How To Do…??Explorative Laparotomy For Abdominal Trauma

Presented by:

Dr. Khalifa Al-Mulhim

GS Consultant

KFHU – Khobar – Saudi Arabia

2008

Introduction• Conduct of a laparotomy for trauma

follows a guidelines that apply irrespective of whether the injury is sustained by blunt or penetrating means

• If patient is stable diagnostic aids required…

•Ultrasounds•CT scan•DPL

Introduction

• If unstable proceed to resuscitative laparotomy without delay as part of the primary survey of ABC

Indications1. Penetrating or perforating wound (missile or

stab)2. Clear clinical evidence of peritonitis3. Unresponsive resuscitation shown by

continuing requirement of intravenous fluids with exclusion of bleeding from other system

4. Presence of air under diaphragm or evidence of diaphragmatic rupture on erect chest x-ray

5. CT evidence of presence of blood and ruptured solid viscera or positive diagnostic peritoneal lavage

• All penetrating wounds should be explored as a role but conservative measures could be carried out provided…

•Patient is stable•Frequent reassessment•Exploration on the 1st signs of deterioration

Before exploration…1. Available blood2. Prevent hypothermia3. NGT and Foley’s catheter4. Prophylactic antibiotics5. Two large suction apparatus

are ready as well as large

• Opening• Midline Incision• Clear away as much clot and free

blood as possible to identify the specific source

• Organized exploration

Retroperitoneal hematoma…–Penetrating explore–Blunt expanding explore–Blunt non expanding or with pelvic fracture Do not explore

Major vessel bleeding…• Controlled with pressure while

dissecting around the vessel to have control above and below the bleeding and repair using polypropylene

Small mesenteric vessels…• Could be oversewn but always

examine the distal bowel for viability• Aorta and Inferior Vena Cava require

vascular surgeon assistance for repair

Stomach…–Oversewing tears–Doubtful viability of the greater curve if there is longitudinal tear parallel to it then resect

Duodenum…–Kocherize to examine posterior surface

–Tears require primary repair or with jejunal patch

–Extensive damage needs diversion gastrojejunostomy and T-tube in CBC in addition to the repair or resection

Small bowel…–Oversew penetrating wounds–Resect if there is multiple tears in a short segment or if doubtful viability

Large bowel…–High chance for contamination–Oversewing small tears < 6hrs old in the right colon

–Right hemicolectomy with 1ry anastomosis

–Resection with anastomosis and colostomy vs. Hartman’s procedure

Liver…–Tears are often mild–Major tears sutured with liver

needles–Pringle maneuver if substantial Heg–Continuing Heg after clamping is

common from hepatic veins or IVC–Major injury may require lobectomy–Uncontrollable Heg consider DCS

Spleen…–Best removed if ruptured–Splenic salvage

Renal trauma…– Blunt conservative except ?– Penetrating

–Explore–Kidney oversewing ( conserve as much kidney as possible)

–Ureter 1ry repair with double J stent

–Bladder 1ry repair with suprapubic catheter

Check List… Hemostasis Visceral viability Diaphragmatic injury Drains Stoma Instrument count

Closure…–Single layer using One Nylon–Entry-exit missile wounds derided and left open

Conclusion…1. Laparotomy for trauma could save

injured patients by controlling bleeding

2. Never start laparotomy without available blood

3. Ask for HELP when needed4. Consider DCS if injuries are beyond

repair5. Make thorough exploration so not

to miss any intraperitoneal injury