Performing a complete and efficient emergency exploration of the abdominal cavity is an essential skill of the trauma surgeon. Trauma laparotomy is a commonly performed procedure after both penetrating and blunt abdominal trauma. The operation must be performed in a systematic and thorough fashion with primary objectives including control of hemorrhage, control of contamination from the gastrointestinal tract, and identification of all injuries followed by definitive repair or damage control management. Definitive repair of injuries may or may not be performed at the initial operation; it is up to the surgeon to devise a plan to address all injuries in a comprehensive and time-sensitive manner.

The word “laparotomy” comes from Greek origin, with lapara signifying the flank or abdomen, and tomoz meaning to cut. In modern trauma surgery, the word laparotomy is used interchangeably with celiotomy, which also stems from the Greek word koilia, belly. Both words imply opening of the peritoneal cavity for access to its contents. After either penetrating or blunt forces, laparotomy is indicated for hemodynamic instability, peritonitis, evisceration, positive or questionable radiographic findings of organ injury, a positive diagnostic peritoneal tap (or lavage), and in some cases, a persistent fall in hematocrit. In a hemodynamically stable patient with a gunshot wound, a tangential bullet trajectory may dictate intervention, whereas a stab wound to the flank may have a variety of treatment options other than laparotomy. Given the many indications for celiotomy, there is some variability in celiotomy technique, with physiologic stability of the patient dictating the urgency of the steps of the procedure.

This chapter provides an overview of the trauma laparotomy. The first part of the chapter describes the principles of the trauma laparotomy as well as the preparation and team effort that must occur for a successful operation. A detailed description of the technical steps and key maneuvers of a laparotomy, as well as considerations for damage control and the practical aspects of temporary abdominal closure follows. Complications of trauma laparotomy and the nontherapeutic laparotomy will be discussed. The final part of the chapter addresses special types of abdominal exploration, including planned and unplanned reoperations after initial laparotomy as well as bedside laparotomy.

The Core Mission

In a trauma laparotomy, the core mission is to identify the greatest threat to the patient’s life and alleviate that threat as quickly as possible. In a trauma situation, the most common threat to life is exsanguination, and thus the mission is to stop the bleeding. The success of the operation depends on the team’s ability to identify, expose, and control hemorrhage, while simultaneously resuscitating the patient with appropriate blood products, fluids, and electrolytes to maintain intravascular volume, correct coagulopathy, and counterbalance physiologic insult. If the patient is not hemorrhaging, the mission is shifted to one of accurately identifying and addressing contamination from bowel injuries. Lastly, but no less important is addressing other injuries, including injuries to the genitourinary tract, pancreas, spleen, and liver.

Prehospital transport, emergency department triage, and the early presence of a trauma surgeon all play a role in the success of the mission, since time to definitive control of bleeding is the major determinant of outcome. Once the indication for laparotomy has been established in the hemodynamically unstable patient, there should be a focused effort by the entire medical team to get the patient to the operating room as quickly as possible.

Length of time spent in the emergency department has been shown to correlate with mortality in hypotensive trauma patients requiring laparotomy and in those with a positive FAST exam.^1,2 Hypotensive patients with penetrating abdominal trauma may benefit from bypassing the trauma bay completely and going directly to the operating room, thus minimizing time to incision and definitive hemorrhage control.

Preparation

Preparing a patient for a trauma laparotomy begins in the trauma bay. The less stable the patient, the less time should be allocated to preoperative preparations. In the hemodynamically unstable trauma patient, activities in the trauma bay should be limited to the primary and secondary survey, chest decompression for significant hemopneumothorax, obtaining intravenous access and initiating blood transfusion, placing direct pressure on sites of external hemorrhage, pelvic sheeting (if mechanism dictates), and obtaining a blood specimen for type and cross. At our institution, a blood gas, base deficit, lactate, and a thromboelastogram are obtained on all high-level trauma activations to quantify and qualify physiologic and coagulopathic insult in order to guide resuscitation.

Plain films of the chest, abdomen, and pelvis have been long advocated as adjuncts to the primary survey, and each has a special role, but not all three are needed at all times. Pelvis x-rays can be reserved for high-energy blunt force, and plain abdominal films when bullet trajectory is in doubt, particularly in the setting of multiple gunshot wounds.

Certain bullet trajectories carry special significance. A thoracoabdominal trajectory has been shown to predict a higher morbidity. Trajectory across the abdominal midline in a hypotensive patient is an early predictor of the need for damage control and a marker for increased mortality.³ X-rays may be examined in the operating room as not to delay transport and time to incision.

Once arriving in the operating room, priorities prior to 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. This requires an organized effort between the surgeon, anesthesiologists, and the nursing team. Introductions should be made when time permits. Communication with the entire operating room team regarding objectives, operative plan, anticipated pitfalls, and necessary equipment is essential. Rapid transfuser devices, thermal control garments, electrocautery, suction, sequential compression devices, and appropriate padding are all required and should be a standard part of advanced preparation.

Trauma patients should initially be positioned in the supine position with arms fully abducted at a 90° angle (Fig. 27-1). If the patient is unstable, prepping and draping may occur before or simultaneously with intubation. At this time, other members of the team can work on venous and arterial access and the other issues noted above. This allows for immediate commencement of the operation should the patient decompensate further with induction of anesthesia.

The groin is isolated with a sterile towel, leaving room to access the femoral vessels if needed. Typical draping for trauma laparotomy should be performed with exposure from chin to knees. The posterior axillary line is the limit of draping laterally. Anesthesia is allowed access the head and arms while the surgeon maintains access to the neck, chest, abdomen, bilateral groins, and saphenous veins.⁴ A wide sterile field allows the surgeon to be prepared for a variety of scenarios, and specifically the dreaded worst-case scenario, as in a single gunshot wound to the abdomen that tracks superiorly into the great vessels of the chest.

In the clearly exsanguinating patient, sterility remains desirable, but is not essential. Protection from blood-borne infectious agents is essential at all times. In instances where the patient has rolled to the operating room with a skilled finger holding hemostasis, the assistant’s hand may be prepped into the field until surgical control is achieved. In the relatively stable patient, prophylactic antibiotics should be given prior to incision, and a proper time-out should be performed.

Role of the Surgeon

During a trauma laparotomy, the surgeon plays many different roles that must be quickly integrated. They conduct the operation with the core mission as primary objective and have a plan on how to achieve it, but always with a high index of suspicion for associated injuries and occult sources of hemorrhage.

The surgeon must physically perform the operation in a technically proficient manner while supervising the other members of the team. Attention to the fine details of the case as well as to big-picture physiology of the patient is necessary. The surgeon must anticipate the steps of the operation in advance as to prepare the anesthesiologists and scrub nurses, while having a clear vision of the end-point of the operation (eg, “Next we are going to perform splenectomy, staple off the bowel injuries and be in the SICU in under an hour with a temporary abdominal closure in place. Please let them know we will be coming and have a rapid transfuser ready.”). Early on, a decision must be made regarding the operative profile of the case: specifically whether to perform damage control or a definitive repair, and the sequence of operative priorities. These considerations will be discussed later in the chapter.

The trauma laparotomy is not performed by the surgeon alone. It is a concerted effort from the surgeon, the anesthesiologists, the nurses, the blood bank, and others. For the operation to be a success, continuous dialogue must be maintained amongst the entire team regarding the broad picture of what is being done and how the plan is evolving. The anesthesiologists should keep the operating surgeon updated on hemodynamics and volume status, dysrhythmias, and need for vasopressors, as well as on the presence of acidosis, coagulopathy, and hypothermia. It is with these variables of physiologic reserve that the surgeon must make critical decisions regarding the operative profile. Likewise, the patient may be bleeding from another visceral cavity, for example hemorrhaging from a chest tube, and this may be only noted by those away from the operative field. In turn, the surgeon must communicate with anesthesia upon opening the abdomen with potential release of tamponade, the presence of massive bleeding, and regarding the clamping and unclamping of major vessels which may alter hemodynamics and arterial pH. These examples illustrate that a safe operation necessitates open communication lines between the surgeon and the anesthesiologist across the sterile drapes. Likewise, the scrub and circulating nurse have responsibilities regarding availability of needed devices and supplies, suction and irrigation, sutures and staplers, and family contacts or new information regarding the patient’s medical history.

A final responsibility of the operating surgeon is to know when to get help. When a technical challenge arises that requires more specialized assistance, the appropriate thing to do is to call for help. The decision to stop and call for additional help often reflects sound judgment, humility, and ultimately puts patient safety in utmost regard.

Throughout the course of the operation, appropriate break points occur which allow the surgeon the opportunity to reexamine the big picture and alter the operative profile, assess hemodynamics and coagulopathy, and summon consultants or assistance when needed. The first such opportunity arises when temporary hemostasis has been achieved with ligation, packing, or a shunt. Another valid pause in the operation exists after exploring the abdomen and finding a large retroperitoneal hematoma, allowing time to consider other operative approach options, including angiography. Control of gastrointestinal tract leaks should next allow a pause to consider if definitive hand-sewn repair or damage control is the best approach. Prior to abdominal closure is yet another time to consider the next steps in management, the timing of orthopedic or other operations, and the best disposition for the patient.

Sequence of Operation

The trauma laparotomy generally follows a reproducible sequence of steps that are expected to provide a goal-directed, efficient, and thorough approach to the abdomen (Fig. 27-2).⁵ A typical trauma laparotomy includes the task of gaining access into the peritoneum, early control of bleeding and contamination, a thorough exploration of the abdominal cavity, and then either a damage-control approach with temporary abdominal closure or definite repair; the patient’s hemodynamic and physiologic profile should guide this decision.

This sequence reflects the objectives and priorities of the procedure; however, the ability to vary this sequence based on exigent operative findings is the hallmark of a good trauma surgeon. For example, if upon entry into the abdomen, a liter of bright red blood is suctioned from the peritoneum with an avulsed spleen identified as the source, priority will first be given to the splenectomy as the most imminent threat to life. In this case, complete exploration would be deferred until the hemorrhage has been controlled, and then returning to the standard sequence and objectives should follow.

After entry into the abdomen in the hemorrhaging patient, the early objective is hemostasis. Initial steps include bowel evisceration to allow for better exposure of bleeding sites (Fig. 27-3). Note we do not advocate a routine “4-quadrant packing” as the first step. It is our contention that this packing is not adequate to tamponade bleeding, it may injure delicate structures (splenic ligaments; friable or injured mesentery), and simply masks ongoing bleeding. Evisceration and exposure should be the first steps, directed at the sites of bleeding. Control of bleeding should be rapidly obtained with a finger, suture, sponge stick, or directed packing. Once temporary hemorrhage control has been obtained, a break in the operation should occur, giving the entire team time to regroup. The surgeon can take a moment to assess the severity of the injury, reformulate the plan of action and call for additional instruments or assistance if needed. The nursing team has time to obtain appropriate suture, instruments, and trays and organize for the next portion of the procedure. Anesthesia has time to catch up on blood loss and correcting coagulopathy. Effective temporary hemostasis is a critical objective early in the operation, without it the surgical team is denied the above advantages and the operation continues at a frantic pace.

The methodical exploration of the abdomen allows the surgeon to catalog all injuries and devise a comprehensive plan of action. Ultimately the repair of one injury may hinge on the repair of a second injury, and therefore the plan should generally not be finalized until all damage is assessed. The need for good decision making abounds in a trauma laparotomy, and the principles of hemorrhage control followed by contamination control with attention to coagulation physiology should help direct the surgeon.

A critical judgment to be made by the surgeon is that of the operative profile: damage control versus definitive repair. The decision to perform damage control surgery can be made before the operating room for the patient in shock, or it can be made intraoperatively once injury severity has been assessed. Damage control implies utilizing a modified, abbreviated operative course designed to control hemorrhage and control gross contamination, a temporary abdominal closure, and a plan for reexploration and definitive repair once the patient has been resuscitated. The purpose is to avoid a permanent physiologic insult from which the patient cannot recover; this insult has been termed to as the “bloody, viscous cycle” and consists of coagulopathy, acidosis and hypothermia.⁶

Gaining Access to the Peritoneum

The trauma exploratory laparotomy is most commonly performed through a midline incision from xiphoid to pubis. This incision affords wide exposure of intraperitoneal and retroperitoneal organs and may easily be extended into a sternotomy as needed. Most general and trauma surgeons are comfortable with this incision and can use the midline to enter the abdomen quickly.

Incising down through skin and soft tissue can be made with a few strokes of the knife. Staying in the midline, the white decussating fibers of the anterior rectus sheath are encountered. The linea alba is divided sharply, revealing preperitoneal fat and the peritoneum which lies beneath. The peritoneum may be entered bluntly above the umbilicus, or is entered sharply with a pair of Metzenbaum scissors while pinching the peritoneum up to avoid injuring the bowel. This is best performed near the xiphoid with the lateral segments of the liver providing some protection beneath. Iatrogenic bowel injuries can be catastrophic and care must be taken to prevent them. Once the peritoneum is deemed free of adhesions, the peritoneum may be freely opened with electrocautery, or when speed is essential, with a pair of Mayo scissors.

In the patient with a prior abdominal incision, it is safest to enter the abdomen away from the preexisting scar in order to avoid adhesions. Alternatively, a bilateral subcostal incision (chevron) or even a flank incision may be utilized to circumvent a midline scar. While these options provide adequate access to isolated areas of the abdomen, they are much less desirable for complete exploration of the abdomen and pelvis. In addition, these incisions are likely to take more time and have their own significant morbidity, therefore the midline incision is preferred whenever possible.

Early Goals: Hemostasis and Control of Contamination

The patient’s hemodynamic status dictates the course and urgency of the laparotomy. Once the peritoneum has been opened in the bleeding patient, two pooled suction catheters are utilized to rapidly evacuate blood from the peritoneum. The bowel is then eviscerated and hemorrhage control or directed packing is performed. Likely sources of bleeding are bowel mesentery, solid organs, or the great blood vessels. The solid organs are quickly inspected and palpated for injury. When liver hemorrhage is identified, packing should occur laterally, superiorly, and inferiorly to the liver. Splenic hemorrhage should be managed with immediate splenectomy in most circumstances. Mesenteric bleeding is managed by clamps and ligature as the first step, with later evaluation of bowel viability.

Retroperitoneal and great vessel injuries are more challenging. An aid to their management is an understanding of the anatomy of the three zones of the retroperitoneum. Zone I is the central zone of the retroperitoneum, bounded by the kidneys laterally and extending from the diaphragmatic hiatus to the bifurcation of the inferior vena cava and aorta. This zone can be further divided by a supramesocolic or inframesocolic location. It is inspected by lifting the transverse colon and gently retracting it either caudally or cranially. Bleeding or hematoma in this area signifies great vessel injury, including aorta, vena cava, and celiac axis vessels or superior mesenteric artery, vein or portal vein injury. Zone II is located laterally from the kidneys to the paracolic gutters, and hematoma in this area usually signifies injury to the renal artery or vein. Zone III of the retroperitoneum includes the pelvis, encompassing the iliac arteries and veins.

If packing controls hemorrhage, a pause in the operation can occur, allowing the team to regroup, restore the patient’s blood volume, obtain equipment and mentally ready for the next portion of the operation. The surgeon’s next immediate priorities include locating the injured vessel or organ, exposing the injury, and then deciding on temporary or definitive repair.

If bleeding is not controlled with packing, or if it manifests as an expanding Zone I retroperitoneal hematoma, proximal control should be obtained with occlusion of the supraceliac aorta with a trained finger or sponge stick compressing the aorta against the vertebral bodies. The supraceliac aorta can be then exposed by first retracting the lateral segments (II and III) of the liver toward the patient’s right. The gastrohepatic ligament is incised. The esophagus can then be laterally displaced, which should expose the aorta. The aorta should be dissected anteriorly and laterally to allow for passage of a vascular clamp. Division of the left crus of the diaphragm will also help to expose the proximal aorta at the hiatus. While suture ligation of most bleeding intra-abdominal vessels is the norm, primary repair of the aorta, vena cava, and very proximal superior mesenteric artery (and rarely the portal vein) should be part of the hemorrhage control plan. Adjuncts can include packing, clamps, or balloon catheter tamponade.

Hollow viscus injuries are repaired or the injured bowel segment is resected, with or without re-anastomosis. Once initial hemorrhage and gastrointestinal spillage have been controlled, the decision to reconstruct complex gastrointestinal and vascular injures is weighed against the decision to place a temporary abdominal closure and come back once the patient is fully resuscitated.

Exploring the Peritoneal Cavity

The peritoneal cavity is explored in the same fashion each time, as not to overlook any injuries. As previously described, Zones I, II, and III of the retroperitoneum are examined for hematoma early in the procedure. The anterior aspect of the stomach is examined in its entirety from the gastroesophageal junction to the pylorus. The lesser sac is then opened by dividing the gastrocolic omentum, and the posterior aspect of the stomach and the anterior aspect of the pancreas are inspected.

From the pylorus, the gastrointestinal tract can be examined from proximal to distal. If the duodenum has been mobilized with a Kocher maneuver, the anterior and posterior aspects of the duodenum can be visualized. The small bowel is then run in a methodical fashion, examining the circumference of the bowel and identifying any abnormalities. As a segment of small bowel is lifted for examination, the corresponding mesentery is also inspected for hematoma.

Serosal injuries or full-thickness perforations of the small bowel may be contained with a Babcock clamp or over sewn with a rapid whipstitch as they are encountered. Once the terminal ileum is encountered, the appendix, ascending, transverse, descending, and sigmoid colon are inspected. It may be necessary to mobilize the colon along the white line of Toldt to examine the retroperitoneal aspect, particularly in cases of penetrating trauma where the trajectory is suspicious. The liver, spleen, kidneys, and gallbladder are palpated for injury. In the pelvis, the genitourinary organs are inspected for injury. Finally, the diaphragm is inspected carefully as a site of potential missed injury. Structures appearing bruised or those located close to a missile trajectory should be fully mobilized and carefully examined for injury.

Medial Visceral Rotations

In the presence of a retroperitoneal hematoma, the decision on whether or not to explore the hematoma must be made. Zone I retroperitoneal hematomas require surgical exploration. Penetrating injuries to Zone II are generally explored, while blunt injuries are only explored if the hematoma is expanding. Zone III, the pelvis, should only be explored in the case of penetrating injury. Blunt injury to Zone III is best dealt with via an interventional approach or preperitoneal packing.

The medial visceral rotations are maneuvers utilized to expose key retroperitoneal structures, including the great vessels and their branches, the kidneys, and the duodenum. Both maneuvers are based on a technique of mobilizing intraperitoneal structures off of the posterior abdominal wall, and mobilizing them medially to allow access to the retroperitoneum. The decision to perform such maneuvers should be based upon anatomic location of hematoma and suspected injuries.

A right medial visceral rotation, also known as the Cattell-Braasch maneuver, is used to expose the intra-abdominal inferior vena cava, the right renal pedicle, and the right iliac artery and vein (Fig. 27-4). The ureter, head of the pancreas, and duodenum will also be exposed. The Cattell-Braasch begins with mobilization of the hepatic flexure of the right colon and a full Kocher maneuver to mobilize the duodenum and pancreatic head along the peritoneal reflection. This is further carried down the right colon along the paracolic gutter by dividing the white line of Toldt. The exposure ends by dividing the avascular plane which exists between the root of the mesentery and the peritoneum. The small bowel and right colon are then retracted medially, allowing visualization of the inferior vena cava.

Another technique that can be used to expose the retrohepatic vena cava is extension of the midline incision across the costal margin into an intercostal space of the right chest. The diaphragm can thus be incised to expose the vena cava and hepatic veins. Proximal control of the inferior vena cava is best achieved from inside the chest.

Injuries to the aorta present most commonly as exsanguinating hemorrhage or as pulsatile hematomas in Zone I of the retroperitoneum. To explore a Zone I or a Zone II retroperitoneal hematoma on the left, a left medial visceral rotation, the Mattox maneuver, is performed (Fig. 27-5). The left-sided organs are mobilized off the aorta, which allows for broad exposure of the aorta from the diaphragmatic hiatus to the iliac vessels. Before opening the retroperitoneum, proximal control at the supraceliac aorta should be obtained. A left medial visceral rotation is initiated by dividing the splenorenal ligament. The left peritoneal reflection, or the white line of Toldt, is then divided from the splenocolic flexure down the paracolic gutter to the distal sigmoid colon. The left colon, spleen, stomach, and pancreas are then mobilized to the midline, just anterior to Gerota’s fascia surrounding the kidney. The abdominal aorta is thus exposed, along with the celiac axis, the superior mesenteric artery, the left renal artery and vein, and the left iliac artery and vein. In the classic Mattox maneuver, the kidney is included in the mobilization, which allows for access to the posterior aspect of the kidney and the aorta below the renal pedicle. Otherwise, the left renal vein would restrict access to the anterior aorta. Care must be taken to avoid iatrogenic injury to the spleen when placing traction on the descending colon.