Blunt trauma
Persistent hypotension and clinical evidence of intra-abdominal bleeding (including positive FAST or DPL)
Free air, retroperitoneal air, or evidence of ruptured diaphragm
Contrast-enhanced CT scan suggesting ruptured hollow viscus, ongoing bleeding, or organ injury requiring repair
Peritonitis
Penetrating trauma
With hypotension
Inability to rule out penetration of anterior fascia via wound exploration
Gunshot wound traversing the peritoneal cavity or retroperitoneum
Evisceration
Bleeding from stomach, rectum, or urinary tract
The majority of surgeons indicate early laparotomy for omental evisceration, despite reports from some centers, often with high-volume of penetrating trauma, of successful nonoperative management of these patients [7]. Deciding to perform a laparotomy by local wound exploration and suspicion of peritoneal violation of stab wounds is questionable. The presence of peritonitis or hemodynamic instability after penetrating abdominal trauma remains unquestionable grounds for early laparotomy.
In practice, trauma patients are deemed stable when the systolic blood pressure is above 90 mmHg, and unstable if below. This definition of instability has many limitations, and “occult shock,” or shock with acceptable blood pressure, remains a cause of many unnecessary deaths. Ideally, trauma patients should have investigations, such as lactate measurement, and base excess, in addition to physical examination in search of occult shock to prevent being incorrectly labeled stable when they are in shock. When profound instability resulting from intra-abdominal hemorrhage is present, the patient requires intubation and immediate laparotomy. Considering that many trauma patients with significant bleeding are coagulopathic, a growing number of trauma centers have developed massive blood transfusion protocols to the management of these patients. Bleeding coagulopathic and acidotic patients should undergo abbreviated laparotomy following the principles of damage control [8–10].
Other factors to be considered when indicating laparotomy in a trauma patient are the hospital resources including the surgical team with experience in trauma, equipment, blood bank, and intensive care unit support. While life-saving operations to control large bleedings are necessarily performed in community hospital, there is ample evidence that patient victims of major trauma should be transferred to a trauma center where the chances of survival with less sequela are significantly higher.
1.2 Preparing the Patient for Early Laparotomy
Hemorrhage is the most common cause of shock in trauma patients. Tachycardia is the first change in vital signs in early shock, while cool skin due to cutaneous vasoconstriction is the earliest physical finding. The first step in managing unstable patients in the emergency department is resuscitation [9]. If there is airway compromise, altered mental status, or hypoxia, the patient should be intubated with cervical spine immobilization. Two large-bore intravenous (IV) lines should be established, and placement of introducers should be considered in very unstable patients. Blood typing and cross matching is recommended. Often resuscitation starts with 0.9 % sodium chloride or lactated Ringer’s solution, but in patients with significant bleeding and unstable, blood may the fluid of choice. Not all resuscitations are best done in the emergency department. For unstable patients, the operating room, particularly those with imaging/angiography capabilities, may be the ideal resuscitation place. For most patients however, surgery follows the initial stabilization in the emergency department. The following points are important in preparing the patient for laparotomy:
Obtain from the patient, or family, emergency personnel, or bystanders information about the trauma, preexisting medical conditions, allergies, medications, and last meal.
For blunt trauma patients, keep neck and spine immobilized until X-rays or CT rule out spinal injuries.
Blood samples for baseline lab values: hemoglobin and hematocrit (results may be normal due to volume loss and hemoconcentration), arterial blood gas, prothrombin time, international normalized ratio, and activated partial thromboplastin time (screen for coagulopathy).
Prevent hypothermia. Basic passive heating measures such as covering the patient and turning on the patient compartment heater until it is uncomfortably warm can slow down the loss rate. Make sure to remove any wet clothing prior to warming measures. All intravenous fluids should be warmed. The operating room temperature should be measured and recorded before the anesthesia.
For evisceration, cover the viscera with a sterile dressing moistened with 0.9 % sodium chloride solution to prevent drying.
Insert a urinary catheter, unless suspicion of urethral injury.
Consider inserting a gastric tube to decompress the patient’s stomach and minimize leakage of gastric contents and contamination if viscus perforation.
Administer tetanus prophylaxis if indicated.
Routine perioperative antibiotics administered within 30 min of making the incision.
Explain to the patient and/or family the indications and risks associated with the operation and obtain informed consent if possible.
1.3 Preparing the Operating Room
As we mentioned earlier in this chapter, gravely ill and unstable trauma patients may benefit from being resuscitated in the operating room instead of the emergency department. A number of trauma centers across the world have hybrid ORs with resources for multiple types of operation and imaging capabilities, including angiography suite and even CT scans. The ability to offer multi-specialty care without having to move the patient across the hospital may make a difference in their outcome, but this remains to be proven. Currently, many trauma centers can perform simple radiographies using portable instruments brought to the OR.
Hypothermia should be actively prevented and treated in all trauma patients taken to the OR. Hypothermia is common in trauma where patients experience large heat losses as consequence of cold IV fluids, blood losses, and exposure to the environment. Surgeons prefer cooler temperatures in the OR because of the many protective layers of clothing they use. Operating room temperatures should be maintained from 68 to 73 °F (20–22 °C). For operations on babies or young children, temperatures of 71–73 °F (21–22 °C) are desirable. A variety of commercial devices, such as the Level I, are available and may be required in the OR to cope with the rapid infusion of warming intravenous fluids and blood rates used during trauma patient resuscitation.
Surgical instruments exist in vast numbers and varieties. Basic laparotomy but also thoracic and vascular instruments are essential to accomplish most types of surgery in trauma. Table 1.2 lists some equipment that are desirable to have available in the OR.
Table 1.2
Equipment and instruments in the OR for trauma laparotomy
Suction apparatus (at least 2) |
Warm blanket and thermometer (temperature should be measured every 30 min during the operation) |
Multiple retractors capable of holding different incision |
Electrocautery, argon plasma coagulation, or other similar instruments |
Hemostatic agents and fibrin glue |
Drains, plastic sheaths, and other devices that permit temporary abdominal closure (i.e., Bogota bag, negative-pressure wound therapy, and others) |
1.4 The Surgical Team
The surgical team consists of surgeons, anesthetists, nurses, and all other health professionals directly involved in patient care in the OR. Safety is a major concern for the patient and surgical team. Each member of the OR team performs specific function in coordination with one another to have a successful operation and to create an atmosphere that best benefit the patient. Surgical checklists are an example of how concerns about patient safety are changing surgical practice. Checklists have long been accepted in other high-risk industries (e.g., aviation and nuclear power). In routine surgeries, checklists are associated with significant reductions in morbidity and mortality and are rapidly becoming the standard of care [12]. The same should happen in trauma, where checklists should be checked, except for those cases where the patient is so ill no time can be spent.
In recent years, there has been tremendous growth in the field of telemedicine. Telemedicine facilitates access to care for traditionally underserved populations in remote areas, and trauma surgeons can now remotely assist in the evaluation and care of patients, including surgical procedures as laparotomy [13]. Through telemedicine, students and residents can observe the procedure from a remote classroom. Furthermore, reducing the number of people in the OR results in less noise and distraction for the surgical team.
1.5 Anesthesia, Patient Position, and Preoperative Antisepsis
Most laparotomies begin with the administration of general anesthesia, except in extreme cases where some sedation may be all the patient may tolerate. Preanesthetic evaluation may be incomplete and lacking information on preexisting medical conditions, proper assessment, and optimization including investigations and many physiological derangements not corrected. Because of the rapidly progressive course of the surgical presentation, patients may require surgery outside of normal operating hours.
The patient should be positioned in the surgical table in the supine position. In patients who have penetrating trauma in the buttock area or lower abdomen, the lithotomy position may be required to approach potential rectal injuries.
Once the anesthesia takes effect, the skin of the abdomen is prepared from the neck to thigh, with special attention to the abdomen and chest, as a thoracotomy may be necessary. An antibacterial solution to prevent infection at the surgical site, preferentially chlorhexidine, should be used for preoperative antisepsis.
1.6 Exploratory Laparotomy
1.6.1 Incision
The most common laparotomy incision for trauma is the midline, which is a vertical incision down the patient’s midline extending from the xiphoid to the pubic bone. In some cases, the abdominal incision may be smaller, at least at the beginning of the surgery and then extended as needed. Adequate exposure may save the surgical team time and the patient’s life.
Patients with no ventilator effort, no femoral pulse, and no response to painful stimuli after penetrating abdominal trauma may benefit from a resuscitative thoracotomy before laparotomy to occlude the thoracic aorta. This indication is controversial since the aorta may be clamped at the diaphragmatic hiatus. In these patients with hemorrhagic shock, damage control (DC) resuscitation, a strategy combining the techniques of permissive hypotension, hemostatic resuscitation, and damage control surgery, has been widely adopted as the preferred method of resuscitation. DC, defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit and subsequent definitive reexploration [9, 10].
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
