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Top Knife - Art and Craft of Trauma Surgery PDF
Top Knife - Art and Craft of Trauma Surgery PDF
I||P
IIE
IIITART& GRA]I||TIRAUTIIA
SURGTRY
AsherHirshbergMD
&
KennethL. Mattox MD
TOPKNIFE
TheAd a C ofl ofTrolmo slrgery
lJmPub shingLtd, CastleHillBarns,Harley,Nr Shrewsbury,
SY5 6LX, UK.
Telr+44 (0)1952510061iFax:+44 (0)1952510192
E-mai nikki@lfnrpublishing.com;
Web s ie: www.ifmpublishing.com
Ediior:
lMaryK Allen
Designand ayout:
Nikk Bramhll
Coverdesign:
lllstrationsby ScotiWeldon,CopyrighiO BayorCollegeof Medcine2005
CopyightO January
2005,AsherH rshbergMD & KennethL MattoxMD
ReprntedApri 2005, October 2006
lsBN 1 90337822 2
Apad ironr any fair dea ing for the purposesof researchor privatestudy,
or crtcsrn or review,as permlttedunderthe Copyright,Designsand
PaientsAcl 1988,this publcatonrnaynot be reproduced,
stored n a
retneva sysiem or irarsmitted n any forrn or by any means,eectronic,
digiial,mechanica,photocopyng,recordingor othelwise,witholt the
prior writtenpermisson of the publisher.
NOTICE
Neiherthe authors,norlhe pubisher,nor anyotherpartywho has been
invoved in lhe preparaiionor publication
of this work can accept
responsibiltyfor any injuryor damageto personsor propertyoccasioned
throughihe mp ementationol any ideasor use of any productdescribed
herein,Neiihercan they accepl any responsbriiy for errors,or.iss ons or
msrepresentatrons,
howsoever
caused,
Whilst everycare is takenby the authors,the ed tors and the p!b isherto
ensure that all informatiof and data in ths book are as accurateas
possibe ai ihe time of goingio press,il is recommended
thai readersseek
independeni
verJcaton of adviceon drugor oihefproductusage,surgical
racl_n
qJes.r d c irKa p.ocess6c
pr or to r'rei.Jsa.
E
!
Contents
pqge
Introduction
What this Book is all About
Chapterl
The 3-D TraumaSurgeon
Chapter 2
Stop That Bleeding!
I
i
19
35
ct'upte'e
Youi Vascular Toolkit
53
7L
Chapter 6
The Injured Liver Ninja Masier
Chapter 7
The ' Take-outable" Solid Organs
99
TOPKNIFE
TheAr1& Croft of TroumoSuroerv
pase
Chapter8
TheWoundedSurgicalSoul
115
Chapter9
Big Red & Big Blue:Abdominal VascularTmuma
131
147
Chaptff
157
11
Chapter 12
The Chesr Inside and Out
17L
Chapter 13
Thoracic Vascular Tmuma for the General Surgeon
181
't99
Chapter lS
Peripheral Vascular Trauma Made Simpl
215
Epilogue
233
TheJoy of TraumaSuigery
Contributors
Authors
o{ Surgery'
in the Depariment
AsherHirshbergMD FACS,is Professor
of Emergency
o.*n",*" college of N/edicineand Director
iut"
in Bfooklyn'NewYork
i"'""rtu!'Srrg"ry XingsCountyHospiialCenier
"t
andViceChairof theMichael
KennethL. ManoxN4DFACS,is Prolessor
and
Deparir.entof surgery,Baylorcollegeo{ Medicine'
i. o"ir*t
Hospltal'
si"olin*t of Surgeryat the Ben Taub General
Cn[i
"t
lllustletot
Medicallllusiratorin the Divisiono{
is Supervisor
Scott WeldonN,4A,
surgery of the MichaelE DeBakeyDepartmentol
Cardiothoracic
Texas'
Houston'
BaylorCollegeof lvledicine,
Surgery,
Editot
in ihe MichaelE DeBakey
Associate
MaryK. AllenBA, is Administrative
of
andAdministrator
o"p"ri-"nt ot srrg.ry, BaylorCollegeo{ N4edicine'
Houslon'Texas
the SurgeryDivisio;al ihe BenTaubGeneralHospital'
To our residentspast,presentandfuture
Introduction
TOPKNIFE
TheAd & Croft of TroumoSurgery
operalingtab e are all pad of real-lifetraumasurgery.Oh, and by the way,
haveyou noticedthe anorexicchap in the black robe and hood,standing
in the corner of the OR, holdingthis big scythe,and patientywailirg for
you io make lusl one mistake?He, too, s an iniegral part of lrauma
surgery.
Traurnasurgeryis an art ihat combinesdecision-making
wth technica
and leadershlpskllls.The purposeof this book is io help you take a badly
woundedpatientto the OR, organze yourselfand your team, do battle
with some viciousinjuries,and come out wiih a live patieniand the best
possibleresult.The siardard surgicalatlasmayshow you whal to do wrth
youf hands bul not how to ihink, plan, and improvise.This book is
different.Here you wlllfind practrcaladviceon how to use your head as
wel as your handswhen you are operatng on a cfashingtraumapatient.
Who shouldreadthis book?Afe you a resldenior registrarin the senor
years of slrgical traning? A generalsurgeon iniefestedln trauma?A
felow ln traurnaand crrtcal care? lf you are, we wrote this book primarily
wilhyou in m nd.
lf you are cufrentlyin lfaining,you must be aware oI ihe strongforces
dramaiicallyfeducing your operative trauma experience.lJrban
penetraiingiraumais dec ining,non'operatrve
r.anagementis on the rise,
and surgica trainng is undergoinga noisy revouUon.Whle this book
cannotsubstitlte for gelting your clogs wet in a real OR, i can opt r.ize
ihe educationavalueof everyAaumaoperationyou do becauseyou wii
lntroductlon
w,o ih BoorB or "".,
The book beginsand ends in lhe OR. lf you are lookingfor information
on careof ihe njuredpatientbeJoreor afterihe operation,looke sewhere.
We also assumethat yo! are famillarwith generalsurgicalprincp es and
lechniques.lf you seek nstruclionon how to reseciandloin bowelor how
you w ll not find lt here.However,
to do a standardvascularanastomosis,
if you wish io learnhow io do a no-nonsense
crash laparoiomy,
deal with
a bleedng Lung,or repairan injuredpoplitealariefy,read on.
The f rst seciionof the book, Toalsof the Trade,presentsprinclplesof
irauma surgerythat cll across injurytypes and afatomicalareas. Our
focls s not so muchon how you shouldbe sewing,but ratheron how you
should be thinkingand reactlng.These skillsare rarey if ever talght ln
surgicalirainlng.lf anyoneevershowedyo! how io developan alternative
planwhllestrugglingwilh a bleedingsubcavlanarteryor to pay aiteniion
to whatthe circulatingnurse s do ng whileyou are manualycompressng
a shatteredliver,consideryourselfvery fortunaie.IVostsurgicalresidenls
Chapter 1
Slrgerv
TOPKNIFElhe Arl & Crofi ol lroumo
The shategicdimension
oJ an oPeraiion is ihe
broad considerationol
goals, means, and
When You
alternatives.
operale with a teachrng
assistant,Your teacher
usually handles ihe
strategicdimensionlor
you. While You are
the
absorbedin mobllizing
splnlc tlexure, Your
already
is
ieacher
weighingthe optionsof a
rapid damage control
againsta timelaparotomy
on your own' tne
consuminodefinrtiverepair.when you are working
"ait"""io"
suddenlyfalls on your shouldefs You can no longer
'Big
",r.*i"
alsoconsiderthe
io"r"""*"tr"iu"tv on d," fole; ln the colon,but must
Being a
The ihird dimensionof every operationls team leadetship
are
members
the
OR
ieam
surqeonmeansmakingsurethat ihe etforiso{
yoLlr
assume
coordinatedand {ocused on ihe same goals You cannoi
is smari and
she
he
or
because
t""t' lno*" tt'"t to do nextlust
the
pLan
Similarly'
your
"irui
You must clearly communicale
experienced.
guess
cannot
percepiionand
does not haveextrasensory
anesthesiologist
dunnga
ihe
yourplanuniessyou shareit- Mishandling team dlmension
you can make
iuuma op"rationis one of the worsi mlstakes
train yourselfto
To operateeffectivelyon woundedpaiients'you musi
in and out ot the
be a 3-dimensionalsurgeon who consianilyzooms
nronlioring Progress ano
lactical, strategic, and team dirnensions'
reassessingoptionsin each
I The 3 D Troumoslrgeon
in motion
Putting brain in gear before knife
oe{ore yo!' make the 'ncslon
Srraleqic lnrnk;ngis essentialeven
oJ,sLrse'[
no'e',
;;^d;: ;,'";"-pi",he brack
l;'fitiii,"J:.;"f:
obrisatorv,os;s
#,'-Jl-il:iiJ"" r,san
::i:'",'::il:::,H""6J
ano preoa-edbut
p..,entis'novFd oosirioned
[1;;;;::;;;;';r'""
nothingis done 10stop inlernalbleedrng
"""]"1""
;;;;"'.
;J
; ;;;;"
-"".
,ni *n''r''""t"'".'
to deorov?
"ers
You ca'not address these
vouaresurethat
anas"rubonlvwhen
ir!ii'.#r",n ir''"""',u "inkGo
is set uP ano reaoy'
everyihing
on scrubbing Everysecond
lf the patieniis in shock,don't waste.time
j*, g" u go"n und gloves'grab a knife'and rapidlydive intothe
"orni".
chesi or abdomen.
shock
Sterilityis a luxuryin severehemorrhagic
The way You Posiiionthe
patientand definethe operatlve
lield are otherindicatorcof }/our
sirategicvision.AlwaysPfepare
lof a worst_casescenario' In
iorso irauma, this typically
involvesaccesslo bothsideso{
the diaphragm and to the
grolns, Your worst_case
operativefield extendsfromihe
chin to above the knees'
IOP KNIFE
lhe Art & Croli of TroumoSuroerv
between the posterior axtllarylines. Abduct both arms to allow the
anesthesrology
team full accessto the upperextremities.
For isolatedextremitytrauma,includethe entire niuredextreriilyin the
fieldto facilitaternanipulation,
and preparean uniniuredlowerextremity{or
saphenousvein harvesting.For a neck exploration,pfepare ihe entire
chest,sincethe uoDermediastinumis a coniinuationof ihe neck.
Alwaysprepfor a worst-casescenario
t rhe 3-Drro,rmosurseonI
jlilH;"i""ji;ft
::::"H;Fti
:;:1::ilil1',::ilT
"l:";f
1['ili::^-H]
Tiit"i,l,"?:Jl[:":'ff
?:r,ff
ily:Jt"f
iK,f
il"'
:;:lJ
ii::t'*"ll];rl:::lxH"lff
:il;:*[:lmig
-t""
oJ"""i t-i
ut
it willwo* thistimeWecantellyou
maybe
"naini
thatn,Ihe
iolr"eided
Getused
nt ::"",liJli"i"TJJ::1"::":::j
no'l
ve'|v
-re'rrect
"*"'"-'";'ill'liJl"i,liiil;'i] Ll'l"""'";'|t 'ai'|
oersondl
a
ike:t as
ooesrt wori don
*n"" a maneLver
"."*i"'',
failure.Pauseand consideryouroptlons'
First,reconsidefthe need{orthe
lailed ac1. ls it reallynecessary?
Doesihe bleederrequirea sulure?
Perhapsit will stop wlth iemporary
pressureand Patience'
AnotheroPtionis to retreatand
gei help lt You are iortunate
enough to have backup' use lI'
Someonemore experiencedoiten
has a betterchanceof solvingthe
the needlor
problem,Recognizing
you
(whether
ii
for
asking
irelpand
trauma
seasoned
or
are a resident
surgeon), is a sign of good
getreaf
.f"
ca
o
t.
ludgmenl
compreierv
are
iryou
what
*i"J,?:;J;til;,:::lilT:
":1111:Y:
one
upwirh
l'"" "stcome
l::'[f]''T#'.""''fl5'$li]:"i"."iJ::1ff
ihai will.
T:['""5i
ll'iil"Jff
,i:ili,tii,'i5;Jlliiiill
,'"Hl"i::"i:Xff
TOPKNIFE
TheAri a Crofiof TroumoSurgery
envrronment:
lletter exposure,an improvedangle,a longerneedledrrver,
a bigger needle,or a better asslstant.Such a taciical change
improves
your chance to succeed in ihe next aitempi. tdentjcatrepetitionof an
unsuccessful
iechnicalact is a nristakebecauseii almostalwaysfails.Thrs
is lhe very deflnitionof flailingand exactlywhai you must avoid.
Rememberthesefour optionsfor dealingwlthtechnicalfailure.Theyare
youriicketsoui offrustraUngand dangeroussituations.Effectjvesurqeofs
don I takelech'r,cat
talLreas a persora.nsrtt.Tt-ey.apdly reasse;sthe
siluationand come up with an alternativesolltion.
Avoidflailing;
learnto dealwithtechnicalfailufe
Tactical flexibility
Regafdlessofyour experience,
you willfi/rdyourseifin sttuatrons
where
your inventoryof slandardtechniquessimplywill not solvethe problem,
forcingyou to figure out a new solution.Tactlcalflexibilityjs the abilityto
devisenew solutionsto unusualoperativesituations.lt is an acquiredsklll
that you can developby learningto thinkoutsideihe box.
When facing an unfamiliarproblenr,ask yourselJthe following
a
a
a
a
a
Havelencouniered
a srmilar
sttuation
in anothercontext?
ln electve
surgery?In anotherinjuredorgan or anatomicalregion?
Can I modifyor adapi a standardtechniqueto the situation?
How aboutsolvingpart of the problem?
Can I leavethe probem unsolved{or a whileand come back later?
Whai is lhe mininralaccepiableoptionto deatwtththe probtem?Witl
drainingthe niury(andcreaiinga conifolledfisrua) be good enough?
Can I hgatethe vessellnsteadof repairifg it?
In a complex
situation,
alwaysstrlveto simpllfy
theproblem.
Assessihe
iniufres
anddecidewhichinjuredorgansmustbe fixedandwhichcanbe
rapidlyremoved(or fesected)and, thus,etiminaied
fromthe equation.
1 The3-DTroumosureeon I
lrnes
as simpleas possible.The fewer suture
Makeyour reconstructions
compLex
solutionsworKi
yoLrrnake,the better.ln traumasurgery'simple
solulionsoften backfireon You
Simplitycomplextacticalsituations
//
K"
//,//
/7/
Acc$ and
Expo.ur
\..t11-
"
"
"*'
t! \
+\9 ot;*a
\
F'i'
Bleedlng
TempoEry
conlrol
ErploEtion
dh
and
measures
control
bailoutu"ingtemporary
Damagecontrolis thegreatequalizer
of traumasurgery
surseonn
r The3-Drroumo
'Yes" pleasesay you
lf you answer'
bowel resectionand anastomosis?
:r";';
* :i"#;**:6116';F#
:rinrijffi
ver'|J'o
;'"""," m;ss
l,1i#lll,J""''-,"?l;,1':#T"
"T
iJil'iJ""":*iii:lil
i,Bff
:r"L",":*:*1,*n::i:'::::"ffi
on the monitofscreen'
Ir*ri"il" ont"i""n'""1 insult,not the numbers
shouldguideYourdecision
TOPKNIFE
TheAd & Crofl of TroumoSL,rgery
Insteadof the lethaltriadj re y on a seres of subileperceptuacues to
rndicaiea developinghostie physlology.
IntraoperativeCues of Hostile Physiology
Edemaof the bowel nrucosa
L/idgutdistension
Duskyserosalsudaces
Tissuescold io the touch
Non compliantswollenabdominalwalJ
D ffuse oozingfrom surgicalincisions
Edemaand distension
of the smallbow are relatrvey
earlywarning
signs,whereasdiffuseoozingfrom the operaiiveincisions a lateone.
Experenced
iraumasurgeons
decideon damagecontrolwthn minltes
of enieringthe abdomenand sometimesevenbeforemakingihe incisionl
They often recognze a paltern of iijury and physology thai, in their
experience,amost always eads to darnagecontro. N4oreon this n ihe
chapteron thoracoabdominal
injuries.
I The 3 D TrournoSlrgeon
(Gl)
will suruvea leak {rom a gasiroiniestinal
an rsolatedbowelrniLlry
injuredpatieniln mulii-ofganfailurewill not'
surureline A criiicallv
Team leadershiP
holein an iliac
Pictureyourselfgoingheadlo'headwiih an inaccessible
and
tlJ peru:" Your oalier' s n ororounosl'ock
o'ryoJr
""'" ""*'4"*",i
aLdo'y.YoLrieamhasore c rcualng lurse DepFnd'ng
blFeoinq
needle
pe'solalized
your
n"',i,"0"""t. ,a" .rr-" *il eilhrgo nJ'r,i"glor
a
Fogarty
bites' bring
ariuer ttrat ttas ihe ideal angle {or your next 2_3
ihe bleeder'or
compressing
from
yourfinger
free
iattooncatleter itratcan
ore
a-.olr1s{usio-'devcewhcn is more impolant?
;;,;-;-'
_
Iime
same
ar
t'r.
needeo
p:eceso equrp'ne,rI
lir""t"tor, ,r'r""
".."niiul
it s your call
your prioritiesand your team' adapt to the
Constantlyre_evaluate
excellentsurgeons
situation,and makecomprornises'lt is often said thal
i""" .oo*" wiih a knife and fork' ls the specialclamp you requested
bJr _nedralely
reallvessentia?Ca'r you gel by wirn a 'ess opiimar
+en
mi,lL'es?
wn"t *ill vor neeoir live mi'utes? lr
""lii"oi" "r".p"
is to siay aheadol
The kevto a smoothand welfcoordinatedoperalion
leastonestepaheadol
tfe oam"les a rut",tt scrubnurseshouldbe at
"
""0"*i"" at any given
mor'ent When you are exposingan lnjured
ii"
nu."" musi alreadyhaveclampsfor pfoximaland disial
ue""eL,the
".rrb
nurse must be at leastlwo steps ahead' riaking
ff't"
"it"ufutlng
you will need fot
"oni.i.
if1" ,n" FogadyLalloon calheterand the suiures
"rr"
ready You, ihe surgeon'must be at least
,"pul,
*r"*""a.t
"r"
"ia
options Just as in
three steps ;head, consideringyour reconstrLrctive
of the operationyou wrl!
ci"ss, tne bette,play"ryou are,the furtherahead
stay.
Knowthekeyrnafeuver
andpiifallin everyoperative
siep.
r The3-DTrcumostrrgeonI
failure
Avoidflailing;learnto dealwithtechnical
tacticalsituations'
comPlex
SimPlify
>
of faumasurgery
controlis the "greatequlizer"
Damag
>
well'
repairoptionthat'fails
Choosea definitive
Staywellaheadof theoperalion
Chapter2
but'
clanrp'
a vascular
is noihowvotrhandle
"r"""ss
contfoLLsnot
ralhef.how vou handleyoursolfand your ieam Bleeding
some cool moves lt is ihe ability to rapidly select
one after the oiher In a
"Oorr'."oJrnn
appropriatehe;ostaiic optionsand deployihem
do it
discipiined,eflectivefashion Here s how lo
Choosing a hemostaticoption
jump on a bleedingvesselwiththe {irsiavailablectamp.
Don t feflexively
Instead,trainyourselftothinko{ everybLeeding
siiuationas a problemthat
requiresan effectivesolution.Thereis alwaysmore than one alternative.
Your job ls to come up wiih a solutionihat will work for the specific
siluationin front of you. Therefore,the first rule of bleedingcontro s
alwaysseJectthe simplest,most expedienihemostaticoptjon.
Bleedingcontrolis a gradedresponse
lf the first soution you chose didn'l work, graduallyescalateyour
efforts. An experiencedsurgeon rapidly zoor.s in on the 2-3 best
hernostaticoptons for a given situation.This principle of a graded
response has an importantcorollary:while you deploy a hemosiatic
soluiion,ihnk ahead and preparean alternaiivein case your selected
iechniquedoesf't work. Why is this importanl?
The morecomplexyouf nexthemostaticsolulion,the moretime rt takes
to prepafe.When faced with massivebleedirgfrom an inaccessiblesiie,
preparingan alternativebecomescrucial.l{ your chosensolutiondoesn't
work and you are not readywith an immediatealternative,
you are up the
2 siop ThotBLeedinslH
i;i;t;:
hemo::1h":iTli,',^1ii
ora paddre,Havins-a
insearch
creek
accideni. lt requires careful plannlngano
they can be iound'
iO"iO*"",
V." *ill need and where
"t,""*
Be readywith an altemativehemostaticoptbn
Obtaining
tempolarYcontlol
Manualof digitalPressure
is an excellentfirst chorce.
Conirol bleeding from a
cardiac laceraiionwilh Your
{ingef. Pinch a mesenteric
bleederbeiweenlhumb ano
forefinger. Compress a
bleedinginiernaljugularvein
with your finger' lnseri a
finger into a hosing gforn
TOPKNIFE
TheAd & Crofl of TrournoSurgery
Have your assistant
compress an Injured
liverbeiweenthe palms
of boih hands. Using
your hands is quick,
instirctive, completely
airaumatic,and very
n
2 stoprhotBreecrine
can relaxfor iust a momenl'ger
Temporaryconirol buysyou time You
hand' s!rvey the situationand
,f'""i,Jufu,io" o".f i*o your compressing
decidehow io Proceed
olt"r.i*
pedicle
it th,"lt""aing organhas a vascular
2 stopIhai BleedinsLI
Update
co'Irol_STOP'Res:stlnetemplalion
OnceyouhavFgainedte-po arv
'ontror' Ins'ead orgarrTeard oprrm:ze
," I-.""a1"*,, p,"J""" to de 'nrLrve
your atiackl
. l"l::T,:",",."jf
il:x'.:JxilJ,",.'fi"1'J"':;ii::J
; :li:;*".::;"n,::il
fl:"';:11",":ili:1"11:
O
lnruser'
least8_10unitsof bloodand a raprd
i-ed
and wo'(lng
p
Ger an a.rovans us;ondev:ce
. "J*m.J1';;x;14
5l;:x:
l+i!ill:.#.'":,,#
likea Foleyor fol
equipmeni
additional
therorreF
handre
'"".' canthev
.- X"'S::"'H"#;;ffi:Jil!:f""";
additional
vouset
1""",* l.lJ"ai""at should
u
f"uFfi"""ning
""r{'',:,:f;::ii::ffiJ'il'"'#J"t'1i11",,*"""*"
with your
are movingforward'don't fiddle
While all ihese preparations
ano
pressurer
manual
L"""" the packsalone'maintain
,".o"i"tt
"""i,J
don t moveanyclamps
Don't fiddle - be a rocx
When_dealing
wrthBtc TROUBLE,
resistthetemptation
io keepon
Selectedhemostatic techniques
Pdckitlg 701
Packingis one oJ the most underratedand badtytaughtiechniques
in
su]Sery.lt is also one of your best weaponsfof deatingwiih BtG
Ilula
TROUBLE.Surgeonstend to thinkof packingas suchan intuitive
skillthat
they rarelybother to teach it properly.After all, you
don,t have to be a
surgjcalgeniusto stuff some pieces of cjoth afound a bleeding
liver _
wrongl
2 stoplhot Bleedinsln
relieson'clot
packing
is io do ii early.since
Thefitstruleof packing
cansiillrorm
if donewhenthepatient
l" Jtfective
and
is coagulopathic
"* ",i,,
whenthepatient
"rril,""l',i
n""J"[i'" t"lnan "" " lastresort'
everywhere,is futile
oozingfronr
Toomuchpackingis bad
The fourth (and ast) rule of effeciivepackingis to be paranoid.There
rs aways the dangerthatyourpackswillfot work, bui it usLtaly takestime
to find out. Laparotomypads havean amazingabsorptivecapactty,and ihe
patient may wel/ continueto bleed lnderneath them. lf the patiefi s
physiologyallows,spendat leasta few minutesdoingsomethingelse,and
2 sroprhoiBleed.q n
::il":ff;:[';
fsupef;urallayer
::;il,:i
':T':J
i"J::"::,,,1"if
t:T;:'il";ift
-ost
ot the
peer.o{i
the
.,"*1,,*.lat U)/".,*" notsJ-e
AreiheyturnrngprnK
tul" goodlookat thedeeperlayers
l"naiui"t'
youoo nor
aparibecause
" h*e to takethesandwich
'f *, yo,
lij-rno'"tf"na
mechanlsm
patienfscloiting
n"ueette"tivele.ostasis Neverrelyon the
besi time to acheve
The
for ine{fectivepacking
i"
hours(and12 undsor
iwo
"".0"*t"i" r"*" vou leavethe oR' noi
l"#iJJ
blood)Later'
removethe soakedpacks
Whatif yourpackingdoesnt work?Fitst'
more Didyouhavea gooo
*" u1lo""'*a l*p""ithe injuredarea.once
of did youbuilda
siructures'
sandiichsotiatysupporiedby surroundlng
addmore
in .id_airwithno support?Do youneedlo
"f_to"ting
ls lherean
""na*i"l','
a vouuaa packing{romwithinor lromwlthout?
o"'"-f."iSf,ouf
it directlv
,i' tn",",,'"a a'"at lttlre'eis' yo' musidealwiih
ii"''"i
eLseto help
techniquecan youdo something
,"1"" "-""J* *.*"i'c
ageni?A blindhem.ostalic
aii"o'"n" naa a topicathemostatic
i.t',a""""n"i
"""0
*"it ag;in uniilyouare sufethatyouhaveef{ective
*"t""u
"r,lr""
conirol
bleedlng
Be paranoidaboutYourPacKs
(figrre of 8) suture
a bleederihat is eiiherinvisible
Use a blindhemosiaiicsuiureto conitol
see the bleedernor can you
o, ias retract.a inlo the tissue You cannot
usins brrnd
'i, but vou can imasinewhefe it is After
;;;;;.
;;;
you
surgeryi
emergency
*any iimes in eJective.and
t',".o"tuti"
you
are'
",ltrt"" "o
io do ii well Chances
.uv f""i"onfia""t tl"t vou know ho*
don'ii hereare some usefulpointers:
a
'
is aPpropriaiefor a blind
Make sure the anatomicalsituation
malor
lf the bleedingis close to an unexposed
;";;;;
";*".assr.rmethat lhe maior vessel is the bleedet and
"""""i "f*"y"
Whileinserting
a bind stich,planyournexthemostatic
alternative.
Experience
hastaughtus ihai il you havenoi obtainedhemostasis
wjih
2 StopThotBeedins n
filTf,I[of
"
onthetissue
h..ostatic stitchsainspurchase
Aottic clafiPittg
heroic maneuversin ifauma
Ao ic clampingis one of the traditional
in a crashinqpatientor
suroerv.Use it eltier as an adiunclto resuscitation
vascularlrauma You are
i*"oriur pt.*i..r contfol in rnajorabdominal
aortai
'-.'i"l' '. i*- r'.. - oroperlvco'rlrolll-esJoraceriacaodom:ndl
and
orauL'ce
LFarn
.t Ln"li'sr 'ime-ira berlvlul ol blooo
V""
"ti"-oi'i
the lechniqueundereleciivecifcumstances
When used as a
Use aoriic clamping judiciously,noi reflexively
on the blood
the
numberc
resuscitativeadjunct' ii temporarilycorrects
pfice o{ globalvisceralischemia
0r""""t" t*it"t, O* "t the
As with any maiorbleeding,
avaibble
the best inrmediately
Pull
the
hand
tool is Your
bluntly
and
stomachdownward
enterthe lesseromenlumIn rc
avascular Poi(ion. Feel the
aorta Pulsating imnrediately
below and to lhe right oi the
esophagus,and compress it
againsi the sPine. lt You are
occluding the aona as a
manual
maneuver'
resuscitalive
compression is often good
enough. li Yotl need formal
aortic control, Proceed wiih
transabdominal suPracellac
aortrcclamPlng
Bleedingcontrolis a gradedresponse
Be readywiih an alternativehemostaticoption'
>
peorcle
Determineif the bleedingorgan has a vascular
'fr
to, *"nr rn. ^rt&crofrofTroumo
Jurgery
Chapter 3
r
-Tt
11,:r
Your VascularloolKlr
haztingthe
Hutuall
'ot,ititu beings,who ate almost utique in
(e
are atso
olhe$'
of
to tria froa th? etpeie
TOPKNIFE
TheAd & Croit of TroumoSurgery
of technicaloplionsfor damagecontrol and definittverepair of vascular
injuries.Remember,
a good outcome n vasculartraumadepends.fore on
clear thinkingand keepingpiorities slraighi than on cool gadgets and
elegantmoves.Keepyourvasculartookit in mindas you learnto dealwith
specificvasculafinjuriesin subsequentchapters.
Sequenceand pliodties
Much like any oiher trauma operation,avoid making 'excitng
discoveries'when dealingwith majorvascuar inj!ries by followinga we[definedsequenceof steps.
,<v
)J
,,t,,^ )t
./a-
ogo{_TJ+(fpi
Bleeding
Conlrol
Extnsile
Delinilive
Control
Grafr
Decision
roolkiiI
g vourvoscutor
"
;;;;;.
intransiiron;"J:L?,:::::;^:,1':l:
ffii;;;nd), especia'v
(t
I \l
\l
r*
fossa'
groin, supraclavicular
these
In
neck.
or
axilla,
compression
localions,manual
is less offeciive.lnsert a Foley
catheter into the bleeding
tract, inflatethe balloonunill
bleeding stoPs, and lhen
clamp the main Port of the
Foley.lf the wound is wide
and the balloon PoPs oul'
approximate the wound
edges aroundit with a stilch
to helpholdit in place
bleedingin kansitionzones
-" *n t"aponud" *ntrols external
TOPKNIFE
TheAd & Crofi of Tro!mo Surgery
Alignbonebeforeaderialreconshuction
Angiography
Preoperativeangography is noi an option for a hemodynamicaly
lrnsiabe or activelybleedingpatent. If a stablepatient,get an angogranr
d you can, especiallyif you aren't sure where the injury s. Consider a
patientwiih multiplegunshotwounds or severalfractlres n the same
extrernity.
How willyou know wherethe injuryis withouta roadmap? With
a srnglepenetratinginjury,ihjngs are sjmplerbecauseyou can find ihe
injurywiih a limitedexploraiion,so you can skip the angiogram.
3 YourvoscuLorroolkltH
you have
andthe localcitcumstances'
on yourexperience
Depending
anangiogram:
threeoptionsfor obtaining
in the ER _ rapidlybecominga
angiograriperformed
1. A single-shot
loslan
strl:
in the angiographv.
,_ e"i",r"r studyperformed
":^^9:
ihe needfor openreParr'
couldpreclude
inierveniion
"ndovascularansiosraphv
of the exposedaderv
b1,cannulalion
;;;;;;"
a
the
"
the inflowbeJofeinjectrng
by clamping
oL ai"ned
o""il!"rn"
"t"
dv".
;;
Pre-emPtive f asciotomy
the vascularreparr'nol
beforebeginning
Considerdoinga fasciotomy
on an
obviousWhenoperaling
L clinically
*f,i"
"v"arome
repairis goingto take
,r'ri
i""t".""".p"*"""a
,;, .ften knowihai theformal
{asciotomy
"ttt,
of actionis to do a pre-empiive
ii"". i""r.
""f""'"""""
ol your
Regardless
A poplitealadefy repait is a good examPle'
alwaysenduptakinglongetthanyou
poprit."it""onstructions
of
"rp.rlni", in" unforgiving
naiure these iniuriesand ihe paucity
-ofguaranteeyor'rwill noi finishthis
"ri"li"o
aroundihe kneevrrtually
collaterals
the vascular
a fasciotomvBe smart Do it before
il;"i
;;il
fasciotomvusing I d:]bl: Jl"l:i::
we do a fourconrpartment
*"';q;
Pr"""
incision
iaterar
vour
:tC'*'l"lfll,y-:"1':::::i11"li:
the rasrciaall the way down to the
tateral;o rne edgFo'the tbia OpFn
theinlermuscular
,f,"",'a""ityandincise
::t:l#*f^-+*H
Avoidda-ase to rh
""ni"'
4t","'
;;;;.;;";
rve ihat llesl!
"o'p"'i'"'.t'
imityio th
of ihe fibula\Then,makea
ffie
t<z$ol'.. =r
edgeof
medial
cf"^h
'<-?tw^
.a
/
,./
the iibialshaft.Injuryto lhq
greatersapherfousveiny'nor pad of tnis
/ncrsron,
so be cafofulUsrng'lhecautery..6erach
the loleus muscteiro,r1
the modialaspect of ihe tibja to decompressthe deep posterlor
compartment.
Do pre-emptive
fasciotomybeforepoplitearaneryrepair
ToorkilH
3 Yourvosculor
l:1iT.-:l
:T'J"'n::;l
;T"""l"li
l'"3:,i:'::T
..H::1,::::""J
:i::;
;:J,::':::iT:fl
:fi:::it'::".m,:*if:i:'
:
":lil;:15::TJl:,""":
;::ii:rtli:l'*::J::"1fi
.;ffi;111"T:J-'j:ff
::;:ll"Jl;
i""'-ff
:*-::rm"""Jff
jT;:iT::'.*:"??"Jt"1li?
t*ff ffio.*"",*":
a"ria""'t
i.,'
whe.vour n troubre
concep'
'rse{ur
;;
;"i #;;;;j';"
"'tremelv
territorY
unfamiliar
Knowthe key an6tomicallandmarKs
Distal control
How importanils distal control? li depends.Usuallypfoximalcontrol
alonedoes not dry up ihe operativefietd becauseback beeding fronrthe
dislaivesselcontinuesto give you grief.The patieniwil not exsangurnaie,
but you will not be ab/eto do a vascularreconstructionin peace.
For ihe aortaand iis proximalbranches(e.g. subclavianand com..on
i|ac arteres), proximalc/ampingserves only to convert fierce audible
bleedinginto weakerbleeding,but you stillcannotsee ihe injurywell, and
ihe patieni is losing blood at an alarmingrate. you mlsi obtaln distal
control.Do ihis outsidoihe hematomaif you can. lf not, exposethe injury
n
3 YolrvoscuorToorkii
withinthe I'emaloma
conkol andgai4d stalcontrollrom
unde.pro).ima'
are the distalrrle-nal
i""'"^i to"rtion, wne-edistarconkol is dfticult
ol thepelvrs
.uu"t,ui"narteryandthe a'ge verrs
"'"loiio"i"rv,
choosethetechnique-thal
Fordistalconirol{romwithinthe hemaioma'
:;i'f
i:"il;",ii;
mt"l';li:xru!T;i"1,fl",;"il1ll'ff
to a 3'wavstopcock)rnto
connected
l"*#
fiol""|lt li"n"rtv cathe-ier
usedin eleclivevasculaf
ffti" l"st technique' frequently
ii"
" "*rV
havingto dissectoutthe
"rrrr"*i ""tfy"" n"in distalcontrolwithout
"
"ff"""
G"lnillotr.inut
distalcontrol
u"tloonfor problematic
, -r ' -
.}.::i
Vf-=,,au
YoursaJedissection
plane along an artery
is the Periadventihal
plane directly on the
arterial wall lt will
carry you saJelyfrom
uninjured terrltory lo
the injured segmenl
without laceratingthe
vessel or ripping off
branchos, You know
you are in this sa{e
plane when ]/ou see
arlenal
the pearly_white
wall wiih the vasa-
IOP KNTFE
TheArt 6 Croft of TroumoSurgery
As you enterthehemaioma,de{inethe injuryby rapidlyansweringthfee
questions:
a
a
a
ToorkiEl
3 Yourvoscuror
ffi:Hlii!##
:::ii:+:
H:iH3T*"i"".#
lT,',Ji[$i..""?TJ"T""i"'.1"*Y,"i.
optimize
and
l[, ;:::::[:T*, ,neincision
infi:,:H:""j;H'
* I "lTllljllii":.i:
.n'*oii"*,","i'p"ino:".0
:?:;:",*:::l';
evenuno
quickly
lrnethaicanb completed
_
sucha lateralrepairwillwork justdo it
(ormorsihanone) Anend_
anastomosis
A complexrepaiisa\tascular
gratt are
and
a Patchangioplasty an iniePosition
a-"nJ
"n""toto"i",
:*it,:",:x;ir*:ll:':;;JJ3#i;i:Jl::'i"
c pateni wno wrlr;ustbreedon and on
';
;r;'e;';;.';,"ft
unit'
tniJPaiieni needsio be in the intensivecare
,t* "..egu'opath
i--',-*
bood
more
tabrerosins
;;;;;;;; "",r.i" '"""""''"ted not or the ope'at'ns
ba l oui
Ynu'nusl
i""ot ng ptog*""'ve'y hvporl'tric
"'"i
tne paiienl unslableor'acrveLy
Second,consideraddilionalaclors ls
ll il'e arswer is ves -damagecont'o,s-your
fr"iorg i"
"*'ty?
"n"th*
f:'"XnX'i
:lll'i::;":"",",::l;J;'R::'"fi::.il"J"',:X
,""
"tin"""
0"".*""'l
illlilil"",,
corlrol
damage
no'aga'nchoose
control
repakanddamage
va3cular
"o.otex
TOPKNIFE
TheAd & Croft oi TroumoSurgery
Ligetion
Ligationof an injuredvesselis olten a no bfainer.The exlernalcarot/d
artery,celiacaxis,and iniernali iac arteryare obviousexamplesof arteries
that can be ligatedwith impunity.Otherarterles,such as the subclavianor
brachial,can be ligatedwlth a low risk of limb{hreatening
ischemia.lf you
are forcedto bailolt bui planto repairihe vesseltater,don't ligaieii , use
a temporaryshuntinstead.
Ivlosi large veins can be igaied wjih impunityof with accepiable
consequences(suchas leg edema).In ihe past,repaifof the popliiealvein
was vrewed as cr!cial for a good outcome with popliteal adery
reconstruclion,but this sacredcow was slaughteredlongago. Thefeare
even reports ol successfulligationof the podal vein, althoughthis ls
probablyone of ihe very few visceralvelnsihat you shouldrepairif you
can. Remember,ligatinga vesselis not an admissionof defeat;ii can be
a sign oJ good jLrdgment.
Tefiporary sh nts
lf you have liltle vascular experiencebr are operating in austere
circumsiarces,a temporaryshuntmay be your best opiion.Inserta shunl
whenthe patient'sphysiologyis prohibiiive,when orthopedicalignmefiof
the bonesprecedesihe aderialrepair,or when you lack the resourcesto
do a complexreconstructon.
Shunt maierjalis not an issue;use whateveris immediaielyavailable.
We havesuccessfullyusedpiecesof nasogastric
tubes,suciioncatheters,
3 iourVorcuorroo ht E
preter to use an Argyle snunl
cafotid shunts, and silasticTlubes We
and.
sursery'
incarotid
it-resularlv
illil"tr" in"l ir*io""ause weuse Lhemostsoeclacular
casesoi
lnadequateinfLow(proximalinjuryor tesidualthrombus)
of the shunt into a
Compromisedoutflow (residualclot or mlgratlon
disialartetialbranch)
Obstructed
shunt(angulatron
dueto excessive
lengthor ligatures
ihat
aretoo trghil.
Shuntdislodgemeni
(presents
as a rapidlyexpanding
hematoma).
Clearlhe inflowand outflowhacts beloreshuntinsertion
Transected
graft
artery= interposition
Patchangioplastyis an optlonto keep in mind,especiatlyif at leasthatf
the circumferenceof the arteryis still intactor if the vesse is small.We
rarelyrepaira lacerationtn a brachialor popliiealarterywthout a small
vein patch,becauseevena transversey oienied latera repaf wi I narrow
the lumenof lhese smal vessels,
Before you begin ihe reparr,pass a Fogartycatheterproximallyand
disially,and then flush the vesse with heparinizedsaiine.The Fogariy
catheierwlll not only evacuatecoi, but aso will dilatea spasticvessel,
facilitatingyour repair.
To"rkig
3 /ourvoscuro
vasculaftrauma'raisingfears
Systemicheparinhas a bad reputationin
soft {rssueor In remore
o'clusing U'eea,ngIn Ihe adlacenttrdumatiTed
especiallyil
wfrendeal:ngwrh an isolatoarler;alInjury'
'ni, nes. Hlowever,
rime'givesystemc heoajn to proteclIl'e d;stal
t"o"', n"t"n
tir,
'microcirculation
" "ke ariery repairs are a good examplewhere
"
Popliteal
sysiemicheparinmakesa difference
rol a mJsl ll a vein
Oo vou l'ave Io tepair injuredveins?lt is a 'urury
ine toJble These
,. i"*i'"" a co.pre* ,epai' t may not be wonh
often
"
t""n"tnrt rno'ederand'ng lhanarte'ialreconsrruclions
,J""1t"
l'as
palient
lr
Ih
"]"
*in
*tencv' and mav oe 'nnecessatv
physiorogical
lcant
"i"t"i"""J,'i
sustaneo a srgn
ti" ,"qui,"
.ti*
w'thoul
"""ntion
"'r"""
t'" oR {or manyhouts' ligaielhe Inluredve n
'"""rr,
"ih"]0""" "
hesitaton.
venousreparr'lhe
l{ vou decid Io iaduge i.] a combinodarleria'ard
because a thrombosedven
u"nou" ,"con"tru"rio't should come {irsl
tissue
cleared R6membefio interposeviablesoil
o"
fislula
"ff".tiu"fy
a
"""noi
Setweenthe ve"ous and arieial tepars Io nreveni
3 Yourvoscuo,rooLkll
THE
KEY
POINTS
aredifferenlpiorilies
andischemia
Bleeding
>
in lfans(ronzones
bleeding
conirolsexternal
Balloontamponade
physrology'
Knowthe patienis ioialtraumaburdenand
Alignbonebefotearierialreconstrucliofl
arieryreparr'
beforepopliieal
fascioiomy
Do pre-emplive
>
landmarks'
Knowthekeyanatomical
conlroloutsidethe hematoma
Get pfoximal
dlsialcontrol
balloonfor problematic
Usean iniralumlnal
>
lnlury
De{ineihe fullexientof ihe vascular
yourworkspace
developandoptimize
Gradually
repairanddamagecontrol
Decidebetweencomplexvascular
>
of defeai'
Ligationis noi anadmission
Clearihe inflowandoutflowtractsbeforeshuntinsertion
gra{t'
artery= interposition
Transected
TOPKNIFE
TheArt & Croft of TroumoSurgery
Chapter4
The CrashLaParotomY
Damnthe totpedoes,
full speedahead!
Admiral David l. Faragut
programs,you spndmuchtime in the OR with
In mostsurgicaltraining
awayat 5uayeynrocfes whileyoLr
braslrnq
,^-.,,*".v in nand.merrirv
wilh a r'gl-t-a-gled
i",.1# ,,i"o"rt'""'t op"ns tl^e correctliss'reo'anes
pretendlngyou a'e
{'nqer'
educated
*cl"r Irp or ar
r"
"i]-.
"""oot""""t*"t
a'ranserelraclon and
vo- cut ss''e . tie trots
Ii"|
-_r.r;e,a"
ge'e'al sLIgef
ol
""""1t*
are all parl ol In" tecnrrcdllargudge
oowe,
_oI an acce'e'ated vrs'on oI the elect've
A rrauma operarror is
rmoortantly'
o tlerell I"cnn cdl langLagea'rd moct
it .-tr'r""
.r*"irr"
"
tnFsed'{erenccsby
I ii"r""trnnd""t ln thischdpler'we dero'sirale
and translaiinglt Into
Lilng r";irl"t op"t"tlon' exploraiorylaparotomy'
alternationsbetween
"
Rapid
ifre tleclnicat anguage of traurfa surgery
rhe
-a_euversa.rd reliculous dlssectonare
"*n-","a"
"*-""tt" nparolonvll's likedancingthrougha Iearm ne{ield
i"'."""""i"i'ir",
pictufe?
*iii. pi.yl"soOOL/- onvourlaptopGetthe
The oPerativesequence
/"r
Exposue
.r ^'fib
\,t("
rr\" - +,0;;;;1
Bleoding
Tenporary
I Exprotion
Control
r-++^"\y:
oamagsControl
Gaining access
Enter the periionealcavityihrough a long mid/ineincisron,the Texas
namefor whichis 'Hey diddlediddte,rightdown the middte.,,
The tess
stabe the paiient,the fasteryoushoulddivejn. Takeihe scalpelandmake
a bold cut throughthe skin and subcutaneous
tissue.lf you grab the
djaihermyto systematicaily
barbequesubcuianeousbleedersIn a patient
wilh a systolicpressureof 60, you are probabtyin the wrongspeciattyand
should consider a career change. The hypotensivetraunrapatieni is
peripherally
vasoconstricted,
and you are wastingtime orj nonsenseoozng
wnilerapidintra-abdominal
bleedlngcontinuesunabaied2cm belowthe tip
oJyoLrrdiathermy.
Soundsprettyst!pid becauseI |s.
Theincision
beginsbelowthexiphoid,
skrrtsaroundthe umbilicus,
and
ends above ihe pubis. An experiencedsurgeon uses ihree long and
precisepassesof the knifeto enterthe peritonealcavity.The first sweep
getsyou pastthe skinand intoihe subcutaneous
tissue.The secondpass
landsyou on the lirieaalba. Developthe abiliiyto gaugethe depih of th
subcutaneous
fat and ihe 'feel"of landingon the fasciawitholt cuiting it.
The third and last pass of ihe knife dividesihe lineaalba to visualizeihe
prepentonealfat.
=
==
'--
- ---
peritonealcaviiy forca
"=.:;==;-2')
='
the elaboraie dance
(often iaught in elective
surgery) of Picklng uP
'wo parrso{ p c{'p- ard makirgd s'all n:c\ lo
,m betwee.
rh-"-oe;itone
dbovF
defeclimmedralely
l"iju-;. 5r-p1 po^ea frrqerirro rl-isoer'tone't
yo, find yourselfin lhe peritonealcavlty
tf'" u*lifi"u",
"na
pFrfioreu_1toge'he-wrth rhe
tlsinq a parr ol l^Fvyscissors crr Ihe
Useyourron-J,n"o or"p"tito.""riai'Loll'e rullexlento{ the:ncision
tor youl
prolect
tnem
oown Io
pusn ine IntesrilFs
i".i'""i,i,"a'o
it
between
ldeniiJythe {alciformligamentand divide
.i".""i"g
bellv'
""i**"
to ih" tishi uppet quadrant You fe in the
; ;;';
;;;;
""""""
readyto Rock n' Roll
ilf,Ih"
finger
ot theknifeandoneeducated
ttr"e sweeps
u"tly
"itt
Il
4 ThecroshLoporotomy
the bowelearly
Eviscerate
basedon the mechanismol
Choosea iemporaryhemostaiiciechnique
-rat-mabegi,]w'in empi'caroacli,rg Handyourassisianl
nurv.In or.r'rl
eaunqLaoralri- IUrn
, 1i"" '**"t"' to e'eva; ltseabdo-rralwa ' ol
'aprd'vBegi' wittslne 'igl'' LpperqJad a,trbv
i".. ,""
gentrvloward
"Oo"-""
".i
t*o ou", 'n" ao-" ol the 'rve pJl ng ''
.,"1'i] *,,
Ir e l:ver'
oelow
ano iFen
#;,;t "r, pac\s overvo ' nanoa'ove
;;
non-dorninant
to iheleftandputyour
N'4ove
i,""kli" iionto"'"*," nutter'
lowardyou'ihenpackoveryour
it gently
pulling
tf'"
n"nJ
"pf""n'
"fou"
TOPKNIFE
TheArt & Crafi of TroLJma
Surgery
reiractinghand above
the spleenand left lobe
of the iver. Create a
sandwich by packing
medial io the spleen.
lVoveto the leftparacolic
guiier and then to ihe
pervrs,and pack them,
Al this tinre, the eviscerated bowel remains
out of the way.lf blood is
accumulating on the
evsceratedbowel, the
source is a mesenleric
bleeder. Deal wiih it
drrectly.During packing
and while your nondominanthandis retfactrngand proiectingthe liverand spJeen,
fee/for any
obviousinjury,and begin planningyour approachbased on this tactile
In penetratrng
lrauma,yourbest bet is to go straightai the bleeder
Glanceinto the eviscerated
peritoneal
cavityto deierminewherethe
bleeding
is comingfrom.Youwillthenbe ableio achieve
iafqetedrather
pac^ a b,eeding
lra. bl:ndrempora.y
herosrasis.
sohdorguno,,
hematoma'Manuallycompressa {reelybleeding
containedretroperitoneal
bleedet some surgeonspack empiricallyin
u""""i. Ct"rnp
"."""n,eric
cases,just asthey do in blunttraumaWe preierto see
traurna
penetrating
eracilywhat is bleedingand addressit directlr'
In an exsanguinatingPaiieni,
consider compressingihe aorta.
Manual compression of the
supraceliacaortathrougha,ho!eIn
the lesseromenlumrs mucn sarcr
and as ef{ective as formal
clamping. Transfer responsibility
for aoriic compressionto the righi
handof your assrsianl
TOPKNIFE
TheArt & Croli of TroumoSurgery
Systematically
explorethe peritonealcaviiy.It doesn,tmatterwhereyou
begin as long as you maintaina iinearsequencethat covers the enlire
conieni of both conrpartments.Thls sequence sholld be rouiine and
reproducible.You learn it in residencyand methodicallyrepeat
it in
subsequentoperations,ln your sleep (andjn courr).
Beginyour explorationof the infranresocolic
comparrmentby tiftingihe
transversecolon craniallyand funningthe gut irom the ligamentof Treitz
down io the rectum (or from the rectum backwardsto the ligamentof
Treitz).
Two pairs of hands ,
yoursard yourassistant's
' {lp eachloopof bowelin
a coordinatedfashionto
inspectbothsjdes,paying
special attention to ihe
mesenteryThe posierror
aspect ol the transverse
colonand the hepaticand
splenicflexuresare notorious for mrssednjurjes.lf
you rdentjfy a bowel
perioratron, contro the
spillagewith a soft bowel
clamp.Youtypical/ysmella colonicperforation
bforeyou see it. Remember
to lookai the bladderafd fematereproduciive
organsin ihe pelvts.
Pull lhe hansverse colon caudad to explore the supramesocolic
compartmenl.Inspectand palpatethe llver and gallbladder,and palpate
ihe fight kidney. Then, inspect the stomach all ihe way up 10 the
esophagogastric
(EG)junciionand the duodenum(includingwhai you can
see of the duodenalloop).To fullyvisualizethe duodenum,you musi do a
Kocher maneuverand take down the ligamentof Treiiz. palpale the
convexityof ihe spleenand ihe left kidney.Don,t forget to inspeci both
hemidiaphragms
and noteany injury,as wetl as whetherthe diaphragmis
flator bulgingintothe abdomen.
compartments
and inframesocolic
Explorethe supramesocolic
the
So far, you have exploredlhe petitonealcavity-Underneath'
in
the
lurking
is
still
r"t;;"'-ft"";;., a sepa;atevisceralcompartment'
4 TheCroshLoparoromy
This moveenablesYou
to roiaie ihe spleen,
pancreasand left kdney
in a media direction
toward the midline As
your hand sweeps rrom
below upward and
mediallybehind the lettsided organs,Your Plane
is directlyon the muscles
of ihe posteriorabdominal
ln most srtuatrons
requiringthis maneuver,
hema_
the retroperlioneal
of the
much
wilL
do
toma
lifls
dissectionfor you. As it spreads laterally'the expandinghematoma
you to
the lefi sided ;iscera off ihe posteriorabdominalwall, allowing
and rapidly
bluntLy
performthe maneuver
An expandingcentral hematomadoes the disseclionfor
You know you are In
the correcl planeas long
as You can feel the
posieriorabdominalwal!
agalnst Your fingediPs
whileyou bluntlydissect
behind ihe viscera with
your hand. Continuethe
medlalrotaiionallthe way
up to the diaPhagmatc
hiatus.You can then cut
the left diaphragmatic
cfus laterally,and bluntly
dissectaroundthe aorta
you
i.Jl
L\,,/)rA
rl
4 rhecroshLoporotomv
Right-sided medial viscelal lotation "
medialvisceralrotationin three distinctslaqes'
Performrighl_sided
belterexposureol tne
stagegivesyou progressively
Eachsuccessive
;:|,.ff"",dt:irlHr;::##:"ffiil1^i".
;Til:ifln:
:",;"T:::;:
;i;,il;l:
*::i:"'"'",'""n.,'*iiJ,
Doarisht.sided
mediar
ni"""J.IiIiIIiIt"-!"!
_^ll:
]n|:O
Fri:{,ili:iiJi:,ili"]ii:",1""#,3
::"."#::t,ff
il;;l;i*m*iri
;
i:ri:[:]r,
iffi
c'ania'rv
aro
obJq*'v
r'o''rn.
J
;:'il1;:iT".li";;"'"rero'
"*u-
maneuver
beginsar ihe commonbr/educi (CBD)
---]h:--C.n:,tp*i*h
ano
ends at the ligamentof Treiiz.When
rJl"rt":::":
p-anoramic
vrew
orriee",''."r,,"."""""i" ,"1i#0"',"J"'L,l
g
4 rhe croshLoparolomy
parts of the duodenumano the
vessels lt is
superiormesenteric
an awesome exposure we
stfongly recommend that You
carefullysiudy, understand'and
memorizeii becauseil is ihe key
someof the most
to approaching
iniuries.
difficultabdominal
The maior Pitiall with tightsided medialvisceralrotatronrs
injuryto ihe SMV at ihe root ol
Once Youdetach
the mesentery.
from its
colon
the fight
peritoneal attachnreni,ii is
hangingbY its mesentetyaone.
An inadvertentPull will avulse
the dght colic vein off the SMV
bleedlng
resuliingin unexPected
mesenterY
from the root of the
:":T:fl;,
:::l?"5ffi
:'ilr
*rh:]:
"i:[iF:';Hig
*"";;.;;il;"i
;
;f""ilffH:ff
Jiil:i,iliti"'
"i::;:i;:::'
contain
andprotect
theuo*"r*t*, t"iplilfiI--inJlfii
liJij:i:-;,":;;
:t:
::i'f:":it!.i,qii"i,:"_'ii"*r#:,::ft
j:l,i#:ijT:iii:i!;jl
creaies
a physicar
banier
beti,een
ffiJfl
mass.This
barrierpreventsadhesion
formatiofbeiween,f," l"*",1"j
f.#"i:,:JI**
"",ry
a.riniiv"
g
4 Thecroih toporoiomy
Now, Placeiwo siliconedrarnson
the towels and bring them oui
ihrough separate stab incisions
Coverthe wound with a wide sienle
polyestr drape, comPleting .lhe
upper layer o{ lhe sandwrcn'
Connect the suctiontubing to a Y_
connector,then to a suclion source,
bag is unfolded bY
cutiing the seam and
then sterilized. We
suiureil to the skinalong
the edge of the wound
with a running heavy
monofilamenl sulufe,
preservingthe fascialor
the definitive closufe
This technique is more
than ihe
tima-consuming
vacuumpackbut provdes
inexpensive,alraumatic
containmentof the abd_
akeady know about
There isn t much we can tell you thal you don'l
The
correcttechnque
definitiveclosureof a midlinelapatotomyincision
withoLitersronWe do a tass closure
Jrutino Uiqoire"c'ote rogthFr,
sutJ'F'beoirnrrgai both
'",i i"v"",",i" ns . .-i19 heavymo'rofi'?mert
The cardinalsin s
middle
tn" i""i"i." and workingtoward the
distended
""a" "t
tension lf you siruggle lo contain bulging or
""0",
"i"""* ,f'"
f" ;uch betler off with temporaryclosure l/lakea
uo*"t,
outi"n,
"iff
rorrrn,*^.
_ ,* 44
8 CroltoI
i,outo
Surger/
iihtil*r,",31
il'r".ffi
:,T:iT,,H,",:
THE KEY
POINTS
)
)
)
)
)
)
In blunttrauma,
beginwithempirical
packrng.
In penehating
trauma,eviscerate
andt" t"r thebleede'
Exprore
rhesupram""""",::*
,;,;
Keepretroperitone",",r,:.;;,.,r;":::;J-*-.
An expandingceniral
hemaiomadoes
)
)
EnterihebelJy
wjththfeesweeps
'--- ''ofi'n" nn^
oneeducated
finger
"nd
siay awayfrom
ord
"""r".
Evisceraie
ihe boweteariy.
Feerrhemuscres
o,,r" ;";";;*,
t""""
,:";.
Do a rjght-sided
medialvisceralrotatjon
in threestages.
The Caiiell_Braasch
maneuverifrom
CE
) conian
and
prorec,,,,"
;;:; ;; ;;,:";ffi_:"_"
ChaPter5
Immediate concerns
g n d c o n l a i l s p l l l a g eo ' ' 1 l e s t ' n a l
Y o u rl i ' s ' p r ' o ' i i e s a r e I o c o n l r o l o l e e d ' n a
mesertery does
,i:"" ff'" **e' does 1oi bleed mJcn bJ'the
-"*t
",
vesselhas
lf the bleeding
retracted beiween lhe
leavesof the mesentery'
all you can see is an
expanding mesentenc
hemaioma.Raiher than
waste irme ttyrng Io
ideniify the bleeder,
simplyapply PressureIo
lhe area,We usuallyuse
either the assistants
hand or long sPonge_
holding{orcepsaPplleo
TheHolowo'nt*
5 Fllng TLJbes:
Missed injuries
will
wherecursoryinsPection
Pay specialatientionto five locaiions
oftenmissa holeln thegu:
c
tuophagogast
or
Lbament
Tleits
'nosl immeoiatecoiseorerces'
Mrssinga gastr;cPerfora'iorhas me
gLlt -lssing a I'ole
ci""" rL".qtomarhis tne 'nost vascLlarorgan ol tne
wthin a coLpleo{ hoursrac'nga
i""""- t", *if' be bacl in ll^eoR
Much like a
*atermelonfilledwith blood and clois
;" ;
Hil;;"
missed sastdc
;";"" the mosi problematicand easilv
;i;"J;;
;;;
wall near
posterior
or in ihe
iniuriesare locatedhigh on the lessercurve
;il
111';
;;;t;"
the
bv dividins
or the stomach
t"h"s'"ut"'
""u'
greatercurve
TOPKNIFE
TheAri & Croft of TroumoSurgery
ln additionto a very meiiculousexplorationroutine(Chapter4),
two
saleguardshelpyou to avoidmissinga hiddenjnjuryto the Gl ?aci:
1.
TubesTheHolowOrgo's n
5 Fr,lng
::ffilll
J:'l
::1"x1;;,:';li
3:l
r:r*il
:"1i1*:::':il"d1,"
';"::,*:;'
":"'il;"'
:i;"'i;
;r;:*ru:x'i:!J:,'il""i:'"
YoLdon\
;"-;;'iai";;i;o;-"sorLi'ons
to preventspillage'
andreconstruction
l've Io do a ro-mal'esecton
;';;;;;
areofte"ll|]*"1-1""^llllill
;;",;;.;''however,there
ard-assourarFd
phvs'orosv,
ffi.;:1."ti;;
;;
up.hor"
prcn
i": i" il"""i",r.-il rooarieri,y
i-,::]ill"]lljllt",i
tnFmostcommon'Y
tle'e ar
Bowel interruptlon oY
stapling across wfln a
linearsiaplerPfoxmalano
distal to the Perforated
segment, or ligating ihe
bowel usinga cotionlaPe
wiihoutreseci|on
Bowel resection without
anasiomosis is a good
solutionif ihe injuryinvolves
a bleeding mesentery ll
you have to resect a
considerable lengih ol
bowel in a Patrenl /n
exfremis, Your qulcKesl
fire
optionis to sequentially
cutting
linear
a series of
siaPLerswith vascular
Ulological damagecontrol
Ur ne spillageintoihe periionealcavty caffiesa much lowershort_term
nsk of infectionthan intesiinalspillage.If time is criticaland you need
to
get out of the abdomen, tle off a transected ureter and plan
a
percutaneousnephrostomyif the patjentsurvives.lf you haveno time
to
fepair an injuredbladder,just pack ii and rety on a Fotey catheterfor
drarnage- a suboptirnal
bul accepiablesolutionif extremecircu..stances.
It you have a few minuies,intubatethe tnjuredor transectedureter
proximallyusing any availableihin caiheter (such as a pediatricfeeding
tube). Secure ihe ureterto ihis drajn with a tie and exierlorizeihe drai;
throughthe abdominalwall. Leavethe distalureteralone.It will not leak.
The biggestm stakeyo! can make with a ureteralinjuryls io mobilize
and dissectoui the ureterin an attempito betterdefinethe injury.you will
only jeopardizethe blood suppty of the njured ureter and make
subsequefireconstructron
more difficult.lf you afe noi goingto repairit,
lust divertthe urineand don t fjddlewith the Lrreter.
HollowOrgons f
5 FixingTubes:The
runningstitch lt doesn'thaveto be
Close a bladderiniurywith a quick
layerwrll
if you are pressed{or time: a single
r."'"ni"1l","a
iay loi be
"^^ '
"t.a-*pair
tne besl oot;on' sLture closure
" ;." Wfit" a'wavs
vou'naveecr
oLcasions
L"j o,"r"'ir u u"'v,"tn"deleclOnrhose'are
theopenbladder
andiightlvpacking
lt *tr#r"J roih ureters
,ffi.ri
{orhemosiasis
i-,"i*n" it
Def inifive
"n "t""tt.nt
lePair techniques
TOPKNIFE
]he Art & Croft of TroumoSurgery
Someijmesyou have to develop a creativetechnicalsolutionfor a
proximaJ
gastricinjury.Jfyou cannotroli ihe distalesophagusand cardra
io exposethe injLrrybecauseit is posterior,open the anteriorwall of the
stomachlongitudinally
near ihe cardia,ihen jderiify and repair ihe hjgh
postenorperforationfrom withinih siomach.
Injuriesto the disial (abdominat)esophagusrequire the same
mobilization
of the EG junctionand care{u definitionofthe lnjury.lfyouare
operatingjn damagecontrol mode and there is no trme for meiicuous
dissectionard repair,inserta largesuctior drainintoihe open esophagus
and bring it out thfoughthe abdomifalwall, creatinga controlledlistua.
This effectivetemporarysoution eaves ihe door open for later
TheHolow O'gt*
5 FlxlngTLJbesr
E|
lManysurgeonstalk aboutcolocolostomy
for lrauma;fewerdo it
Deal with an niuryto the intrapeftonealrectumexactlyas you would
handle a peforaied left colon. ManagementoJ trauma to the
extfaperilonearecium used io be an elaborateritualihat lnclLrdediotal
diversion,repairof the injury,washoutof the distatreciatstump,and presacraldrainage.The currentapproachis much slmpler:
1 . Tryto identifyihe injuryusinga rigid procioscope.Repairit only if tt is
easrlyaccesstble.lf you suspeci a rectal rnjurybut canrot prove it,
perlorm an enrpiricalfecal diversion.A temporarycolostomyis a
nuisanceia missedlower rectalinjurycan be iatat.
2. Do a slgmoid loop colostomy.When properlyconstruciedat skinlevel,ii is totaly diverilng.Somesurgeonsuse a linearstaplerto ctose
the coionimmediately
distaitothe colostomy,oryou can sjrnplyiie the
sigmoidwiih a heavypolypropylene
sutureand anchorthe stitch to
ihe fascia.
3,
6IJ
t"*t
tn"-"*
tn"
"tr""t
awayfromextrapetonealrecialinluries
Bladderandwetet inities
word: DON'TLWhen
Here, we can summarizeour advice in a single
of an injuredbladder
oos"ifL. ast u urofogi"tto performdefiniiiverepair
las a beitergrasp of the varioustechnicalopiions
lr ureie. The ,-rrotogist
fest one for a specificsituationFurthermote'the
f]o* to
"loo*in"manageany complicaiionsand underiakelong'term
""J
ufolooistwill also
pre even wrlh
folrowl-rp.Wheneve. pocsibe. we aol^ereIo tnis onnc
Jto'ogst is nol
straiohtlo'wardilltapethoneal badde' njuries li a
avail;ble,damageconirol is alwaysa soundoption
>
junctron'
Accessproximalgastricinjuriesby mobilizingthe EG
>
rectalinjuries'
Dlvedthe fecal stteamawayfrom extfaperitoneal
reseciion
a.npoa,tt aa$
{
J
"49
^"- ^B carry'u'67-
- r^'v')
' /1,-0 \r,
----.-\
?'.ct<1 t{*:
o .L\}-,**G4-.
#-
&r'-
o-
(1fnt
t,.t".tzl-}\
'z
g,tt 4
&,t.-s-x-
uJ^rr^d r-*.4
r*7*l< -
Chapter 6
TOPKNIFE
TheArt & Croft of TroLrmo
Surgery
a
Lverrinl" v"'t"' Il
6Ihelnjured
thereare ihree posslbe reasons
incorrectlyperformedPrlnglemaneuver),
Jorongoinghemorfhage:
a
a
1
-
'ntlowocclus:on
Packsoo 1ol conlrolane'al b eeoilg Youreeo
inilow occlusron'
despite
lf the bleedinglrom lhe liver looks aderial
Try supracellac
ihe hepaiic ;ery may have an anomalousorigin
aodicclamPing
ihe liver'you
lf dark bloodi; gushingfrom the deep recessesbehind
you aren'i sufe' ask
are aeatlng*iih'a rei;hepatic venousinjury lf
the paiientfrom ih
disconnect
to momentatily
ilJ
uonf'r ed and yoJ
is
"n""tf'"""iofosi"t
your
s'rspicron
ventlalo- l{ tne b,eeoingabares'
ligameni'
lalc;forlhe
lncise
panentare i; dt;FlroLb'
,no
*::
''i,,:1
"or.
g"-'i, *i'i a"-p ald oushs"rirvPosr"rio'''
il:t: bleedlngwn |e
"
ilts tne rv"r ba'kward end maylemporarily"ortrolil'e
yol.rcolsioer your oprio,rsand orgarrTeyoJr attaLk
pack'or clamp
Controlthelivertemporarilyuginghand,
TOPKNIFE
TheArl & CroftofTroumoSurgery
S r.ilarly,puttlngyour hand
behrnd the right iobe and
rotating jt medialjystreiches
the right triangular ligament
and allows you to divide it
safely.Continuethe mobil
izatiof by releasing the
anteror corofary ligament
(takingcare not to inlure the
lver capsule or the right
draphragm)and then the
posterior coronary ligameni.
Your goal is to deliver the
eftire rrghilobeio the midline.
Be liberalwithyour mobilization,
but atso be carefulithe hepaticverns
and IVC are wa,t.rgtor a carele5s
move,ano tre smal,acce;so-yve 1s
enieringthe IVC below the right hepaticvein are easrlyavulsedwith a
6 rhe lnturedLrver'NinloMoster
bloodloss'andyou
iniurywithmassive
is a high-gtade
BIGTROUBLE
i lJsingyourpatientThedecisionwhetherlhe
*"'i" it.i"""ia*g"t
is the kevstategicdecisionin
ptoSL. or BIGTROUBLE
ii,y i"
" "."rr
lrauma
hepatrc
is not
injuriesdirectlylf a superficialaceration
Dealwith low_grade
pressure
for a lew
of"eJlnq,f"au" it lrone l{ ihereis slowoozing,direct
be
should
effods
stopsthe bleedingYour hemostatic
t""i."".U""
of theinjury(Chapier2)
themagnitude
proportionalto
With deePerlaceraiions'
have your assistant Pinch
ihe edges of the laceration,
turn the cautery to KILL,
and blast the faw bleeding
sudace, focusing on the
disruPied edges of the
hepaiic caPsule APP|Yihe
cautery to a metal sucker
lip to achieve a wider
effect.Use an Argon Beam
Coagulaior,i{ available,to
thoroughlYbarbequeihe
raw surface. Use a toplcal
hemostailcagent You are
Jamiliarwith from electve
surgery.
,-
tJ-'
TOPKNTFE
TheAri & Croft of TroumoSurgery
WrrhBlc TROUBLE,
youare ope.aring
..l damagecontrotrnode.Ihe
,
Key lo sLccess ts yorr ability-o srop the ooFraltol a1o o.ga'lizeyoLl
attack on the injury rather than get canied away and attempi
h;rorc
maneuverson an exsanguinating
patient {Chapter 2). The rest of thig
chapterdescribesihe techniqueswe have found most lseful in
baifles
wilh hepaticBlc TROUBLE.
"Packing plus,,
Packingis the techniqueyou will use most commonJy
for a high-grade
|ver injury.lf you have packedthe liver early as a temporaryhemostatic
maneuverand the bleedinghas stopped,you haveachievedhomostasis.
Removingpacksat this point is a mistake.
When you cannot be sure thai you have completehemostasiswth
packing,especiallyjf you hadto removethe packsfor bleedingbui did
noi
find any discrete arte al bleedefs, considetpacking p/us - imrnediate
postoperativeangiographywith selectiveembolizalionas a hemostatic
adjunct. Thjs is a risky undertakingin a critical patient and involves
mobilizingfesourcesthai may not be avajlableto you. However,if it is a
realistcoptionai yourinstltution,
selectiveembolization
of arterialbleeders
deep within the liver can be lfesaving. lf your OR has rntraoperative
angiographiccapabilities,the decision is easy, and embotizationis
possibiewithouimovingthe paiient.lt is crucialio makethe decisionearly.
Decidethat you are going fof angiographywhile you ar6 repackingthe
liver,noi thfee hourclaler.
Keep in mind that angiographjcemboljzationis an adluncito effeciive
packing,not a substitutefor sloppyhemostasis.lf you didnt packthe ljvef
properly,angiogfaphicembolization
will not saveyour patient.
Considerangiographic
embolization
as an adjunctto packing
Deepliver sutures
bl"'t 'ti1
c \ ' t t ' / n "c' ' ; ' ^
;'f*J(r. '
L+7
of tissue
Theycausenecrosis
Deeplivelsulureshavea badreputation
'liver
{ever'from
to inlectionor
in the stitch,predisposing
lnclorpJratea
rob
teoutalior
vol o{ an
ntec,iot Do,.t lel rhs bdd
;;;;ir*l
donI
i{
bahrewitl^tnp\rniaMaster'espec:aryvou
;;p#:#
,",'
oui
"
wlth the injuredliveror needa rapid bail
;;".;;;;*";"
a
dead
ihan
betier
is
far
O f,* O"t'*, *ith somehepaticnecrosis
""ili'"".
aust nave a,l i,rlacl caosule to
Wnen olac nq deep hve- "LLures you
as r vou are tyr'lg a sJrure
em Wh; ryirg righter ver)/ carelully
hol
parenchyrna
[utter' Look for blanchingof the liver
ir,-r,*gi oft,go""i
t:qhl Cl"oosea suru'e
u."",*,n. =ut,-r".w\icl'siqnf:esthe sulLrPis
spec:fc anatomiuc'rcJmstdnces:
r""a"r"t'"" Ihat is best lof lhe
posioperativebleeding As the
A irap with deep liver suluresis early
cJt lh'oLgh the ede'natoJs
rnureo l,ver swells the s'ilures mdy
and rebleedilq'
pu,"n"t'yt" *'tn 'o"" ot Lnehemoslaticef{ecl
iiJo"'" l"
lo findsarerv
goto tneheartot danger
"""'"o,*
,a-,oeenc
,rrLrrroa malo.reparc
: ll-:::*-nn
duct
o. h la. vesser.LJceir onty afler you havFo.ga'rizeoyoLr
ailact and
wnen rne pdnent c esLscitatedand ca'r io,erateadoilior.t
olood loss. lf
you don t have-ucn expefiercewirhneparictrauma,
deep rivFrsutJres
can Ee a s mpteralternative,
Hepatotomy
withselective
ligationis easiersaidthandone
6 TheInluredU'er: NinioMo'ter
Balloon tamponade
Whendealingwith a
through-and.ihrough
(transfixing)
lver injury,
whrchrnayoccasionally
Invoive both lobes,
renremberthe optionof
bailoontamponade- an
Ingenrousand easy
solutionto a very bad
problem.Thealternairve
is erlensjve iractotomy
to achieve direct
hemostasis.
lf the tract is wide (2cm in diameteror more),we use a Blakemoretube.
Insedthe iube intothe tractso thatthe gastricballoon,inflatedoutsidethe
exitwoundfrom the liver,will serveas an anchorto preventdrslodoement
of lle ruoe.Then genry ir,latFrhe esool^ageal
oaloo,rr. the tait u-ril
bleedingstops.
lf the tract is ioo narrowor ioo shortfor a Blakemoretube,we improvise
a balloonlroma .ed .Lbbercarheterand a pe'rrosedrain.T,eofl onpend of
the drain with two heavysitk ties. Tie the otherend afoundihe catheter.
creaiinga sausage-shaped
bal/oon.Checkthe balloonfor leaksbv iniectino
calinerlroughthe reo .Lbbercalhererard La-pirg f.
ne'aevce,i
working,insertthe ballooninto the lract and brjng the oiher end of the
catheterout througha stab rncisionin the abdominalwall, as if it were a
drain.Inflatethe balloonandwatchbleedingstop as if by magic.Securethe
red rubbefcatheierio the skinand makesurethe end is ciamped.
Youcan safelybegin removingthe balloonat ihe bedsideafter 24-4g
hours.Firsi deflatethe device,but keep ii jn placefor 6-8 hours.lf ihere
is no clinicalevidence
of bleeding,
pulltheballoonoui likeyouwouldafv
olherdraif.
Resectionaldebridement
bleeding
When a subslaniialpart of the hepaticlobe is desiroyedand
your
Have
debridemeni
orofusely,ihe mostexpedientopiionis reseclional
the
around
lhe non'injuredliverparenchyma
^"ai"t"ni n
your
o{ien
"nuully"otpress
area you wish to resect lf the lobe ls properly mobilized'
part'
minimizing
injured
ihe
assiint wiLlbe able to completelyencircle
blood loss whlLeyou do the reseclon
thai
Turnthe cauterylo maximumand use it to de{inea lineof resectlon
Always
is immediatelyoutsidethe injuredarea in healthyhepatictissue
iniaci
ate
vessels
where
the
area
resect imrneiiatelyoutsidethe injured
\ev
is
,he
rh,s
and have 1or rer;credi
"_j.=-jj!I:El_!jg]
of resectonaldebndemenl
maneuver
'pinched corn bread' maneuver)and
Perform finger fracture (ihe
The slmplest
selective ligati;n along your chosen !ine of resection
lobe along
left
lateraL
o{
the
examplefoiuse of this techniqueis resection
Llse
surgeons
Some
to the left of the lalciformligament
a llneimnrediately
ih
s
non_
a linearcuiting staplerwiih a vascularstaple load io faciliiate
anatomichePaticresection
Much like hepatotomyand seleclive vascular ligatlon' reseciional
Don'l
debridementtakes iime and involvesconslderableblood loss
youf
ze
Organ
aitempi it in a Patientrapidlydving on the operatlngtable
aliack and resuscitaieihe patientbeforeyou begrn
debridementin healthylivertissue
Performresectional
Othel techniques
The traLrmaliteratrrreis repleiewith manytechniquesthat resourcelul
injuries One example
suroeonshavedevelopedior dealingwilh bad liver
'pita
of absorbablemesh
is tie absorbablemeshwrap. By snuglyJittinga
elfectlve
arounda shatteredobe, ihe advocaiesof thistechniqueachieve
iamponade, avoidng lhe need for packing We find this technrque
c!mbersoraeand do noi use it,
TOPKNIFE
TheAd & Croft of TroumoSurgery
Hepaiicarteryligationis siill meniionedin traumatextsas an effective
hemostatic_
technique. Somesurgeonsuse ji for ongoingarterialbleeding
noi controlledby oiher means.We havenot usedthis iechniquein years.
How about drainirgthe inluredljver?This is a somewhatcontroversjal
iopic. One of us routinelydrainsall high-gradeliverifjuries usinga closed
suctiof drain,whilethe otheralmosineverdoes.
Rehohepaticvenousiniury
Gushingdark blood from a deep hote in the tiveror from behrndafd
around t usuallymeansan njuryto eitherthe retrohepaticIVC or hepatic
veins.Theseencountersare rare, brief, and brutal.[4or often ihan fot,
the resultrs of-tableexsanguination
and a veryfrustratedsurgeon.
The retrohepaticveins are ihe east accessiblevascularsiructuresin
the abdomen.You cannoi get to them and define the injuryunlessyou
somehowcontrolthe hemorhage.The classictechniqueto accomplish
this rs the atriocaval(Schrock)shunt,one o{ ihe ,,greattechnicalfeats,,of
traumasurgery.Youwillfind elegantlll!stralionsdeprctingihe techniquen
everymalortraumabook, bui not rn ihis one.Why? Becauseif real life il
very rarely works. In fact, even rn the most expeienced hands, the
atriocavalshunthas drsmalresults.
lrstead of engagng in Jutle heroics,use common sense. The
retrohepalicvetnsare a lowpressure sysiem amenableto containment
and tamponade.Yourbest move,therefore,is to containthe injlry, not try
and fix it. A retrohepaticvenousinjurybleedsfreelyonly if one or more of
its containmertstructuresis disr!pted. These structuresare ihe
suspensoryltgameftsof ihe liver (markirgihe bordersof the bare area),
ihe rightdiaphragm,and the liv6ritsetf.
Yourrealisticopliofs for dealingwith a retrohepaticvenousinjuryare:
a
a
a
parenchyma'
l{ dark bloodis gushingout from a deep holein the liver
pLugthe hole. Pack ii with a laparotomypad, viable omentum'or
ballooniamponade.Whateverii takes- iusi plug the hole'
'Pandora'sBox (Chapter10) A hole in the right
Don't open
diaphfagm bleeding inlo the chest in a patieni wlth penetratrng
thoracoabdominaltrauma can hide a retrohepatlcvenous rnlury
Simplyclosethe holeand don t mobilizethe hver'
When bleedingemanatesffom behindthe liver,iry to determineif the
sourceis belowor behindthe liver.Injuriesto ihe IVC belowthe liver
(ihe pararenaland suprarenalsegments)afe accessibleto direct
repair.lt's difficult,but can be done.
lf the suspensoryligamenisof the liver are distupied, your best
chanceto controlthe bleedingis packingihe areaquicklyand tightly'
Wiih limted disrupiion of the ligamenis,you may be able io re_
esiablishconlainmentwith packing.Wiih massivedisruplion,often
associatedwith a high-gradeliverinjurythe battleis usuallylosl even
beforeyou siad Packrng.
- don't be a hero
venousiniury,restorecontainment
ln retrohepatic
IOP KNIFE
TheArt & Croft of lroumo Surgery
THE
KEY POINTS
usinghand,pack,or clamp
Controltheliveftempofarily
>
as an adjunciio packrng
Considerangiographicembolizaiion
FiLllargeparenchymaldefectswith omentum
>
venouslniury'festorecontainment'don'tbe a hero
In fetrohePatic
Chapter 7
The
'Take-outable"
SolidOrgans
Fot eztery complex ptoblem, thete is a
solution that is simple, neat, dnil Tototrg'
- H.L. Mencken
The spleen
Mobilization
If you see or suspecta spienicinjuryyourfirst movemust be mobilizing
.
the spleento ihe midline.Youcan nejiheradequatety
assessnof repairthe
spleenwiihout havingii tn your hand. Mobilizingthe spleen is the key
maneuverthat unlocksthe left upper quadrani.lt bringsthe sp/eenand
drstalpancfeasoui of the dark recessesof the abdomenjntoyour incision
and exposes the left kidney.White mobitizingthe spteen is a basic
maneuverrn surgry,pedormjngit quickty,btindty,and tn a poot of blood
is not as it appearsin the illushaiions.
midline'you
The siuck spleenis, you guessedii' siuck To gel it to the
the
have to deal with two obstacles.The firct are adhesionsbeiween
your
nano
pass
you
let
will
not
ihat
wall
spleniccapsuleand lhe abdominal
youcan takeyour
lfihere is littleor no bLeeding,
overthe splenicconvexityBut if you
iime and ;harplydivideihe adhesionswith scissorsor cautery
quicklygel them
are workingin a poolof blood,just do whaleverittakesto
to ihe splenlc
Damage
oui of ihe way with yourfingers,scissors,or boih
capsuledoesnt matiersinceihe sPleenis comingout anyway
The secondobsiaclewiih ihe stuck
spleen ls a short and unyielding
splenorenalligament.Put your nondominanlhandover the spleenso the
tips of your fingers resi on the
behlndand lateraltoit This
menrbrane
is the splenotenalligamenlGentlypull
the spleentoward you io stretchihe
ligament.Workingin a pool of blood,
you often cannotsee [, bul you can
easilyleel it. lmmediatelybeyondthe
tips o{ yourfingers,makea nick in lhe
wiihyourscissors
streichedligament
(withscissors)or bluntly(withyour{ingers)up
sharply
the-nick
Enlarge
Ligaments
splenophrenic
anda;oundihespleenBoththesplenorenaland
are avascular'and dividingihem
allowsyou to bring ihe spleento ihe
midline.
Palpatethe left kidneyand bluntly
developthe planebehindlhe spleen
and in iront oi the kidney,bringingthe
spleenandtailof the pancreasup into
the wound.The piifalLhere,especLally
in the prcsenceof masslvebleeding'
is going behindthe left kidney and
thatyo! havebroughtlt t0
discovering
wiih
midline
the
You.
Remooeot rcpab?
Youarenowfacingthekeyslrategicdecision
ln sp/enictrauma:
romove
of repair?Splenectonry
or splenorrhaphy?
Forsplenicrepair,considertEumaburden,age,injury,andexperience
,l
."tt /'
7
I
compteungthe s1lenecto,nq
CJi""'y Lo the imorsson you may havo fro.r readingthe rauma
literalureol the pasl decade,splenectomyis not a crime lt is otten ihe
safest and mosi expedientsolution One very effectlvetechnique of
is the {omalin jar
splenicpreseruation
Once you have the mobilized
spleenin your hand,comPleling
the splenectomyis easy Clamp
and divide the vessels of the
splenic hilum from the back or
side, whichever Ls mosl
convenieni.The key technical
prlnciplehereLsto stayverycbse
to thespleenso youwillnoiinjure
the tail of the pancreas or lhe
siomach.Fot the sake of sPeed,
,..\
ij
O'ncl"t E
7 TheTokeoulobe SoLid
pachl wor\s in super{'cia
Local pressJ'e lwrlh yor- hand-or a
rocdl hemostaircagert
laceratro']sand capsLlaravu's;or- Your lavorfte
if availab/e'does wondersfor
.f". n"fp fn" ,q,g"n beamcoaguiator'
"""
rawsurfaceor a deeperlaceration-
a larger
are-ovo"r:::':lH
0."J",'".**. t", **'e theolPeders
T,i.il
Argonbeam Youcanthen
oversewthe op6n splen|c
'siump' with mattfess
suturesbetweentwo sirips
of Teflon.lf the sPleenLs
flai rather than bu kY,
anotheroPtion is using a
linear staplefwiih 4 8mm
staples.Bring the stapLer
io the line o{ transection
and slowlyclose I so as
noi to break the caPsule.
Fire ihe staPler and
amputaiethe sPlenictissue
disialto the staPledline.
7 Therake-oirioblesoioorgonsI
the injured area What.you
open the posterior peritoneumoverlying
or superrical
i" be an innoLenr-lookingminor hernatoma
;;"";;
it
you
un'oo{ and look il in
*,, .f,"^ oro"e a st;ousInjurywh"n
i"""*."
fie lace.
For signi{icanlinjury, and
especiallyif You are going lo
resectthe dislalPancreas,the
quickestway io bringihe body
and tail into{ullview (including
the posterior asPeci of the
gland)is to mobilizeit out of ils
bod. Mobilizeihe sPleenand
continueto develoPihe Plane
behindthe Pancreaticiail and
body until it can be lifted
medialLylnto the operative
incision.DistalPancreateclomy
without splenectomy rs an
laborate exercise suitable
mosilyto an electivesituatron.
We do not recommendnor use
it in traumapanents.
Iook
"t
left
Decision
assessrngIne
ls thete a ductal injury?This is the key quesuonwhan
pancreasls
ihe
that
see
iniuredpancreas someiimesyou immediately
['4ore
in
wound
deep
a
;;;;iJ
vou can rdenlilylheinruted duct
'niury
palpanon
and
basedon Inspeclioi
tu," out a duclal
you ",
ot
""n;ot
"n,
alone.What then?
maiof
inir
e,ercise
cared,nraopar,,
r";;.;;;:;#;:;jJ:i;T,:lj"'j;::ilI:
-catn.rer
II.e ga,'bladderrrrough a ";
reedle and
7 The Toke-ouiobleSolidOrgons
lf you happento come across the
pancreata duci, ligate it Otherwise,
don'i spend time looking{or it. Liit
the spleenand the Pancreasto the
midline,lake a linearstapler,placeit
across ihe body ol the Pancreas
includingihe splenic vessels,and
shoot.Amputaiethe disialpancreas
and spleenand give the Pancrcatic
stump a close look Control any
bleedingfrom the splenic vessels
with a hemosiaticatiich.One ol us
usuallyundeffunsthe siapled line
with a 3:O monofilament nonabsorbablesuture;the other nevet
does. Don'tforgetto leavea closed
suctiondrainin ihe pancreaticbed
'+ @
Thekidneys
*"*tH
Access&ndotlscttltu contxol
the iniufed
At laparotomy,
presents
as
kidneyiypically
a lateral feiroPentoneal
(perinephric) hematoma
(Chapier 9). Deal wth a
massivelybleeding kidneY
in an unstable Patient b),
rapid mobilizaiion and
contfol of the vasc!lar
pedicle,just like You deal
with the iniured spleen A
TOPKNIFEThe
A.t & Croflof]rounroSurgery
/.1-J
V,r
7 TheTake-outobleSolidO,S.",
thisallowsyoubetter
firstbecause
(distalanastomosis)
io ihe renaladery
Choosea convenient
," tr't" posterlor*atl of the anastomosis
aoria'convolii wiih a side".|e""
L"ationontnelat"ratu"pectof theinftarenal
the
graftand comPlete
Uiti"gautp, anddo a smallaoriolomyTrimthe
in anendio sideconfiquration
lo the aortotomy
pror-mal
anastomosis
Don't killthe patientwhile kying to save a kidney
doesnt work
Don t persistif splenorrhaphy
leJi
Look at ihe pancreasfrornihe tront-but mobilizeit fior' the
'
and dfaLnage
Damagecontrolfor the distalpancreasis hemostasis
>
kidney
Palpaiethe contralateral
ChaPter8
Soul
Surgical
The Wounded
i^ "/''r+vu'!
t ')u7
(vQ
t!a-,.'a^*
Immediate concetns
Yolr first priorty wlih soul wounds is to contro her.orrhage.Always
assr.rme
lhal bleedingis from more than one major vascularinjury unti
provenotherwise.The major bleedlngsourcesafoundthe surgical
soul
are arrangedin ihree layers:deep, middle,and superfrciai.
fhe deep layer includes
ihe IVC and the righi renal
pedicle. You will see a
raprdly expandingrighrsrded retroperrioneal
hematoma or active bleeding
from the area of the righr
renal h Ium- Pack or
manuarry compress it.
Don't unroofit.
2. fhe niddle layer irc)udes
tfie retropancreatic
vessels:
the superior mesenteric
artery (SIMA) and vein
(SMV),and the portalvein.
The secret of tempofary
b eeding control ts rapid
mobilization
with a Kocher
L
-\ji.'.------'-'-.
\:1,--:1.)
g
sThewoundedsursrcosou
the rool ot lhe mesentery
maneuver(Cl'dple'4). lf bleedingis {ron
yourlelthand
it byinsinuating
control
iJ"t i."rJ., ,"f *" o"ncreas'
ihumband
it beiween
andpinching
s.i-i"a'iil ."t ortr',..eseniery
mdnJally
{oref,noer.l{ the sourceo{ bleedrngis beh no the oarcreas
Temoo'anLy
complex
pancreat;coduodenal
t're ent're
"ompr'"ss
fiom the hepaioduodenalligamentby pinchingthe
bleeding
control
portaltriad (Chapter6)
3. fhe su?erticial laYer
consistsof ihe iniured
pancreaticoduodenal
complexrtself.Injuryio
the head of the
pancreas can be lhe
sourceof brisk bright_
red bleedingfrom the
pancreaticoduodenal
vessels, Here again,
ihe quickest way to
gam temPoraryconrrcl
is a Kochermaneuver'
which enablesYou to
comPress the entire
pancreaiicoduodenal
complexin Yourhands
of encircle il with a
Penrosedrain lo gei
temporaryhemostasis
while others
Some soul woundsbLeed{reelyinto the peritonealcavity'
he_laromaCo'Irol o'i'ee bleedingcomestlrsl
as a conlarneo
DTesent
'pote skunk'by enrenrga coniained
unli all1e
hemaLomd
a
Neverever
your
attack'
bleedinghas been controlledand you haveorganized
patient
Supraceliacaortic clampingis a usefuladjunctin a cfashing
(to
control
aorta
infrarenal
Doubleclampingof bolh the supraceliacand
mesenlenc
backflow)helPsreducebleedingJrominiuriesto the superlof
field'
vesselsand the portalveinbui will nol dry up lhe operative
Imptoving exposure
The keyto anfhing you
may need to do around
ihe surgtcal soul is ihe
wrdesi possjbie Kocher
maneuver(Chapter 4).
For bleeding from the
deeplayer(lVCafd right
kidney), extend the
Kochermaneuverinto a
full right-sided medial
vrsceralroiatronby mobiJizingthe right colon and
retractthe liver cephaladto create a wofk space around
the pararefal
lVC. lf the rightfenathitumis involved,
mobilizing
the rightkidneyout of
Gerota's fascia afd rotating it mediallyhelps you gain control
of ihe
hilum.
I T h ew o L r n d e dS u r g i c o l S o u !
The retropancteaticvessels
InJunesto the retropancreatic
vessels(the confluenceof the superior
mesentencand splenicvetns,as well as the reiropancrealicpart
of the
SMA) are particularlyjethaj becauseyou can,i get to them. pancreaijc
rfans-Aclonacrossthe neck exposesthese injuries.One
of us finds this
techniqueusefuland lifesaving,
whilethe otheravoidsdividingthe neck of
the pancreasunlessthe jnjuryhas done it for rrm.
To transectthe pancreas,compressihe breeorngpancreatrcoduodenal
complexwith your left hand to temporarilycontrol the
bleedifg. Do a
co-.]pele Cafel-Braasuh maneLverro oplimtzFacLess io
the complex
'rom all s.des.
Rapiorycreatea relropancrea,ic
tun,reloy openingtre
hepatodlodenailigamentand blunflydissectingimmediatety
to rh; teft,
anterior to the common bile duct, and behind the pancreatic
neck.
Transectthe neck of the pancreasusingihe cauteryoveryour
finger,but
surqicolsoul
A
8 rhewounded
inlo lhe lunnelbecause
avordot-shingInsfumentslc'amps or slaolPrs)
'njJ'y Cudng rhe
a retopancleai'c porta' vei'r
t"." ,l^"
iniu'ed
ra'ge vein Lnde'nearl^'
""',rt"""," tace-loJacewith rhe
u.i"n"
v.,
""ri".""i
to l:x i Conl'ol blFFdng rror the eoges ol the
,"
Ii"^-t",
"oo"n-',yror t'om adlacerr bleFde'sr onlv atter vou have
p""f,"r.
i"."""i*"
controlledthe iniuredpodal vern.
'epair o{ the retroparurealicveins However'd
It oossible,do a laleral
liveoatierl' take
you Jno up wiil_a ligated{o/ oversew.])porta'vFir a.ld a
yoursefi
a deep breathand congratulate
podalveinconfluence
Transectthe pancreasto gainaccessto the
..'l
..'.)a-.
rre
rIU?o srMvrt yoJ "cani i, nor.,;gare:r. Fotlowing
",,T:"J^:,#T"
hgalronof Fithert1Fportal
vernor ihe SMV ihe jneviiableconsequencejs
massivefluid sequestration
an^dmidgut,edema,
whjchtranslateinto extremelyhigh postoperative
fiuiJ
requrrements
and an tnab/lityio closethe aboomen,In iact,
as we wrote
ris;ri";.
l,':
:::o]L oac\
: l?l'*'"
nrs vacLLr
drdiredib itj tttersoi sero,rst,u;ofro_ rhe p"n-torea,
cavty on lhe fjrsi posloperatjve
day.Don,tforgetthat venousgangreneof
'" , oirr ncr rhrear.so
atwaysoo a se.ond rook."pa,o-romy
ro
ll: T.y:i bowei
ascedarn
viabitii!
Blindclampingat the root of the mesenteryis
a recipefor
The pancreaticoduodenal@mple.,
disaster
..
il;"l'J;j"n,."
8 TheWoundeclSurgicolsouL
Duodenal injuries
ln mosi cases'
Can vou closeihe injuredduodenumwilhoutiension?
suiure Justas
lateral
a,simple
a"ti"iii'i |'"p.i|.of a arodenal laceraijonis
iransversely'even il the
in small bowel injuries,orient your suiure line
!s
io avoidnarrowingthe lumen lf the lacerairon
lacerationis longiiudinal,
u u"nsverse repaifwithouitension'do a longiiudinal
tio iono,o
""fli"""
is a matterof personalpreferenceWe usually
,li"i. it"
"rtur"t""lnique
fashion
do a sinqlelayercontinuousrepairin an inveriing
'oopon lhe pancrealic
Tne probleralic wounosare ins'dethe duodonal
of the laceralionis difflcult
precisevisualization
aso"alt tt'" watL,wt
"re
wall of a struciurers
,qs in other situationswhere the injuredposterior
lhe ouoderLmand teo,ai5glhe iriury
consrde'openi.1g
inaccessible,
't!'1
'a n\aw
'ron rheirside.
u.$:i'rl '1)1
-i-fl
- r'*
tnan a siraigl^torwardsho'r
reparrr\ar is
Protecl any ouode.1ar
good
advicefof suturelinesthat
This is
pytorl.
tin"
"xclusion
"
Sorne surgeons
"riur"tong,"niit'
tenuous
nlrltiptL, delayed' or appear
aie
dJodenostomyor Dy
decompies. duooenalrepairs etne' by a aleral
parl o{ a 3_IUbe
-""g*0" trbe {romil'e p'o{imaljej'r1Lmas
We
jeiuroslomy
ng
a
fe"d
ano
"""rt'"n,
svs'emtnat also inclLdesa gastros+omy
-epai's
al'duoo"nal
drair
br''we
n'."i ror,in"ruao, *o" duoienosromy
drain
suction
exlernallywlth a closed
I t3,,1'4
rh
L * N
There.areno good damagecontrolopiionslor
a bad injuryrd rha 9nd
part of the duodenum.lf you need to bail our quickly,approximare
the
edges of a large defect around an externaldrajn to convert the open
duodenur.Intoa controlledJisiula.Thlsshouldbe an absolulelylasi resoft,
since repairingthe duodenalinjLrryis alwaysa much beiter option.
Repairinaccessible
duodenalinjuriesfrom the inside
Pancreaticiniuries
What are the damagecontrol optionsfor injuriesto the head of the
pancreas?For a non-bleedinginjury,the quick and simple solutionis
externaldrainage,convertingevena majorduct disrupiionintoa controlled
pancreatrcJistulathat has a surprisinglybefign naturalcourse.
Bleedingfrom a proximalpancreaticinjuryrequirescarefulassessment.
Once ihe pancreaiicoduodenal
comptexhas been mobilzedby a Kocher
maneuverjcofirol bleeding by local pressure, hemostaticsutures, or
packing. Unless the entrfe pancreaticoduodenal
complex is shattered,
massivehemorrhagefrom a proximalpancreaticinjuryis alwaysfronr an
undeiyingmajorvascuar njury.
Don t fiddle with the pancreastThe classicteachingis to estab|shthe
presenceol a malorpancreaticduct injury.Realityis somewhatdifferent.
lntraoperative
examination
ofthe lnjurywit setoomprovroean answer,and
you are aheadyfanriliarwith our lack of enthusiasmfor oniable
pancrealography
(Chaprer7). The truth is thai it probabtydoesnt matter
whetherthe duct is rnluredor not becauseexternaldralnageworks well in
concept
Thosewho like playingwilh dynamiteadhefeto the traditional
Io ls perfor-lrg a
of o'pservirq palcrealic tissLe Wnal ir amoJrls
Fig,r-rrsl
on a 'rormal pa,rcealic sl'mp a
o"ri"*":."1"1".*".v
'or
ev.n J.]Oerrne besi eleLllveclrcunstarcesCons:de'
,"..,..*i"
pancreas'where fie
example,the optionsfor lraciure of ihe neck of the
againstihe splne The
ot"na i" tr"n"""t"a by an anteroposteriorinrpact
proximalslurnp'
oJ
iafest definitiveoption for this injury is closure the
the open drstaL
followodby resectingthe disial pancreasor oversewing
oi the stump
st!mp. Analomicalreconsiructionwould meandebridement
loop of
."1 i*ti"g a normalso{l pancreaiicremnaniinto a Roux_en'Y
a
bowel
and
head
pancreatic
bowel, in ciose proximityto an oversewn
y
usiastical
Wh ile enth
sutureline. lf this sounds unsafeto you' we agree
feports oi what
described in texibooks and often discussed,current
indicatethls
about)
talk
they
surqeonsactuallydo (as opposedto what
learned
have
i" u",v *t"rv used Apparenily,enoughsurgeons
pay
not
pancreasdoes
"pplo".n
tie oainfullessonthat{iddlingwith the vaumatized
We preferio closethe pancreaiicstumpand drain ii
for trauma
Avoidpancreaticoieiunostomy
Combined injuries
'niuriesto Ihe pancreasard
Bleeo,ngpaiienls with comor,red
So slop
_oI de tom a dLodenaleak lhyersangurrale
a-oden.,m-oo
do I
duodenum'
the bleedingand bail oui l{ you can rapidlyclose ihe
conlrol
and ligaiionio
Otherwise,use a combinationof externaldrainage
a laterreconstruction
for
Relurn
Juodenal,biliary,and pancreaiicconteni
if the paiientmakeslt.
divertingthe
Pvloricexclusionls an effectivetechniquefot temporarily
complex
qast'ric
away {fonr the iniured pancfeaticoduodenal
procedure
we
"ontent
elegant
ihis
nuehavea bias toward
i"ing e"yrot
"rtg"on",l- -lordan,Jr', who conceivedii We adviseusingt
i""rnl"a tro. e"otg"
injuries
to oroteciduodenaisututelinesin combinedpancrealicoduodenal
is
intact
ampulla
wherelhe duodenumcan be closedand ihe
TOPKNIFE
TheAd & Craft of TrournoSurgery
After repairing the
duodenaiinjury,identify
the pylorusand makea
longitudinalgastrotomy
on the antefiorsurface
of the antrum,close to
ihe pylorus. Through
the gastrotomy,palpate
ihe pyloric ring with
your lrnger, gfasp it
with a Babcock clanrp,
and pull it toward you.
Ovefsew the pyloric
ring with a heavy(size
0) suture on a large
needle,iakingbig bites.
We lse a monofilament
suture,but regardlessofthe suturemaierial,
the pylorusopensin 2,4 weeks.
Infact,you canslapleacrossthepylorususinga linearstaplerwiththe same
result,
Once the pyJorus
is closed,brlng up a
loop of proxima
jelunum and do a
gastrojejunostomy.
The Jast siep in the
procedureis pfoviding
a route for enteral
Jeeding into ihe
jejunum.The operation
is noi ulcerogenic,
and vagoiomy is not
part ot it.
l oul
8 T h eW o u n d e c5l u r g i c oS
slnce Lt
The Achillesheel of pyloricexclusionis ihe gastroenierostomy
some
probem'
this
cades a significantrisk of nonJunction To avoid
relyrng
surgeonspreJetlo do pyloricexclusionwithoutgasiroenterostomy'
on distalenteralfeedinguniilthe pylorusopens
lines
Usepylodcexclusionto protectcomplicatedduodenalsuture
,vf-\
Use
A vaumaWhipple is tha ultimatebig whack of abdominaltrauma
complexis destroyedor
it as a lasi resoriwhen the pancreaticoduodenal
solutionwill
when the ampullacannot be reconstruciedand no simpler
when the
Whipple
a
trauma
work. ll is oftensaidihai you shouldconsider ror
'he b g
lies
Hrein
:nJ1 l^asalreaoydonemoslof lhe d:sseclion you
snatterpd
nlrrao" ot rnis'operariol: tn" e{sangurnalirgpaiierL wlh a
palient
who
A
-tabre
it
curvrvF
to
is Loosick
i".l,".i""ar.o*a
akernat've'
".rp'ex
lesser
a
Jf .rru,u" n o{Iendoes not need t so choose
howeverimperfeci,wheneveryou can'
TOPKNTFE
TheArt & Croft of TroumoSlrgery
Thethreeimportant
differences
betweena Whipplefor tfaumaanda
r,arcerar": drssecring
the Lnc,nare
orocess.removrrgtne
lllllp,:,a'
gaIo|adde.,
andstagedreconskuclion,
a
a
as the patLentls
Are you goingto hook the pancreaticstunrpto bowel
u,ril o{ orood?YoL rust be kiodngl A raoid dislal
*tino'rl"-g+ti
'eft side of Lhe
pu""r"""t"atotu howeve' may enabreyou to reacn lFe
eatic Porialvein
retropancf
Conslantly
Theseexamplesshow you how io simpli{ylacticalsituationsinJUry and go lor
ask yourselfwhal the simplestsoluiionis for a specific
who ihinks
il. The only hope lor a patientwith a soul wound is a surgeon
_
about sprralvern
abour liqaiion,resection,drainage'and shunting noi
pancreaiicojejunostomles'
graftsaid Roux_en_Y
injLlry'
Soul woundsbleedlrom moreihan one vascular
>
portalveincontluence
Transectihepancreaslo gainaccessto the
for disaster'
Blind clampingat the root of ihe mesenlefyls a recipe
>
itl
Don'lfiddlewiththe pancreas'drain
for trauma
Avoid pancreaticojelunostomy
Usepyjoricexclusion
to protctcomplicated
duodnal
suturelines.
Chapter9
*zi,:i?::i',;X:,Til;
antheAssas"^"."
canmission
"f
Hematoma
OperativeApproachto Retropedtoneal
Explore?
Hematoma
Proximal
control
PenetEling Blunt
Midline
N4idline
res
Yes
SuPraceliac
Matioxmaneuver
Yss
lnlrarenal
aoita or IVC
Infrarenalaorijc
exPosureor right_
sided viscel rotaton
looping
Distalaorta/
tvc
AbdominolVasctror rrourio H
9 BigRed& BigBlLre:
Midline suPramesocolichematoma
All midline sLrpfamesocolic
hemalomasmust be exPloredlf
thepatieniis in shockor if Yousee
fromthe
rapidaclivehemorrhage
supramesocolicarea, manuall)/
compressthe supfacellacaona
(Chapter 2). lf ihe Patenl rs
siable, begrn
hemodynamically
wlth the Maiiox maneuver'The
rctationallowsyou
medialvisceral
prcximal
control of the
gain
to
aota bYcuitingthe
lowefthoracic
lefi crus of the diaphragm
(Chapier4). AlwaysobtaindislaL
control above ihe aortic
bifurcationbecause without it,
considerableback bleedingwill
and ihe
Iniuriesto ihe patavisceralaodic segmentbetweenthe celiac
lethal They are alwaysassociatedwith injuriesio
renaiarteriesare highly
'Blooo
'o"" '" typicary -assive confo' is not
".ort"t.and repairreqJiressJptac'iac
ula-ping For althese
"ii"l".t
str'ao'rforwarO,
you
can'
il
repair
reasins, iry to get awaywith a laieral
g'alt yoL are obvously
'nte-posiliol
ll vou mJsr sew n a sy1ll^eLrc
ot
racinoaaainstine rela' ischemiclime' ano lhe oalienr'schances
latge'
cligl"tly
n'akin'qiiare not sreai S-"lecta \,littFd Dacrong'ail lhalis
rr shocl<r
oaliert
ol
a
aona
the
oecaus"
vou.lg
ir,".,i" aon" a'i."*t
Since you have no alternaiive,don t hesitateto put rn a
vasoconstricied.
no enectLvo
orafi even in the presenceof intestinalsPillage Thefe are
'n;ur'es
hoPF s a
patrenl
s
only
The
iumaq" conror op ons fo- thesF
for
associated
soutions
out
bail
,-i. i"ri"+"" rapai'of the aortaano
Inlunes.
TOPKNIFE
TheAl-t& Crofl of TroumoSurgery
Pentratingtraumato ihe proximalfenalarteryis essentiallya side-hole
in the aorta. Initia control and exposureare the same as previously
described above. The realisticoptions for definiliverepair or damage
conhol of the renalvesselswere describedjn Chapter7.
Injuryto lhe celiacaxis or lts branchesis uncommon,but deadly.
Typically,you see a gastric injury with either an expandinghematonra
behindthe stomachof brisk aftefal bleedingfrom behindand aboveihe
essercurve.This is one of ihe toughestand leastadvertisedsltuationsin
abdominaltrauma.
Wh le you car gain
proximal control of the
celiac axis by rnedial
visceralroiation,this wil
not help yo! see or
controlbleedinglrom its
branches. Furthermor-o,
the operal/ve circumsiancesmayforceyou to
attack the bleederfronf
the front. There are no
slandard prepackaged
solulionsfor this d tficuli
silLration.A lechnique
that has workedfor us is
insertinga gross hemostaiic stitch wiih a heavy
vosculorlraur'o E|
9 BlsRed& BisBluerAbdomjnoL
s;t'iafontnatprelpnis
IntLryIo tne p o\rmalSMA 15anothe unlo-giv'ng 'he
sMA dbovelhe
.ematomdAn irjLryto
,"':';:;"
";';-"'"colic anteriorhole in the suprarenalaorta ControlI
J *""*'",'t
the aorta
"n
""*r"*
Uyp"*orming a Mattoxmaneuverand clamplng
iror tt'" t"t
injured
get
the
to
"ia"
then
You
can
*J oa"* ,i" t"le-off o-fthe vessel
oment!m
in the lesser
"0"""
SL4A,eitherfromthe side orfront, by makinga hole
These injuries
caudally
pancreas
and retractingthe upper border of the
bowel
adjacent
and
pancreas
wiih damagelo the
are tvpicallva=ssociated
by
followed
ligation'
Ott"'nyour b""t option*ith a proximalSMA injufyis
retrogradereconsiruction
is achievedby
Control of bleeding from the reiropancreaucSMA
SMA below ihe
dividingthe pancreas (Chapter 8) An injury to the
of the mesentery
parcre-aswill manifestas a largeher'atomaat the root
ng a tenrpofary
The damagecontrolopiion for S[4A injuriesis insert
{orthem
Wt it"i"" t'"u. not done it, othershavereportedit wofked
ano vasoco,rslicted
"lrnt.
t ioari,rqt're proximalSIVIAi_ a sFvereryhypotelsive
-o bowel iscl-e-id So \ow
il
lFaos
p."t,"nt:. noi gooa op ro' oecaJsF
"
shouldyou reconslructlhe SIVIA?
The pinciples are lo use
the most exPedientmethod
andstayawayfromthe injured
pancreas,becausea aKrng
pancteas and an anerlal
sulure line dont sri welL
togetherTo do a retrograde
from lhe infra'
reconsvuction
mesocolic aorta, J/ou need
accessto the side or to ihe
posierior aspect or tne
vessel,Youcan approacnfie
SIMA immediatelybelow the
pancreasand frori the left b)/
dividingthe liganrentof Treitz
the fourih
and mobiLizing
portionof the duodenum.
aorticinjuryasyouwouJda rupluredaortic
aninlramesocolic
Aooroach
retractorand ofganize
place
a self'retaining
lf you havetme,
aneurysm.
and
theo;erativefieldlo keepthebowelevisceraied outof vourway The
g
9 BiqRed& BlgBIue:AbdominoVoscuLarrroumo
classicpitfallln proxirnalconirol
o{ lhe infrarenal aorla rs
iatrogeniciniury to the LRV or
lVC. To avoid ii, look at ihe
shape and Pfecise locatlon ol
the hematoma.ls ii distal,away
from the root of the transverse
mesocolon?lf so' ihe 'sk ol
inadverieniinjuryto the LRV is
small. Mobilizeihe ligamentof
Treiiz,refleci ihe fourth poriion
o{ the duodenumlalerally,and
enter the safe PedaodicPlane'
Blunily cfeate a space lor a
clampon boih sidesoi the aorta
using Your {ingers However,if
the hematomaexlendshigheruP
obscuringihe ligamentof Treilz'
it will be much safer io gain
supraceliaccontrolihrough the
man!allycompresslrglne
Lesseromeniurnabovethe stomach,eltherby
ot the
the spine or by clampingthrough the tighi crus
".,t" "g"ln"t
diaphragm(Chapter2).
and' using blunt
Wlth proximalconirol in pLace'enter the hernatoma
in the
oti"nt yourselJto avoidthe LRV Dlssecidistally
ai"""iiiJn,
the
below
your
clamps
".t"turrv
to a"tin"it'" injLrry'Reposition
."r-""nt
or
aoria
distal
lhe
tfoublesomeback bleedingfrom
i*Jlrt"r,"" "f"*to
"onttot
I
tom 'he lLmbarafe'es ard oegn lhe reoa
hematoma
-eware of iahogenicveininjuryin an inframesocolic
lor the
we cannotof{eryou good damageconiroloptlons
lJn{odunateLy,
lemporary
a chestiube as a
infrarenalaortaeither'We havelried inserting
survivor'However'in 1945'
a
have
not
but did
"irrutlons
aorticde{eci{rom a
""t,"*"
"tluniin
C.i. Hotr", ot Cin"innuiibrldgeda large abdominal
The Infedor
t' ''t"t
Vena Cava
vasculorlroumo
9 BlgRed& BigBlueiAbclomlnol
or cannotapolyd slde-bililg
tne b.eoi'1g']olebui ca11oldelile the edge
r'1lot\F lJmpn
rwilh
a 3omlballoo,1r
clarp,'n.e-rnga ld'geFolevcatnercr
and inflatingit can helP.
warn you ot a
A hematomabehindor aboveihe duodenalloop should
retfactor
Deaver
long
cavalinjuryaroundor abovethe renalveins lnserla
compress Ine
over the inferior surlace of the liver and iow ln to
the liver 10
reiracting
supfarenallVC, while simultaneously
inaccessibLe
posterior
and
fl.it"O wofk space Expose lhe right lateral
or*ia"
kidney medially
"
!"0""o oi tf'" pafarenalIVC by mobilizingthe tighi
to
improveaccess
impuniiy
wiih
you can divideihe proximalLRV
Similarly,
of the IVC
conitol
to ttre titt siae ot tle tVC. Evnwith these maneuvers'
ai or aboveihe renalveinsis a realtechnlcalchallenge
Pelvic hematoma
lJfless you specificallysuspecian iliac vascularinlury,do not oper a
pelvlchematomain a bluni ttaumapatent wilh a pelvc lracture You w ll
only make matterswofse. lf you tind yourselfJacinga rupiured pelvc
hematomain such a patient,your best moveis to quicklypack the pe vis,
which shoud controlvenousbleeders.Fo low th s with a tapid ter.pofary
fof selectveembolization
cosureandproceedto angiography
abdor.inaL
iniernal liac arieties.
of
lhe
cally
sma
I
branches
bLeeders,
typ
of aderial
Ina patientwithpenetrating
t|auma, a pelvLcnemaloma
meansinjuryto an iiac vessel
unlessprovenotherwise.You
must unroofthe lnjuryand flx
it. lf the injuryis on lhe right,
mobillzethe cecum;lf on ihe
lefl, mobillzethe s gnroid.
When you can t be sure and
suspect a bilateralinjuty,
doing a full Cattel-Braasch
maneuvergrves you wde
exposureof the illac vesseLs
and keeps all your opiions
open, Now you musi gain
controLof the pelvlcvessels.
Pfoximalconirol is obviously
not enough. You maY have
forgottenthe ntenraliiac
Abclomholvosculorlralmo
9 BigRecl& BigBLue:
What are your repairoptlonsfor the iLiacvessels?By the iime you have
gainedvascllar control,ihe patienthas iypicaly sufferedriassve bood
oss and has associaiediniuriesto olher abdominaotgans, usuallyihe
og sl and assesslhe
co on. bladderor smallbowel.Talkio the anesthesio
jnsult.
Moreoltenthannoi, the siiuationwil
magniiudeof the physiological
1.lf the artety requres on y a simple
contro
wrltten
alL
over
havedamage
l a l " ' a ' e p a ' - j - s _ o o i . l. f r h ei _ j u r iys m o ' ee n e n sv p a t e - p o r c r ys l ' u 1 l
is a classicand effeciiveba I oui ootion.
hols,andbeforeyouknowit,1hegameisover- you'velost.Thegmartest
movsyoucanmakeis ligatelhe vein,
ShuntingaRdli$lion ar the bailout optionsfor iliacarteryiniury
Reconstruct
theSIV1A
awayfromlho injuredpancreas.
Bewareof iahogenic
veininjuryin an inframosocolic
hmatoma,
>
Shunting
andligation
areth bailoutopiionsfor iliacartryinjury.
Chapter10
DoubleJeoPardY:
ThoracoabdominalInjuries
A battle is a Pheflorfienofl that alu)ays htkes
place ifi the i nctiorr between tTDo'naps'
- AnonYmous Bdtish Officer' 1914
Where to go {irst - bellyor chesi?
kld in severe
You are in ihe OR preparingto opefateon a 17_year_old
mLndrng
ihe
street
down
walking
was
shock.Hls story is very {amlliar:he
in
the left
him
shoi
and
his own businesswhen two dudes approached
(especially
chesi.Thesesameiwo dudes pop up fegularlyon the stfeeis
were just
on weekendnighis),shootingpeople who alwaysclaim ihey
show
mindingtheir o;n business Plainx'raysof ihe chestand abdomen
across
a bullei in the epigastriumso, lhe buLletwent inio the Leftchest'
andintoihe abdomenThechestiube youinsededon ihe
the diaphragm,
noiiceabLy
left is acliv;ly drainingblood, while the abdomenis getting
you
begin?
do
plummeiing
Where
distended,and the blood pressureis
Chest or belly?
The clock ls ticking,and yout patieniis bleeding Bellyor chest?
the mosi
lf you are unsurewhereto begln,you are noi alone Some ot
baitlesin traumasurgeryoccur in the iunctionbetweenthe
exasperatlng
about
abdomenand chest Duflng trainingyou are likely to hear
bul
conferences'
mortallty
thoracoabdominaliniuriesat morbidily and
small
for
a
you
in
are
when you try to ook them up in trauma texts,
in any
on
thoracoabdominaltrauma
chapter
a
single
Thereis not
surprise.
cur;entmajoriraumaiexlbook Why? What exactlyare thoracoabdomrnal
injuries?Whai makesihenr so special?
Fivecompartments
convergein the thoracoabdominal
region
tr"*'
lO DoubLeJeopordv:Thorocoobdomino
E|
Strategicconsiderations
two'th tds of patienlswith penetratingthoracoabdominal
Approximately
followed by
managedby chest tube drainaqe
,",rr|";
needoperative
"t" "r**"t'V
bparoscopv)Roushlvone-ihirdwill
i.i;";;
i;;
thatthe
andit is inthesepatients
andabdomen'
l"
iiiJ*""ii"'" notr',
"r,"",
traps awaii]/ou
ol multicavitary
injuriesare ihe most commanlotn
Thoracoabdominal
-ore
Ihar onevisceral
ir
dearrs win b'|eeoins
*"""l;;:;;";
";e
:l:ilu.:n;:":31,i^"L1".jlllifi;,""
IoL"" - r*gf, youhaveanassortment
soLrces
lromseve'al
""
tnepatenlrsbreeoilq
*',ala" p-"'"t gut wl_en
"i."n.",1"*'r,
;;";;joil;ii;Jt
'*i:
lhe
you are not nearlyas fiective Why? Because
bleedins
o{
is sreatl;,acceleratedMultiplesoufces
lllfJJffi"::l"Ji:
ij:
"im;:ru.*"",""""-"""1j
I'ne
leld Lotsol wornto do:rol enough
,r""t o'i"t',t'" th" ope'atve
mooe
contro
to damage
il J i. vo, .u"t O."laeveryquicklyio switch
HowearlycanYoumakethedecision?
You may be suPrisedto
Learnthat the trajecioryoJ
ihe bulletcan help]/oumake
an earlydecisionto bailout
A bulleitrajectoryacro$ ihe
iruncal midline in a hYPo_
tensive Patieni ls a very
ominoussqn becauseine
bundle
major neurovascular
ol the human body (aorla'
vena cava, and splne)ls a
midlinestruciureTherefore,
the likelihoodof a major
injurYis high
cardiovasculat
modalrty A
is
the
and so
trajectory across lne
a
a
t
a
hr!r es El
bdomlnoL
Thorocoa
lO DoubleJeoparclv:
maintainlactLcal
The most impodantadvice we can ofler you is to
caviiywhile the
in
one
begin
*"lUi|',r".Si"l"t"" show that you will o{ien
compensale
and
fact
mainsourceof bleedingis in another'Recognizethis
seFk cl res Il_al
_o, i, u, o"i_q vigilaniano rac.rcay lle/b' AuL'vely
ng o'l lhe others'deol Ih' didp'tagml're
so-"'n ng susio ou. ,s ndpPen
,renioiapn
ag oroore'srve'yobsuu'r'19your
a qraoLaJypro'rtroi'rg
'
A,waysoo p'eparedro cl'argeyoJ'pra- rr id_operator
ooe".a'ue'r.ld.
a;d rapidLydive intoihe otherside of the diaphragm
play Talk io the
Here again, good team leadershipcomes lnto
of
anesthesioLogisiOften a subiLe physlologicalderangemenl
s
de
other
on
lhe
is
ongoing
theonlycluethathemorrhage
lnconsistenctls
o{ ihe diaphragm
clues to Bleedingon lhe Other side of the Diaphragm
hYPotension
Unexplained
Inappropriaieresponseto lV fluidsor blood
Graiuai in"reas" ln air*ay pressures(signof a hemo/pneumoihorax)
Elevatedcentralvenouspressure(signof lamponade)
Maintaintactical f lexibility
pericardiotomy
Mobilizethe left laterallobefor transdiaph.agmatic
hluies El
lo DoubleJeopordv:Thorocoabdomrnol
tubing, ls t clear or can
you iell what the Patient
had for supper? lt the
chest is heavilycontam_
inaied, or f You are
evacuaiinglois of blood
and clot,formallyopenthe
chest to address the
oleural space directly
Wilh heavycontamtnalpn
trying
o{the pLeuralspace,
to clean the hemiihorax
throughthe diaPhragmatic
defect is keyholesurgety
It is unsafeand ineffective
- dont do rt.
Close ihe diaphragmatic
laceration wrih a non_
absorbable heavy suture
We Lrsea runningsuturefor
and slmple
shortlacerations
inierrupiedsuiuresfor long
ones.some surgeonspreler
horizontalmatlress sutures
or even a twolayer repair.
An impodani technical
principleis to leavathe ends
oJeverysuturelongand use
them as handlesio Pulllhe
de{ectioward
diaphragmatic
you. The edges ot a d|a_
ohraomaticde{ect tend io
ne'l ore will l-elpyou
,nue,i,so p.rffingo" Lhelastsntchwher placinglhe
preven breedirgfrom t5e
^"t':""" oooo a'ppos'tronTake large oites Lo
pl'ren'cJessersor ihe p eJra sioe of lhe diaol_raqm
TOPKNIFE
TheAar& Croft ol TraurnoSurgery
What if the defectis largeand you cafnot approxlmate
it wiih a simple
suture? lf the diaphragms avLrlsedperipheraly,as sometimesseen in
severeblunitrauma,and the paiientis stable,you may be ab e to realtach
the avulseddiaphragmto a rib, usuaLly1-2 ribs above the eveLof the
originalavulsion.When reattachments not an optionand ihe defectis ioo
largefor primaryrepair,a non-absorbable
pfosiheticmeshis a quick and
easysotulton,
lf you have to bail out or the operativefield ls heavilycontaminated,
reconstruciion
with syntheticnon-absorbabemeshis not an oplion.While
thereis no compellingreasonto closea largediaphragmaiic
defectwhen
operatingin damagecontrolr.ode,failuretodo so willlorceyouto dealwlth
an even arger defect at reoperation.The muscularedges of the defeci
rapidlyreiraci,progressively
enlarglngihe gap.Preventthisfrom happening
by insertrngan absorbablemeshas a temporaryphysicabarriefbetween
the abdomenand chesl.At reoperaion,if the field is clean,the absorbable
meshcan be replacedby a permanenlnon-absorbable
prosthosls.
Opening Pandora'sBox
Thirk iwice (andpossibly
ihree times) beforedeciding
io mobilizethe liver in a
paiieni with a thoracoabdomnal ifjury.Youmay be
blowingthe ld off Pandora's
Box. A patientwiih a rightsidedthoracoabdominal
injury
drainng large amountsof
dark bood from a rnedia
holein thed aphragms likely
to havea retrohepatic
venous
ifjury draining nto the chest
ihrough lhe diaphragmatic
defect. Going into the
lO Doube Jeopordy:Thoracoobdominol
","'t'
is a lethal
abdomento mobilizethe liver and iix ihe hole from below
mistake.lf indeed you are dealingwith a coniainedretrohepairccaval
inrounconi'o'led
rnrurv.lorl w J rosecontainment.converlinglre slluallon
ttyirg
to sqLeeTe
nd
yoJrsell
i
venor,. h".orrh"g" Very rapidlyyou wi|
the toothpasteback intothe tube
The correctapproachis notio mobilizothe liverand staywellawayfrom
postenor
the bare area.lnslead,returnto ihe chesi and simplyclosethe
will
hole with a coupleof big siitches This simplsoLution
diaphragmatic
preventthe
re-establishcontainment,keep Pandoras Box closed, and
caiastrophichemorrhage
Neveropen Pandora'sBoxl
region
Five compaitmentsconvergeln ihe thoracoabdominal
Everybulletie ls a story
Maintainiactical{lexibility
peticardiotomy
the leit laierallobe for tfansdiaphragmatic
L4obilize
When-rxinglhe diaohrag-,pu I t lowardyou
Nev6ropen Pandota'sBoxl
Chapter 11
The No-nonsense
Trauma ThoracotomY
Life is pleasaflt Death is peaceful
It's the fuansitiolrthat's ttoublesome.
- IsaacAsimov
or
lmagineplayinga new computergame The plot takes place In one
one domain'the
morei tve do.ains o|.terrltoriesWhile you'reerpLoring
has a separate
domain
Each
anothef'
realactionmay well be unfoldingin
you in deep
game
lands
portal,andchoosingihe wrongportalfor a speciiic
ihe gamehas
iroublefromthe get-go.To makethingsevenmoreintersting,
your game rs last_
a differentstorylinein each terdiory.To top everythlng,
'
pacedand short with no teplays
game'
Beginningio thinkthat you don't wani to play?Sorry' ii s noi a
that
and you have no choice lts thoracotomyfor trauma,an operation
roller
operatlve
olien starts as a good case and quickLyiurns into an
coasier,especlallyif you are a generalsurgeonwho does not frequenlly
visit the chesi. The action can unfold in one of more of iive separaie
viscefalcompartments{two pleura!spaces' peticardialspace' thoraclc
outLet,and posieriormediastinum),each accessiblethrough a difiefent
mechanismsmay be at work
incision.Severalpathophysiological
simultaneously:bleeding, hypoxia, catdiac lamponade' tension
and air embolism,each evolvingat a differentpace Gei
pneumothorax,
the picture?
Where to cut?
Choosingthe corfecl incisionmaywell be yourmostimportantstrategrc
a
decision jn a trauma ihofacoiomy.The wrong incision can turn
siraightfoMardcase into a technicalnightmare'
TOPKNIFE
TheArl & Crofi of TrournoSurgery
For the hemodynamicaly
unstablepatieniin need of a crashoperation,
the utility incision is af arterolaterai thoracoiomy through the 4th
rntercostalspace on the njured side. Ths quick incision keeps your
oplionsopen.Youcan easilyexlendit acrossthe sternumto the otherside
of the chest or go into lhe abdomenwiihout havingto repositionthe
patient. However,flexiblity comes at a prce. Whle an anierolatera
thoracotomyallowsyou to get to all parts oJ the lpsilateralung, tryingto
reach a deep posteror chest wall bleeder or a posterior mediastinal
structuremay be virluallyimpossible.
For a penelratingwound to the rlghi lower chest with hemothorax,
considergoing into ihe abdomenfrst. The liver domnaiesihe rght
thoracoabomnal regon and is, therefore,the most ikelysourceo{ severe
(Chapier10).
hemorrhage
Beginwith anterolateral
thoracotomyin the unstablepatient
[,/edan sternoiomyis a good ncisionfor precordia]siab wounds,s nce
it gives yo! flll access to ihe heart and great vessels of the upper
mediasiirum.lts biggestadvantageis extensibilrty;
you can easilycarry it
into the abdomen,neck, or alongihe clavicle.lt also providesaccessto
ihe hilumof each lung,but accessto the per pheryof the lungis resiricted,
and the oosteriormediastinum
is naccessible.
In lhe patientaciivelybleedingfrom penetratlngtraumato the thoracrc
outlei,you can stumble nto a big lrap if yo! chooselhe wrong incision.
You rnustbase your decisionon an educatedguess as to the sourceof
hemorrhage.lf the patientpresentsin shockwith a arge hemothorax,
you
typicallybegin with the ltility anierolateraihoracotomybut nraydiscover
you cannotrepar the injurythroughthis incision.
You mustthetrrapdly
extend t (or makea new one) to gel to the bleeder
lf the patieni is not aclivelybleedinginto ihe pleuralspace, median
sternoiomyis a good incislonfor right-sidedand midlinethoracjc ouilet
wounds, giving you access io the rnnominaieartery and rts brarches,
However,it is difficullto get to ihe leit subcavan artery from the fronl
becausethe vessel is intrapleuraland posterior So, in a patientwith a
TroumoThorocorornv
ll TheNo-nonsense
penetralinginjurYaboveot
belowthe lettclavicle,gain
proximal control of the
aderyihrougha
subclavian
anterolateraL
left
high
thoracoiomy in ihe 3rd
intercosialspace (above
lhe nipple), recognizing
that you cannot fix the
vessel through this very
llmited incision. You will
haveto exposethe lniured
arterythrougha
subclavian
separaieincision(ChaPtef
13).
The classictfap door incisionis a creativecomblnationo{ a medran
incision lt
sternotomy,left anterolateraihoracotomy,and a lefl clavicuLar
and
requiresforcefulretractionto openthe uppermediastinum has a high
incldenceof postoperativecausalgialikepain due to siretchingof ihe
you ca1
brdLhalp'e*usard olher le'ves We rpver uqe il because
the trap
of
elements
jLlsitwo
ihree
o{the
achievethe sameexposureusing
door with much Lessmorbidity
Slable pat.,llshrde iewer surorises You ^'row your sJ-gica iargel
imaging,andthis targeidictatesyourchoiceof incision
iiom preopefative
Extensibilityinto another visceraLcomparimentis usually not a
slruclLrF:sucn as lhe ao'la or
Posleror medlasli,ral
consrde-aton.
thoracotomyat a level
esophagusare approachedthrougha posierolateral
provrdes
lhoracolomy
poslerolatera
correspondingto the injury ln fact,
that
mediastinum
such outstanJingexposureof the chesi wall, lung, and
if
usesit in activelybleedingpaiients,especially the
one o{ us occasionaLly
peneiralingwound is posteriorand low.
for thoracicoutletiniury
selectyourincision
Caretully
TOPKNIFE
TheArl & Croft of lroumo Surgery
Makea boldcui in
the 4th lntercosial
space, In a mae
paiient,this s below
ihe nipple. In a
female, retract the
breasi craniallyand
makethe incisionin
the inframammary
Jold.Avoidthe buk
of the pecloralis
major by placingthe
incision immediately
belowit.
Thinkof this operaiioras ihe thoracicequjvaleniof a crash aparotomy.
Work quicklyand deliberaiely.
This is not the time to be minimallyinvasivo
or go huntingfor stray erythroc).tes
with your thunderstick. lust grab a
kn fe and go into the chest.Carryyour incisionfrom lhe sterna borderto
the midaxillaryline, foLlowngthe intercostalspace in a sLightupward
curve. Laterally,you soon encounterthe law of dim nishingreturns:the
furlheryou extendyour incsion,ihe rrloremuscleyou haveto cut w th less
An experienced
surgeoneniersthe chestwith threebold strokesof the
knife:theJirsldivideslhe skinandsubcutaneous
tssue;the secondcuts
through the pectoralisfascia, the pectoralismuscle anteriorlyand the
serratuslaterally;ihe thifd is a shortincisionin the intefcostalmusclesthat
brrngsyou intothe pleuralspace.
rhorocotomv
TraLrmo
rr TheNo-nonsense
lf necessary,extend Your
incisionto the othersideofthe
chest by cutting across lhe
sternumcleanlyusinga Gigli
saw, an oscillatingsaw, or
bone cutters,When crossing
the stemumfrom left to right,
carry the incisionuPwafdto
lhe 3rd intercosialsPace to
stay above the right niPPle,
ol the
exPosure
thusiacilitaling
upper mediastinalstructurcs,
especially the innominaie
bifurcation.
The classicpidallin anterolaiefalthofacotomys failureto identifyand
the
ligate the transeciedends of ihe internalmammaryarlery When
patieni ls hypotensiveand vasoconstricied,this deceitfulartery seldom
TOPKNIFE
TheArt & Croft of TroumoSurgery
bleeds.Afteryou closethe chest,it soonmakesits presenceknown.lfyou
don t tie the ilansectedends,you guaranteeyour patientan earlyreturnto
the OR.
Don'tforgettheinternal
mammary
arterybecause
it won'tforgetyou
Troumorho'ocotomv
ll TheNo-nonsense
-ho,o.otolv
El
Aortic clamping
The descendingthoracicaorta s flaccidand pulseless,easiy mistaken
lor an adjacentllaccid pulseess tube, the esophagus.Clamping lhe
esophagusdoes not improvethe palients hemodynamics
one bit.
Placinga camp on the descendng thoracc aortaduringan urgent
anterolateral
thoracotomyis guidedmostlyby palpationratherthan direct
vision.Relractthe left lung anterioryand s ide your handon ihe posteror
chestwa lfrom lateralto medial,fee|ng the concavtyof the posteror ribs
as theyarch towardthe sp ne. The first tubularsiructureyou feel aga nst
the i p of your fingersis the aorta.You can eiiher manuallycompressii
agarnstthe spineor placean aorticclampacrossit freeingyour handfor
Tltt'.]t"t.trtv
TraLrm.
I I TheNo nonsense
gI
Median stelnotomy
Make a verticalrncisionif the
sternal r.idllne exiending from
2cm above the siernal noich to
3-4cm below the xiphold.
Deepen your. incisio. io the
anterior iable of ihe slernum,
keepir,gto the midline.Define
the superior border of ihe
manubrium
and blunllydevelop
the retrosternalplanefrom above
with your finger.Then, go to ihe
nferiofpartof yourircisionand
open the I nea alba lmmediatey
caudal to the xipholdio bluntly
develop ihe same plane from
Thorocoiomv
El
Trouma
r TheNo-nonsense
retractofand graduallYoPen
it wiihoui cracking the
. |"ft in-.in"t"
of the uppermediastinum
u"in is the gatekeeper
iniosignificani
ongoing
btoodtoss,especia
y ii thl
111-l"l
]'Tq"
parent rs coagutopathic.
.
tl" '*
usinsrs6yye"r,"o","|su,u.es
tor,owed
oy rayered
1ll.:: T,"::
crosLre
ot the chesrwdllrLscres,lasctaandskin,h c,osing
a c,am-s\el,
*'e topreciserv
reapproximate
thedjvided
sternum
li"llir'J;1,,5i?il"
Beginwith a/.rierolaterat
ihoracotomyin the unstabtepatient.
>
Worryaboutpersonalandteamsafetyin a reslscilatrve
thoracotomy.
ChapterL2
p,'""".r""1j::i,"""j#"ri;^:
kea,si.nple
ll roo(s
""",y.
". ",","""t"
sttch Then'as you ky to gel to rr
hemostanc
you '
i"i
graduallydawns on
1""""""" oehi;d the diaphragm'it
1"."""J"
ihingsare far ffom simPle
your{ace' you can barelyseeihe
Wiih the lung rh}thmicallybillowingin
thoracolomy
an anterolatefal
or""l". iu"" ,itou ao' gettinglo it through
rinattvfl""t?iJilJ
Wnen
vou
ni",ni""."tri'*i.pos-srure
['il1i:
you
cann(
a frgureof I stltch,you discover
;;ffi il";;,
"i*i "f:*ti";";1"*:"ry"13i$,:1,",,i,
n
(Chapter5), a bleedinghole in ihe psoas
extremitv
i;;; i" ;i" rower
":::"]:.:"1'1"
;;#:1
1""il:"".i:i::l"j
TheJa'enot"t o'_T1:'."-1ldo.*,d
good
"xd-pls
ar ri,srgrarue.Bur
souland mayseemslralgl
to lhe surqical
you-a'ein deeperwatersthanyou
*nl" r", iru. *". - yo'rdiscover
o{ Lrauma
wel,overyoJ'heao Thel^iddermo'1slert
somotime.
thouq,1t,
up w ln
Lome
yotr
lo
anoimag;narol{orcing
,uil"orl oo",a,t"
"'"",iv;ty
solutions
unorthodox
)"'
rZrneChesi:
rnslde
onctOut @
Define the precise
locaton of the injury and
use a linear cutting
stapler to rapidiy open
the inteflobarfiss!re, if
fused.Now, takea good
look at the injuredlung
segment and plan your
lineof reseclion.Youraim
is to remove ihe injured
trssue with the east
amount ot surrounding
heaithyparenchynra.
Have
a I stapers and 3:0 or 4:O
poprypropyrenesutures
readilyavaibblebeforeyou start.Ask the anesthesiologist
to momentarily
deflatethe injuredlung. Use eiihera wide inearsiapler (60 or gomm)or
several applicationsof a linear cuttng siapler to resect the injured
parerchyma.lf lhe stapledlineof reseciioncontinuesio ooze or leakatr.
underrunit wilh a cont nuousmonofilarnent
sut!re.
Pulmonarytractotomy
rs a an elegani lungsparing solutton for
t h r o ug h - a n d ' i hr o u g h
penetratinginjuries ihat
are too deep for a
slapled reseciion.The
underlyingprincipleis to
lay open the tract so you
can gei to the bleeders
insideit. In oiher words,
you connectihe iract to
the lung surface by
dividingthe br dge of
nssuebetweenthem.
TOPKNIFE
TheArt a CroftofTroumoSurqery
Inserlone arm of a l/near
cutiingstapler(we preferio
use a vascularstaple load)
into lhe missile tract and
applythe oiher arm to yo!r
chosen target sudace,
C ose ihe siaplerand lire it,
layifg the m/ssileiract wide
open.Now,carefulyjnspect
I for beeding vesse]sand
suiure-ligate
ihem selective
y
using4t0 polypropyene.
Do
not closethe traci,
lf yo! don i havea lineafcuitingsiapler,you can do the sanretractotomy
betweentwo iongaorticclampsappjiedto the bridgeof trssueoverlyingihe
missiletract.Afterselectively
co.trollingbleedersin the openiraci, underrun
eachaoriicclampwiih a 4:0 polypropylene
sururebeforeremovingii.
Pumonarylractoiomyworks so well ihat you shouldconsiderusing it
evenin deep penetratingwoundsthat are not through-andthrough
(i.e.no
exitwound).Inseria fnger inioihe mssiletractand assesshow mlch
uninjuredlung parenchymamlst be crossedto completea thro!gh-andihrough tracl. lf ihe dislanceis short, use the stapleras a ,missile,to
completethe lraci, pushng ii throughthe tract uriil the iip emergesfrom
the otherside of the lLrng.Partoi the tract will be iatrogenic,but a ?aci is
a tfaci, andthereforeamenableto tractotomy.Lay it open and suture-ligate
individualbleeders.
Pulmonary
hactotomyis a neatsolutionto a ditficultproblem
When confronted
with massivebleeding
from an lnjuryclose to
the pulmonaryhilunr,
rapidly mobillze ihe
lung,gatheringit in your
non-dominaft hand,
and pinchthe bleeding
hllum beiween thumb
and forefinger The
simiadiyto ihe Pringle
maneuverrs oovous.
Now organize youf
anacK: rmprove exp
' ihe
os!re, "mainslera
endotracheal
tube i.to the conlralatefalbronchusif possible,and get a full
sei of vasc!lar instfumentsand an autotranstusion
device.
At th s point,your oplionsdependprimarilyon the mechanismof nlury.
With a simplestabwound,pinchingthe ifjlred hium maygiveyoLrjLtst
enough control and visibilityto rapidly do a aieral repalr using 5:O
polypropylene.
The situationbearsan uncannyresemblance
io the injured
portalve n n the hepatoduodenaligament.In boih cases,you are dea ing
with a laceratedlow-pressure(but h gh flow) sysiemwiih n a very narrow
anatornicspaceihat affordsyou litlleroomfor maneuvering
or comfortable
clamprng.
Controlthe pulmonaryhilumbetweenthumbandforefinger
A centralglnshot injuryis bad news. Dar.age is r.ore extensive,you
often must clampihe hilur., and may be forced to resecia lobe (or even
the entirelung)io achievehemostasis.
A theoretically
appeallngopton fof
hilar injuriesis vascularcontrolfrom within the pericardiumbecalse it is
basedon the prlncipleof anaiomca barfers (Chapter3).
lf yo! open ihe pericardiumanteriorand pafallelio the phrenicnerue,
you are work ng if uninjuredv rgin terrilory,much ltkeworkingabovethe
inguinal
lgamenln a groingunshotwound.However,
thislakestimeand
Drainthe perforationby
inserting a large-bore
suclion drain through ihe
perforaiionand up intothe
proximalesophagus,and
secure it in place. lf you
can get an esophageaT,
iube, use it. lf possible,
approxrmate
ihe edges of
the hole aroundthe dfainA ways rememberto drajn
the pleural space with a
separatedrain or a tube
thoracosiomy.Use this
damage conirol option
when you have to bail oui in a hurry,the injury s too largeto be
approximated
withoutiension,or the operaiion
is delayed(morethan1224 hoursfrom injury)and the pleuraispaceis severely
inflamed,
making
primaryclosureunsafe,
An esophagealperfofaiionis a holeln the gut. lf you decideto close it,
alwaysbeginby carefullydebrjdingand deflnlngthe edgesof the nrucosal
defect,just as you would do for any other part o{ the Gl tract. Do not
mobi|zelhe esophagusout oI its bed becauseyou will devascularzeit,
jeopardizingyour repair.Close the perforationin two layers(mucosaand
muscle),
anddrainthe pleuralspace.
Coverihe repairwiiha vascularized
pedicleof tissue.Dependingon ihe
operaiivecircumstances,ihis can be an iniefcostalmuscleflap, a Thal
patchof gasiricfundus(Chapter5), or a chunkof omenium.Perlcardialor
pleura flaps are not well-vascularrzed
n ihe acute settinq,so don't use
them. Providea roule for earlyenieralfeeding
TOPXNIFE
]he Ad a Crofi of TroumoSurgery
The majol
airways
Fixskaightforward
majorairwayiniurieswith absorbablesuture
Do a stapledpneumonectomy
oniy as a last resort.
Drainan esophageal
perforation
as a bailout sotLrton.
Fix straightforward
malora rway injurieswith absorbablesuiure.
'I
Chapter13
Do a leftanterolatefal
thoracotomy
for cardiacgunshotwounds
4 A,MI
F
5f--',t
?+
to
ToP KNTFE
TheArt & Croft of TraumoSurgery
Epinephrine
is the enemyof the myocardial
sutureline
Repairingsimplecardiacwounds
C ose a simple laceration
Complexcatdiacwounds
.
are
yoJroarieni
rasa nigh,ihetihood
or 1orna(.ng
:"d
"1n".,.
f T-n-".
?.,^1
rr,
une $uch
eramplFis a posterio.
ir r+ *,:*!
. '*-",rJ
^{\-i1
" L.^4
Disseciionn a mediastinal
hematomais nevereasy.lf
you fee ost, a usefullrick
is to open the pericardium
to orient youfself. The
pedcardum is an anaiomical
barrier that blocks lhe
extensionof lhe mediastinal
hematoma,jusi like ihe
inguinaligament
blocksthe
extensionof a groin hematoma (Chapier 3). By
opening the per cardium,
you can follow ihe aortc
arch upward into ihe
hemaloma to identify ihe
vessels oJ ihe ihoracc
outlet.
hematoma
Followa trail ot safetyin exploringan uppermediastinal
Youf nexi priorityis proximaland distalcontrolof the bleedingvessel
are niceLyarrangedin two layers:
The vesselsof ihe superiotmediastinum
to the neck are
s!perficialveinsand deep arteries Again' the simllarities
and
fix ihe hole
clamp,
with
a
side-biting
injury
a
venous
Control
strlklng.
_
without
a second
the
veln
ligaie
do
will
noi
repair
lf a simple lateral
thoughi.
When disseciingthe proximalleft carotidartery,you musi ideniifyand
preservelhe left vagusnerveas it descendsbetweenthe caroiid and Left
subclavianartedesto cross in front of lhe aorticarch and give o{f the left
recurrentlaryngealnerve ProximalcontroJof the lefi subclavianarteryLs
discussedlaier in thrschapter
Neverjust plungeinio a mediastinalhemaiomafrom blunttrauma The
most common blunt arterial injury in the upper mediastinumrs an
(widened
lnnominaiearteryinjurythat presentsas a coniainedher'atoma
patient
Bllndly
superior mediastlnum)in a hemodynamcallystable
enteringlhe hemalomais the worst possibleerror you can make lhe
inlurvjs avulsionof lhe lake_offof the innominatearteryJromlhe aortic
aich. In other words, you are dealingwith a sde_holein the aorta lt
TOPKNIFE
TheArt & Craft of TroumqSurgery
doesn'ltakemuchsurgicalimagination
io realizewhatwil/hapoenif vou
oelvento -hrsrFnatoncu'rprepa.eo.
lne correclapproac-is or;Jlv
ouilinedin the nextsectionof thischapter
How about distal
control of thoracic outlet
injuries?As a generalrule,
the exposureprovidedby
a median sternotomyis
oltennotsufficentto a ow
dista conifolofthe carotid
and subclavianvessels.A
medran sternoior.y is,
however, an eminenily
extensleincision,so yor,l
can easilycafiy it Intothe
neckor alongthe clavicle.
lf you are going into the
reck, drvide the strap
muscresoown |ow, fear
the r inseriion inio the
sternum, to expose the
carotidsheath.
Neverplungeblindlyintothe mediastinum
in blunttrauma
1 3i ' o o . ' ,
'geon
o ,uo' I ou-o o I 'Ge__'ol5
[JseDscronfof thoracicoutletarterialreconstructions
The azygosvein
In penetratingchest traunra,azygosverninjuryis seenin conlunctron
wth lnjures to the adjacentcentralalrways,esophagus,or thoracLcout et
vessels.The chalengewith an azygosvein injuryls geltingio lt. Access
througha mediansternolomyis extremelyditficult,and it may even be
"'ntt"
fat padand
ihescalene
idenlify
Behindthedividedslernocleidomastoid,
nerveOn
phrenic
ofthe
search
it fromlateraliomedjalln
mobilize
caretully
ductas ii entersthe
lhe leftside,youshouldbeableto identitihethoracic
jugularveinslf iniured'suture'
and iniernal
iunclionof the leftsubclavian
eaveI abne
il
not'
suture;
ligateit witha 6:0polypropylene
f, -\ 4-'Y
L"J'A
! 3 - h o r o - ' .v o . !
o, 'ro 1o o _eCan'o
5 roeo'
artifi=_
theaxillarv
aeltop"ctoil$ooi66
""pise
TOPKNIFE
TheArl & Croft of TroumoSurgery
torri'e ceneror'surseon
$
vosculorTroumo
13Thorocic
for cardiacgunsholwounds
thoracotomy
Do a leftanterolateral
weaponin cardiactrauma
is yourultimato
Inflowocclusion
>
sutureline
is the enemyof the myocardial
Epinephrine
sewingheart.wounds'
Tyingsuturesis thechallengowhen
>
for complexcardiacinjuris.
Usequickandqimplegolulions
>
hematoml'
anuPpermdiastinal
Followa trailofsaftyin exploring
- '
trauma
in
msdiastinum
blunt
into
the
plunge
blindiy
Nover
tharacicoutletarterialteconstrucJionsi
) . Usq D4gr-arriQr
)
artery
Thephrenicnerveis yourkyto thsubclavian
Chapter14
in TigerCountrY
The Neck:SaJari
Go to the heartof dange4fot thercyou will find safetq,
- Old Chineseproverb
'tiger country,"a group of viial
The woundedneck is the anatomical
midlinestruciurestighty packedtogether,carryinga large neurovascular
bundleon each side. This delcate anatomyis jusl sitiing insidea lafge
hematomawaitingfor you to make a wrong move Evensurgeonswith
by a rapidy expanding
eleciiveexperiencein the neck w ll be chaLlenged
cervicalhematomaihat obscureskey landmafksand dlstortsthe anatomy.
To avoid geiting lost in ihe injuredneck, use the trail of safety,a well
defined sequence of steps thai carefully guides you from one key
anaiomicallandmarkio the nexl withoutgettinglosl of causingiatrogenic
damage.
TRAILOF SAFEW
W1W'7@=
Jugulafvein
(-,
(
TOPKNIFE
TheArt & Crofi of TroumoSurgery
The facial vein is the
gatekeeperof the neck, the
key landmark you must
identify,clamp, and ligateto
open the way 10 the carotid
bifurcation. Ligating and
dividingit also allowsyou to
continue developingyour
work space by repositioning
the self-retainingretractorin
a deeper layer so it pushes
the U out of your way. Yoll
are now drrecllyon top of ihe
carotid artery. In most
paients the facialveinis also
a convenientmarkerfor the
levelofthe carotidbifurcation.
In the presenceof a large hematoma,taking the necessarytime to
dissectout the facialvein s a smartmove,evenif you are in a hurry.Keep
in mindthai somepalienishave2-3 smallveinsinsteadof one largefacial
vein,and all must be identifiedand dividedalongthe anteriorbofderof the
U. A classicpitfallis mistakingthe lJ {or the facia veinand lgat ng it, only
to makethe drsseciionmoredifficult.YouhavenegolialedIhe trailof safety
throughthe injlred neck. li's t me to beginthe nexi part of yolr operatoni
idenlifyingand fixingthe lnluries.
The facial vein is the gatekeeperof the neck
TlgerCountry
l4 TheNeck:Soforiin
ertend your incisionto the
sternalnotchor evenrntoa
nredian sternotomy to
obtain safe proximal
control. Once inside the
cafotidsheath,find,identiiy,
and protect the vagus
nerve.Encirclethe common
carotid ariery with a
Rurnmel tourntquei and
proceed with dissection
towardthe areaof injury
dislal
about
How
control? This is otten
problemaiic because a
cervicalhematomatypically
exiendsup io the angleof
the mandible(Chapier3). Therefore,gaining dlstal control outside the
hemalomamay not be possible lnstead,prepareto gain distal conttol
from wlthlnthe hematoma.lf you are readyfor ii, you can controlback
bleedingfromthe iniernalandexiernalcaroiidarterieswith minimallossof
As wiih any other namedartery in the body the safe planealong the
plane(Chapter
carotidthat protectsyoufrom mischiefis the periadventitial
3). As you reachthe injury,you encounterback bleedingfrom lhe internal
and exiernalcarotidarterles.First, use your fingef for temporaryconirol
Then, eiiher clamp the distal artery or insert an intralunrinalFogarty
catheterconneciedto a 3-waystopcockintothe outflowtfact. Remember
that the hypoglossalnervecfossesoverihe proximalinternalcaroiid,and
the vagus nerve lies just behindit You have come to the heari ol tiger
plale and bluntlypush asrde
country,so stay in ihe sa{e periadventilial
(rather than cut) any unideniifiedstruciures Definitivecontrol of ihe
carotid bifurcationmeans occluding all thtee vessels: the comrnon'
internal,and exlernalcarotidarteries
TOPKNIFE
Ihe Art & Crofi of TroumoSurgery
Once you havecontrolof the lnluredcarotid,lalk to the anesthesiology
teamlo assurethe patienthas a good blood pressure(a meanof ai least
100mmHg)while the carotid is clamped.This is even more critical if
backflow
fromtheinternal
carotid
is notverybrisk.
planeof the carotid
Stayin the periadventitial
l 4 T h eN e c k : 5 o f o r l i nT g e rC o u n i r Y
Preciselydefinethe carotidiniury
Your nexl step is thrombectomyto clear ihe inflowand outflowtracts
Carefullypass a No. 3 Fogartyballooncatheterproximallyand distally.
Don't push the caiheterdlstallymore than 2-3cm pasi the bi{urcationdiving ii throughihe carotidsiphonwill havespectacularresults Flushthe
proximaland distalends of the injuredarterywilh heparlnizedsalineand
begin the repair. lf inseriing an interposiiion graft, do the disial
anaslomosisfirsi, especiallyif you are hookingup io the iniernalcarolid
abovethe bifurcation.lt is difficultiowork on the posteriorwallofihe distal
anastomosiswhenthe proximalanastomosisis akeadysewn in
Whal should you do if there is no backflowfrom the dislal Internal
carotidariery?This is a conitoversialpoini.We preferto hgatethe artery,
lor fear of convertngan ischemicstroke into a hemorthagicone Some
surgeonsfeconstructthe arteryregardlessof backflow
lf you haveexperiencewith electivecarotidsurgeryand know how to
smooihlyinserta shunl and work afound it - considerdo ng just lhal A
shunt is a smart move,especiallyif backflowfrom lhe iniernalcarotidis
weak or reconstructionis going io take iime Thteadyour shuntthrough
graftbeforeinsedion,and do theniiredistal
the lumenofthe lnterposition
with the shuntin place
and mosi of the proxlmalanastomosis
TOPKNIFE
TheArt & Croft of TroumoSurgery
A carotidinjuryin Zone lll is uncommonand shouldideallybe idenilfed
preoperaiive
y when youf control options are eiiher a Foley balLoon
caiheter nsertedintothe missiletract or angiographicocclusion.
But what if yo! encoLniera high iniernalcarotidinjuryduflngan urgent
exploration?
Youcannotreachthe dlstalinternalcarotidwithoutoptimizing
your exposure.In the presenceof relentessback bleeding,yo! have no
iime for e aboratemaneuverssuch as subluxafion
of the iaw Yourbest bet
- a muscularand deierminedassistantarmed
is a rnuchsimoleralternative
with a suitableretractor Extendyour incisionto the mastoid process,
insert a retractorinio the upper corner of the wolnd, and have your
assistantpul rea ly hard,givingyou a few cr iical mi limeiers.lf this is not
enough,dividethe posteriorbely of the dgastic musce to gan more
TlgerColniry
l4 TheNeck:Soforiin
TOPKNIFE
TheArt & Crofi of TroumoSLrrgery
The esophagus
Thereare two routesio
the cervical esophagus,
going either medial or
lateral to the carotid
sheath.The nredialroute
is a naturalcontinuation
of
carotid exploratronand
probablythe one which
youaremostfar.iliarwiih.
Before exploring the
esophagus, ask ihe
anesthesiologist
to insert
a large-borenasogasiric
tube to help you identifythe esophaglsby palpatingthe tube in a hostile
operativefield.The esophagusis locatedslighilyto the left of the midline,
makingit easierto explorefromthe leftside of the neck.
Retract ihe conient of the
carotidsheathlaterallyand enter
the plane between it and the
trachea. You will find the
esophagusbehind lhe tfachea
and anieror to ihe spine. Full
exposure of the esophagus
requires you identify and divide
three structuresihai cross over
the esophagus:the omohyoid
muscle,middle thyroidvein, and
inferor thyroid ariery. The
recurrentlaryngealnerueis rarely
identified in the jnjured hosiile
TlgerCowiry
l4 TheNeck:Soforlin
The otherapproachto the esophagus,goinglaleralloihe carolidadery,
is a "back door" approach,Llsefulwhen a large hemaiomain the caroiid
sheath obscufes ihe anatomy Retract the caroiid sheath struciufes
mediallyinsiead of laterally,and enier ihe plane between the carotrd
sheathand the cervicalspineto find the esophagusYour work space is
limited,but you are Iess likelyio causeiatrogenicdamage.
Regardless
of the optionyouchoose,the keytacucalprincipe is io be
sureaboutthe hiddenaspectsof the esophagus
beforeconcludng youf
exDtoTaIlon,
Transcervicaliniuries
How shouldyou approacha peneiratinginjurythat crossesthe neck
injuriesmay requirebiLaierdexpLoraiion
from sldeio-side?Transceruica!
Rulingout an injuryto the oiher slde of the esophagusor trachea by
irtfaoperaiiveendoscopy,while iechnicallypossible,is logisiically
To explore a transcervical
penetration, we prefer a lJ
ncjsion,the ceryica equivalent
of a clam-shel thoracotomy.lf
you spend a few minutes
deveoprng
a superror
skinfap in
the subplaiysmaplane (as you
would do in a thyroidectomy),
yougainmaximalexposure
of ihe
bilaieral neck, mlch like ifting
the hood of your car to look ai
lhe engine. Exposure just
doesn'tget any betterthanthis.
\ - l
\\.r11
Finishing up
Havea good look at the edgesot your ncisionin searchof superlical
bleeders.In the neck, a smal muscularbleedercan easily lead to a
postoperaiveexpandinghematomaand the need for urgent reexploration,Inspect your suture lines and make sure they are nicely
separatedby viablemuscle.
We stronglyadviseyou dra n everyneck exploration
{or lraumausinga
closed suctiondrain.The mosi commonlymlssedinjuryin the neck is a
smallesophagealperforaiion.Your dra n will conved a poientlaldisaster
inlo a minorproblem.Jf drainng an esophageal
sutureline,bringyour
drain out anierorlywiihoutcrossingoverthe caroiid artery'drains have
been knownto erodeinto lt. The only ayeryou haveto approximate
deep
to the skin is the plaiysma.Thencose the skin and you havesuccessfuly
compleiedyour safariin tiger country.
II
)
)
)
)
)
)
)
)
)
)
Lift.thehoodoffthensckwitha U incision
Chapter15
PeripheralVascular
Trauma Made Simple
Eoerything shoulil be fia ile as
simpleaspossible,but not sirftpler.
- Alberi Einstein
li you thinkyou know whai a bloodymesslookslike,a closeencounter
with a hosinggroin wi I haveyou think agan The patientis n shock,with
most of the bLoodvolumeeilherlelt at the sceneor all overihe paranredlc
compressingthe bleedinggfolnfor dear life.Sinceihls is one oJthe most
spectacularpenetratinginjuries,ii is easyto forgei priotities,r.ake critical
errors,and lose ihe patlenlin the midstof the chaos
In ihis chapier we try to bridge the wide gap between the neat
ilustrationsof vascularexposuresyou see n books and the harshteality
of the OR, where the paiient is bleedingand all you can see in ihe
operativefield is tfaumaiizedmuscleand lots of hernaloma.Bridgingth s
vascular
gap is especiallyimportantfor surgeonswho don t do periPheral
repair
the
work on a regularbasis but are called upon to conifo and
occasionalarterialinjury.Our key messageis that the injufed artery is
alwayspart of a wo!nded patienl,and the patient'soveralltraumaburden
oflFn orcraies1ow yoJ approachlhe vdscuar 'njury
Reiroperitoneal
approachexpose the exiernal i|ac
artery through an obljque
lower abdor.inallnclsron
approxrmately2cm above
a.d pafallelto the nguinal
ligameni.Incisethe aponeurosesof the externaland
internalob|que, and open
the iransversls abdominis
and transversalisfascia io
exposethe preperitoneal
fat.
Gentlecephaladretraction
of
the peritonealsac will bring
you to lhe external iliac
artery.Thisapproachavoids
laparotomy,but takes time,
so is farely used in the
bleedingpatieni.
Verticalgroininclsion- the simplestway to gain proximalcontrolof ihe
nosrnggrorn,
So much for the good news.The bad news is that evenwith proxima
control, the paiient continles to beed, albeit at a slower rate. lf back
bleedingis noi very brisk and you can identifythe key structures,use a
combinatonof sharpand blunt disseciionlo exposethe fer.ora vessels.
Bluntdisseciionis saler in hostileterriiory.You want to avoiddamageto
the femora nerve,and yo! cannotcut the femoralnervewiih yourfinger
lf you can t see whatyou'redoingbecauseol briskback bleeding,walk
the camps (Chapter9). The solrce of persistentback bleedng is often
the deep femoralarterythat must be identifedand controlled.When you
succeed,breatha sgh of relief;you havesuccessfullydeat with one of
the cobrasoi traurnasufgery.
TOPKNIFE
TheArt & Croft of TroumoSurgery
Next,open ihe femoralsheaihio jdentifyihe femoratartery.Reposition
ihe self-retajning
retractorat a deeperlevelor add anotherretractor.Stay
on top oi the arteryin ihe pedadventitial
plane.lf you deviater.edially,you
may be greetedby a gush of dark bloodfrom the fer.ora vein.If vou strav
laterally,
you may injurethe lemorainerue.
lsolaie and control the
commonlemoralarteryand iis
branches.While the common
and superficial femoral
arteries can be readily
identifiedand encircledin the
proxmaland
distalparts
of the
incision,isolatingthe deep
femoralartery can be difficuli
for surgeonswith few 'groin
hours.' The lateralfemoral
circumflex vein is ihe most
keacherousvein in the groir.
It crossesimmediatelyin froni
of the proximaldeep femoralartery in ihe crotch betweenthe deep and
supedicialfemofalartery.lf you try to exposethe deep femoralarteryby
unroofingit, you soon encounterbrisk venousbleedinolrom ihe iniufed
vein.Avordils-rhis
;i6;iJiiiiruaTioi-ii rar'tcteiihantryirgto.ixir.oo
not disseciout the deep femoralartery,plainand simptel
The origin of the deep
femoralarteryis markedby an
abrupi change in the drameter
of the commonfemoralartery.
Take a vessel ioop and pass
one end from lateralto media
underneath the common
femoral artery weli above ihe
bifurcation.Grab the otherend
of the loop and pass it from
medialto lateralwell belowthe
bifurcation.Lift up bothendsof
I 5 PerlpheroVosculorTroumoMode simp e
the loop io discoverthai you have neatlyisolatedthe deep femofalafiery
withoutdissectingit out
TOPKNIFE
TheAri a Croftof IroumoSugery
hesfiateto cut ihe inguina]Iigament.lt is a smallpriceio payfor expedieft
proxmal conlrot,
face of extensivedamage to
the bifufcationis to join the
stur.ps of the superflcialand
de6p femoralarteriesside{osideto createa shortcommon
arterialtrunk before inserting
an nterposltiongraft. This
sparesyouthe awkwardjob of
implaniingthe deep femora
arterylnto the gra{i.
What are your repair optons? YoLlmay elecl to inserta shunt if you
needto bailout or if you decide (withihe orihopedicsurgeons)to achleve
bone alignmentpriorto arterialrepair.This is genetallya good idea since
sewinga graft in an unslableflailinglir.b is somethingyo! shouldavoidlf
possible.When the superficialfemoral artery is iransected' Insert an
graft.
interposition
to ii,
bordero{ ihefemurandinciseihe deepfasciaposterior
the posterior
lnserl
a
finger
popliteal
lossa.
into
the
fatiy
contentofthe
you
s?aight
bringing
arteryagainsitheposteioraspectof
the pulseof ihe popliteal
andpalpate
TOPKNIFE
TheA.t & Croit of TroumoSurgery
to the anastomosisto excludethe inluredsegment.pass the pusating
graftthroughihe tunnel,and hookit up to a similararterioiomyin ihe distal
pop itealarierybelowthe knee.Thenligatethe arteryimmediately
proxima
to the d stal anastomosisto completethe excusion,In an obese pattent
with a deep artery,ii is easierto transectthe proximaland drstaloopliteal
arreJ.oversewrhe endso l-F e.ctLdeo<eg-ent.a.ld .henhoot up -he
vein graft end-io-end.
The huge advartageof this approachis simplicity.you don t haveio
dealwith the inj!red segmentai all.The on y vatidreasonto take down the
ligamentsand exposeihe poplitealfossa is ongoing bleedingfrom the
njufedsegmentdespiteexcluson, a s tuaton we naveyet io encounter
popliieal
are forced to run to the OR urgenily'begin by exposingthe
stlb_
artery below the knee and shootingan on_tableangiogramA
ot
what
exploration
lengihy
optimalangiogramcan send you on a
turns oui to be an intactaitery in spasm
3. Where to begin?The popliiealfossa below the knee ls an excellent
siartingpoint becauseyou can always{ind the ariery there, even if
you havelilte vascularexperiencell is v rginterrltory,the vesselsate
bundle and follow t
large, and you can ideniifythe neurovascular
disialy.
Retracl the medial
head of the gastrocnemius posteriorlyand
exposethe edge of the
soleusmusclearchlng
ovef the popliteal
vessels.Hook a finger
underneaththe r.usce
and detach ii trom the
tibia. This opens the
sPace,alowlngyou to
place a self-retainlng
retfactorin the wound.
Proceeddistallytoward
the injury by taking
down the atlachmentof the soleuslo the posterioraspect of the Ubia
Look for ihe anteriortibialvein as a markerof the iake-offof the anienor
artery.Further
tibiaL
identifythe
distaLly,
of ihe
bifurcation
irunk
tiboperoneal
into the postenor
libial and peroneal
arteries,wherethe
formeris the more
al vessel.
superfic
TOPKNIFE
TheAd & Croli of TroumoSurgery
Exposeihe anteriortibialarteryln the mid'and lowef leg ihroughyour
anteriorfasciotomyincision,lnsert a self-retaining
retractorbetweenthe
tibiaisaniefor and the extensorhallucislongusmlscles,and find the
neurovascu
ar b!nde deep down between the musces, on the
Inlerosseus
raemDTane,
Before you begin a vascularexplorationbelow the knee, slrongly
considerus ng a proximapneumatciourniquet
aboveihe knee.Nothng
is morelrustratrngthan tryingio identlfyand isolatethe smalland frag le
vesselsof the lowerleg in the presenceof activebleeding not io meniion
ihe ncreasedrsk of iairogenic njury io other eements of the
neurovascular
bundle,
Whch ariery shoud you reconstruct?Always go lor the most
straightforwardso ution n the mosl accessibe ariery and take into
accountsoft tissuecoverage.lMostoften,th s lranslatesinlo reconstruciing
the posteror libialadery.In a badlyinj!red eg, be preparedto spend some
time lookingfor the dstal end of the transectedvessel,which may be
yourbest reconstructive
dtficuli10 fnd. In most instances,
optionis an
graft usinga reversedsaphenousveinfrornthe otheranke.
interposition
is goodenough
Oneopentibialartery
The axillaryartery
To gain rapld access io the,4&iy,"
^,-proximalaxilary artery,you have io
,r 1, ,.a^or)
;r;1
go ihrough the pectorais major
muscle.Abduct the arm and make
incsion extending
an nfraclavlcular
mid-clavicle
io the
from the
deltopectoral groove. This trans- i) ,-.4-'
pectoral rouie is an extensle
exposure.You can extendit distally
along lhe dellopectoralgroove.
Dissectionbetweenthe delioid and
ihe pectoralisr.ajor, combned wilh
Modesimpe
r5 Peipheravoscuarlroumo
lateralrevactlonof ihe cephalicvein, will revealthe clavipectotalfascra
containingthe neurovascularbundle Fudher distal exienspn Into the
groove betweenthe biceps and the tticeps muscleswill get you to the
proximalbrachialadery
Cul down io the
pecioral lascia, divide
it, and then spreadthe
pectoralismajor fibers
by insedrng closed
Mayo scissorsinio ihe
muscle and oPenjng
them pefPendicularto
ihe fibers lo nrake a
you
hole. Underneath
pectotalis
minor
the
find
and the claviPectoraL
fasciamedialtoll. OPen
the clavipecloralfascla
fai to identifythe axillaryvein,the gatekeepero{
and dlssectln the axilLary
lhe ar lla.Tl^eaneryis oeep and supetiorIo it To opt'nizeyou'worl
space,get the pectoralismlnormuscleoui of the way eitherby retractrng
or dividingits upper aitachr.ent1o ihe coracoid process To
ii lateraiLy
safelymobilizethe axillaryartery,you musi fitst identify'clanrP,and cui the
thoracoacfomialartery,one o{ the only arterialbfanchesin the body io
come siraightat you when exposingthe parenivessel
Your damage conhol opiions for axillaryartery iniuries are shunt
ligationand fasciotomyAmple collaterals
insertionand, less commonLy,
aroundihe sho!lder wilLpreventcriticaldistal ischemiain most patienis
rusnga saohelors
wrh an ir.e Jptedari,a-yalery but rFuonstrLcion
vein gra{i hawesiedfrom the ihigh) is a betier optionif {easible
major,not aroundrt
the axillaryarterythroughthe pectoralis
Approach
)'.,
.,;,..,
.|trr.",r..*,J
'q'.
l.J
,,,y
lr-,-
il-^r
itr.\.v./-
>
major,not aroundt
arterythroughthe pectoraiis
Approachthe axillary
'*
ll