If the patient is hemodynamically unstable, preoperative preparations will need to be expedited, but not so much as to jeopardize patient safety. The use of a preoperative checklist has been shown to improve patient mortality and decrease complications. The rapid completion of a checklist may help ensure that the patient has adequate large-caliber vascular access, has blood available, and has received any indicated antibiotics, that necessary equipment is available, and that the correct patient is having the correct procedure. The expenditure of 60 to 90 seconds to complete this process may give long-term dividends. If time allows, an arterial line as well as a Foley catheter and nasogastric tube should be inserted, though these may be placed once control of hemorrhage has been achieved and resuscitation is underway. Central venous lines are rarely helpful in this situation and should be reserved for the occasion when no other access, including by the cut-down or intraossesous route, can be achieved. The use of a warming blanket and warmed resuscitation fluids will help to prevent hypothermia. Tetanus prophylaxis should be considered.
Laparoscopy may be indicated as an initial maneuver under certain conditions: a hemodynamically stable patient with physical examination findings concerning for hollow viscus injury. A thorough laparoscopic exploration may avoid laparotomy, especially when it is possible to demonstrate that the peritoneum has not been violated in penetrating trauma.
The child is placed supine on the operating table and the skin is prepped from the suprasternal notch to the middle thigh level. A vertical midline incision provides excellent exposure to all quadrants of the abdomen. In children younger than 5 years of age, a transverse supraumbilical incision is an alternative, but the midline approach is the best option where speed is a critical factor. In dire circumstances, the skin may be prepped and the surgical field draped as the patient is being induced for the procedure. The surgeon should be prepared to incise the skin immediately should the patient become hypotensive if peripheral vascular resistance is diminished by the anesthetic agents used.
Upon opening the peritoneum, the surgeon may be greeted with massive intraperitoneal bleeding. This may be decreased by compression of the infradiaphragmatic aorta at the hiatus with a small Richardson retractor, a sponge stick, or manual compression, while the 4 quadrants of the abdomen are packed. After they are packed, the vascular compression may then be released. Once the patient has been resuscitated, systematic exploration of each quadrant, with the presumed bleeding quadrant carefully unpacked last, allows the demonstration of the injury while maintaining hemodynamic stability. A retroperitoneal hematoma should be left undisturbed unless it is found to be expanding or overlies the duodenum and pancreas. If the bleeding is controlled with packing and the patient is hypothermic, coagulopathic, or acidotic, the abdominal wall should be expeditiously covered. This may be done using a variety of techniques including the zipper, the Bogota bag, or towels covered with adhesive plastic wraps. The patient should then receive additional resuscitation and stabilization prior to reexploration and completion of injury repair in 12 to 36 hours.