Laparotomy is the most common operation performed for truncal trauma. It consists of a methodical sequence of steps that enable the surgeon to gain access to abdominal injuries, and identify and address them. These steps are guided by a series of priority-driven decisions that shape the operation.1
There are two modes of laparotomy for trauma, corresponding to the two major indications for the procedure: peritonitis and bleeding.2 The first mode is abdominal exploration in a hemodynamically stable patient with a tender abdomen. In these cases, the operation proceeds along the lines of an explorative laparotomy for an acute abdominal condition such as a hollow organ perforation: it is urgent but not hectic since there is no danger of imminent death. A less common but more dramatic mode is a crash laparotomy in a patient in shock with intra-abdominal hemorrhage.1 Here the patient’s life is in immediate jeopardy because on-table exsanguination is a real threat. Despite its hectic pace, a crash laparotomy is not merely an accelerated version of the first mode. Instead, it is a multidimensional effort that combines technical and team leadership skills. In a crash laparotomy, the surgeon has to calibrate the operative effort not only to the patient’s clinical condition but also to the capabilities of the surgical team and the available resources.
A crash laparotomy requires therefore not only a more expedient technical approach to the task but also a different frame of mind. When operating for peritonitis in the stable patient, the focus is on reconstructing the anatomy. In a crash laparotomy, the focus is on rapid control of hemorrhage and preservation of the patient’s physiology. The anatomical integrity of the repair is less important, and is sometimes temporarily sacrificed to prevent an irreversible physiological insult. It is in these adverse circumstances that the special expertise of the trauma surgeon can make a difference.
This chapter provides an overview of laparotomy for trauma, with an emphasis on crash laparotomy in an unstable patient. The first part of the chapter describes the guiding principles of the procedure from the perspective of the trauma surgeon. This is followed by a detailed description of the technical steps and key maneuvers of a trauma laparotomy against the background of ongoing decision making. The final part of the chapter addresses special types of abdominal exploration in the injured patient such as urgent or planned reoperation after damage control surgery as well as bedside laparotomy and the current role of laparoscopy.
In a trauma laparotomy, the core mission of the surgeon is to stop the bleeding. The success of the procedure hinges on the surgeon’s ability to rapidly reach the source of intra-abdominal hemorrhage and control it effectively. All else is of secondary importance simply because there is no alternative to achieving hemostasis. If the patient is not bleeding significantly, the mission then becomes to identify ...