AUVaLILCU Llauila Upuauve iviauaguuueue Editor Lenworth M. Jacobs, MD, MPH, FACS Professor and Chairman Department of Traumatology University of Connecticut Hartford Hospital Director, Trauma Program Hartford, CT Associate Editor Stephen S. Luk, MD, FACS Associate Professor of Surgery Chief, Emergency General Surgery Services University of Texas Southwestern Dallas, TX Chapter Contributors Lenworth M, Jacobs, MD, MPH, FACS Robert T. Brautigam, MD, FACS Karyl Burns, RN, PhD Vicente Cortes, MD, FACS Ronald I. Gross, MD, FAC Orlando Kirton, MD, FACS Stephen S. Luk, MD, FACS George A. Perdrizet, MD, PhD, FACS Editorial Assistant Vijay Jayaraman, MD Research Fellow Hartford Hospital Hartford, CT 2nd Edition Ciné-Med” PUBLISHINGCopyright © 2010 American College of Surgeons American College of Surgeons 633 N Saint Clair Street Chicago, IL 60611-3211 All sights reserved. No part of this publication may be reproduced, stored in a retrieval system, or ‘ransmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, swithout prior written permission of the publisher. ISBN: 978-1-880696-48-4 ‘inted in Canada tblished by: Ciné-Med Publishing, Inc, 127 Main Street North Woodbury, CT 06798 (203) 263-0006Foreword hhe Advanced Trauma Operative Management (TOM) Course was developed asa response tothe creasing number of penetrating trauma operative focedures to which surgeons in training and trgeons in practice have been exposed. The onoperative philosophy for penetrating. trauma argery coupled with more sophisticated imaging sd nonoperative interventional, modalities have cen good for patients. It also represents a sbstantial challenge for the education of surgeons ‘the management of penetrating trauma. Surgeons cw only operate on organs that have been severely sjured and patients who are usually significantly smodynamically compromised. ‘This has resulted | trauma surgeons operating in very challenging tuations on severely injured organs without szificant experience in performing these fovedures. The ATOM Course has been an fective way to provide realistic training on -verely injured organs in a real operating room vironment on fully monitored non-human tients. he Course provides a predictable elective aviconment for managing severe injuries that the axgeon is expected to competently manage but frequently encounters. TOM is now available in 30 sites in the United. tates, Canada, Africa, the Middle East, and Japan. has trained more than 1,600 surgeons and there re more than 300 fully trained ATOM surgical astructors. The Course has been carefully evaluated 1nd has been found to be reliable, reproducible, and substantial benefit ro surgeons who complete the The second edition results from the hard work of the Suepical Skills Committee of the American College of Surgeons Committee on Trauma. Members of the commice reviewed each of the chapters and all of their comments have been incorporated. Comments from surgeons who have taken the Course have also been incorporated into the second edition. Surgeons have enjoyed the easy readability of the ATOM texthook and the liberal twse of drawings and photographs. The second edition takes this into account with its extensive use ‘of nev drawings and photographs. We are indebted to the Committee on Trauma Surgical Skills Committee and all of the surgeons ‘who have given their comments and suggestions to us, Ie is clear that ATOM has fulfilled the original desire of enhancing the confidence and competence ‘of surgeons in managing penetrating operative trauma, The Course is worthwhile if any patient has a positive outcome that has been enhanced by the knowledge and skills of surgeons who have participated in this educational activity. Dr. Fred Luchette and Dr Mark Bowyer, the Chairmen of the Surgical Skills Committee, Dr. John Fildes, the Chairman of the Committee on Trauma, and Dr. Wayne Meredith, Trauma Director of the American College of Surgeons, have worked tirelessly to make the ATOM course a major educational course of the American College of Surgeons Committee on Trauma. We are indebted to them and appreciate all their efforts. Leneorth M. Jacobs, MD, MPH, FACSPreface ‘orn out of the necessity to educate and train eneral surgeons in operative management of omplex injury, the Advanced Trauma Operative fanagement (ATOM) Course materialized from 1e forward thinking vision of Lenworth M. Jacobs, {D, MPH, FACS, over a decade ago. Using a arefully crafted data-driven adult learning proach, Dr. Jacobs, a passionate and innovative sader in the field of trauma, developed an ucational product designed to give the learner the gnitive basis of practice as well asthe sychomotor skills necessary to manage the most complex. of traumatic injuries. After initial evelopment, the course was methodically tested for 5 effectiveness, re-worked, and honed to a fine Age in an effort to guarantee the learner a useful rnd exceptional experience. Moreover, learners fre tested months after completion of the course to examine content retention. As a result, ATOM has emerged as a highly effective leaning tool that has changed the face of operative management of the injured patient much like Advanced Trauma Life Suppore di for resuscitative care. Since its inception, abou 1,600 surgeons have been taught in mote than 300 courses at 30 different sites. This latest edition of the text and the accompanying materials were developed under Dr. Jacobs’ watchful eye in conjunction with the Surgical Skills Committee of the Committee on “Trauma of the American College of Surgeons. The Committee on Trauma is both proud and honored to present this work t0 you in collaboration with De. Jacobs in hopes that it will serve as a transforming educational instrument on behalf of injured patients all over the world Michael E. Rotondo, MD, FACS Chairman, Committee on Travema American College of Surgeons Professor and Chairman, Department of Surgery Brody School of Medicine East Carolina University Greemille, NCAcknowledgements ‘bis edition of the Advanced Trauma Operative fanagement (ATOM) Course was driven by the fonstructive comments and criticisms of all the targeons who have taken the course. We are rofoundly grateful to the leadership of the unerican College of Surgeons Committee on ~auma, specifically Dr. Wayne Meredith, Dr. John ‘des, Dr. Michael Rotondo, Ds. Fred Luchette, e Mark Bowyer, and Dr. Sharon Henry, and all the embers of the Surgical Skills Committee who couraged the American College of Surgeons to dopt ATOM as a formal American College of urgeons It provides an_ operative ‘ompanion to the Advanced Trauma Life Support ‘ourse of the American College of Surgeons. de Karyl Burns has continued 10 provide great visdom in the appropriate and rigorous evaluation ‘of an educational course of this magnitude. This has enabled us to provide consistency _and reproducibility in all ATOM sites. Dr Vijay Jayaraman has worked extensively in reviewing the manuscript and providing editorial and artistic assistance to enhance this edition of ATOM. Florence Leishman has reviewed, collected, and prepared each manuscript for the publisher. The publishing expertise of Mary Panagrosso, Director ‘of Publishing, and Caca Forbes, Graphic Designer, along with the incredible artistic talents of Brooks Hart and the support of Kevin McGovern, President and CEO of Ciné-Med, have enabled the publishing of this edition of ATOM. We are delighted that this edition of ATOM continues to provide a fine ‘educational opportunity for all of those surgeons who manage injured patients.\merican College of Surgeons Committee on Trauma Michael F. Rotondo, MD, FACS Committee on Trauma, Chair Professor and Chairman Department of Surgery Brody School of Medicine East Carolina University Chief of Surgery Pitt County Memorial Hospital Director Senter of Excellence for Trauma & Surgical Critical Care Greenville, NC John Fildes, MD, FACS Committee on Trauma, Past Chair Professor of Surgery Vice Chair, Department of Surgery Program Director General Surgery Residency Chief, Division of Trauma & Critical Care University of Nevada School of Medicine Las Vegas, NV J. Wayne Meredith, MD, FACS Committee on Trauma, Past Chair Director of Division of Surgical Sciences Richard T. Myers Professor and Chairman Wake Forest University School of Medicine ‘Winston-Salem, NC David B. Hoyt, MD, FACS Committee on Trauma, Past Chair Professor of Surgery University of California Executive Director American College of Surgeons Chicago, IL.Ad Hoc Committee on Surgical Skills and Editorial Reviewers ‘Mark W. Bowyer, MD, FACS, DMCC, CHAIR ‘Gol, USAF, MC (Ret) Chief, Division of Combat and Trauma Surgery Uniformed Services University of the Health Sciences Bethesda, MD Fred A. Luchette, MD, FACS, Past Chair Director, Cardiothoracic Critical Care Services Ambrose and Gladys Bowyer Professor of Surgery Loyola University Medical Center Maywood, IL Sharon M. Henry, MD, FACS American College of Surgeons Liason to ATOM Associate Professor of Surgery University of Maryland School of Medicine R.A, Cowley Shock Trauma Center Baltimore, MD ohn L-D. Atkinson, MD, FACS ‘alter L. Bifl, MD, FACS oseph B. Cofet, MD, FACS saul Coimbra, MD, PhD, FACS rancisco D.S. Collet de Silva, MD, FACS, PhD aul R.G. Cunningham, MB, BS, FACS srad M. Cushing, MD, FACS Demetrios Demetriades, MD, FACS nique A. Guzman Cotallat, MD, FACS S. Hammond, MD, FACS Davie Harrington, MD, FACS {a0 R. Ivatury, MD, FACS enworth M. Jacobs, MD, MPH, FACS iregory J. Jurkovich, MD, FACS 1. Margaret Knudson, MD, FACS ha B. Kortbeek, MD, FACS arvesh Logsetts, MD, FRCSC, FACS tephen Luk, MD, FACS Douglas Lundy, MD, FACS Robert C, Mackersie, MD, FACS Mark A. Malangoni, MD, FACS Frederick A. Moore, MD, FACS Allen F. Morey, MD, FACS Kimberly Nagy, MD, FACS Neil Parry, MD, FACS J. David Richardson, MD, FACS ‘Michael Rotondo, MD, FACS Ajit Sachdeva, MD, FRCSC, FACS Carol R. Schermer, MD, FACS Ronald Simon, MD, FACS Michael J. Sise, MD, FACS David A. Spain, MD, FACS Glen H. Tinkoff, MD, FACS Alex B. Valadka, MD, FACS Mary H. van Wijngaarden, MD, FACS Matthew J. Wall, Jt MD, FACS David H. Wisner, MD, FACSContributors ameel Ali, MD, FACS. sofessor of Surgery Iniversity of Toronto {. Michael's Hospital ‘ronto, Ontario, Canada aud A. Ab-Turki, MD, FACS ‘onsultan, Vasctlar Surgeon chairman, ATLS Middle East Region ing Abelulaziz Medical City Siyadh, Saudi Arabia san A. Asensio, MD, FACS rofessor of Surgery director, Trauma Clinical Research and Community Afsirs eior Attending Surgeon Division of Trauma Surgery and Surgical Critical Care Dewitt Daughtry Family Department of Surgery iniversity of Miami Miller School of Medicine fami, FL ‘enneth D. Boffard, MB, BCh, FACS rofessor and Head Department of Sangery hannesburg Hospital Jniversity ofthe Witwatersrand ‘ohannesburg, South Africa tobert T. Brautigam, MD, PACS \ssistant Professor of Surgery University of Connecticut Schoo! of Medicine Associate Director Seurosurgery/Trauma Intensive Care Unit arcford Hospital arford, CT ‘usan M. Briggs, MD, MPH, FACS {ssociate Professor of Surgery 4arvard Medical School sssachusets General Hospital foston, MA . Brit, MD, MPH, FACS Irickhouse Professor and Chairman Department of Surge ‘astern Virginia Medical Schoo! Norfolk, VA, Karyl Burns, RN, PhD Assistant Professor University of Connecticut Director, Research Section Hartford Hospital Trauma Program Hartford, CT David G. Buers, MD, FACS, DMCC Associate Professor Interim Chaieman ‘Norman M, Rich Department of Surgery Miliary Region Chief, ACS, COT Uniformed Services University Walter Reed Army Medical Center Bethesda, MD Patricia M. Byers, MD, FACS Profestor of Surgery Division of Trauma and Surgical Critical Care University of Miami Health System Miami, FL David L. Ciraulo, DO, MPH, FACS Associate Professor of Surgery “Tufts University College of Medicine University of New England College of ‘Osteopathic Medicine Maine Medical Center Pordland, ME Paul E. Colicot, MD, FACS Director, Member Services American College of Surgeons Chicago, [Alasdair K.T. Conn, MD, FACS (Chief, Emergency Services Massachusetts General Hospital Associate Profesor of Surgery Harvard Medical School Boston, MA Edward E, Comnvell IT, MD, FACS LaSalle D. Leffall, Je. Professor and ‘Chairman of Surgery College of Medicine‘cente Cortes, MD, FACS, ‘ending Trauma Surgeon sock Trauma Center licgheny General Hospital insburgh, PA sul R.G, Cunningham, MD, FACS ‘ean and Senior Associate Vice Chancellor for Medical fairs hae Brody School of Medicine at East Carolina University reenville, NC sad Cushing, MD, FACS haieman, Department of Surgery ssociate Professor of Surgery {ine Medical Center ortland, ME ‘emetrios Demetriades, MD, PhD, FACS ‘ofessor and Vice Chairman of Surgery ‘eector, Division of Trauma tmergeney Surgery and Critical Care siversity of Southern California ts Angeles, CA laine L. Enderson, MD, MBA, FACS, FCCM rofessor of Surgery and Chief ‘sision of Trauma/Crtical Care niversity of Tennessee Medical Center at Knowle soxville, TN ‘liam F. Fallon, Je, MD, MBA, FACS ssociate Professor of Surgery ‘epartment of Surgery amma Health System Kron, OH ‘avid V. Feliciano, MD, FACS srgeot-in-Chief sady Memorial Hospital “ofewor of Surgery ‘mory University School of Medicine lana, GA Fie R. Frykberg, MD, FACS ‘ofestor of Surgery piversty of Florida College of Medicine sands Jacksonville Medical Center ‘cksonville, FL ‘onald 1. Gross, MD, FACS hief of Trauma and Emergency Surgery aystare Medical Center sangficld, MA Sharon M. Henry, MD, FACS Associate Professor of Surgery University of Maryland School of Medicine R.A. Cowley Shock Trauma Center Bakimore, MD David B. Hoyt, MD, FACS Professor of Surgery’ University of California Executive Director American College of Surgeons (Chiago, IL Rao R. Ivatury, MD, FACS Professor of Sargery’ Chief, Division of Trauma, Critical Care and Emergency Surgery Virginia Commonwealth University Richmond, VA. Lenworth M. Jacobs, MD, MPH, FACS Professor of Surgery Professor and Chairman Department of Traumatology and Emergency Medicine University of Connecticut Health Center Chairman, EM/Trauma Program/LIFE STAR, Rehabilisaion Harcford Hospital Hartford, CT Orlando C. Kirton, MD, FACS Ludwig J. Pyrtek, MD Chair in Surgery Director of Surgery Harrford Hospital Professor of Surgery Vice Chait, Department of Surgery University of Connecticut School of Medicine Hartiord, CT M. Margaret Knudson, MD, FACS Professor of Surgery University of California, San Francisco, San Francisco General Hospital San Francisco, CA ‘Thomas E. Knuth, MD, MPH, FACS Senior Surgeon Henry Ford Hospital Professor of Surgery ‘Wayne State University Medical School Detroit, MI ‘Charles E. Lucas, MD, FACS Professor of Surgery Wayne State University Detroit, MI‘ed A. Luchette, MD, MS, FACS, FCCM The Ambrose and Gladys Bowyer Profesor of Surgery tritch School of Medicine ‘oyola University of Chicago Medical Centr ‘Aaywood, IL tephen SY. Luk, MD, FACS, FCCP ‘hlef, Emergency General Surgery Services \srociate Professor of Surgery iniversity of Texas Southwestern dallas, TX tobert C. Mackersie, MD, FACS rofessor of Surgery Iniversty of California, San Francisco Director, Tratuma Services an Francisco General Hospital & Trauma Ceoter tan Francisco, CA ‘enneth L, Mattox, MD, FACS stinguished Service Professor Yepartment of Surgery aylor College of Medic hie of Surgery fen Taub General Hospital fouston, TX ‘imball I. Maull, MD, FACS sdjmcr Professor of Surgery rivesity of Pittsburgh lead, Section of Trauma Surgery ‘epartment of Surgery lamad General Hospital voba, State of Qatar forman E. McSwain, jr, MD, FACS rofessar of Surgery ‘lane University Department of Surgery "ecctor of Trauma sire of Charity Trauma Center jew Orleans, LA, ‘Wayne Meredith, MD, FACS inector, Division of Surgical Sciences ‘ofessor and Chairman ‘epartment of General Surgery Take Forest University School of Medicine inston Salem, Ni ‘oceo Orlando, II, MD, FACS hief Medical Officer ‘artiord Hoopital ‘ofessor of Clinical Surgery niversity of Connecticut School of Medicine CT Hi, Leon Pachter, MD, FACS George David Stewart Professor and Chair Department of Surgery New York University Medical Center New York, NY Mare D. Palter, MD, FACS Medical Director ‘Neurotrauma ICU Hartford Hospital Assistant Professor of Surgery University of Connecticut School of Medicine Hartiord, CT) Gorge A. Perdtizet, MD, PRD, FACS Director of Surgical Research Morristown Memorial Hospital Morristown, NJ Peter Rhee, MD, MPH, FACS Assistant Professor of Surgery Uniformed Services University of the Health Sciences Los Angeles, CA, Michael Rhodes, MD, FACS Professor of Surgery “Thomas Jefferson University Chairman of Surgery Christiana Care Health System Newatk, DE Aurelio Rodriguez, MD, FACS Professor of Surgery Drexel University College of Medicine Director Allegheny General Shock Trauma Center Allegheny General Hospital Picsburgh, PA Michael F. Rotondo, MD, FACS Professor and Chair Department of Sungery Director, Center of Excellence for Trauma and Surgical Critical Care East Carolina Univers Brody School of Medicine Greenville, NC Grace 8, Rozyeki, MD, MBA, RDMS, FACS. Professor of Surgery Director, Tenuma/Suegical Critical Care Emory University School of Medicine Atlanta, GAKOM. Atearend Tama Operate Management Thomas M. Scalea, MD, FACS, FOCM. Dysician-in-Chief Shock Teauma Center Director, Program in Trauma >rofessor of Surgery “nsversity of Maryland School of Medicine Salimore, MD 2. William Schwab, MD, FACS Jrofessor of Surgery ‘icf of Trauma and Surgical Critical Care “versity of Pennsylvania Health Systeme Dhaladelphia, PA Mark W. Sebastian, MD, FACS ‘enior Staff Tactford Hospital Acsstant Professor of Surgery University of Connecticut School of Medicine arford, CT “len Tinkoff, MD, FACS ‘ice Chairman Deparment of Surgery “prtiana Care Health Systems Sinica Associate Professor of Surgery’ “fferson University Schoo! of Medicine Newark, DE Donald D. Trunkey, MD, FACS Srofessor Emerites Department of Surgery Deegan Heal &¢ Sciences University ‘oriand, OR ‘ohn P. Welch, MD, FACS “lnical Profesor of Surgery Jniversity of Connecticut School of Medicine Jartford Hospital Janford, CT Dietmar H. Wittmann, MD, PhD, FACS ‘rofessor of Surgery Emeritus University of Hamburg ‘amburg, GermanyIntroduction to the Advanced Trauma Operative Management (ATOM) Course he expectations that any patient has when injured clude having a highly skilled surgeon. This :pectation is true in urban, rural, wilderness, and ilitary environments, where trauma can range ‘om simple injuries resulting from surface cerations to complex low- and high-velocity juries that affect one or more body systems. ‘major expectation of surgeons is being adequately ained and competent ro manage injuries that they ay be called to provide emergency care for at any ne during their surgical practice. Resident raining xd continuing education for practicing surgeons 1ve evolved substantially over the last 2 decades. the past, the policy for managing any penetrating jury to the neck and abdomen involved operative ‘ploration of the area. This was thought to be ‘ore effective and safe, missing fewer injuries than oe exploring the anatomic region that was injured. hese policies resulted ina high frequency of sdominal and neck explorations for all surgical ainees, At the completion of a surgical residency, arcicularly in urban inner-city teaching hospital, ‘ost residents had suecessfully completed hundreds explorations and had repaired numerous injured wan, structures, and vessels. Young surgeons in actice were comfortable with these skills in the erating room and were confident that they could ‘anage most injures. In addition, the Vietnam Wa, hich resulted in hundreds of thousands of tsualkies, provided vast experience for hundreds of irgeons hhere have been substantial changes in the aluation and management of injured patients in te last 2 decades. Policies that have been plemented have resulted in less operative ‘posure for surgeons. These policies have degraded ‘e confidence and competence of surgeons in their >ilty to respond to and operate upon penetrating juries to the neck, chest, and abdomen. In addition, modem diagnostic modalities such as CT scan, angiography-enhanced CT, and MRI angiography, along with selective angio- ‘embolization, have dramatically improved the diagnosis and nonoperative management of injuries in the chest, abdomen, and pelvis. “The decrease in resident work hours has also had a negative impact on the exposure of residents t0 trauma and operative repair of penetrating injuries. Penetrating trauma frequently occurs at night and. con weekends, Therefore, decreased continuous work periods have resulted in less exposure of surgical residents to trauma [A decrease in the ineidence of penetrating trauma and an increase in more accurate diagnostic investigations and nonoperative management philosophies have mandated a change in the method. of educating surgeons on operative management techniques in penetrating trauma. The ATOM Course has been designed to provide operative education for the surgeon, using a CD-ROM to demonstrate operative management procedures. Surgeons become familiar withthe types of injuries that they would be expected to manage in the ‘operating room. Before participating in the course, surgeons are given a pre-test to determine their knowledge and faniliary with the management of penetrating injuries to solid organs, hollow visera, and vascular structures in the chest and abdomen. The surgeon's self-confidence in identifying, exposing, and repairing penetrating injuries to multiple structures inthe chest and abdomen is also measured using a pre-test, which must be completed prior to the ‘The 1 day ATOM Course is comprised of two sections. The first is a didactic lecture series covering the anatomy, principles of evaluation, and. details of operative management of injuries in thebest and abdomen. The second part of the course akes place in an operating suite, where large 50-ke wine are used for the operating experience. The nimals are anesthetized, and the operating room is crepared in exactly the same manner that it would ‘© for a human patient, This recreates the same ‘vironment, inclading visual and auditory cues, for be surgeon. The instruments are the same as those ‘sed for human operations. {clinical situation taken from an actual penetrating rauma event is presented to the surgeon. The turgeon is asked to leave the room while the ‘structor creates the injuries to specific organs and. tructares. The surgeon is then invited to the ‘perating table, where all of the injuries must be Sentified. An appropriate operative management lan must be presented to the instructors, and then be injuries must be successfully repaired. ‘he instruments, stapling devices, surures, and back. able are the same as the ones used in an actual perating environment, Surgeons can request and se the instruments, equipment, and sutures that hey feel are appropriate to safely and effectively cerform the operative procedure of choice. The astructors are familiar with numerous safe and fective ways to successfully complete repairs ofthe ajuries that are presented to the student surgeons. At the end of the day, a post-test is used to evaluate the cognitive ability of the surgeon, and a test ‘measuring self-confidence is also administered. ‘The ATOM Course is an intense operative surgical experience that focuses on operative management of penetrating injuries. Its objectives are to educate surgeons on the surgical management of penetrating injuries, improve their self-confidence in managing these injuries, and promote their technical ‘competence in the surgical repair of penetrating injuries. Experienced trauma. surgical instructors teach the course, and the intended audience includes senior surgical residents, trauma fellows, military surgeons, and fully trained general surgeons who are not frequent called upon to treat penetrating injuries. The ATOM Course is a tightly structured ‘educational experience with a rigorous evaluative component. It is designed 10 be completely reproducible. ‘The ATOM Course is an effective method of increasing surgical competence and confidence in the operative management of penetrating injuries to the chest and abdomen.Table of Contents Foreword... Preface. Acknowledgements.. < American College of Surgeons Committee on Trauma. Ad Hoc Committee on Surgical Skills and Editorial Reviewers Contributors enn xi Introduction. Chapter 1 Trauma Laparotomy. Tips From the Masters.aesnu Chapter 2 The Spleen and Diapheagm Tips From the Masters. Chapter 3 The Liver sun o Tips From the Masters. Chapter 4 The Pancreas and Duodenum.. Tips From the Masters. Chapter $ Phe Urinary System Tips From the Masters Chapter 6 The Cardiovascular System nnn Tips From the Masters Chapter 7 ATOM Evaluation: Participant and Course Evaluation, eX nsTrauma Laparotomy ——Figure It: Masive hemoperitoneum with a Ste-Drape Dperating Room hhe physical aspects of the operating room vironment are a priority in the management of a sserely injured hypovolemic patient. The room ould be large enough to support maltiple operating sams and all of the artendant equipment necessary de a major trauma laparotomy. In addition, the dom temperature should be set within the upper OF to lower 80°F range. warm room is essential to avoid hypothermia sasienrs who are in shock and have been resuscitated sth a combination of erystalloid and colloid, which below body temperature, and have had. their loches removed in order t0 perform a complete ‘spection, are at risk for hypothermia. The room ‘mperature #0 maintain an optimal normothermic mmperature for the patient is likely to be jscomfortable forthe surgeons and support reams rapid transfusion device is an essential piece of {uipment. In addition to delivering large volumes of uid, i can also warm the fluid up 10 body smperature. Before the incision, the patient should en blankets or warming devices to prevent amther hypothermia. in the operating room Ie is essential to be able to collect blood from the peritoneal or pleural cavities. This blood is the ‘optimal resuscitating fluid because itis warm and already typed and cross-matched and has no infectious diseases. It also has an_ optimal 2,3-diphosphoglycerate (2,3-DPG) level. The blood should be washed and centrifuged before autotransfusing the packed red blood cells back to the patient. ‘The shed blood will be rapidly lost to the laparotomy pads and spilled outside of the abdominal cavity upon opening a tense hemoperitoneum. Therefore, itis critical to have the appropriate equipment and suetion devices in place prior to the first incision. The suction devices must be ready and available at the beginning of the exploratory laparoromy.gure 1-2: Rapid infuser livers warm fluid and 0d products igarel-3: Autotranstser Blood is collected, washed, centrifuged and returned tothe patient. ‘The abdomen must be widely prepared and draped. ‘The surgical preparation includes the suprasternal notch and continues inferiorly to the midthigh. Extensive preparation allows access to the groin if the patient needs further resusetating, with large- bore intravenous lines. It also gives access t0 the saphenous vein ifan autologous vascular conduit is needed. The prep extends down to the operating table on both sides laterally: This allows access to the chest cavities for the placement of a thoracotomy tube or for a thoracotomy. A wide lateral prep on the abdomen allows for the placement of drains or a colostomy. Figure I: Prep and drape the patient widely from the neck to the midthighs and down tothe table laterally on cach side.‘The lange incision provides excellent exposure of the tolid organs in the superior abdomen, the entire retroperitoncum, and the pelvis. It also allows the surgeon to have a wide field for control of major bemorthage, Figure 1-5: Choice of incision, The suandard [eparoromy can he cominaed ino the chest and up onto the oeck, [Wich an adequate number of surgical assistants, the ‘ese of handheld abdominal retractors can selectively ‘eahance visualization of organs in the upper ‘quadrants. Selfretaining, mokiple-bladed retractor ‘ystems can also be used to enhance exposure. These systems have the advantage of minimizing the need {for assistants who only provide handheld exposure. Once been life-threatening hemorthage has ‘controlled, the anesthesiologist rapidly resuscicates ‘the patient. Ar this poiny, its important co assess the severity of the patient’ injries, determine if the appropriate personnel are available, and put out a call for surgical assinance, as well as additional anesthesia assistance. The blood bank should be notified of the likelihood of sgnfiant blood loss requiring initiation of the massive transfusion protocol. This isthe time to assess the situation and assemble the appropriate team, equipment, and supplies in preparation for a major operative intervention. ‘Trauma Laparotomy ‘The trauma laparotomy consists of four essential parts, First, major hemorrhage is controlled. Second, all of the injuries are identified. Thied, any contamination fom the small or large bowel or the biliary tee is controlled. Finally, the injuries are repaired. Irmay not be possible ro definitively repairall of the injuries because of the unstable nature of the patient, In these cases, damage control serves 10 ‘correct life-threatening injuries before moving to the intensive care unit to continue resuscitation. The goals are to return the patient 10 a stable metabolic state and to correct hypothermia, hypovolemia, acidosis, and coagulopathy. Once these goals have been achieved, the patient is moved back t0 the ‘operating room for definitive management of any remaining injuries. Control Major Hemorrhage “The control of massive exsanguinating hemorrhage is essential. Audible hemorthage usually results from ‘a large venous laceration on an area such as the inferior vena cava (IVC). A severe vena cava laceration is characterized by a large amount of dark blood welling up from the peritoneum, which must be controlled immediately. Pulsatile hemorrhage must also be controlled immediately. This can be achieved either directly on the vessel itself or by gaining proximal vascular control. For example, the hilum of the kidney o spleen can be controlled to stop all arterial inflow to the organ. Once hemorrhage is controlled, moreefinitive distal vascular control can be achieved, allowing preservation of the organ. Figure 1-6: lood pooling in the operative fed When major hemorrhage is under control, it is gain time to reassess the general condition of the patient, assemble appropriate additional personnel, and make sure that the blood and blood products fare being transported from the blood bank to the ‘operating room for immediate use. This is now the ‘ime to begin autotransfusion of the shed blood collected from the abdominal and pleural cavities. It is essential to warm any transfused fluid to normothermic levels before delivery. ‘Techniques in Packing ‘The use of abdominal packs to tamponade bleeding and aid in the identification of ongoing bleeding is. an important concept. The technique is designed 10 protect the solid organs from iatrogenic injury, as well as t0 allow for the placement of the packs in the most dependent parts of the abdomen. ‘The abdominal wall is rettacted away from the spleen, and a hand is placed over che spleen for protection. Blood and eloss are removed from the posterior aspect of the abdomen, and a dey pack is carefully introduced into the deepest recess of the left upper quadrant. More packs are then placed on top ofthe spleen. ‘The faleiform ligament is taken down sharply, providing excellent exposure of the liver. Blood and clots are then removed from the perihepatie areas. ‘The abdominal wall is retracted superiorly, and the liver is retracted inferiorly. Packs are introduced above the liver, and additional packs are placed below the liver. Manual compression of the organ between the packs ensures a tamponading effec. PME MeeVee§ Fire 1.7 Sple-pactng equ, Pet he ‘cen sh the noon han, Pace packs Over and nde the sponFigure 18: Pack above shelve arrow shows deetion ‘of manual ier retraction) Figure 1-10: The lise is vetractd in acandocephslad Figure T-11s The packed liver can then be compres Srestion (arrow) to pack below i between hands (areows show compression ores). Figure 1-12: Radiopague packs above and below the liverEffective control of the loops of small bowel intially ‘requires opening a blue rowel on the right side of the incision. The loops of bowel ae then eviscerated ‘onto this towel and partially wrapped. The wrap is completed with a second blue towel over the remaining exposed eviscerated bowel. The ‘wrapped, and now controlled, small bowel loops ‘can now be returmed to the peritoneum. ‘Sweeping the small bowel medially and superiorly now allows excellent evaluation of the base of the mesentery and the retroperitoneum. Look carefully for any hematoma. If there is a retroperitoneal Jnematoma extending into the mesentery, this is 2 sign of eke retroperitoneal bleeding, that requires urgent attention. If there is mesenteric hematoma with a clear retroperitoneum, it is likely ‘confined to the bowel and can be addressed after completely exploring the abdomen. ‘The right colon is retracted medially, and packs are placed in the laceral ascending colic recess of the abdomen. The same procedure is repeated with the descending colon. The wrapped bowel is drawn out of the pelvis. Blood and clors are removed from the pelvis and packs are placed inside. This process identifies areas of the abdomen without injury and without hematoma, allowing the sturgeon to focus on the areas of the abdomen ‘containing injures. Only large radiologically marked abdominal packs are used. Its helpful to have packs with radiopaque rings, which are easy 10 identify digitally and. radiographically. Figure 1-13: Wrapping bowe!—smal bowel is eviscerated onto able towel, wrapped ina second bie rowel, thon returned to the abdomen.Sentify Injury “swound in the posterior right upper quadrant can suse injuries in the solid organs and viscera. Free ile in the abdomen or bile staining in the feriduodenal and pancreatic tissues raises the ‘sibility of an injury to the duodenum or biliary ‘ee. These organs should be inspected and any sjury identified. A large lateral retroperitoneal ‘ematoma indicates an injury to the kidney or renal ilar vessels, The hematoma should be inspected for ‘lsation oF a urinoma, It should be measured if it foes not appear unstable at first. It should be measured later in the procedure and explored if ere is a significant increase in size. The vena cava hould also be inspected and judgment made as to ‘ether the hematoma is arising fom the vena ava, the renal pedicle, or the kidney itself, ‘he lapacotomy packs should be removed from one juadeant at atime, starting in the noninjured area ‘id ending in the most seriously injured area. Ie is ritcal to deteemine whether the bleeding has topped ot if there is active ongoing, bleeding. resh blood or clots on the laparotomy packs dicate continuing hemorrhage. The active hemorrhage must be controlled and any injury ro the small or large bowel identified. Contamination ‘must be controlled immediately. The amount and type of contaminant determines the likelihood of developing sepsis in the future. igure 1-14: Small owel laceration and retroperitoneal hematoma. “The final component of the laparotomy involves identification of other non-lfe-threatening injuries, specifically to the diaphragm andior the bladdes. Control Contamination Control of contamination is an important priority. Essential observations must include the location of the injury, the number of injuries, the size of the sofrent, and the location on the mesenteric or antimesenteric border of the bowel. Obvious leakage must be controlled, re 1-15: Inspecting the mesenteric root afer wrapping the small bowel. On che left is a mesenteric hematoma thats [Grungent. On the right you can se a retroperitoneal hematoma spreading up into the mesentery—2 serious condition.‘gare 1-16: Small bowel injries are identified and ‘neolled with Babcock clamps. be entire small bowel, from the ligament of Treitz ‘the ileocecal valve, and the ascending, transverse, sscending, and sigmoid colon need to be inspected. his is best achieved with the help of an assistant ach segment is passed hand over hand and flipped de to side berween the surgeon and an assistant, ‘th both people inspecting the same segment. Ifthe wel is dropped, afresh start from the ligament of ‘eitz is essential Its also important to conduct a omplete evaluation of the antimesenteric and iesenteric border of the bowel, as well as the sssentery. An odd number of bowel enterotomies soul prompt a second look for a missed injury. fy enterotomy in the bowel can be rapidly mntrolled with Babcock clamps, skin staples, or scares. Alchough this stops ongoing contamination f che operative field, itis not a definitive closure. ‘econstruction nother major component of the exploratory parotomy is reconstruction of injured organs and ‘scera. Definitive repair of significantly damaged ‘organs should fit within the context of the overall patient. Evaluating the injured organ helps to determine whether repairing the injury or removing the organ is a better option. If the organ can be repaired, the next important consideration is ‘whether the organ can be repaired in the presenting patient. I's essential to evaluate the overall metabolic status of the patient, che amount of additional surgery needed, the extent of acidosis and coagulopathy, and injury to other systems and the impact of these injuries on the patient's overall well-being. A patient ‘with a severe head injury and a splenic injury amenable to splenorrhaphy may not benefit from the extra time spent performing a complex repair. A splenectomy may be more beneficial. Figure 1-17: Evaluate the injured organ ro determine it can he repaired, Im order to determine ifthe injured organ can be repaired, the organ must be fully mobilized to evaluate the entire extent of the injury. An injured spleen should be fully mobilized so that the entire organ is brought up to the anterior abdomen, This maneuver allows full inspection of the convex and concave surfaces of the spleen to determine the feasibility ofa repait.Retroperitoneal Hematoma As part of the exploratory laparotomy, it i ieyportant to evaluate the retroperitoneum. ‘The retroperioneum consists of three zones. Zone 1 inches the centromedial superior aspect of the retroperitoneum. ‘The centromedial zone extends from the diaphragm to just distal to the bifurcation of the aorta and the IVC, Numerous important ‘vascular stuctures reside within this zone. They include the celiac trunk, the superior mesenteric artery, the inferior mesenteric artery, the renal pedicle vessels, the aorta, and the vena cava, The pancreas and the second, third, and fourth portions cof the duodenum also reside inthis area. Any injury in this area requires a mandatory exploration to identify and manage the injury. igure 1-18: Zones ofthe retroperioneum. ge 1 ent he ef Tb inte af Figure 1-20: Hand overhand method to evaluate small bowel, stating a the ligament of Treitz and evaluating both sides of bowel in a stepwise{one Il of the retroperitoneum includes the lateral spects of the superior abdomen. The kidney, érenal glands, the ureter, and the hilum of the ascular pedicle of the kidney reside inthis area. All ‘enetrating injuries in Zone I require an xploration. However in blunt injury the area needs » be explored if the hematoma is expanding, or ulsating or if chere is extravasation of urine. Ifthe ‘ematoma is not expanding or pulsating or if there {no obvious extravasation of urine, the zone needs > be reassessed at the end of the abdominal xplocation to see if the injury is stable or if it is ering worse. If the injury is stable, i is prudent to ‘or explore the kidney. Figure 1-21: Open-book pelvic fracture. fone III is the pelvic retroperitoneum. This area is plored only in @ penetrating injury such as a anspelvie gunshot wound. Itis critical to determine the vasculature, the ureters, or the intrapelvic slon and rectum have been injured. Exploration of vis atea is not recommended in blunt trauma, vstead, the appropriate maneuver is to conteol enous pelvic hemorrhage with an external ompression device, This works by returning the clvis to its original dimensions, and since fluid such + blood is incompressible, ir acts to tamponade the leeding veins. This can be effectively done Figure 1-22: Reduced pelvis with a specialized clamp, a binder or a sheet. In addition, an arteriogram can evaluate arterial injury before selectively embolizing the bleeding vessel. Aortic Control Although injuries to the aorta can be approached through the left chest, the preferred approach is to ain control of the aorta through the superior abdomen at the hiatus of the diaphragm. The absence aban tgiuey ta the ket chest mashes ie easy to densify the aorta and gain control of it in the chest ‘with 2 left thoracotomy. This allows for proximal control of an abdominal aortic injury. However, a significant amount of time is requiced to make a thoracotomy incision and gain control of the aorta in a situation where the patient is hemorthaging, from an injury to che abdominal aorta When approaching injuries through the superior aspect of the abdomen, manual digital occlusion can directly control the aorta, which can then be bluntly dissected, Care should be taken to avoid an injury 0 the vena cava. Proximal control is achieved by passing a vascular loop around the aorta. Various occluding devices can be applied direetly to tamponade the aorta against the vertebral column. Great care should be taken to avoid directly injuring the aorta with the occluding device. In the older population, there is a risk that the occluding device may break off an atherosclerotic plague and cause it to embolize distally.Aortic Exposure: Mattox Maneuver A number of surgical maneuvers allow identification and control of the proximal abdominal aorta, The left medial rotation, or Mattox maneuver, mobilizes che splenie flexure of the colon inferiorly and medially and then allows mobilization of the kidney, spleen, and pancreas superiorly and medially. This maneuver completely exposes the lateral aspect of the aorta and gives direct access t0 the celiac trunk, the superior ‘mesenteric artery, and the inferior mesenteric artery. Ic is possible to place a vascular tape or a vascular clamp a the base ofthe celiac artery or the superior mesenteric artery, where they take off from the aorta, This allows for proximal control of exsanguinating hemorrhage from these vessels cn Aortic Exposure: Modified Mattox Maneuver ‘The modified left medial rotation is performed by allowing the kidney to remain in Gerota’ fascia and selecting a dissection plane thar includes the spleen and the pancreas. These organs are then rotated medially and superiorly. This approach helps gain excellent exposure to the celiac trunk and the ‘superior mesenteric artery. The exposure also gives ready access to the left renal pedicle vessels. Figure 1-25: Supeacelite aortic conto‘Figure 1-24: Matix maneuver and resolkant exposure. Left image shows line of dsection, Figure 1.25: Modified Matcox mancuver leaves left kidney in place.IVC Exposure Exposure of the rtroperitoneum on the right side of the abdomen can be gained by a right medial rotation maneuver, or the Cartell-Braasch maneuver, This includes dissecting the cecum, the ascending colon, and the hepatic flexure at the ‘white line of Toldt and reflecting the colon and the base of the mesentery medially and superiorly. The ascending colon and its mesentery are then placed in the left upper quadrant. This provides excellent exposure of the bifurcation of the aorta and the vena cava, the presacral artery, and the gonadal vessels, Ie also allows for excellent exposure of the ureter and the kidney. Performing an extended Kocher maneuver ean help gain access to and exposure of the vena cava, the Figure 126: IVC exposure posterior aspect of the head of the pancreas, al the duodenum, The duodenum and the head of the panereas are bluntly dissected away from the vena cava and rotated medially. The dissection must be taken to the medial aspect of the IVC. The posterior aspect of the pancreas is inspected for evidence of bile, which is characteristic of an injury 10 the biliary tree or duodenum. This also provides excellent exposure tothe right kidney and the renal pedicle vessels. Stable Patient Toward the end of the laparotomy it is time to reassess the patient for hemodynamic stability. The unstable patient may require damage control techniques that are discussed later in the chapter.© ATOM Advancod Tuma Operative Management ‘gure 1-27: Small Bowel stapled anastomosis nthe hemodynamically stable patient, it is mportant to re-explore the bowel and look pecifically at areas of mesenteric hematoma. This is he appropriate time to perform a definitive bowel epai Areas to inspect and evaluate include the nti superior abdomen, both diaphragms, and the aferior abdomen, as wel as the pelvis to specifically ‘clude an injury to the bladdet. ‘olonic Injury ‘he management of colonic injuries has evolved ver the past 30 years. Colonic management siginally involved performing a diverting olostomy in any injury to the colon with fecal village. The diversion was classically caried out ith a defunctionalizing diverting colostomy. today, selective colostomy is performed, and a rimary repair of injuries t0 the colon is often ossible. 1 order to safely manage the multiply injured atient, itis essential to fully evaluate the patient ad che colonic injury. A primary repai of the colon lay be considered for the hemodynamically stable stent who has a colonic injury with minimal fecal village or a small injury involving the antimesenteric border of the colon. A significant number of units of blood should not have been required for the resuscitation. A diverting colostomy isa good, safe option for the patient who has multiple injuries; has required a ‘number of units of blood for resuscitation; has acidosis, hypothermia, and coagulopathy; and has a wound of more than 50% of the lumen of the colon, a significant volume of fecal spillage, or a high-velocity gunshot wound. Figure 1-29: Haremann’s procedure—stapled distal segment and diverting colostomy.ntibiotie therapy in penetrating injuries co the bomen is an important issue. If colonic injury is a sibility, antibiotics covering gram-positive and ram-negative organisms and anaerobes for acteroides need to be administered in the criresuscitative phase. An exploratory laparotomy an confirm or exclude an injury to the colon. There ‘no further need for antibiotics if there is no olonic injury. If there is an injury, the degree of >illage will determine the duration and intensity of ntibiotic coverage. At a minimum, perioperative ntibiotie coverage should be inchided in the ‘eatment regimen. A longer course of antibiotics is commended when there is significant peritoneum silage. instable Patient hhe unstable patient is described as the severely sjared patient who has been hemodynamically nstable, acidoti, hypothermic, and coagulopathic. requently, this patient has had 2 significant volume £ hemorrhage and has needed multiple blood tansfusions to become euvolemic. A general ooze ‘om injured organs and the incision provides linical evidence of coagulopathy. Although the atient may currently have a normal blood ressure, the patient is unstable if the anesthesia vam has had to ageressively transfuse crystalloid rnd colloid to maintain a normal blood pressure. ‘he unstable patient is not a candidate for definitive consteuction, It is best to shorten the duration of 4e operative procedure and move to the intensive are unit for continued metabolic resuscitation. The stable patient is a candidate for damage control rocedures. damage Control Damage control is defined as a procedure that llows for further stabilization in the intensive care unit with the intent of returning to the operating room for definitive management when the patient ‘becomes metabolically stable. The patient should be normalotic, normothermic, not coagulopathic, and hhave no base deficit prior to returning to the ‘operating room for a definitive surgical repait. This resuscitative process may take a number of hours. When a stable state has been attained, it is important to make sure that the operating team is also physically able to reeurn to the operating room and carry out the definitive procedures. It may be mote effective to delay the return to the operating room for a number of hours until the operating room team, the blood bank, and the anesthesia team are fully ready to proceed with a major operative procedure Figure 1-30; Packing the liver for damage control Deciding on an optimal time to return to the ‘operating room involves sound surgical judgement. ‘The time period may be only 2to 6 hours, although it may be necessary to delay the retumn to the ‘operating room for as long as 24 to 48 hours in ‘order to attain a stable physiologic stare.Alu Roane ram Operas Management Damage Control Techniques: Solid Organ Injury Damage control procedures in solid organ injuries involve the use of various local hemostatic agents. Any active bleeding from the parenchyma of the solid organs such as the liver must be controlled with a ligature or surgical clip. Surface oozing. should be tamponaded using digital compression. Hemostatic agents are effective when there is minimal oozing from the cut surface. ‘The hemostatic agent is directly applied to the oozing surface, and an abdominal pack is placed on the ‘organ to exert primary pressure on the hemostatic agent and to tamponade the bleeding. In order for the hemostatic agent to he effective, it cannot be ‘washed off the surface of the organ by excessive bleeding. Different agents, including fibrin glue, Avitene, thrombin, and Gelfoam, have been employed with varying degrees of succes. It is important to remember that local hemostatic agents will not control significant arterial or venous bleeding. This kind of bleeding needs to be controlled surgically. Damage Control Techniques: Bowel Injuries Contamination must be quickly and effectively controlled in the severely injured patient who is a candidate for a damage control procedure and who has injuries to the small and/or large bowel. Rapid ‘control can be achieved by a number of methods that control contamination but are not designed 10 definitively repair the injury. Small enterotomics in the small or lage bowel ean be conttoled with the use of a staple. A few staples can easily and effectively stop any effluent from passing dhrough the enterotomy. Similaely, a single layer rapid closure with interrupted oF continuous sutures can effectively control contamination Another effective technique involves using a stapling device to sesect an injured portion of the bowel. An attempe ro complete the anastomosis is not necessary, a8 the main goal ofthe procedue is o:minimize the patients time in dhe operating room and then quickly move to the intensive care unit for definitive resuscitation. DEEN ORC ems Solid Organ Injury or Nonsurgical Bleeding Packing ‘tne, rhramblaPee Concur Erm es Stapled dsoontnuty damage Control Abdominal Closure Josue of the abdomen is a significant challenge in severely injured trauma patient who has had aulkiple transfusions and has coagulopathy, and abdominal pa amponade of acidosis, ks in sim to jing bleeding. The ability to bring the fascia together in a primary abdominal closure should be carefully evaluated. If the fascia is under significant stress, as evidenced by difficulty in approximating the fascia in the midline or by sutures beginning to tear on closing the abdomen, itis best to abandon the primary closure and utilize different techniques for temporary closure. A number of techniques have been used with considerable success. Damage Control Abdominal Closure Wittmann patch (Veer)veel Clips + towel clip closure is designed to quickly scoximiate the skin with the use of multiple rowel 's placed in the midline, The advantage to this nique is that it is very easy to apply the towel ‘sand the entire closure can be effected ina short ‘od of time. The disadvantages are that the rowel vs are metal and radiopaque and therefore will fude any attempt at diagnostic angiography Vor a therapeutic selective angiographic bolism of bleeding vessels. Similarly, the metal sel clips will render a CT scan or an MRI possible to perform. Another problem with ¢his thod of closure is that the patient will have nificant discomfort from the towel clips. Figuce 131: Towel clip abdominal closure Figure 1-32: AP x-ray obscured by towel cis. Bogota Bag ‘The Bogota bag closure, which was developed in Bogoté, Colombia, is an effective, fast, simple, and inexpensive method of closing the abdomen. The procedure involves obtaining a 2-liter urology irrigation bag. The bag is opened widely and then. placed over the open abdomen and fashioned to the laparotomy incision, Next, it is either sutured of stapled to the skin. This method is rapid and easy to perform, and gives a view of the abdominal viscera through the transparent bag, providing, visual evidence of the viability of the bowel and allowing visual quantification of the amount of ongoing bleeding.gure 1-34; Mesh closure ofthe abdomen. lesh ifferent types of mesh closures have been used. A amber ofthese materials are porous, and although vey are effective in containing eviscerated viscera ad providing visualization of the bowel, che fluent of blood and serum can be difficult #0 ntain, An Esmarch rubberized dressing can also = sutured to the skin or fascia, creating an effective sure of the abdomen. However, this material is sually opaque so itis difficult, if not impossible, to sualize the bowel. A fenestrated plastic dressing, ‘hich is placed over the abdominal contents and uided into the lateral paracolic gutters on either deof the abdomen, effectively contains the viscera suction catheter such as a Jackson-Pratt deain is laced superiorly and inferiorly to collect effluent. A setile operating room pack is placed over the rape, and an Ioban dressing is placed over the nire abdomen to effectively close the wound. The isadvantage of these methods is that care must be aken to be sure that the effluent is adequately ollected and that the skin does not macerate under ve dressing. ‘elero Dressings The use of Velero dressings has been a_useful dition to abdominal closures. This technique iploys a Velero-type dressing sutured to the fascia nd tailored to come together in the midline, The felcro is then advanced every 4 to 6 hours, bringing hie fascia closer together. It is very difficult co create 44 compartment syndrome with this method, since the Velcro will unfasten as the abdominal pressures increase. Excess Velcro can be trimmed off and readjusted as the third space losses allow for abdominal content to gradually become smaller ‘Another major advantage to this method is that the abdomen can be re-entered for a definitive procedure by simply unfastening the Velero at the midline Abdominal Compartment Syndrome “The World Society of the Abdominal Compartment Syndrome defines abdominal compartment syndrome (ACS) as an intra-abdominal pressure (VAP) 2 20 mnmFig associated with organ dysfunction, It is important ¢o identify the early signs of an impending abdominal compartment syndrome, At the end of a difficult exploratory laparotomy with significant blood loss and the potential for a substantial degree of third space losses, the index for suspicion of compartment syndrome should be high. Ik is important to observe the peak inspiratory pressure on the ventilator as the abdomen is being closed. If it rises by 15 to 20 mmblg during the abdominal closure, it is very likely that the abdominal viscera are compressing the diaphragms. Obviously, this compromises the ventilation of the patient and alerts che surgeon to the fact that continued fascia-to-fascia closure of the abdomen will result in iners-abdominal hypertension and extreme ventilatory embarrassment. Fascial closure will also result in increased pressure on the renal ‘enous vasculature, causing olguria. If the pressure in the retroperitomeum increases £0 greater than that in the IVC, there will be a decreased venous retum with a resulting decreas in cardiac inflow, Ultimately, this will lead to a decrease in cardiac ouspur and hypotension. Te is critical to identify this impending situation, abandon the abdominal fascial closure, and switch to a procedure that allows for creatively closing the abdomen without increasing intra-abdominal pressurees 135 Cae an efi of AS emia compare syndrome jneraabdominal hypertension 520 mm¥g and organ dysfunction. Figure 1-36: ACS elevates peak airway pressures, Figure 1:38: ACS elevates bladder pressure,hhe increasing pressure in the abdominal ompartment is also cransmitted to the bladder. In te ICU sercing, this becomes an important method F diagnosing and following a patient with intea- bdominal hypertension (LAH).ADVANCED TRAUMA OPERATIVE MANAGEMENT. Selected Readings Chapter 1: Trauma Laparotomy ickell WH, Wall MJ, Pepe PE, etal. Immediate srsus delayed resuscitation for hypotensive avients with penetrating torso injuries. N Emgl J fed. 1994 331:1105-1109, lirshberg A, Mattox KL, eds. Damage control vr abdominal trauma. Surg Clin North Am. 997;77(4):813-820. shason JW, Gracias VH, Gupta R, et al. Hepatic agiography in patients undergoing damage ontrol laparotomy. J Trauma, 2002;52:1102- 106. shnson JW, Gracias VH, Schwab CW, etal volution in damage control with exsanguinating senetrating abdominal injury. J Trauma, D01;51:261-271 Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same, J Trawma. 2003;55:1095-1110. ‘Simon RJ, Rabin J, Kuhls D. Impact of increased, use of laparoscopy on negative laparotomy rates after penetrating trauma. J Trauma. 2002353:297- 302. ‘Wyrzykowski AD. Feliciano DV, Trauma damage control. In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma, 6th ed. New York:McGraw- Hill2008:851-870.TERS ‘here are a number of safe methods to manage blunt and penetrating trauma in the operating suite. The slowing technical surgical tips have been successfully used by the authors to deal with dificult or hallenging operating situations Chapter 1: Trauma Laparotomy Damage Control and Abdominal Casures Lasetin Be a 908 © ‘bdominal Closure in the Damage Control Procedure (The Advancing See Sewine 3, dtl careatinotin * So ib CS nwo ttn OPCS ‘itso Rei ST Wt mann FE esse fora Orn Lon aay Wn etait Os over ena Tene 2 tan ; 5 ert tc EPS elas tigen ent ae ack on al nee te : sce ss NeHomestate Agents (chan nt i FS Congdon Stich 88 wel Cp Abdominal Wall Closure ag) Leiner a ee EA AS Sree ao res “epic ens pens in Ta _amage Control ofthe Abdomen with Penetrating Injury ag ah as Te som me Ps Crate vr iat ce Honoring Fn Go feosote et = -Managemet of Multiple Small Bowel juries Dr Sra Fs Co trowel etn ed rests ‘@iam F Fallon, Jt, MO, MBA, FACS Ni svsrel saree tbo ree oe Sal et Sb ars x ‘esdair KT Cann, MO, FACS ED AC DS, eve Sobizn © ‘te Sob Wastes oe a ‘eine L. Enderson, MD, MBA, FACS, FCCM wan mans ‘FAS anit Trcnbni is & 1. Colon Injury and Diversion Grace S. Razycki MD, MBA, ROMS, FACS tea oc eh ‘(ed A Luchette, MD, FACS, FCOM ‘Vi crieetipraiaotay Crotty eos katoi a = pe rm “4 Dssoation Technique. . 68 ae ‘Paul A.G. Cunningham, MO, FACS bw Gunshot Wound to Descending Clon 46 ‘emetnas Demetiages, MO, PR, FACS(Ad - Anca Tea Opens Management I. Damage Control and Abdominal Closures \bdominal Closure in the ane Control Procedure The Advancing Silo Technique) enworth M. Jacobs, MD, MPH, FACS cenaro | 24yearold woman was involved in a motor cchicle crash, She sustained a Grade IV liver injury nd a Grade V splenic injury. The liver injury was sanaged with packing and local control. A plenectomy was performed. At the end of the rocedure, the abdominal viscera were protruding browgh the midline incision and the fascia could 1ot be closed. Upon trying to close the fascia, the \eak inspiratory pressure (PIP) on the respirator rucreased by 15 mmHg. It was clear that an trempt to continue primary fascial closure would ear the fascia and induce abdominal bypertension ind create ant abdominal compartment syndrome. \ creative closure of the abdomen was necessary. "rocedure lange sheet of Marlex: mesh was sutured to the ascia with a #2 continuous Prolene suture. {second sheet was sutured to the fascia on the ther side of the incision. The omentum was drawn own over the small bowel to cover the bowel. These two leaves were then used to contain the iscera, The two leaves were pulled up vertically. A £2 continuous suture was then used t0 sew the two. eaves of the Marlex mesh together. The firs stitch prought the apex of the fascia together at the ciphoid. This ensures that the small bowel will not semniate through a small defect at the apex of the Josure. The two leaves were approximated along. the length of che wound and a similar procedure ‘was performed ar the inferior end of the wound to prevent herniation. The repair formed a silo that contained the viscera. Figure 1-39; A Marlex sil is created. Bowel loops are visble through the mesh Since the mesh is exansparent, the bowel can be ‘observed for viability. Special attention needs to be paid ro the nock of this hernia where the bowel protrudes out of the abdominal wall. The bowel ‘and its vascular supply can be pinched and kinked at the fascia and cause ischemia ofa loop of bowel. “The problem is easily solved by manually moving the bowel and releasing the pressure on the vascular supply. The bowel is then observed to return to pink, well-pecfused stare, ‘The wound is then re-examined in 4 t0 6 hours. The bowel is then eased back into the abdomen and the silois pinched and cinched closed. Usually the suture line can be advanced by about an inch. A second layer of #2 Prolene is then placed. This procedure is performed in the intensive care unit.procedure is repeated at 6-houe intervals. If re is more rapid mobilization of fluid, the scedure can be ropeated at shorter intervals. The is advanced with mulkple suture lines. This procedure gradually retums the bowel into the the fascia ean be closed primarily. Fire 1-4: After multiple advancements, the wound i for primary closu ‘The PIP on the respirator should be observed at the beginning and end of each advancement. This ancuver will ensure thatthe closure is not creating minal compartment syndrome, Figure 1-42: The wound after primary clos Staged Abdominal Repair (STAR) with Wittmann Patch Closure For Penetrating Abdominal Trauma Dietmar H. Wittmann, MD, PhD, FACS Scenario A 27parold man presented 45 minutes after a gunshot injury with a wound penetrating the abdominal wall 5 em below the umbilicus. In spite of vigorous resuscitation with crystalloid during transport, be remained bypotensive. immediately taken to the operating room. The abdomen was distended and dull 10. percussion, suggesting abdonsinal hypertension from hemorrhage. Operative Management: Staged Abdominal Repair (STAR #1) AA fulblength midline incision from xiphoid to the symphysis provides sufficient access to the injuries. As the incision is opened further, edematous bowel protrudes. There are multiple ileal perforations Blood comes from a source within the pelvis. Clotted blood is scooped out of the abdomen and the extent ‘of the injury inspected. The projectile has also injured the internal iliac vein and the presacral venous plexus, and has perforated the sigmoid colon twice. A clean pack is brought into the presacral space and the internal iliac vein is freed, clamped, and ligaed, “There is still considerable bleeding from the sacral venous plexus. The patient temperature is 35.8°C. New packs inserted into the presacral space control bleeding. A second dose of 2 g of cefotaxime and 500 mg of metronidazole is given intravenously. He was Figure 1-43: The artificial bure sheets are suured to‘The sigmoid perforations are debrided, connected, and closed with single-layer 4-0 PDS. To avoid time consuming repairs ofthe six irregular small bowel perforations, the entire 20-cm segment is resected and both ends are stapled. Anastomosis is deferred to the next abdominal entry (STAR#2) when the patient has been rewarmed and his hemodynamics and coagulation have stabilized and peritoneal edema has decreased. The abdomen is now irrigated with about 8 liters of ‘Ringer’ lactate and then quickly closed temporarily using the artificial burr (Wittmann Patch and Hypopack [WP & H]) to provide abdominal closure over the edematous intestines, and to prevent complications of compartment syndrome. ‘The Hypopack system helps to avoid exogenous ‘contamination, and to measure prowin losses for ‘meaningful replacement and for research, (For details, see wwwopenabdomen.org) Hypopack includes gauze (eg. Kerlix) that is placed into the open wound above the artificial burr and wrapped around a stiff plastic suetion tube (e.g the cone that has been used during the operation) and. covered by a plastic drape (eg. Steri-Drape) that adheres to atleast 10 t0 15 cm of skin around the incision and forms a mesentery around the suetion tube to permit an immediate airtight connection to a suction pump while the patient is stil on the ‘operating room table. To establish wound-sealing hypobaric conditions underneath the plastic drape, timing is crucial and suetion must be applied as soon as the drape sticks to the skin, Otherwise peritoneal fluid will leak its way between skin and drape, jeopardizing Hypopack’s raison dr. Artificial Burr Closure ‘The softer loop sheet is sutured to the right fascia using a running looped #1 nylon suture. The stitches are 2 cm apart, 2 em into the fascia and 1 to 2 em imto the bur. The sheet with loops facing ‘outward is then pushed between the parietal and visceral peritoneum of the other side ofthe incision covering the absominal contents. Planned subsequent abdominal entries, STAR#2 through STAR#S, are scheduled immediately with the charge nurse inthe operating room to make sure that all subsequent abdominal entries are happening at 24-hour interval. ‘The harder hook sheet is similarly sutured to the left fascia, and the hooks are gently pressed into the loops of the loop sheet. Because of the massive peritoneal hypertension in this cas, the hook sheet does not need trimming to fit the wound opening. ‘The space above the burr sheets is now packed with Kerlix wrapped around tubing that was used for suctioning during the operation. It stays connected to the intraoperative suction pump, which must continue suctioning until the wound is hermetically sealed and the tubing is connected to a transportable suction pump. ‘The wound including Kerlix and at least 15 em of skin surrounding the wound is now covered with a self-adhesive sterile plastic drape. A mesentery is, formed between the tubing and the skin to avoid any fluid leak around ehe tubing, I is important to keep suction running continuously (even during eceqecasrt) ey avoid ttsd cake between cheatin the drape that would open a path for exogenous contamination igare 1-44: The two Layers attached to the fascia in ess26 Hours Later Hemodynamics have stabilized, coagulation is formal, and there is no evidence of further hemorrhage. Hypobaric tubing is used to collect 3,580 mi. of slightly hemorshagie Quid, and the peritoneal Maid protein content is 30% of serum levels. These protein losses have been replaced by letravenous fresh frozen plasma. Antibiotics are continued every 12 hours because ofthe potentially oataminated pack within the pelvis. Antibiotic concentration in the peritoneal fluid is four to ten ‘Smes above the minimum inhibitory concentration MIC) of intraperitoneal pathogens isolated. There ‘so fluid leak underneath the hypopack. STARH2 ‘The wound shield and Kerlix are removed and the burr hook sheet pulled off the loop sheet and folded tssing 2 laparotomy pack to cover the hooks. The loop shet is then pulled to open the abdomen. The pesitoneal fluid is reddish clear, and the bowel is ‘sdematous. Before removing the presacral pack, the seapled end ofthe ileum is reconnected using a 4-0 fuaning PDS suture to form a single-layer (Aleernatively, stapling of the fsnastomosis has the advantage that the bowel edema is gently squeered out, while hand-sewn sutures may loosen as edema decreases.) The presacral packs are now gently removed. There is fonly some minor oozing from the presacral space. Iespection of the surured sigmoid reveals no leak snd no nectoic issue around the sutures. Figure 1-45: The buce sheets are opened t0 ispest the abdominal cavity and perform any procedures that ace sued Chater Ore | Trauma Laparotomy 31 All four quadrants of the abdomen are i ‘with Ringer’ lactate. A new pack is brought into the pelvis, and the abdomen is closed by pulling the burr sheets together with some tension to re- approximate the fascia. A hypopack is applied as described for STAR #1 (first procedure). 26 Hours Later “The patient has been stable with no fever and slight leukocytosis. The peritoneal fluid was yellowish clear with a protein content of 50% of serum protein. The patient continues t0 receive rotal parenteral nutrition (TPN). Diuretics have been administered to reduce peritoneal edema and permit fascial re-approximation. TARE “The burr is opened as described above. There is still some bowel edema. Neither the small bowel anastomosis nor the sigmoid colon suture is leaking, and the peritoneal fluid is clear and peritoneal inflammation is much improved. The pack is removed from the pelvis. There is no further hemorrhage. The peritoneal cavity is then washed ‘with 6 liters of Ringers lactate and closing the burr permits re-approximating the fascia up to a 7-cm gap and a hypopack is applied bec Figure 1-46: With each abdominal closure, the bur ste iasned to cegain abdominal domain ina stepwiseSTARSS After re-opening the burr, the abdomen looks ready for final closure. An abdominal x-ray is performed +o identify any laparotomy sponges that may have been left. Meanwhile, all suture lines appear to be healing well. There is no leak, no necrosis, and no new pathology. The burr sheets are pulled and the fascia edges are approximated. Both sheets are then removed and multiple fascial sutures (#1 PDS) are placed. The surgeon ties each single fascial suture. ‘There were no complications postoperatively. Figure 1-47: After the final abdominal exploration, the bre shects are removed andthe facial edges are sppeosimated ‘Suggested Reading ‘Wikmann DH. Compartment syndrome of the abdominal ‘cavity. In: Irvin RS, Carr FR, Rippe JM, eds. Intensive Care Medicine. Sch ed Wickforé, Rl: Lippincoe- Raven Publishers 2002:1698:1709, ‘Witenann DH. Newer methods of operative therapy for peritonitis In: Nyhus LM, Baker BJ, Fischer JE, ed, Mastery 0f Surgery. ede. Boston, Mass: Lite, own and Companys To96146-152, ‘Winenann DH. Staged abdominal repair: development and current practice ofan advanced operative technique for difase ‘Supporative peritonitis Eur Sung, 2000332171178, ‘Wirsnana DH. Setus ofthe open abdomen in paiens with uncontrolled inr-abdomialinfetson with sepals. Ins Deitch A, Vincent JL, Windsoe A, eds. Sepsis and Multiple Orga Daafention. London, New York: WB. Sanders 2002:308- 316. ‘Wirmann DH, Schein M, Condon RE. Management of secondary peritonitis Aron Surg 1996 224:10-1ing Techniques and Vac-Pack «icloninal Wall Closure Aer Damage Control (lichael F. Rotondo, MD, FACS ccenario | thin 26-yearold male presents with a ‘ansabdominal gunshot wosnd just below the ight costal margin in the midclavicular line with a alpable bullet located om the left just above the lac crest in the muidaxillary line, He is initially onfused, combative, and hypotensive. lenagement: Initial Resuscitation and Damage ‘ontro! Laparotomy ‘he need for operation is immediately recognized pon discovery of the right upper quadrant cenetration and the palpable left flank bullet. After ving large-bore peripheral intravenous access, turing which blood is obtained for type and cross- tarch, and conducting an abbreviated neurologic xam, the patient undergoes rapid sequence duction and intubation for immediate airway control. Resuscitation is initiated with warm ‘pstalloids and universal type O blood. The patient | fully exposed and examined for additional cenetrations or palpable missiles. No other injuries re identified. A rectal examination reveals gross ood, and a placement of a Foley catheter reveals lear urine. Insertion of a nasogastric cube also sveals gross blood. A single directed abdominal Im is obtained to determine the presence of ditional. missiles or fragmentation within. the bxlomen. No other missles are identified, with the ception of a large-caliber bullet in the lef flank ofe tissues. The intial remperacure is 35°C. ‘he patient’s total resuscitation time is 12 minutes fad he is taken to the operating room for xploratory laparotomy. At this point, two factors fitcal to this patient's outcome include whether: ) the operating room is totally prepared to receive sis patient; and 2) the surgical team is well aware fF the time course. In this particular scenario, the veal rime to the operating room is less than 18 sinures. This includes performing rapid sequence ttubation, obtaining large-bore intravenous access, placing a nasogastric tube and Foley catheter, performing a digital rectal examination, and obtaining a single film to determine trajectory. It is clear from the information available thatthe patient has a torso injury confined to the abdomen, which is likely 0 involve the liver or other major vascular structures, the stomach, the small bowel, and the colon, and unlikely to involve the genitourinary system. Because of the transabdominal trajectory and the persistent hypotension, this patient should immediately be identified as a candidate for damage control. In this regard, time is of the essence and attentiveness to the amount of time of resuscitation and operation is important in determining. the outcome of this patient. ‘The patient is brought to the operating room and placed on the table in a supine position. The patient is prepped and draped from chin to knees and two suction devices are placed on the operative field, including a device for blood scavenging and autotransfusion. A midline incision is performed. ‘The peritoneum is identified and a small opening is created a cell saver suction deviee is inserted. Two- and-a-half liters of gross blood are evacuated and. the peritoncum is further opened throughout the extent of the incision. Four quadrant and central retroperitoneal packing then ensues. The Bookwalter retractor is set up for general exposure Figure 1-48: A Bookwalte (shoxen here) or other retvactor system is useful to provide exposure.‘© this point, the packs should be systematically moveds itis my practice to first remove the packs sarare least likely to be involved with hemorrhage. This creates more room in the abdomen for posure of the bleeding area. Systematic tracking f the trajectory of this missile should then take lace starting at the right upper quadrant. A large zllate laceration to the dome of the right lobe of ve liver is identified with an additional wound veated just medial to the gallbladder and through ‘xe medial segment of the left lobe of the liver. This easily controlled with perihepatic packing with sinimal mobilization of the liver. Further sploration reveals a through-and-through injury to ve stomach, which is primarily repaired in two \yers. Four holes in the midjejunum are managed primary stapled resection without anastomosis, nid a through-and-through injury t0 the sigmoid lon with significant tissue loss is likewise ranaged by simple stapled resection. Exit of the uller into the retroperitoneum on the left, anterior nd lateral to the ureter and the psoas muscle, is red. Toral operation time is $4 minutes. Figure 149+ A VAC dressing is applied o the open abdomen, rocedure: Packing Techniques and Temporary ‘bdominal Wall Closure After Damage Control ‘he patient is cold with a temperature of 34°C, sagulopathic with evidence of nonmechanical leeding, and acidotie with a base deficic of -9. The ver is then reexamined for pack integrity. Ie is enerally my practice t0 replace the perihepatic acking at this time and to be certain that care is ‘Ken to judiciously place the packs in order to ontrol bleeding. Avoid aggressive overpacking, as leads toto hepatic necrosis. The number of packs laced around the liver is also noted and recorded. Figure 1-50: A VAC dressing after suction is started Procedure: Vac-Pack Dressing If skin-only closure is not possible, a vac-pack dressing is placed by first inserting a. nonstick ‘material in contact with the intestinal viscera. This is achieved by applying an adhesive plastic dressing to a surgical towel and placing the surgical towel within the abdomen such that the abdominal viscera are below the level of the fascia in contact with the plastic nonstick surface of the towel. Two 10-Fr Jackson-Prare drains are then placed in the gutters created by the towel and subcutaneous tissues, and brought out superiorly without a subcutaneous tunnel. A subcutaneous tunnel creates unnecessary tissue damage, which can lead to scarring later and subsequent difficulty with flap closure. Benzoin is then applied to the skin and an additional towel or Kerlix dressings are placed above the level of the previously placed towel and. Jackson-Pratt drains. A second adhesive plastic dressing is then placed to seal the wound and the Jackson-Pratt drains are placed to low wall suction. This achieves a vacuum closure. The patient is then transported back to the intensive care unit for additional resuscitation.fowel Clip Abdominal Wall Jlosure ‘ohn P Welch, MD, FACS cenario 35.yearold male presented following a bead-on totor vebicle accident. He was alert but tachycardic sth a blood pressure of 85 mmtlg systolic. A chest x- xy showed several fractured ribs on the right, and bis Indomen was distended. A focused assessment with ography in trauma (FAST) ultrasound amination showed free intracabdominal fluid. A eritoneal lavage was grossly positive In the erating room, a deep laceration ofthe right lobe of +e liver wus bleeding actively: Ongoing bleeding was iffcul o conorol unless the liver wound was packed. rocedure 1 this type of damage control situation, I have ound that an expeditious abdominal wall closure is fone easily with a large number of towel clips. 1 refer short clips sine they only cover a small area Jjacent 0 the wound and ate easily tucked under ve wound dressing, consisting of sterile gauze oF rwels covered with an adhesive drape. Clips are laced ina parallel fashion about 1 em to 2em apart rd 1 em to 2 em from the edge of the incision. In 1ost cases the patient remains on a ventilator, and bominal wall pressures are well controlled. proximation of the skin and some of the derlying subcutaneous fat is sufficient to prevent sisceration, except when the bowel is massively lated. Clips can be easily removed if an abdominal ompartment syndrome develops. Fascial closure ith or without mesh is usually done afew days later then the patient has stabilized and abdominal istention and edema have subsided. If fascial srraction oseurs, abdominal wall closure might 2guire use of mesh drawback of towel clip closure is interference ith imaging procedures. If desired, a portion ofthe ‘ound, skin, and subcutaneous tissue can be closed ith a running heavy surure such as #1 PDS or igure 1-51: Towel clips are used to expeditiously close the skin and subsutancon fat Prolene to facilitate imaging, such as angiographic embolization. After several days, erythema and localized abscesses can develop atthe towel clip skin puncture sites. Ifthe clips are left for more than a week, there is some risk of skin breakdown and secondary wound infection. I have also seen herniation of small bowel into the subcutaneous fat ina patient whose return to the operating room for removal of che clips was delayed because of recurrent delirium tremors. In most cases of abdominal trauma, the abdominal ‘wound can be closed in a moderately rapid manner with primary fascial closure, whereas a distended abdomen can be closed with some form of mesh or silastic sutured to the fascia, [only employ the towel clip closure in situations where very expeditious abdominal wall closure is needed, usually in cases of damage control. surgery following trauma or in hemodynamically unstable patients developing acute intraoperative complications such as an acute ‘myocardial infarction, Suggested Reading Hensbrock PB, Wind J, Diikpraaf MGW, Busch ORC, Garis JC. Temporary closure of the open abdomen: 3 systematic review on delayed primary fascial. dosore in Baten wih an pen abdomen Wl) ug, 2009519. “Teemblay LN, Feliciano DN, Schmid Jet. Skin only or silo closuze in dhe eal il patene with an open abdomen. Am 1 Sg, 2001:182:670-675.Damage Control of the Abdomen With Penetrating Injury . William Schwab, MD, FACS The experience with damage control of the abdomen with penetrating injury in the early 1990s afforded us an opportunity to make just about every judgment abour closing the abdomen. In those days, Wwe sought to close the abdomen at damage control laparotomy, or at the end of the first operation in the abdomen. What we failed to recognize is that reperfusion injury of the bowel and viscera is @ dynamic process and goes on for 8 to 24 hours after the initial exsanguinating event, We attempted to close the abdomen initially by forcing the fascia together or using plastic vo create synthetic silos. This technique resulted in loss of fascia and at times terrible infection with foreign bodies, and overall more open abdomens. Upon recognizing the problem of the dynamic abdomen leading to increased abdominal pressure and abdominal compartment syndrome, we chose to leave all abdomens open if we performed a damage control laparotomy. One of the best measures that I have used to prove this principle to trainees is to have them back away from the operating room table and look horizontally across the patient, particularly the abdomen. If any bowel is visible above the fascia, we make the point that in the next few hours that hhowel and visceral edema will protrude those organs another 2 to 6 inches above and out of the abdomen, Most times the viscera and the bowel are already well above the skin level with the abdominal opening made by the incision, representing a wide fish mouth, diverting skin, and subcutaneous fat. ‘Therefore, we have made it our practice to leave all damage control laparotomies open initial followed by use of some form of vac-pack dressing. In the intensive care unit, we routinely measure vital signs, peak and plateau inspiratory pressures, bladder pressure, and urinary output, Bladder pressure is constantly displayed on an electronic ‘monitor as routinely measured via a Foley catheter. Although bladder pressure is one of the key determinants for detection of abdominal ‘compartment syndrome, itis not the only one. My most important clinical tick is to watch the overall picture of the patient and integrate all the numbers listed above. Clinically, I have found people with relatively low bladder pressures who have all of the physiologic manifestations of abdominal compartment syndrome, Lastly a patient with an abnormal bladder may exhibie a false high or low bladder pressure. This is something commonly seen. ‘when there is primary injury to the bladder, with repair of the bladder, and with placement of suprapubic tubes. In those cases, bladder pressure should be considered inaccurate and other parameters, including the overall clinical picture, closely watched, Figure 1-52: Laok horizontally across the patent's abdomen, If bowel prorading, the abdomen should he left open,TI. Mana: gement of Multiple Small Bowel Injuries ‘tapled Small Bowel Resection Villiam F. Fallon, Jr, MD, MBA, FACS cenario young male patient was the victim of multiple tunshot wounds to the torso during a robbery. He 12s initially hypotensive but responded to ‘pstalloid resuscitation. An urgent laparotonry was lanned due to the nature of bis torso injury tanagement Ipon arrival, a rapid primary survey is performed to cxermine the status of the patient’s airway, reathing, and hemodynamics. A thorough search or all entrance and exit wounds is essential to avoid rissed injury. Intravenous access is obtained and uid resuscitation begun. Arterial blood gas ceteemination is performed and a specimen sent for ‘pe and cross-match. Imaging studies include a chest adiograph and kidney, ureter, and bladder (KUB). A ladder catheter and a nasogastric tube are inserted. first generation cephalosporin antibiotic is initiated rd tetanus searus determined. The patients taken to 2 operating room for an exploratory laparotomy. rocedure: Stapled Smal Bowel Resection {y standard trauma laparotomy prep is nipples to rnces. The abdomen is draped using an iodoform npregnated adherent plastic sheet with wide ‘ockets on all four sides. The abdomen is entered rough a long midline incision and packed in all dur quadrants with large pads. Once the patient's cemodynamie status is confirmed to be stable with nesthesia, the packs are removed. A thorough amination commences and includes running the In this case, four discrete midjejunal enteroromies are identified and controlled using Babcock clamps. Figure 153: The injuries are identified and controlled with Babsook clams “These through-and-through lacerations can be used to restore intestinal integrity using the linear cutting stapling device in the manner of creating side-to-side functional end-to-end anastomoses. ‘The injured loops are secured with sutures to assist in stabilizing the two limbs for insertion of the stapler. The centerotomies function as the openings in the bowel wall. The antimesenteric borders are approximated and secured in place with surures. The operative field is protected with clean laparotomy pads to control contamination, and a linear stapling device is inserted into each of the openings. Figure 1-54: The fist and last enterotory fanedon a5 the openings forthe lineae staples.‘The length of the instrument selected will determine the size of the anastomoses. The stapler is engaged, fired, and removed. The staple line is inspected for bleeding. The now common opening is then grasped with Allis clamps and a transecting stapler placed across the opening, using the clamps to ensure 1 complete closure. The stapler is fired and the excess amputated with curved Mayo scissors, as this material crosses two staple lines together and is Diseson ssig elierpetion difficult ro amputate with a blade. There is no igure injured bowel ‘mesenteric defect to deal with using this technique. ‘The intestine is re-inspected once more at the completion of the procedure to ensure that there is. zo bleeding from the staple ine on the bowel or the ‘mesentery. ‘gure 1-56: The next load ofthe stapler is used to both ‘Omplet the anastomosis and exclude the segment of Figure 1-59: A saple load is fired actos the mesentary 0 resect the excluded segment. Surgical judgment regarding the proximity of the lacerations will determine the type of repair selected, Alternatively, the most proximal and distal injury sites can be used to perform the anastomosis. In this scenario, a mesenteric window is created andlonger transecting stapler is employed after the astomosis has been fashioned with the linear aplet. This stapler excludes the opening created by « linear stapler as before, Once the segment of tall bowel has been amputated from its mesentery, fe mesenteric window can be closed with rercupted absorbable suture. The middle two erations are incorporated in the resected gure 1-60: The completed anastamosis is shown. Multiple Small Bowel Stab Wounds Alasdair K.T. Gonn, MD, FACS Scenario A patient arrives with six stab wounds 10 the proximal ilewn with significant succus entericus coming from each of the wounds. The wounds are within 3 feet of each other and two of them involve the mesenteric border. There are no other wounds. Management Preoperative antibiotics should have been given to this patient, either in the emergency department or at the time of induction of anesthesia. A generous midline incision to allow a complete exploratory laparotomy is a quick, satisfactory initiation co the operation As Lexplore the small bowel, I apply « noncrushing, clamp to the proximal small bowel to decrease further contamination; and as I explore the small bowel looking for further injuries, 1 apply a roncrushing clamp to the distal howel—again, to control contamination. As the wounds are identified, I usually also try an Allis or a Babeock clamp to approximate the wound edges, both for identification and for easy relocation ofthe injuries. also try to envision the tract of the knife and mentally ry to count the number of injuries to the bowel. Stab wounds to the bowel with an entrance but no exit can occur, bur are unusual. In this ease, two lacerations involve the mesenteric border and where six stab wounds are within 3 feet, I would quickly consider a small bowel resection rather than. primary closure. Although there is a tendency to perform resections and anastomoses using the traditional inner layer of chromic catgut and outer layer of interrupted silk sutures, I think that in the trauma patient, time is of the essence704 - vances Trauma Operative Management igure 1-61: The injured bowel is resected with the OL Spl. Sik sutures are used to conteol the mesentery. Iaving decided to perform the resection, [try r0 do as expeditiously as possible. Isolating the bowel roximal and distal to the injury and using a Gl raple, the damaged bowel is now isolated, and the resentery can be quickly controlled using isolated ik tes, “he quickest way to perform the anastomosis is to se the stapler. I usually place two holding sutures 1f 30 silk to keep the bowel together; use the calpel to make two stab wounds into the proximal nid distal segments, and introduce the stapler into ‘ach limb, After firing and making sure that the snastomosis is patent, one can then close these small tab wounds with an additional application of a ‘apler—although I personally prefer interrupted The saplr is used to create a side-to-side [do not think a second layer is necessary. Interrupted sutures can then be used t0 close the ‘mesentery and prevent an internal herniation. Ihave found the small bowel to be extraordinarily forgiving, and providing a surgeon does not close it under tension or with any ischemia, small bowel Jeaks are uncommon. Thorough itrigation with ‘warm saline, and then closure of the abdomen without a drain, should complete the operation. In ‘good hands, this should be completed in less than 1 hour In healthy individuals, 1 always use a running surure to close the fascia, which speeds up the closure. Figure 1-63: The enterotomies are closed with another staplerViultiple Stab Wounds to the mall Bowel aie L. Enderson, MO, MBA, FACS, FCCM canaio | 30-year-old man was stabbed jn the abdomen nd sustained six 1-cm stab wounds within three et ofeach other in the praxmal small bowel, and erator inthe mesentery. lanagement dications for exploration of patents with stab sounds to the abdomen are often less clear-cut than 1ose for patients with gunshot wounds. However, ‘tienes with hypotension, peritoneal signs, and visceration must be explored. Prior to the incision, roadspectrum ansbioties, such as a. third- cneration exphalosporin, must be given. This oscars sore reliably i a protocol is established to give the nibiories in the emergeney department prior t0 soving to the operating room. The operating room hould be prewarmed to help prevent hypothermia. “he abdomen is explored through a generous midline xcsion to allow complete exploration. Jpon entering the abdomen, the priorities are: 1) control of hemorrhage; 2) control of contamination; ) identification ofall injures; and 4) repair ofall sjuries. To control hemorrhage ll quadrants should «rapidly packed with laparotomy pads, and are hen carefully removed t0 clear shed blood and xamined systematically for active bleeding. The ‘bdomen is examined to evaluae the path ofthe stab vound and to identify injuries to any organs. The ‘owel is evaluated from the ligament of Treitz tothe eocecal vale, controlling any injuries with Babcock lamps to prevent further contamination, until all sjuries are identified. ‘The colon must also be sxamined carefully ‘ocedure: Small Bowel Sutured Repair setention is then turned 10 the mesenteric ematonma. If large, expanding, or obviously still vleeding, the mesentery should be opened to sentify and ligate the bleeding vessels. If small it tay be observed, although iii near the bowel, it ust be explored enough to ensure dhe there is no sidden bowel injury. If exploration does not allow satisfactory control of the bleeding or obviously devascularizes a segment of bowel, the bowel and resected and primary anastomosis performed. IF multiple wounds are involved in a short segment of bowel, it is quicker and safer 10 resect that portion of the bowel. mesentery can be Figure 1-64: Individual lacerations cam be primarily wih sre iced Once the mesenteric hematoma is controlled, attention is returned to the bowel injures. Stab wounds rarely require much debridement and usually can be closed primarily. With six holes over 3 fect of small bowel, I would try to preserve as much bowel as [could by primary repair. 1 close small bowel holes transversely with @ single-layer running closure, with 3-0 silk sutures. The bites should be full thickness with 2 minimal amount of If multiple wounds involve a short segment of bowel, itis often quicker and safer ro resect that portion of bowel with repair of only one oF two of the holes. [use a linear eutting stapler to divide the bowel and todo the anastomosis. This can be done in the standard fashion, by transecting the bowel proximally and distally to the area of injury. After dividing the mesentery berween clamps and ligating the vessels, the two ends of the bowel are anastomosed by inserting the linear cutter at the ancimesenteric portion of each, fring it to ereate the functional end-to-end anastomosis and then using the stapler to close the defect in the bowel. Procedure: Damage Control Stapled Resection An alteative method that I use in a damage2 RUM pores maze Upaer mene ‘control situation or when the segment is small, is to pass one portion of the linear cutter in the proximal-most injury of the segment being resected and the other portion in the distal-most injury, and stapling the two portions together. A second load of the stapler is then used to close the resulting defect and to transect some or all of the mesentery with removal and anastomosis of the injured segment in ‘only two loads ofthe stapler, rather than four, Upon completion of the anastomosis, the bowel is run again to ensure no missed injuries. The abdomen is irrigated with 5 to 10 liters of warm saline to help swith any residual contamination, and the abdomen is closed. Perioperative antibiotics should not be continued for more than 24 hours. Figure 1-65: A stapled skdeo-ide functional ‘end to-end anastomosis,III. Colon Injury and Diversion itab Wound to the Cecum ‘red A. Luchette, MD, FACS, FCCM cenario ‘rehospital personnel sransported a 25-yearold tale t0 the emergency department after he had ustained a stab wound to the right lower quadrant vith a steak knife. The physical examination is onsistent with peritonitis. Exploration reveals a cm laceration to the anterior surface of the cecum sith extensive fecal soilage. Further exploration entfes a right-sided Zone I hematoma of the sesentery with 600 ce of free blood inthe abdomen. Yenagement iroad-spectrum antibiotics that provide coverage or gram-positive organisms, gram-negative rganisms, and bacteroides are administered rnmediarely. A generous midline incision is utilized > allow complete exploration of the peritoneal avity and to evaluate for associated injuries. “here is obvious need for further exploration to ssess for a through-and-through laceration volving the retroperitoneal portion of the cecum, Dne should also recognize the potential for sociated injuries to the right kidney and ureter, ‘ena cava, and iliac vessels. Initial management is licected at minimizing ongoing hemorrhage, ollowed by minimizing further contamination emorthage is controlled by digital pressure until hhe ureter is identified. The cecal wound is temporarily closed with Babcock clamps or sutures. ‘rocedure: Retroperitoneal Exploration and Repair of juries ‘o allow complete evaluation of the cecum and right retroperitoneum, the right colon is mobilized. Beginning at the base ofthe cecum, the whit line of ‘Toldeis incised cephalad to the level of the hepatic flexure. The hepatic flexure is mobilized by blunt and sharp dissection to the midline with exposure of the duodenum, and, if necessary, the pancreatic head. The ascending colon and the mesentery ate mobilized to the midline. Any bleeding from the mesentery is controlled with sutures. The right kkidney and right ureter are now explored from the renal pelvis to the level of the iliac vessels 10 indentify any injuries. Finally, the external iliac artery andl vein are inspected for a laceration. Figuce 1-6 between the right colon and the right urete and iliac vesel This image depict the lose association If the cecal wound is through-and-through, a limited ileocecectomy is performed, especially if the mesenteric hematoma is a vascular injury that will compromise the bowel. The mesenteric vessels should be explored. Ifthe laceration isin proximity to the mesenteric side of the colon or if there is any suggestion or concern that the bowel will be devascularized, one should proceed with a resection and primary anastomosis, Otherwise, if there is maintenance of the collaterals on the mesenteric side of the colon, the injured mesenteric vesselsshould be suture ligated. The anastomosis is completed using either a onedayer or two-layer suture technique. Figure 1.67 Stab wound tothe cecum with mesenteric involvement Lines of reseetion shove ia black. [A stapled anastomosis isan acceptable alternative. An alternative management to resection is. to ecioem two separate closures of each laceration, jpecicularly if there is no significant vascular injury. ‘The initial layer is completed in a through-and- Sevegh fashion with a running 3-0 absorbable esse. A reinforcing layer of 3-0 silk Lembert sess are placed. The fascia should be re- -seeeosimated with a monofilament suture and the “se Fe open and allowed to heal by either delayed closure or secondary intention. [par sped anastomosis berween the Sigmoid Colon Laceration Brad Cushing, MD, FACS Scenario A healthy 25-year-old male sustained a 45-caliber pistol wound that entered at his umbilicus and exited in the lei posterior flank. He was normotensive and nontachycardic. It was clear from the exam and trajectory tha the bullet had traversed the peritoneal ‘cavity. The rectal exam was nonbloody. The injury shad occurred approximately 30 mimes prior. He twas taken directly to the operating room. No consideration was given to the performance of a single-shot intravenous pyelogram, as it is of limited tale and can be done i te operating room if there is renal injury and concern about an intact contralateral kidney. (EAST Practice Guidelines, Fusluation of Genitourinary Trawona, 2003) ‘Management “The patient was placed supine on the operating table, a dose of a second-generation cephalosporin was administered, and after induction of general anesthesia, a Foley catheter was inserted. The urine ‘was nonbloody. ‘A. midline incision was made with the umbilical ‘swerve fo the right ro leave mote room fora leftsded ‘ostomy should it be needed. The fascia was divided for the full length of the incision before entering. the peritoneum so that intraperitoneal blood would not obscure the view and render the cautery unusable. The peritoneum was then entered and fre blood aspirated lear There was a large amount of stool contamination in the peritoneum. The small bowel was eviscerated tothe ight. The retropertoncum was inspected and no bleeding or injury noted. A destructive lesion ofthe sigmoid colon involving 70% of the circumference was noted. The edges were devascularized and there was a small contiguous rent in the mesentery. Kocher clamps were applied to the ‘open edges of the colon to prevent further spillage of stool. The remainder ofthe abdominal contents were inspected and no injuries noted. The patient remained hemodynamically stable Based on the data in the practice guidelines for penetrating colon injuries, presented by the Easternmoved. The mesentery was inspected fora rent that ‘ould allow an internal hernia and none was seen. gure 1-72: A stapler is wsed to complete the primary “he tract where the bullet exited the colon through ve back was ivigated and a single bullet fragment moved, thus reducing the likelihood of later bees formation. The entire abdomen was then ‘rigated with warm normal saline without ribiotcs or other bacteriostatic solution. The Ibdominal fascia was closed with a continuous low absorbing suture and the skin was left open ‘ih the intention of delayed primary closure on ‘ose-op day 4 stoperative care included antibioties for 24 hours see EAST Practice Guidelines). A nasogastric tube ‘snot placed. Rapid diet advancement, following se colon surgery postoperative pathway for elective ssgery, was utilized. The patient was discharged on ‘ostoperative day 4 after delayed primary closure of se wound, but before flatus ora bowel movement. sesgery staff called the patient on postoperative ay 6 and he was doing well. He was seen in clinic ‘n postoperative day 12 and noted to be doing well ‘ichout signs of infection. Low-Velocity Gunshot Wound to Descending Colon Demetrios Demetriades, MD, PhD, FACS Scenario A 24-year-old male was shot with a low velocity bullet to the left lower quadrant. He presented t0 the trauma center 20 minutes after being shot. He required 2 units of blood to become normotensive. There was a 2-cm defect in the mesenteric border of the colon with feces throughout the abdomen. There were no other injuries. Figure 1-73: A hand-sewn anastomosis can be performed inone or two layers. ‘Management ‘The patient needs to go to the operating room for an exploratory laparotomy. 1 would give perioperative antibiotics. Ampicilin and sulbactam provide broad-spectrum coverage. The first dose is given before the patient is taken to the operating, room. The abdomen is entered through a midline incision. A. fall exploratory laparotomy is performed. The colonic injury is identified and any further spillage is immediately controlled. The colonic injury is debrided back to viable tissue. 1 then repair the colon in one or two layers using, absorbable 3-0 Vicryl. If there is a more destructive injury requiring resection, primary anastomosis in cone or two layers is preferred. If feasible, the ‘omentum is placed over the repair the peritoneum| ievigated with warm saline, and the abdomen is losed. The skin is left open for secondary closure to event a wound infection, here is excellent Class I evidence indicating that simary repair is the best treatment option for condestructive colon injuries, regardless of any $o- alled risk factors. Similarly, there is good Class IL rnd some Class evidence that primary anastomosis + the preferred option in civilian destructive colon siuries requiring resection. Colostomy may be served for cases with questionable colonic blood upply or massive colon edema. Laceration to the Colon and Spleen Paul E. Collicott, MO, FACS Scenario ‘A 2eyearold male presented to the emergency room, the apparent victim of an aggravated assault during which he sustained a stab wound to the left upper quadrant. The entrance wound measured approximately 2 om in length and was located just beneath the lft costal margin in the anterior axillary line, The patient remained hemodynamically normal with erystalloid resuscitation, in the emergency department and he was brought to the operating room after prophylactic antibiotics and tetanus toxoid were administered. Operative Findings ‘There was a 2-cm laceration of the splenic flexure of the colon on the antimesenteric surface, as well as 700 cc of free blood in the peritoneal cavity with extensive cots about the hilum of the spleen. Procedure: Laceation tothe Colon and Spleen ‘After satisfactory induction of general endotracheal anesthesia, the abdomen was sterilely prepped and draped and a midline incision made. The operative findings were noted upon entering the peritoneal Blood js evacuated and the left upper quadrant is packed. Abdominal exploration is carried out, no further evidence of active bleeding in the remaining quadrants. ‘The packs are gently ‘removed from the left upper quadrant and noted is ‘a 2-cm laceration of the antimesenteric surface of the splenic flexure with minimal fecal spillage. ‘The laceration is approximated with Babcock clamps and the splenic flexure is mobilized. During the mobilization of the splenic flexure, there is noted to bea significant amount of clot at the hilum of spleen. Since there is no other injury noted to the colon, itis felt that the laceration of the splenic flexure was tangential with the knife creasing the colon and penetrating the hilum of che spleen. ‘Therefore, we felt it necessary to explore this area further to inspece the tail ofthe pancreas.The spleen is mobilized to the midline by dividing its various attachments. During the course of this mobilization, active bleeding ensues from the hilum cof the spleen and the decision is made to proceed with a splenectomy. The hilar vessels are serially clamped and ligated using absorbable sutures, and the spleen is successfully removed. Upon inspection ‘of the body and tail of the pancreas, no hematomas ‘or further injuries are noted. The diapheagm is fntact. The area is then irrigated with copious amounts of s Figure 1-74: Laceation wo the splenic flexure that extends ine the spleen. Attention is then directed to the previously identified splenic flexure injury. Due t0 minimal fecal contamination, primary double-layered suture repair is carried out. This area is then further irrigated with copious amounts of saline, a closed suction drain is placed in the splenic fossa and brought out through a separate stab wound posteriorly, Accurate positioning of the previously placed nasogastric cube is then confirmed and the ‘wound is closed in layers. The patient tolerated the procedure well and received an additional 2 liters of crystalloid during the procedure,Distal Colorectal Irrigation ‘enworth M. Jacobs, MD, MPH, FACS ccenario | 37-yearold man presents with a penetrating injury ‘om a gunshot wound to the rectosigmoid colon at be peritoneal floor, with fecal spillage below the evitoneum in the presacral space. fenagement aumediate preoperative antibiotics to cover gram- sitive and gram-negative organisms, as well as acteroides, should be given. A generous midline acision allows for a complete exploratory sparotomy to identify any other injuries. he injury to the rectosigmoid is identified by ‘pening the pelvic peritoneum and delivering the istal sigmoid and proximal rectum into the wound. hhe full extent of the injury is identified and valuated. The wound is debrided back to viable issue and then a two-layer closure is performed sing a continuous 3-0 absorbable suture for the aucosa, followed by 3-0 interrupted silk sutures to he serosa. The pelvis is then irrigated with at least liters of warm saline o remove any solid of liquid cal material, The liberal use of saline itrigation seduces the bacterial colony count. A closed-suction sain is placed in the most dependent part of the ‘elvis close to the wound. f there is icant fecal spillage in the ctroperitoneal space, a small transverse incision is nade posterior to the anus and anterior to the coccyx and a finger introduced into the most lependent area of the presacral space. A presacral losed-suction drain is then placed in this space and ‘rought out through the incision in the perineum. ‘rocedure: Distal Colorectal inigation hee is a high likelihood that this wound will lak. ‘or this reason, a diverting colostomy with reigation of the distal section of the colorectam is nidicated. The proximal sigmoid colon is drawn up nto the wound. The colon is then divided. The liseal end ofthe colon is identified and a large Foley atheter with a 30-mL balloon is introduced into hhe colon. The balloon is then inflated to secure the atheter in the colon. Figore 1-75: The distal colon is ierigaed with large Foley catheter. The runof is collected by te lear anesthesia tubing placed in the anos. “The lower part of the operating table is lowered to allow full access to the anus. The anus is dilated and clear anesthesia tubing is introduced into the anus and advanced for 2 to 3 inches. The corrugation of the tube allows it to be held in place by the anal sphincter. Saline is then injected through the Foley catheter with a 50-mL syringe ‘The contents of the colon can be observed through the clear anesthesia tubing. ‘The irrigation is continued until clear saline is observed through the anesthesia tubing at the anus. The effluent is directed into a 2iter hortle by the anesthesia tubing, This procedure elegantly contains all the fecal content and prevents fecal contamination of the operating room.Figure 1-76: Photograph showing distal ‘erigaton in a male pavene with a peli facture and perineal laeraton. ‘igure 1-77: The effluent can be contained ecivel using dhe anesthesia tubing. Ar che cad of the irrigation, the distal end of the colon is brought up as a mucous fistula at the ‘efesor aspect of the incision, The abdomen is then closed im layers. If there was severe fecal ‘contamination and a significant risk of a wound ‘mfectom, the skin should be left open. The proximal end of the colon is brought up through the abdominal wall and marured. Prior to considering losing the colostomy, the mucous fistula ean be used to perform a contrast study (weeks or months later) to verify that the rectosigmoid injury is completely healed. ‘Suggested Reading Jacobs LM, Phiser BR. An effcene sytem for controlled distal coloccal iigaton. J Am Coll Surg. 1954,178305 406Totally Diverting Loop Colostomy With Noncontaminating Distal Irrigation Kimball |. Maull MD, FACS Scenario A 26-yearold motoreycist ts sick by ox erie oobi us he aenompes oo maka a ifs farm. He braces himself by extending bis right leg SPesesec eset sear pub faci with esp perinel lacoetion, Management Resuscitation is continued in the emergency unit and the perineal laceration is packed to control bleeding. Upon examination, the laceration is seen to enter the pelvic retroperitoneal space alongside the rectum for a distance of 10 t0 12 em. The anal sphincter appears intact. Fecal diversion is indicated Procedure: Totally Diverting Loop Colostomy Wrth Noncontaminatin Distal irigation The patient is placed in the modified lithotomy positon on a fracture table and is draped to allow sccess (0 the perineum. A left lower quadrant incision is made and a loop of sigmoid colon is identified and drawn up into the field, A small defect is made in che sigmoid mesentery and a flexible plastic bridge is passed and surured to the skin, Using absorbable 3-0 sutures, the exteriorized segment is fastened tothe peritoneum and extecal fascia. A standard noncutting stapler is passed through the mesenteric defect and the colon is stapled, chereby interrupting flow of bowel contents ino the distal segment, A pursestring suture is placed in the distal loop, a stab incision is made, and an 18-Fr irigating catheter is passed into the distal lumen, Figure 1-78 A stapler ied eo divide the colon Figure 179: A stab incision is made inthe distal segment alter placing a punestringsiture Traction is held on the purse-string suture to prevent reflux of luminal contents. The assistant between the patients legs dilates the anus and carefully inserts a retractor, providing egress for rectal contents. Washouts are begun via the inrigating catheter and continued until clear. The inrigaring catheter is removed and the purse-sting surure is tied securely. The colostomy can be opened immediately or delayed, allowing the stomal site to seal. To complete the colostomy, the colonic lumen is entered proximal to the staple line, resulting in a roally diverting loop colostomy. Figure 1-80: The opening is controlled with the orse sting a isvgation proceed,uggested Reading schaello CR, Maull KI Rapid trally diverting loop sigmoid slostomy with noncontaminating rectal irrigation, Am J rg. 1971343300.IV. Hemostatic Agents Coagulation Sandwich Lenworth M. Jacobs, MD, MPH, FACS Scenario ‘A 34-year-old man was involved in a motor vebicle ‘rach where he sustained blunt trauma to the right side of bis chest and abdomen. He was hypotensive and had a tender, distended abdomen. Management The patient was rapidly resuscitated with two large 14-gauge intravenous lines. He was transfused with costaloid and type-specific blood. A chest xray showed no hemopneumothorax and a FAST «examination showed free blood in the abdomen and «significant liver injury to the right lobe. The patient became hypotensive (systolic blood pressure {60 mmHg) and his abdomen continued to distend. He was taken directly t0 the operating suite An exploratory laparotomy was performed using a midline incision, All four quadrants of the abdomen ‘were packed with laparotomy packs. A stellate rear ‘of the right lobe ofthe liver was found to be oozing. Procedure: Hemastatic Coagulation Sandwich Abdominal laparotomy packs are placed above and below the right lobe of the liver. A hand is placed on either pack and primary manual pressure is applied for 5 minutes by the clock. This procedure controlled the bleding. Upon removal ofthe packs, some oozing from the lacerated parenchyma of the right lobe of the liver is noted. “This type of bleeding is an indication for a local hemostatic agent. The hemostatic coagulation sondwich i a useful adjunct in this situation. A 2 x 4 inch Gelfoam patch is placed on a surgical towel A bottle of Avitene povrder (microcrystalline collagen) is emptied onto the Gelfoam sheet ‘The handle of a scalpel is used to spread the Avitene ser the surface of che Gelfoam. A vial of thrombin is then emptied onto the Avitene. The surface should be dried with a laparotomy pack immediately before the Gelfoam/Avitene/thrombin pack is pressed and molded to the parenchyma of the liver. This sandwich is now placed face down onto the oozing surface, The thrombin-moistened Avitene allows the coagulating mixture co be applied directly to the surface, and the firm consistency of the Gelfoam traps the coagulant on the parenchyma and promotes maximal coagulation. Figure 1-81: Thrombin is added tothe Avitee that has ‘been spread onto'a Gelfoam sheet. Figure 1-42: Spread the mixture evenly over the surface ol the Glfoam.