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INTRODUCTION

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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.

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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.

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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.

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PRINCIPLES

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The Core Mission

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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 ...

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