a value of 9 g/dL;
temperature optimisation (> 35 °C).
Monitoring of intra-abdominal pressure (IAP) to prevent abdominal compartment syndrome (ACS).
The patient is returned to the operating theatre as soon as stage 3 is achieved. The timing is determined by:
the indication for damage control in the first place;
the injury pattern;
the physiological response.
Patients with persistent bleeding despite correction of the other parameters merit early return to control the bleeding.
Every effort must be made to return
all
patients to the operating theatre within 24–48 hours of their initial surgery.
Once definitive surgery is complete, and no further operations are contemplated, then the abdominal wall can be closed. This is often difficult and methods involved include:
primary closure;
closure of the sheath, leaving the skin open;
grafts with Vicryl® mesh, or other synthetic sheets;
use of lateral relieving incisions to allow closure of sheath (component separation).