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The Crash Laparotomy Jeffrey Coughenour MD FACS Assistant Professor of Surgery Trauma Medical Director.

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Presentation on theme: "The Crash Laparotomy Jeffrey Coughenour MD FACS Assistant Professor of Surgery Trauma Medical Director."— Presentation transcript:

1 The Crash Laparotomy Jeffrey Coughenour MD FACS Assistant Professor of Surgery Trauma Medical Director

2 … Upon entering the peritoneal cavity, approximately 2 to 3 liters of blood, both liquid and in clots, were encountered. These were removed. The bullet pathway was then identified as having shattered the upper medial surface of the spleen, then entered the retroperitoneal area where there was a large retroperitoneal hematoma in the area of the pancreas. Following this, bleeding seemed to be coming from the right side, and upon inspection there was seen to be an exit to the right through the inferior vena cava, thence through the superior pole of the right kidney, the lower portion of the right lobe of the liver, and into the right lateral body wall… The inferior vena cava hole was clamped with a partial occlusion clamp… The inspection of the retroperitoneal area revealed a huge hematoma in the midline. The spleen was then mobilized, as was the left colon, and the retroperitoneal approach was made to the midline structures. The pancreas was seen to be shattered in its mid portion, bleeding was seen to be coming from the aorta… Bleeding was controlled with finger pressure by Dr. Malcolm O. Perry. Upon identification of this injury, the superior mesenteric artery had been sheared off the aorta… This was clamped with a small, curved DeBakey clamp. The aorta was then occluded with a straight DeBakey clamp above and a Potts clamp below. At this point all major bleeding was controlled… Shortly thereafter… the pulse rate… was found to be 40 and a few seconds later found to be zero. No pulse was felt in the aorta at this time.

3 Operative Record of Lee Harvey Oswald
Parkland Memorial Hospital, 11/24/63 Cited in: The Warren Commission Report: Report of the President’s Commission on the Assassination of President John F. Kennedy, St. Martin’s Press, 1992

4 Objectives Learn the correct operative sequence in a critically ill patient Review what to do once you get inside Organize your exploration Understand basic exposure techniques Summary points

5 Before We Start… Keep the team focused Communicate
Room time to incision can make or break outcome Communicate Chin to knees, table to table Four bars… side, side, top, bottom

6 Operative Sequence Access and exposure Temporary hemorrhage control Exploration Definitive Repair Damage Control

7 Gaining Access “Hey diddle diddle, right down the middle” Three passes
Skin and subcutaneous tissue Land on the linea alba Divide the fascia, expose preperitoneal fat Push through the peritoneum just cranial to umbilicus Cut peritoneum, divide falciform ligament

8 Gaining Access Avoid iatrogenic injury Previous laparotomy scar?
Left liver, small bowel, bladder Avoid pelvic hematoma Previous laparotomy scar? Bilateral subcostal incision

9 Once Inside… Evisceration Blunt trauma Penetrating trauma
Up and to the right, remove clot/blood Blunt trauma Empiric, yet directed packing Penetrating trauma Direct hemorrhage control Exsanguinating hemorrhage Supraceliac aorta

10 Empiric Packing Right upper quadrant—Above and below liver
Right gutter Left upper quadrant—Above and medial to spleen Left gutter Pelvis Survey solid organs, look back at the eviscerated bowel, start making decisions…

11 Survey the Battlefield
Divide the peritoneal cavity at the transverse mesocolon Supramesocolic Liver, stomach, spleen Inframesocolic Small bowel, colon, bladder, female reproductive organs

12 Inframesocolic Exploration
Lift transverse mesocolon cranially Run the gut Visualize the pelvis and female reproductive organs The posterior portions of the transverse mesocolon, hepatic, and splenic flexures are common sites for missed injuries

13 Supramesocolic Exploration
Move transverse colon caudad Inspect and palpate Liver, GB, right kidney Stomach to GE junction and diaphragms Duodenum Spleen, left kidney Lesser sac (LEFT less vascular)

14 Retroperitoneum Clinical suspicion
Duodenal hematoma? Mobilize to see duodenum and pancreatic head Colon injury? Mobilize to check posterior wall and adjacent ureter Limited exposure of relevant structures—medial visceral rotation

15 Left (Mattox maneuver)
Midline supramesocolic area, aorta, branches Start low and lateral Pull colon towards you… move upward Rotate spleen, pancreas, left kidney toward the midline Sweep from below, upward and medial

16 Left (Mattox maneuver)
Midline supramesocolic area, aorta, branches Kidney up or kidney down? Periaortic tissue Left lumbar vein Branch of left renal vein, crosses left lateral aorta immediately below left renal artery


18 Right (Kocher and friends)
Classic Kocher Duodenum from CBD to SMV Extended Kocher Infrahepatic IVC, renal hilum, right iliacs Cattell-Braasch Medial side of cecum, incise line of fusion small bowel mesentery and posterior peritoneum to ligament of Treitz


20 Adult Decision-Making Time
Combined major vascular/hollow viscus Penetrating injury to the “surgical soul” High-grade liver injury Pelvic fracture with expanding hematoma Injuries requiring surgery in another cavity

21 Temporary Closure Best practice? Contain and protect the bowel
Avoid damage to skin or fascia Close skin over temporary closure method to maintain fascial domain

22 Vascular Control Zone 1 Zone 2 Zone 3 Supramesocolic—Proximal aorta
Inframesocolic—Infrarenal aorta Zone 2 Proximal control of renal pedicle Zone 3 Expose bifurcation, control common iliacs, distal external iliacs

23 Vascular Control Portal area Retrohepatic area
Pringle maneuver Retrohepatic area Do not open hematoma unless ruptured, pulsatile, or rapidly expanding Learn how to stay out of trouble, not get out of trouble

24 Supraceliac Aorta Exposure
Incise gastrohepatic ligament Left lobe of liver cephalad Stomach caudad Esophagus and periesophageal tissue lateral Clamp or compress, not repair

25 Vena Cava Suprahepatic—Yikes! Infrahepatic
Median sternotomy with pericardiotomy Infrahepatic Right to left medial visceral rotation Leave the kidney down

26 Pancreas Divide portion of the gastrocolic ligament
Kocher maneuver (proximal, head, uncinate) Mobilize spleen medially (distal)

27 Summary Points Get in with three sweeps of the knife and an educated finger Stay away from old scars Eviscerate early Blunt trauma—empiric packing Penetrating trauma—eviscerate and go for the bleeder

28 Summary Points Explore the infra- and supramesocolic compartments
Keep retroperitoneal exploration targeted and limited Feel the muscles of the back with your fingertips Right-sided medial visceral rotation in 3 steps Cattell-Braasch—CBD to ligament of Treitz

29 Summary Points After careful, but rapid exploration, decide… damage control or definitive repair Contain and protect the underlying viscera Maintain domain Complex problems require simple operative solutions… Top Knife: The Art and Craft of Trauma Surgery Copyright © January 2005 Asher Hirshberg MD and Kenneth L. Mattox MD

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