Exploratory Laparotomy for Trauma

Procedure Snapshot

• Indication/urgency: Hemodynamic instability or peritonitis after blunt or penetrating trauma; positive FAST/DPL with instability.
• Expected duration: Variable — 45 min (damage control) to several hours (definitive).
• Special instruments: Long Deaver and Balfour retractors, vascular clamps, Satinsky/DeBakey forceps, rapid infuser, cell saver, hemostatic agents, temporary abdominal closure (TAC/VAC) kit.

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Step Workflow

1. Exposure and Entry

1. Supine position, arms extended; prep chin-to-knees.
2. Incision: Midline xiphoid to pubis for maximum exposure.
3. Entry: Incise skin/subcutaneous tissue; divide linea alba sharply.
4. Enter peritoneum cautiously (esp. in distended abdomen).
5. Rapid inspection — control visible bleeding with manual pressure or packs.

2. Four-Quadrant Packing (Initial Hemorrhage Control)

1. Pack RUQ, LUQ, Pelvis, and Paracolic gutters sequentially.
2. Remove each pack systematically to identify source of hemorrhage.
3. If bleeding uncontrolled → damage control phase (pack and close temporarily).

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3. Systematic Exploration (Top-to-Bottom “Trauma Survey”)

A. Upper Abdomen

• Liver:
  • Mobilize right lobe (divide triangular ligament).
  • Control bleeding: direct pressure, Pringle maneuver (occlude hepatoduodenal ligament).
  • If bleeding persists → hepatic vein/retrohepatic IVC → pack or shunt (PMID 18255323).
• Diaphragm: Inspect both domes (esp. with penetrating thoracoabdominal trauma).
• Stomach: Palpate entire length, anterior then posterior (rotate).
• Spleen: Divide splenocolic, splenorenal, and splenophrenic ligaments; control hilum early if needed.

B. Retroperitoneum and Zones of Injury

Retroperitoneum divided into three zones:

Zone	Location	Common Injuries	Management
I	Midline (aorta, IVC, pancreas)	Major vessel, duodenum, pancreas	Explore if penetrating or expanding hematoma
II	Flanks (renal)	Renal artery/vein	Explore if penetrating or pulsatile; otherwise observe in blunt
III	Pelvic	Iliac vessels, pelvic venous plexus	Tamponade/pelvic packing; avoid dissection unless pulsatile

• Open Gerota’s fascia only for expanding/pulsatile Zone II hematomas.
• Control aorta (supraceliac) for uncontrolled bleeding if needed.

C. Mid and Lower Abdomen

• Small Bowel: “Run the bowel” from ligament of Treitz → ileocecal valve.
  • Examine mesentery for tears/hematoma.
  • Repair serosal tears; resect ischemic segments.
• Colon: Inspect mesocolon for hematomas; perform resection/anastomosis or diversion as indicated.
• Mesentery/Root: Look for bucket-handle tears (PMID 29324194).

D. Pelvis

• Inspect bladder (fill test with saline via Foley).
• Check for rectal injuries (rigid proctoscopy).
• Pack pelvic venous bleeding; apply pelvic binder/external fixation.

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4. Decision-Making: Damage Control vs Definitive

• Damage Control Indications:
  • Hypothermia (<35°C)
  • Coagulopathy (INR > 1.5)
  • Acidosis (pH < 7.2)
  • Ongoing instability despite transfusion (PMID 18255323)
• Technique:
  • Pack bleeding sites, staple bowel ends (no anastomosis), temporary abdominal closure (VAC or Bogota bag).
  • Return to OR 24–48 h later for definitive repair.

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Key Pimp Questions

• Q: Indications for emergent laparotomy in blunt trauma?
  A: Peritonitis, free air, instability with +FAST (PMID 29324194).
• Q: What does the Pringle maneuver occlude?
  A: Hepatic artery and portal vein within the hepatoduodenal ligament.
• Q: What are the retroperitoneal zones and management principles?
  A: I midline → explore; II flank → selective; III pelvic → pack, not dissect.
• Q: Common causes of missed injury?
  A: Retroperitoneal duodenum, pancreas, small mesenteric tears.

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Critical Anatomy

• Landmarks: Hepatoduodenal ligament (for Pringle), root of mesentery (SMA/SMV), spleen hilum, retrohepatic IVC, bladder dome, rectum.
• Danger zones: Portal triad, aortic bifurcation, iliac veins, pancreatic neck (over SMV), presacral plexus.

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Informed Consent Highlights

• Benefits: Life-saving control of bleeding and contamination.
• Alternatives: Nonoperative management (only if stable).
• Risks:
  • Massive transfusion/bleeding ___
  • Missed injury ___ (PMID 22929585)
  • Abdominal compartment syndrome ___
  • Sepsis, abscess, fistula formation ___

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Post-op Considerations

• ICU admission.
• Correct coagulopathy, acidosis, hypothermia (“lethal triad”).
• If TAC: monitor output and bowel perfusion; plan second-look <48 hr.
• Early nutrition (enteral preferred).
• Consider DVT prophylaxis once hemostasis achieved.

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References

• Chassin’s Operative Strategy in General Surgery, Trauma section.
• Clinical Scenarios in Surgery, Trauma chapter.
• Rotondo MF et al., J Trauma 1993 (PMID 8371302).
• Biffl WL et al., J Trauma 2010 (PMID 20440352).
• Stassen NA et al., EAST Guidelines, J Trauma Acute Care Surg 2012 (PMID 22929585).