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KEY POINTS

KEY POINTS

  • Wide prepping and draping allow the surgeon access to the chest and the groin to complete all necessary procedures.

  • The trauma laparotomy should be performed in a routine, systematic manner, minimizing the likelihood of missed injuries.

  • Damage control laparotomy focuses on immediate control of hemorrhage and contamination, followed by goal-directed resuscitation, reversal of coagulopathy, rewarming, and delayed definitive repair.

  • Preperitoneal packing is proving to be a quick, efficient method to control zone III hematomas.

  • A quality fascial closure helps prevent future morbidity associated with dehiscence, evisceration, and hernias.

  • Surgeons should use laparotomy pads with a radiofrequency detection system or obtain abdominal and pelvic x-rays prior to definitive closure to decrease the risk of retaining foreign bodies.

INTRODUCTION

Performing a complete, efficient emergency exploration of the abdominal cavity is a defining and essential skill of the trauma surgeon. Following penetrating or blunt injury, a 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 drop in hematocrit. The objectives of a trauma laparotomy include control of hemorrhage, control of contamination from the gastrointestinal tract, and identification of all injuries. The patient’s physiology determines whether definitive repair of injuries is accomplished at the initial operation or deferred in a damage control approach. It is the trauma surgeon’s responsibility 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 waist and the suffix “-tomy” from the Greek word tomoz meaning to cut. In modern trauma surgery, the word laparotomy is used interchangeably with celiotomy, which stems from the Greek word koilia, meaning belly or bowels. Both words imply opening the peritoneal cavity, although perhaps a laparotomy would more accurately relate to a flank incision.1,2

This chapter provides an overview of the trauma laparotomy, including principles of the trauma laparotomy, preparation and team effort, a description of the technical steps and key maneuvers, considerations for the damage control approach, the practical aspects of temporary abdominal closure, and complications.

PRINCIPLES

The Core Mission

In a trauma laparotomy, the core mission is to identify and treat the greatest threat to the patient’s life as quickly as possible. Most commonly, this threat is exsanguination, and the primary mission is hemorrhage control. 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. Following hemorrhage control, the mission becomes identifying and addressing contamination from bowel injuries. Lastly, but no less important, is identification and treatment of all other injuries, including injuries to the abdominal wall, the ...

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