How to Open the Pandora’s Box

We want to repeat ourselves citing Top Knife: “[…] a trauma operation is not an accelerated version of the elective procedure. It requires a different technical language and, most importantly, a different mindset […]”.

Introduction to Trauma Laparotomy

The crash or trauma laparotomy is how you get access to the abdomen of the patient, assess the injuries, and quickly decide how to manage them. 

Following penetrating or blunt injury, a laparotomy is indicated in:

• Hemodynamic instability;
• Peritonitis;
• Evisceration;
• Positive or questionable radiographic findings of organ injury;
• Positive diagnostic peritoneal tap;
• Perforation of the posterior fascia sheath/peritoneum (for penetrating trauma);
• Persistent drop in hematocrit (in some cases).

The objectives of a trauma laparotomy include:

• Control of hemorrhage;
• Control of contamination from the gastrointestinal tract;
• Identification of all injuries.

As with every trauma procedure, this one is also teamwork! Our actors here are the surgeons, the anesthetist(s), and the nurses. Whichever character you are, remember to communicate with the other members of the team. 

As a surgeon, you need to anticipate to the nurses what you need to operate (a stapler? a vascular clamp? more gauzes?) in order not to lose time. You also need to tell the findings and your maneuvers to the anesthetists so they can act accordingly (are you clamping or declamping something? Is the liver bleeding massively?). 

As a scrub nurse, you need to follow the operation and try to anticipate the next surgeon’s step (not so easy, we know…) and know where to find anything you may need. 

As an anesthetist, you have to communicate with the surgeon your side of the story: how many blood products you are giving, the results of the blood tests, the level of inotropes you’re using to keep the patient “alive” and so on…

This massive sharing of information will lead the team (and its leader) to the difficult decision of whether to perform a damage control approach or trying a definitive repair on site. We all have been in an uncomfortable situation where, in the middle of a complex bowel anastomosis, we found out the patient is unstable and under a high level of inotropes! A clip and drop technique would have been best, but the butcher didn’t communicate the complex abdominal situation to the anesthetist and the drug-dealer didn’t update the surgeon on the crashing physiology of the patient!

So, don’t be shy and speak up!

The Three-Stage Sequence

We spoke already about the damage control approach during the resuscitation, the same mindset can be used during a laparotomy. The damage control approach, in this case, refers to an abbreviated laparotomy in an unstable trauma patient with goals of quickly controlling hemorrhage and gastrointestinal spillage with a planned return to the OR for definitive repair of injuries following resuscitation.

There are no clear parameters helping to decide when to go for a damage control approach and when a definitive repair can be done. However, you always need to think about a rapid operation when your patient is in profound shock, a high level of inotropes is ongoing, multiple packs of blood are transfused, the patient is cold and/or acidotic or you have multiple lesions to repair (and it would take hours to be done properly).

Damage control is settled in three stages: 

1. The first stage: laparotomy with rapid hemostasis and control of contamination with a temporary abdominal closure;
2. The second stage: resuscitation and restoration of normal physiology in the intensive care unit;
3. The third stage: reexploration, definitive repair, and closure.

The decision to proceed with a damage control approach should be possibly made before the patient develops the lethal triad of physiologic abnormality. 

During the first stage of a damage control approach, the surgeon should:

1. Pack injuries to solid organs such as the liver and kidney;
2. Perform splenectomy as needed; 
3. Ligate or shunt major vascular injuries; 
4. Oversew or staple off injuries to the intestines;
5. Drain suspected biliary or pancreatic injuries;
6. Place a temporary abdominal closure.

In the second stage, the patient should be promptly transported to the surgical intensive care unit for the ongoing resuscitation. In preparation for the third stage, a thorough head-to-toe tertiary exam should be performed to identify any injuries that may have been overlooked during the primary survey.

Once the patient is fully resuscitated the third stage can be faced: in OR, after removing the temporary abdominal closure, copious irrigation is used to soak and rehydrate the packs so they can be removed without disturbing any underlying clot. The abdomen is completely reexplored for missed injuries. Moreover, vascular and gastrointestinal injuries can be definitively repaired. If at any point the patient becomes hemodynamically unstable, the damage control sequence can be reinitiated.

Trauma Laparotomy

Now that we spoke about the mindset you need to have in the OR, let’s see what actually you have to do…

In the OR, priorities before incision include positioning and prepping the patient, ensuring large-bore IV access and Foley catheter placement, obtaining blood products, temperature control of the room and of the patient, and the administration of perioperative antibiotics. This requires an organized effort between the surgeon, anesthesiologist, and the nursing team. Communication with the entire OR team regarding objectives, operative plan, anticipated pitfalls, and necessary equipment is essential. 

The patient is positioned supine with both arms opened, the surgical field needs to be done from the clavicles to the knees so that the surgeon will have access to the whole abdomen, the thorax, and the groin, where the anesthetist will have the arms, neck, and head at his/her disposal.

In general, the “sicker” the patient (e.g. class III/IV shock, multiple torso wounds, etc…), the larger the incision should be, in order to gain rapid control of the hemorrhage and intestinal spillage. Thus, a classic xiphoid-to-pubis incision is indicated. This incision ensures wide exposure of intraperitoneal and retroperitoneal organs and it may easily be extended into a sternotomy as needed. In contrast, in patients who are hemodynamically stable from penetrating trauma and/or those who have undergone preoperative CT scanning, a more directed or limited incision may be used to start.

The incision starts from the xiphoid to the pubis with the scalpel in your hand, in three passes you should be able to gain access to the peritoneum: 

1. Incise skin and subcutaneous tissue;
2. Go deeper into the subcutaneous tissue to expose the linea alba;
3. Open the fascia (without opening the peritoneum!).

Train yourself in an elective setting to do so.

The concept of not opening the peritoneum straight away is that, if the patient has major bleeding in the abdomen, it will open a “closed hematoma” leading to an even more aggressive drop in the blood pressure. So, if you open the linea alba and see blood through the peritoneum, stop for a second, communicate this finding to the team, let the anesthetists catch up with IV lines and blood products, let the nurses prepare the swaps and the cell saver, and then go in! 

Another reason is to avoid iatrogenic injuries to the liver, bowel, and bladder, which are straight under the thin peritoneal layer!

What follows are strict and repetitive gestures, until the abdomen is packed.

Open the peritoneum bluntly with a finger and fully cut it with a pair of heavy scissors. Now you have the abdomen open with liters of blood coming out from it. Eviscerate the small bowel to create space for your swaps, then evacuate rapidly with swaps and hands the blood (otherwise it will be like sinking some napkins into a ramen bowl). 

Start from a quadrant, it doesn’t matter which one you decide first (but we suggest starting with the right upper one) and pack it, then proceed clockwise or anticlockwise to finish with the mesentery root. Put your swaps above the liver and one or two below it. Then above the spleen. Go for the left paracolic gutter and groin, followed by the pelvis (intraperitoneal). Now it’s time for the right paracolic gutter and flank. Finish with two swaps on the mesentery root.

Empirical abdominal packing does not arrest major arterial hemorrhages but it does give you time to recognize it and identify the source. 

Now, remove the packs from where it is not bleeding to where you see swaps full of blood. If you have major bleeding to control, think about clamping the aorta right below the diaphragm to gain rapid (and drastic) control of it. Then quickly do what you need to properly control the source and unclamp the aorta.

Now that major bleedings are under control, systematically explore the peritoneal cavity. It doesn’t matter where you begin as long as you maintain a linear sequence that covers the entire content of the supra- and inframesocolic regions.

Control the whole small bowel and the colon, check the rectum, look at the liver, the gallbladder, the duodenum, the stomach (anterior and posterior face), the pancreas (open the lesser sac), and the spleen. When you find a lesion you should clip them to return later or manage them directly… It depends on the approach you are using (is it a damage control setting or not?).

The retroperitoneum should be checked for hematomas. 

The retroperitoneum is divided into three anatomical areas:

• Zone 1: the central area around the aorta, from the diaphragm to the iliac vessels;
• Zone 2: the two lateral areas including the kidneys;
• Zone 3: the pelvis and iliac vessels.

Zone 1 retroperitoneal hematomas require surgical exploration, as they signify great vessel injury, including the aorta, the vena cava, the celiac axis vessel, the superior mesenteric artery and/or vein, or the portal vein. Penetrating injuries to zone 2 are generally explored, following the trajectory of the bullet or knife to exclude all injuries. Blunt injuries are only explored if the hematoma is expanding. Zone 3 should generally only be explored in the case of penetrating injury, otherwise, they should be packed.

To explore zone 2 and 1 hematomas you need to do a left-sided visceral rotation (Mattox maneuver) or a right-sided visceral rotation (extended Cattell-Braasch maneuver).

The Mattox maneuver “[…] is used to explore a zone I or a zone II retroperitoneal hematoma on the left. The left-sided organs are mobilized off the aorta, which allows for broad exposure of the aorta from the diaphragmatic hiatus to the iliac vessels, including the celiac axis, superior mesenteric artery and vein, left renal artery and vein, and left iliac artery and vein. Before opening the retroperitoneum, proximal control at the supra celiac aorta should be obtained. A left medial visceral rotation is initiated by dividing the splenorenal ligament. The white line of Toldt is then divided from the splenocolic flexure down the paracolic gutter to the distal sigmoid colon. The left colon, spleen, stomach, and pancreas are mobilized to the midline, just anterior to the Gerota fascia. In the classic Mattox maneuver, the kidney is included in the mobilization, which allows for access to the posterior aspect of the kidney and the aorta below the renal pedicle. Otherwise, the left renal vein restricts access to the anterior aorta. Care must be taken to avoid iatrogenic injury to the spleen when placing traction on the descending colon […]”.

The Cattell-Braasch maneuver “[…] is used to expose the intra-abdominal inferior vena cava, the right renal pedicle, and the right iliac artery and vein. The ureter, head of the pancreas, duodenum, and posterior aspect of the right colon will also be exposed. The Cattell-Braasch begins with mobilization of the hepatic flexure of the right colon and a full Kocher maneuver to mobilize the duodenum and pancreatic head along with the peritoneal reflection. This is further carried down the right colon along the paracolic gutter by dividing the white line of Toldt. The exposure ends by dividing the avascular plane, which exists between the root of the mesentery and the peritoneum. The small bowel and right colon are then retracted medially, allowing visualization of the inferior vena cava […]”.

Let’s hope you have assessed all the patient’s injuries in a damage control way (e.g. clip and drop bowel perforations, packing of the pelvis, and shunting of arterial vessels…), you need to temporarily close the abdomen because now it’s time for the second phase of the damage control pathway (i.e. resuscitation in ICU) and then you’ll need to be back in that abdomen. How to close it for the time being?

You have a couple of choices:

• Bogota bag: the oldest way of closing the abdomen, simply suture to the fascia a sterile bag (e.g. an opened saline bag should fit) to cover the bowel and then close with swaps and sterile plastic drape;
• Barker’s pack: an evolution of the Bogota bag together with the VAC system. It is done with an open swap, a sterile plastic drape on it. This will create the film to be put on the bowel (the plastic side must be on the inside). On top of it some swaps and one or two nasogastric tubes (the “gastric end” is inside the swaps). Close the abdomen with another sterile-drape leaving the “suction end” of the drains free to be put on wall suction (-20 to -50 mmHg will be more than enough!). It is easier to see than to explain in words!
• Commercial vacuum systems: there is more than one available.

We know that here we spoke about a lot of different arguments with many concepts to take home and analyze, we would love to be more specific but doing so this post would become a whole book of trauma techniques (there are a lot, and we don’t pretend to get even close to them).

We just want to remind you that this is not intended to be a surgical technique article. So, please, read proper manuals and follow proper courses to train yourself!

See you next time…

Namasté!

References

1. Moore EE, et al. Trauma. 8^th Ed. New York, NY: McGraw-Hill Education; 2018.
2. Hirshberg A, et al. Top Knife: the art & craft in trauma surgery. Shrewsbury, UK: Tfm Pub Ltd; 2015.
3. Boffard KD. Manual of Definitive Surgical Trauma Care. 5^th Ed. Boca Raton, FL: CRC Press; 2019.
4. Demetriades D, et al. Atlas of Surgical Techniques in Trauma. 1^st Ed. Cambridge, UK. Cambridge University Press; 2015.

How to Cite This Post

Marrano E, Bellio G. How to Open the Pandora’s Box. Surgical Pizza. Published on January 24, 2021. Accessed on May 30, 2023. Available at [https://surgicalpizza.org/trauma/how-to-open-the-pandora-box/].