Survey

 Survey solid organs, look back at the

eviscerated bowel, start making decision

 Difficult situations :
 Combined major vascular / viscus injuries
 Penetrating injury to the aorta
 High-grade liver injury
 Pelvic fracture with expanding hematoma
 Injuries requiring surgery in another cavity
Explore
 Divide the peritoneal cavity at the transverse
mesocolon

 Supramesocolic
 Liver, stomach, spleen

 Inframesocolic
 Small bowel, colon, bladder, female reproductive
organs
Supramesocolic Exploration
 Move transverse colon caudad

 Inspect and palpate

 Liver, Gall bladder
 Stomach to GE junction and diaphragms
 Duodenum
 Spleen, left kidney
 Lesser sac
Inframesocolic Exploration
 Lift transverse mesocolon cranially

 Run the gut from the ligament of Treitz down to

the rectum ( or from the rectum bacwards to the
ligament of Treitz)

 Visualize the pelvis and female reproductive

organs
BRIEF DESCRIPTION OF SPECIFIC ORGAN INJURIES

Diaphragm
 Penetrating injuries to the diaphragm are graded as
follows:
 (I) Contusion

 (II) Laceration, < 2 cm

 (III) Laceration, 2-10 cm

 (IV) Laceration, >10 cm

 (V) Total tissue loss, >25 cm2

 Lower-grade injuries may be repaired either via

laparotomy – nonabsorbable sutures ± CTTD
Liver
Liver injuries are also classified by grade
 (I) Non bleeding capsular tears, < 1 cm deep

 (II) Lacerations, 1-3 cm deep and < 10 cm long

 (III) Laceration, >3 cm deep

 (IV) Parenchymal disruption involving 25-75% of a lobe or 1-3

segments
 (V) Parenchymal disruption of >75% of a lobe or >3 segments or

juxtahepatic venous injury

 (VI) Hepatic avulsion
Liver
 Simple lacerations - direct pressure, electrocautery, or topical
hemostatic agents. cautery, sutures, clips, or stapler device

 The Pringle maneuver - more serious injuries

The laceration may then be approached with finger fracture
and direct ligation of the bleeding vessels. After obtaining
hemostasis, the laceration is often
tamponaded with a vascularized omental flap.
PRINGLE MANEUVER
Spleen
 On the basis of the patient's hemodynamic status,
comorbidities, and operative access, the surgeon will plan
for splenorrhaphy or splenectomy.

 Splenorrhaphy includes electrocautery, topical

hemostatic agents, compressive mesh, or partial
splenectomy.

 Penetrating injuries to the spleen can cause significant

bleeding.

 Irreparable vascular injuries, including total avulsion and

extensive lacerations, are indications for splenectomy.
Stomach
 Exposure and thorough inspection of the stomach is
necessary to evaluate and treat penetrating injuries to the
stomach.

 This is facilitated by opening of the gastrocolic ligament,

which allows entrance into the lesser sac.

 Injuries repaired with a stapling device or vicryl sutures

Colon
The management of colonic injuries depends on:
 the extent of the defect,

 the amount of contamination,

 and the stability of the patient.

 Primary repair may be considered if the patient is

hemodynamically stable and if the injury is fairly small with
minimal fecal contamination.
Colon
A diverting colostomy should be performed if the patient has any
of the following:

 Multiple injuries
 Requirement for significant blood product resuscitation
 Acidosis, hypothermia, and coagulopathy
 A large defect (>50% of the circumference) and
considerable fecal spillage
Duodenum
Injuries to the duodenum are graded as follows:
 (I) Hematoma

 (II) Partial-thickness laceration

 (III) Laceration disrupting < 50% circumference of D1, D3, or

D4, or 50-75% circumference of D2

 (IV) Laceration disrupting 50-100% circumference of D1, D3, or D4,

or >75% circumference of D2, or involving the ampulla or distal
common bile duct

 (V) Massive disruption of the duodenopancreatic complex or

devascularization of the duodenum
Duodenum
 The Kocher maneuver is used to mobilize the duodenum, along with the
pancreatic head and distal common bile duct, so that penetrating injuries
can be fully explored.

 Primary repair of injury is the goal, with protection of the repair using
closed-suction drainage.

 Duodenal diverticulization diverts biliary and pancreatic secretions

using T-tube drainage and gastric decompression with a gastrostomy.

 Pyloric exclusion involves closure of the pylorus with non absorbable

suture with bypass via gastrojejunostomy.

 Grade V injuries require pancreaticoduodenectomy, which is often

done as a staged procedure in the unstable trauma patient.
Pancreas
 Most pancreatic injuries are diagnosed intraoperatively.
 Pancreatic duct status and injury location are determinants in the
management of pancreatic injuries.

Pancreatic injuries are graded according to the presence or

absence of ductal injuries, as follows:

 (I) Superficial laceration or minor contusion without ductal

injury
 (II) Major laceration or contusion without ductal injury
 (III) Distal transections without duct injury or tissue loss
 (IV) Proximal transection or parenchymal injury involving the
ampulla
 (V) Massive disruptions of the pancreatic head
Pancreas
 Grade I and II injuries can be managed conservatively

 grade III injuries are best treated with distal

pancreatectomy and splenectomy

 Grade IV injuries require near total pancreatectomy with

reconstruction of pancreatic drainage into the gastrointestinal
tract with either Roux-en-Y pancreaticojejunostomy or
pancreaticogastrostomy
Retroperitoneal Exploration
 Clinical suspicion

 Duodenal hematoma? Mobilize to

see duodenum and pancreatic head

 Colon injury? Mobilize to check posterior

wall and adjacent ureter

 Limited exposure of relevant structures—

medial visceral rotation
LEFT MEDIAL VISCERAL ROTATION(MATTOX
MANEUVER)
Midline supramesocolic area, aorta,
branches
 Start low and lateral

 Pull colon towards you… move upward

 Rotate spleen, pancreas, left kidney toward the

midline
 Sweep from below, upward and medial
LEFT (MATTOX MANEUVER)

 Kidney up or kidney down?

 Periaortic tissues
 Left lumbar vein
 Branch of left renal vein, crosses left lateral aorta
immediately below left renal artery
RIGHT MEDIAL VISCERAL ROTATION
(CATTELL-BRAASCH MANEUVER)
 Cattell-Braasch
 Medial side of cecum, incise line of fusion small
bowel mesentery and posterior peritoneum to
ligament of Treitz
 KOCHER MANEUVER
 Classic Kocher
 Duodenum from CBD to
SMV
 Extended Kocher
 Infrahepatic IVC, renal
hilum, right iliacs
Kidney
Injuries to the kidney are graded according to severity, as follows:
 (I) Contusion

 (II) Lacerations, < 1 cm

 (III) Lacerations, >1 cm

 (IV) Lacerations to the collecting system

 (V) Vascular avulsion

 The kidney is salvaged with renography, using pledgeted sutures

and wrapping, and capsular reapproximation if possible.

 Nephrectomy - severe injury or instability of the patient

(intraoperative intravenous pyelogram to confirm function of the
contralateral kidney)
VASCULAR CONTROL
 Zone 1
 Supramesocolic—Proximal
aorta
 Inframesocolic—Infrarenal
aorta
 Zone 2
 Proximal control of renal
pedicle
 Zone 3
 Expose bifurcation, control
common iliacs, distal
external iliacs
 VASCULAR CONTROL
VENA CAVA
 Suprahepatic

 Median sternotomy with pericardiotomy

 Infrahepatic

 Right to left medial visceral rotation

DAMAGE CONTROL SURGERY

„The modern operation is safe for the patient.

The modern surgeon must make the patient
safe for the modern operation“

Lord Moynihan
INTRODUCTION
 Also known as ‘staged laparotomy’, ‘Bailout surgery’

 The most technically demanding and challenging surgery a trauma

surgeon can perform.

 The concept of ‘damage control’ has as its objective the delay in

imposition of additional surgical stress at a moment of physiological
frailty.

 The primary reason is to minimize hypothermia and metabolic

acidosis in other to prevent coagulopathy,

 Multiple trauma patients (ISS ≥35) are more likely to die from their
intra-operative metabolic failure than from a failure to complete
operative repairs
The trauma triad of death:

- Hypothermia
- Acidosis
- Coagulopathy
Hypothermia:
 Clinically important if less than 36*C for more than 4 hr

 Can lead to cardiac arrhythmias, decreased cardiac

output, increassed systemic vascular resistance

 Can induce and exacerbate coagulopathy by inhibition of

clotting cascade reaction
Acidosis:
 Uncorrected haemorrhagic shock leads into inadequate
cellular perfusion, anaerobic metabolism and the production
of lactatic acid

 Interferes with blood clotting mechanisms and promotes

coagulopathy and blood loss
Coagulopathy:
 Hypothermia, acidosis and the consequences of massive blood
transfusion all lead to the development of a coagulopathy

 Platelet dysfunction at low temperature

 Activation of the fibrinolytic system

 Haemodilution following massive resuscitation

PARAMETERS as a guideline for instituting damage control:
 pH less then or equal to 7.2
 serum bicarbonate level less than or equal to
15 mEq/L
 core temperature less than or equal to 34*C
 transfusion volume of packed RBCs more than or
equal to 4000 ml
 total blood replacement more than or equal to
5000 ml
 total fluid replacement more than or equal to 12
000 ml

If all -
death If
one - DCS
PRINCIPLES OF DAMAGE CONTROL SURGERY
These are:
 Control haemorrhage

 Prevention contamination

 Avoid further injury

NOTE:
 Time is of essence

 Minimum investigations

 Rapid transport to the operating room without repeated

attempts to restrore circulating volume- surgery is part of the
resuscitation
STAGE 1 (OF DCS)
 initial laparotomy

 identify the main source of bleeding

 perihepatic packing (superior and inferior)

 small gastotomies and enterotomies can be rapidly closed

 resect non-viable bowel and close the ends

 minor pancreatic injuries not involving duct - NO TREATMENT

 distal injury including the panceratic duct - DISTAL PANCREATECTOMY

 abdominal closure is rapid and temporary- towel clips, vacuum-pack

technique, intravenous or silo bag, polypropelene mesh. (if there is any
doubt about abdominal compartment syndrome, leave open)
TEMPORARY CLOSURE WITH TOWEL CLIPS
VACUUM-PACK TECHNIQUE
TEMPORARY CLOSURE WITH SILO BAG
STAGE 2
 Begins in ICU

 The next 24 to 48 hours are crucial

 Correction of metabolic disorder

 Core rewarming

 Correction of coagulopathy

 Complete ventilatory support

 Correction of acidosis
STAGE 3
 Window of opportunity is 24-48 hours after the trauma

 Removal of the abdominal packs

 Primary repair with end-to-end anastomosis undertaken

 Copious washout should be performed and the abdomen

closed

The patient sometimes needs early unplanned reoperation

ongoing haemorrhage, abdominal compartment
syndrome or peritonitis
COMPLICATIONS
 Abdominal compartment syndrome

 General copmlications:
 wound sepsis
 wound dehiscence
 intra abdominal abscess
 enteric fistula formation
 ICU-related infections
 pneumonia
CONCLUSION
 Laparotomy is mandatory if shock, evisceration, or
peritonitis is present

 The accuracy of physical examination is limited in cases of

blunt and penetrating trauma. It is less reliable by
distracting injury, altered sensorium

 Clinical indications for laparotomy are more dependable and

more frequently applicable to cases of penetrating trauma
than cases of blunt trauma.
CONCLUSION
 Damage Control is a principle of staged operative
management with control and resuscitation prior to
definitive repair

 Abdominal compartment syndrome is a common problem

in abdominal trauma, and its better anticipated and
prevented
REFERENCES
 Schwartz principles of surgery, 10th ed.
 Sabiston textbook of surgery, 19th ed.
 www.ncbi.nlm.nih.gov.pubmed.
 www.emedicine.medscape.com
 www.trauma.org
 ATLS student manual 9th ed.