Chapter 27: Trauma Laparotomy: Principles and Techniques

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.

Approach to Hemorrhage

Hemorrhagic shock is the most common immediate cause of death in patients with abdominal vascular injuries. Assessment of hemorrhage begins in the trauma bay with the vital signs and physical examination. In an unstable patient, a FAST exam which is positive for abdominal fluid should direct the patient (and surgeon) up to the operating room as quickly as possible. In the penetrating trauma patient who loses vital signs and has had cardiopulmonary resuscitation for less than fifteen minutes, a resuscitative thoracotomy with aortic cross-clamp is the initial maneuver to prevent further hemorrhage into the abdomen and preserve flow to the brain.⁷

In the patient who survives to the operating room, the peritoneum is opened through a midline laparotomy and blood is quickly evacuated from the peritoneum, generally with a combination of suction, manual evacuation of clot, and directed and careful packing. The bowels are then eviscerated. The surgeon should quickly assess hemorrhage severity and potential sources, and an immediate plan must be made at this time.

Hemorrhage from the liver is best treated with manual compression followed by tight packing lateral, superior, and inferior to the liver (Fig. 27-6). If packing controls hemorrhage, packs should be left in place. If bleeding is not controlled, a Pringle maneuver is the next step. This maneuver occludes the portal vein and the hepatic artery, effectively making the liver anoxic; it does not address hepatic venous bleeding, nor retrohepatic vena caval injury. To perform the Pringle maneuver, the anterior edge of the liver is reflected cephalad. A finger is placed through the foramen of Winslow, and with a pinching movement, the portal triad may be controlled. A vascular clamp or Rommel occlusive loop can then replace the surgeon’s hand (Fig 27-7). It is not known exactly how long it is safe to leave the Pringle on, but intermittent release of the clamp every 30 minutes should suffice to maintain perfusion to the liver.

The approach to bleeding from a pedicled organ like the spleen and kidney is best approached with vascular control at the pedicle followed by repair or resection of the involved organ. Details are found in these respective chapters.

Pelvic veins are the most common cause of Zone III retroperitoneal hematoma following blunt trauma. Opening these hematomas can induce uncontrolled hemorrhage and is generally only done for exsanguination or critical limb ischemia. The decision options for managing pelvic retroperitoneal bleeding are affected by the availability of expertise in preperitoneal packing, angioembolization, and urgent external fixation (see chapter on Pelvic Trauma). When confronted by a previously unsuspected expanding Zone III hematoma during a trauma laparotomy, the best management might well be to move rapidly to angioembolization. In our institution, packing of the preperitoneal pelvic space with external fixation of the pelvis is employed in patients with hemodynamically significant pelvic fractures. This can be performed in conjunction to exploratory laparotomy when indicated.

Treatment options for vascular injury include vessel ligation, primary repair, vein patch, interposition grafting, and temporary intravascular shunting. Vessel ligation, shunting, and occasionally small primary repairs can be used in damage control situations. Primary repair of the vessel should be performed whenever time (and the nature of the wound) permits. Debridement to healthy tissue is performed prior to any repair.

Whenever possible, closure of a vascular injury should be performed in a transverse fashion with a running permanent monofilament suture in a lateral arteriorrhaphy, or in an end-to-end anastomosis. Stenosis of the vessel is often accepted in favor of hemorrhage control, but when time permits, stenosis may be avoided with vein patch. In all cases, tenets of vascular surgery including proximal and distal control, adequate inflow and outflow, and a tension-free anastomosis should be followed.

The decision to ligate or repair a vessel depends on the nature of the vessel and the risk of ischemia with ligation. Ligation of the celiac artery and the internal iliac artery may be done with low risk of morbidity as good collateral circulation exists. On the contrary, ligation of the common iliac artery and the external iliac artery carry the risk of amputation.

Aortic injuries mandate repair. Injuries to the suprarenal inferior vena cava also mandate repair. Any vein below the renal vein may be ligated if repair is unsafe. Tying off the external iliac vein, common iliac vein, or even the infrarenal inferior cava is acceptable in critical situations, although lower extremity edema leading to a compartment syndrome may result. In these cases, four compartment fasciotomy should be performed on the ipsilateral limb. Injuries to the iliac veins may be amenable to a primary repair after proximal control at the bifurcation and distal control in the femoral canal is obtained.

Repair of the portal vein with carefully placed monofilament suture should be attempted when possible, although portal triad vascular injuries remain one of the most lethal of intra-abdominal injuries, usually due to exsanguination.⁸ Portal vein ligation should be used as a last resort, as ligation leads to massive intestinal edema. When employed, this strategy should be used in conjunction with an open abdomen and a planned second look procedure.

Injury to the mesenteric vessels may present as shock with active hemorrhage, ischemic or necrotic bowel, or as mesenteric hematoma. A left medial visceral rotation is the optimal way to expose the superior mesenteric artery and vein, but division of the pancreas with distal pancreatectomy is another acceptable approach. The proximal superior mesenteric artery or vein must be repaired to preserve blood flow to the small bowel. Injuries to the superior mesenteric artery beyond the pancreas can be addressed with vessel ligation in conjunction with bypass grafting from the distal aorta, as would be performed for superior mesenteric artery thrombosis. Caution should be used when placing interposition grafts near a major pancreatic injury, as a pancreatic leak could lead to a complete disruption of the anastomosis.⁹ Injury to the mesenteric vessels necessitating vascular repairs and large mesenteric hematomas may compromise blood flow to the intestine. In these circumstances, a planned second-look laparotomy within 24 hours is prudent.

Shunting may be considered in damage control situations with an acidotic, hypothermic, polytrauma as an alternative to vessel ligation. Shunting is a method to temporarily bridge injured vessels with a prosthetic conduit, rapidly restoring blood flow and controlling hemorrhage. This technique allows definitive repair to be deferred until the patient has been fully resuscitated, and addresses both hemorrhage and critical ischemia. In patients with injury to the common or external iliac arteries, shunting has been shown to reduce the rate of amputations and fasciotomies.¹⁰

The Pruit-Inahara shunt (LeMaitre Vascular, Burlington, NJ) is a double-lumen device that has a balloon on each end to secure the shunt in place. Ties and clamps which may damage the vessel are not needed. It also includes a side port thorough which contrast, tissue plasminogen activator, or papaverine may be injected. Nasogastric tubing, intravenous tubing, pediatric feeding tubes, or thoracostomy tubes may be utilized as shunts for larger vessels, as most commercial shunts are too small to utilize in larger vessels such as the aorta or iliacs. The choice of shunt depends mainly on the size of vessel injured, as size-match between shunt and vessel is a primary factor in shunt success.

Before shunting, thrombectomy with proximal and distal embolectomy should be performed with Fogarty catheters to ensure adequate inflow and outflow. It is not necessary to systemically anticoagulate patients with temporary intravascular shunts. Patency and flow through the shunt can be demonstrated with on-table angiography.

Complications of shunting include shunt thrombosis, distal embolization, shunt dislodgement, and infection. The ideal time to shunt removal has not been definitively identified—optimally, removal and definitive repair occurs before shunt thrombosis but after complete resuscitation of the patient.

When segments of critical vessels are destroyed or resected, interposition grafts of polytetrafluoroethylene (PTFE) (Gore-Tex, Newark, DE) or Dacron can be used to bridge the deficit. In clean or minimally contaminated cases, tissue coverage with omentum or muscle may be utilized to protect the graft. Autogenous great saphenous vein can also be harvested as conduit, particularly in instances of bowel perforation and contamination.

Damage Control Considerations

Over the last three decades principles of damage control have been widely adopted and applied to both the military and civilian approach to the critically injured trauma patient. Damage control refers to an abbreviated laparotomy in an unstable trauma patient with goals of controlling hemorrhage and gastrointestinal spillage. A temporary abdominal closure is employed with a planned return to the operating room in 24–48 hours for a second look procedure and definitive repair of injuries. Damage control has become a fundamental concept in modern day trauma surgery.

The concept of damage control was first introduced to the trauma community in 1908, when Dr J. Pringle described the technique of utilizing suture over gauze to control portal venous bleeding in the trauma patient.¹¹ In 1983, Dr H. Harlan Stone described rapid termination of the trauma laparotomy after intra-abdominal packing for nonhepatic trauma once clinical evidence of coagulopathy was noted. He supported delayed, definitive surgery once the patient was fully resuscitated.¹² The damage control sequence was later named in the early 1990s by Dr Michael F. Rotondo and colleagues at the University of Pennsylvania. They described a three-stage approach to damage control: the first, laparotomy with rapid hemostasis and control of contamination with a temporary closure of the abdomen, the second stage of resuscitation and restoration of normal physiology in the intensive care unit, and the third stage, reexploration, definitive repair, and closure. With a retrospective review, he found that survival was improved with abbreviated laparotomy techniques in patients with combined major vascular injury and two or more visceral injuries. These patients were then taken back to the operating room once their coagulopathy, acidosis and/or hypothermia were corrected.¹³

The primary objective of damage control surgery is avoidance of a permanent physiologic insult, the “bloody viscous cycle” of trauma—acidosis, coagulopathy, and hypothermia—from which a patient cannot recover. The “bloody viscous cycle,” also known as the lethal triad, was first described in 1981 by Dr Gene Moore and the Denver General group.⁷ Severely injured patients displaying such physiology are at heightened risk of mortality.

Once the bloody viscous cycle has set in, it can be nearly impossible for one to recover from the insult. Damage control techniques should be used in the patient likely to enter into the bloody viscous cycle, rather than after the patient is in physiologic extremis. In these instances, rapid restoration of normal physiology takes precedence over restoration of normal anatomy.

The decision to perform damage control is ultimately left to the judgment of the surgeon. There are instances in which damage control may be decided on even before the operating room, for example, a patient in a profound shock state or with multisystem/multicavity trauma. Parameters such as an intraoperative pH of <7.20, a temperature of 93°F, and a blood loss of 10 units or more strongly suggest utilizing damage control.¹⁴ Once in the operating room, wounding patterns such as combined major vascular injury and gastrointestinal injury may warrant damage control. The decision for abbreviated laparotomy should be made proactively, before the patient manifests acidosis, coagulopathy, or hypothermia. Intraoperative signs of the bloody viscous cycle include diffuse oozing from all surfaces, edematous bowel, or dusky appearing viscera.

If the decision is made too late, the patient will not be able to recover from physiologic insult, and will enter a downward spiral leading to death.

The damage control sequence is three-stage process. The first stage is the initial emergency trauma laparotomy, with goals being hemostasis, the shunting of major vascular injuries, and control of contamination from gastrointestinal, biliary, and genitourinary injuries. Splenectomy may be performed as needed, and injuries to solid organs such as the liver and kidney are tightly packed. Small injuries to the bowel may be over sewn with a whipstitch. Injuries to the gastrointestinal tract are often stapled off with a gastrointestinal anastomosis stapler, with the bowel left in discontinuity and anastomosis or reconstruction delayed until the definitive repair. Suspected pancreatic injuries should be drained. The fascia is left open with a tension-free temporary abdominal closure to facilitate reexploration. Methods of temporary abdominal closure will be described later in the chapter.

If there is concern for ongoing bleeding from solid organs such as the liver, spleen, or kidney, consideration should be given to angiography and embolization in the interventional radiology suite. Hybrid operating rooms have all the features of a traditional operating room, but in addition capabilities for angiography, endovascular interventions, and fluoroscopy. These hybrid rooms are becoming more popular in large centers and allow multiple teams to intervene on a patient at once.

After the goals of hemostasis and gastrointestinal spillage are achieved, the patient should be promptly transported to the surgical intensive care unit for phase II, resuscitation. Mechanical ventilatory support is provided. Hemodynamics, urine output, and serial lab parameters such as lactate and base deficit are used as quantifiable markers of shock to guide fluid resuscitation. Rewarming with forced-air warmers, radiant heat, and heated fluids is also performed. Transfusion of blood, plasma, platelets, and cryoprecipitate is guided by coagulation labs and serial thromboelastography until coagulopathy has been reversed. Drains and tubes are monitored for signs of bleeding. In preparation for phase III, a thorough head-to-toe tertiary exam should be performed.

Once the patient has been fully resuscitated, phase III, or reexploration with definitive repair can occur. Back in the operating room, packs are removed and definitive gastrointestinal anastomoses and vascular reconstructions are performed. The abdomen is then completely explored for other injuries. If at any point the patient becomes hemodynamically unstable, the damage control sequence can be reinitiated.

When possible, a tension-free fascial closure is performed. In cases of ongoing contamination, bleeding requiring repacking, or concern for bowel viability, the abdomen may be left open again for subsequent reexploration. When the abdomen cannot be fully closed due to loss of domain or bowel edema, a sequential abdominal closure with retention sutures may be employed. When all attempts to close the fascia have failed, complex closure methods with mesh may be utilized.

Temporary Abdominal Closure

Temporary abdominal closure allows the surgeon a quick and easy reentry into the abdomen for subsequent explorations after damage control surgery, and can be reapplied as needed before definitive closure. The temporary abdominal closure ideally will contain the viscera, protect the bowel, provide early identification of intra-abdominal complications, and preserve healthy fascia for subsequent closure.

There are a variety of techniques utilized to perform temporary abdominal closure. Utilization of towel clips to being the skin together is the simplest and fastest method. Towel clips should be placed 1 cm apart and should then be covered with a sterile towel and a piece of Ioban (Ioban, St Paul, MN). A running suture in the skin is another easy method to bring the skin together, but takes longer to apply. Drawbacks to these methods include injury to the skin and possible evisceration of the bowel between clips. These skin-only closures do not allow for fascial expansion and have a higher rate of abdominal compartment syndrome, and thus have fallen out of favor (Fig. 27-8).

Another inexpensive temporary closure method is the Bogotá bag. This technique is credited to surgeons in Columbia who had vast experience with catastrophic abdominal trauma in the setting of limited resources. A 3-L intravenous fluid bag is utilized to cover the abdominal contents. It can be sewn into the skin or the fascia. It allows for a tension-free abdominal wall closure. Drawbacks to the Bogotá bag include the risk of ripping the bag and evisceration, traumatizing the fascia with suture, and loss of domain.

Our institution utilizes a perforated subfascial 1010 Steri-Drape (3M Health Care, St Paul, MN) with two Jackson-Pratt drains placed over the 1010 to be used as sumps, followed by an Ioban drape to close the open abdomen. A sterile blue towel may be placed over the 1010 drape to further protect the bowel (Fig. 27-9). This method allows easy inspection of the bowel through the transparent closure. Jackson-Pratt drains are placed to suction for control of abdominal effluent. Use of a transparent closure device allows for examination of the bowel for ischemic changes. In addition, the suctioned effluent can be monitored for bloody or bilious drainage. The open abdomen may drain several liters over one day, and control of effluent with a vacuum device helps to keep the patient dry.

Commercial vacuum-assisted management devices for the open abdomen, such as the ABThera open abdomen negative pressure therapy system (KCI, Inc, San Antonio, TX) have been designed to promote healing by constant negative pressure applied to the wound. The ABThera is associated with less loss of domain, but at an increased cost.

Patients with open abdomens need not be kept paralyzed and sedated through the course of their operations. In fact, patients may be extubated, enterally fed, and ambulated. In those patients without bowel injury, enteral feeding is associated with a longer duration of open abdomen but significantly improves fascial closure rates, decreases complications, and decreases mortality.¹⁵

After the abdomen has been left open, the problem becomes, “Can we close the fascia, and if so, how?” Once all packs and foreign bodies have been removed from the abdomen, vascular reconstruction is complete and the gastrointestinal tract is in continuity, fascial closure can be attempted. Primary fascial closure is performed whenever possible, as long as it is performed in a tension-free fashion.

Several studies have shown that definitive fascial closure should be performed as early as possible to avoid morbidity and mortality. Earlier returns to the operating room are associated with increased rates of successful closure and decreased intra-abdominal complications.¹⁶ Early abdominal closure shortens hospital and intensive care unit length of stay and diminishes cost. Finally, those patients whose abdomens are closed within a week, report higher quality of life, improved emotional health and are more likely to return to work than those closed after a week.¹⁷ Factors associated with failure to achieve delayed primary closure include the number of reexplorations necessary, the development of intra-abdominal infections, bloodstream infections, acute renal failure, enteric fistula, and ISS greater than fifteen.¹⁸

When the fascia cannot be closed all at once, sequential fascial closure can be employed. Sequential closure may be performed with a sponge “sandwich,” as used at our institution (Fig. 27-10). This technique consists of multiple white sponges (KCI International, San Antonio, TX) covering the bowel with the fascia held under tension with full-thickness no. 1-polydioxanone sutures. A black sponge is placed over the white sponge with an occlusive dressing and the vacuum is placed to suction. This addresses the need to keep the fascia under tension to prevent fascial retraction and loss of domain. The patient is returned to the operating room every other day to perform sequential fascial closure with interrupted no. 1-PDS suture. Prior to definitive closure, the need for enteral access is addressed.¹⁹ Whenever possible, omentum should be placed between the bowel and the abdominal wall before closure.

In some cases, despite all efforts, the fascia cannot be closed. When a primary fascial closure is not possible, options include closure with a permanent prosthetic, closure with autologous tissue, or closure with a temporary prosthetic and anticipating a hernia. An absorbable mesh, such as a vicryl mesh (Ethicon, Somerville, NJ), may be employed in closure, with eventual skin grafting to cover the mesh in 2–3 weeks when granulation has occurred. This method accepts a very high likelihood of ventral hernia in favor of temporarily closing the abdomen. Vicryl has a high tensile strength and a very low rate of infection. This mesh will eventually reabsorb, or can be removed at time of skin grafting. Coverage of these open wounds with autologous skin grafting should be performed as early as possible after granulation has grown through the mesh. These wounds are similar to full-thickness burns and represent a major catabolic drain for the patient, and the unprotected viscera are susceptible to injury and fistulization.

A permanent prosthetic, such as a Marlex mesh (Davol Inc, Cranston, RI) or a Prolene mesh (Ethicon, Somerville, NJ) may also be employed to bridge the fascial deficit. They become well-incorporated into the body but carry a risk of infection, adhesion formation, seroma, and fistulization. Permanent prosthetics should not be utilized in a contaminated abdomen, for if a permanent prosthetic becomes infected it must be removed. Composite meshes utilize different materials in one product in order to take advantage of the various properties of different materials. They have improved tissue incorporation and create less inflammatory reaction, but they are more expensive. Biologic mesh, such as a porcine intestinal submucosa (Surgisis, Cook, Bloomington, IN) or a human acellular dermis such as Alloderm (Lifecell, Branchburg, NJ) are ideal for contaminated wounds as they have no risk of infection, but are very expensive and have a small but significant rate of hernia recurrence.

In complex cases, definitive reconstruction of the abdominal wall can be performed with myofascial advancement, rotational flaps, or lateral rectus release (component separation).

Although damage control laparotomy and temporary closures are performed to decrease mortality for the severely injured, significant morbidity may result. Complications after trauma laparotomy can involve any organ system of the body and including the pulmonary system (atelectasis, pneumonia), the cardiovascular system (myocardial infarction, deep venous thrombosis, arrhythmia), the gastrointestinal system (fistulae, ileus, anastomotic leak, pancreatitis), and the skin and soft tissue (loss of domain, hernia, wound infection).

This section will focus on five potentially devastating complications after trauma laparotomy: fascial dehiscence and evisceration, abdominal compartment syndrome, enterocutaneous fistula, missed injury, and retained foreign body.

Fascial Dehiscence and Evisceration

Dehiscence occurs when previously closed fascia pulls apart. Evisceration occurs when intra-abdominal contents leave the peritoneal cavity and escape through an opening in the fascia. Factors contributing to fascial dehiscence include technical error, closure under tension, and wound infection.²⁰ Additional risk factors for dehiscence include obesity, pulmonary disease, hemodynamic instability, sepsis, poor nutritional status, malignancy, ascites, and steroid use.²¹

Unfortunately, dehiscence may complicate any exploratory laparotomy. Dehiscence with evisceration mandates urgent return to the operating room. Principles of operative management include debridement to healthy fascia, control of any intra-abdominal sepsis, and a tension-free fascial closure. More complex methods of abdominal closure, as described above, may be employed when tension-free closure cannot be obtained. Prophylactic abdominal retention sutures may be useful in decreasing evisceration rates, but ultimately their benefit remains debatable within the literature.

Abdominal Compartment Syndrome

Patients requiring trauma laparotomy are at increased risk for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).²² Intra-abdominal hypertension is defined by intra-abdominal pressures greater than 10 mm Hg. Abdominal compartment syndrome is a clinical entity which reflects impaired organ function as a consequence of intra-abdominal hypertension, and is usually defined as intra-abdominal pressures greater than 20 in the presence of elevated airway pressures or renal impairment. Factors which increase the risk of ACS include large-volume resuscitation, bowel distention, bowel edema, the presence of packing, and ongoing hemorrhage into the abdomen. Abdominal compartment syndrome can still occur in an abdomen that has undergone temporary abdominal closure.

ACS is a clinical diagnosis. On physical examination, the abdomen will be tight and distended. Intra-abdominal hypertension can lead to direct compression of the inferior vena cava, and as a result, increased central venous pressure, increased pulmonary wedge pressure, decreased cardiac preload, and increased afterload can be noted. The lungs must work to expand against a tense abdomen and this elevates peak airway pressures as measured by the ventilator. Compression of the renal veins leads to an oliguria which is unresponsive to fluid resuscitation.

Diagnosis should be based on clinical findings in conjunction with a measurement of a bladder pressure. The trend of the bladder pressure may be more helpful than the absolute number. More importantly, the patient’s physiologic profile and degree of organ dysfunction should hold more value in assessing ACS than the absolute bladder pressure measurement. It is commonly accepted that bladder pressures greater than 26–30 mm Hg should prompt decompression, but the absolute intra-abdominal pressure leading to a compartment syndrome is not definitively known and may vary per patient.

Treatment for abdominal compartment syndrome is emergent decompression of the abdomen via midline laparotomy incision with placement of a tension-free temporary abdominal closure. Repeat closure of the fascia should not be performed. Decompression may be performed in the operating room or at the bedside.

Enterocutaneous and Enteroatmospheric Fistulae

An open abdomen after a damage control sequence is associated with increased incidence of enterocutaneous fistula. A fistula is an abnormal connection between two epithelialized organs. Factors contributing to the formation of fistulas include deserosalization, erosion of the bowel against a prosthetic mesh, missed traumatic or iatrogenic injury to the bowel, and anastomotic breakdown. In the patient with an open abdomen, bowel ischemia and inflammation, bowel obstruction, increased manipulation of the bowel, desiccation of the bowel, and the presence of intra-abdominal infection can also contribute to fistula formation. Prevention of a fistula can be attempted by placing omentum over the bowel, minimizing injury to the serosal layer of the bowel, keeping the bowel moist when the abdomen is open, and obtaining fascial closure as early as possible. Some surgeons prefer to cover exposed bowel with Vaseline gauze to prevent direct contact during dressing changes while moving towards definitive closure. Commercially available vacuum-assisted closure devises have specialized materials for this specific use as well, all with the idea of less micro-trauma to the bowel wall. Intraoperatively, a sound technical repair and a diligent exploration to avoid missed injures will also minimize fistula occurrence.

Principles of enterocutaneous fistula management include protecting the skin and controlling effluent with wound care, aggressive nutritional support, managing fluid and electrolyte imbalances, and potentially operating to resect the fistula. Once a fistula forms, it is a difficult problem to manage, as spontaneous closure is uncommon. In select patients, fibrin glue and acellular dermal matrix can occasionally seal a small fistula. Fistula resection should be planned once nutritional status has been optimized and intra-abdominal sepsis has been controlled. Preoperative planning should attempt to anatomically locate the fistula.

An enteroatmospheric fistula occurs when the fistula arises immediately under a mesh or skin graft and is open to the atmosphere. This is a unique and challenging problem as no vascularized tissue exists over the fistula tract, which decreases the possibility of spontaneous healing. Continuous drainage of enteric succus over the exposed loops of bowel can lead to ongoing peritonitis and sepsis. The enteroatmospheric fistula cannot be simply resected in the setting of dense abdominal adhesions, also known as a “frozen abdomen.” The presence of such fistulae delays fascial closure and can lead to ongoing sepsis, electrolyte imbalance, malnutrition, prolonged ICU and hospital stays, and increased mortality.

Missed Injury and Retained Foreign Bodies

Missed injuries and retained foreign bodies can be devastating to patient health and contribute to increased mortality. These problems are embarrassing to the entire team involved, particularly the surgeon, and can have significant medicolegal repercussions.

A missed injury is any traumatic insult that is overlooked during initial assessment, diagnostic imaging, or an injury not identified during exploratory laparotomy. Missed injuries may present as bleeding, peritonitis, sepsis, or pain. In the trauma bay, failure to completely expose the patient or perform a thorough primary and secondary survey with attention to axillae and perineum may contribute to overlooked signs of trauma. The tertiary exam performed out of the acute resuscitation but still within 24 hours of admission is designed to pick up on injuries not initially identified. At the time of tertiary exam, the patient should be sober and alert when possible. Pain from distracting injuries should be controlled and the patient should be questioned for any new complaints.

Incorrect reads on imaging studies and false negative tests can also contribute to an inaccurate assessment of injury. In the trauma team with a low index of suspicion, a false sense of security with a negative study may cause harm.

Injuries can also be missed at the time of operative abdominal exploration. Injuries to the colon, diaphragm, and genitourinary tract are the most common missed intra-abdominal injuries.²³ Errors in technique and judgment can contribute to an imperfect exploration, as may hemodynamic instability and distracting injuries.

After penetrating trauma, accurate identification of all external wounding sites is the first step in identifying any internal injury. Bullet trajectory should be assessed with a complete and thorough internal exploration along the tract. An uneven number of bullet holes should alert the surgeon to a retained missile. A single bullet hole in the abdomen may signify a bullet in the abdomen, chest, or pelvis. X-rays performed prior to operation can sometimes identify bullet location in these cases.

After trauma laparotomy, there are various factors which may contribute to a retained foreign body. The emergent nature of the procedure precludes the routine counting of instruments. During the initial entry and packing of the abdomen, it is easy to lose track of the number of laparotomy pads placed in the abdomen when the focus is on lifesaving hemorrhage control. The presence of multiple teams operating in multiple body cavities may also contribute to the potential for instruments to be left behind. In one retrospective analysis, emergency surgery, unplanned change in procedure, and body mass index of the patient were found to be significantly associated with risk of foreign body retention.²⁴

Fortunately there are a few simple things which can be done to circumvent the retained foreign body. Before preparing to close fascia, the surgeon should perform a thorough search of the peritoneum for laparotomy pads and instruments. When a patient’s abdomen is left open and packed, it is helpful to note the number and location of packs left inside the abdomen on the operative note. Prior to exiting the operating room after definitive closure of any body cavity after multiple operations or with an incorrect count, an x-ray should be performed and assessed by a radiologist and the surgeon to look for retained foreign bodies.

Paramount to the management of any missed injury or retained foreign body is prompt identification. Once the missed injury has become evident to the team, full disclosure to the patient and family must occur. A hospital’s risk management team may help to manage and mitigate this difficult situation.

A nontherapeutic laparotomy is a laparotomy in which no intra-abdominal injuries are identified and therefore no interventions are performed, including suture, debridement, or drainage. Despite the evolution of multislice computerized tomography, diagnostic peritoneal aspiration and lavage, and the focused abdominal sonogram for trauma, the decision to perform laparotomy for trauma is not always straightforward. On occasions where imaging or physical examination is equivocal or when the imaging does not correlate with the patient’s clinical state, there is not always a clear decision algorithm. In these instances, the risk of a nontherapeutic laparotomy must be weighed against the risk of a delay in diagnosis.

There is controversy about the relative morbidity of a nontherapeutic laparotomy. Potential complications include, but are not limited to cellulitis, wound infection, dehiscence, ileus, deep-vein thrombosis, and myocardial infarction. It appears long-term risks such as bowel obstruction and hernia are low.²⁵ Repercussions after a missed injury may pose a greater threat than the repercussions of a negative laparotomy.²⁶

The greater acceptance of minimally invasive techniques for trauma has reduced the negative laparotomy rate. Thoracoscopy or laparoscopy for penetrating trauma can be used in select hemodynamically stable patients with thoracoabdominal stab wounds to rule out diaphragm injury. Laparoscopy is a useful tool in the evaluation of left-sided thoracoabdominal gunshot wounds, gunshot wounds with suspected extraperitoneal trajectory, and for assessment of peritoneal violation after stab wounds to the flank and anterior abdomen.²⁷

Urgent Relaparotomy for Hemorrhage

Urgent relaparotomy for hemorrhage is generally performed in the hemodynamically unstable patient with ongoing transfusion requirements. In those patients with a temporary abdominal closure with a sump device, large volumes of sanguinous drainage may be used as a trigger to return to the operating room. For the surgeon, the decision to return to the operating room is not always straightforward and should be made with an assessment of original injury pattern, potential for missed injury, and the patient’s overall coagulopathic profile in mind. Ultimately there is minimal benefit to returning a patient to the operating room for coagulopathic, or nonsurgical bleeding. In that patient, transport and reopening can be detrimental to a patient who truly needs rewarming and correction of coagulopathy and acidosis. It is the patient with “surgical bleeding” from inadequate packing, technical failure of suture ligatures, bleeding anastomoses, or a missed injury who may potentially benefit from a return to the operating room.

The relaparotomy sequence for hemorrhage is similar to that of the original laparotomy: reopening of the laparotomy wound, evisceration, and a thorough exploration of the abdomen. Hemostasis is achieved with a well-placed finger, pack, or suture, followed by definitive repair. These patients should be left with a temporary closure as they have a high rate of abdominal compartment syndrome after massive transfusion.

Urgent Relaparotomy for Intra-Abdominal Infection

An urgent relaparotomy for intra-abdominal infection is a morbid operation performed for a variety of potential indications. In the right clinical situation, succus or bile coming from abdominal drains after a temporary abdominal closure indicates a missed injury or anastomotic dehiscence. In the closed abdomen, drains are occasionally placed near an anastomosis or tenuous repair. Enteric or bilious effluent into these drains may be the first harbinger of anastomotic leak or dehiscence. A septic clinical picture indicates that the drain is not sufficiently controlling the leak and the patient warrants return to the operating room. Infected biloma, hematoma, or abscess cavities that are multiloculated or not amenable to percutaneous drainage also necessitate return to the operating room.

Once back in the operating room, regaining access to the abdomen can be a challenging and difficult problem. After a few days, the abdominal cavity becomes entrapped and immobile secondary to adhesions and contamination. In these situations, the bowel is hard to free and is often highly edematous and easily injured. After entry into the abdomen is achieved, the second goal is to identify the source of ongoing contamination and control it. A variety of treatment options exist, but repairs are fraught with potential complication. When possible, simple suture closure of a bowel leak or perforation often puts part of the bowel under tension. Secondary to the inflamed nature of the bowel surrounding the leak, this simple method has a high likelihood of failure. Resection and reanastomosis is a better option when enough bowel can be mobilized, although any new anastomosis remains at high risk for failure in this situation. Tube drainage is generally not favored for the risk of continued leak around the tube, and in addition the tube can serve to enlarge the enterotomy and maintain patency.

Another treatment option exists with proximal diversion. Injuries to the duodenum and proximal jejunum may be addressed with pyloric exclusion and a gastrojejunostomy. A diverting ileostomy would permit more distal repairs in the ileum and large bowel to heal while diverting enteric contents. The technical options for reoperation for sepsis are outlined in Table 27-1.

Planned Reoperation

A planned reoperation should take place when the patient has been adequately rewarmed, acidosis has been corrected as denoted by resolution of base deficit and normalizing lactate levels, and coagulopathy has been normalized as evidenced by thromboelastography and clinical signs of coagulation. These parameters signify a return of healthy physiology. Once acidosis, coagulopathy, and hypothermia have been corrected, then and only then should planned reexploration with definitive repair occur.

Most patients are adequately resuscitated by 24–48 hours after initial operation, but a patient should be assessed for return to the operating room as soon as physiologic parameters have normalized. Packs should be changed or removed as early as possible as they are a nidus for infection. Definitive gastrointestinal anastomoses and vascular reconstructions are performed once hemodynamics are adequate, as signified by an absence of vasopressor requirement. Once all injuries have been repaired and functional anatomy restored, the abdomen is completely explored for other injuries and fascia is closed in a tension-free manner. For those patients requiring additional trips to the operating room, temporary closure may be reemployed.

Resuscitative laparotomy may be performed at the bedside in the intensive care unit for those patients with respiratory or cardiovascular instability rendering them unable transport to the operating room. In general, escalating vasopressor requirements or high levels of ventilatory support with high fraction of inhaled oxygen or high levels of positive end-expiratory pressure preclude safe transport to the operating room. Procedures which may be performed at the bedside include decompressive laparotomy for abdominal compartment syndrome, washout and fascial closure, exploration for suspected intra-abdominal sepsis, perforation, or ischemia, and exploration for hemorrhage, although the latter should be performed with extreme caution. Patients who are not in extremis should be brought to the operating room for the safety, sterility, and added resources it provides.

Willingness from the surgeon, anesthesia, and nursing staff is essential for success of the bedside laparotomy. A portable electrocautery and suction should be arranged. Drawbacks to bedside surgery include suboptimal sterility and lighting, lack of access to instrument trays and trained operating room staff, and the challenge of operating over a larger bed with less space. Despite these disadvantages and high associated mortality, resuscitative laparotomy at the bedside can be the best option to perform a potentially lifesaving operation for a critically ill trauma patient.