1. The Crash Laparotomy Jeffrey Coughenour MD FACS Assistant Professor of Surgery Trauma Medical Director

2. … Upon entering the peritoneal cavity, approximately 2 to 3 liters of blood, both liquid and in clots, were encountered. These were removed. The bullet pathway was then identified as having shattered the upper medial surface of the spleen, then entered the retroperitoneal area where there was a large retroperitoneal hematoma in the area of the pancreas. Following this, bleeding seemed to be coming from the right side, and upon inspection there was seen to be an exit to the right through the inferior vena cava, thence through the superior pole of the right kidney, the lower portion of the right lobe of the liver, and into the right lateral body wall… The inferior vena cava hole was clamped with a partial occlusion clamp… The inspection of the retroperitoneal area revealed a huge hematoma in the midline. The spleen was then mobilized, as was the left colon, and the retroperitoneal approach was made to the midline structures. The pancreas was seen to be shattered in its mid portion, bleeding was seen to be coming from the aorta… Bleeding was controlled with finger pressure by Dr. Malcolm O. Perry. Upon identification of this injury, the superior mesenteric artery had been sheared off the aorta… This was clamped with a small, curved DeBakey clamp. The aorta was then occluded with a straight DeBakey clamp above and a Potts clamp below. At this point all major bleeding was controlled… Shortly thereafter… the pulse rate… was found to be 40 and a few seconds later found to be zero. No pulse was felt in the aorta at this time.

3. Operative Record of Lee Harvey Oswald
Parkland Memorial Hospital, 11/24/63
Cited in: The Warren Commission Report: Report of the President’s Commission on the Assassination of President John F. Kennedy, St. Martin’s Press, 1992

4. Objectives
Learn the correct operative sequence in a critically ill patient
Review what to do once you get inside
Organize your exploration
Understand basic exposure techniques
Summary points

5. Before We Start… Keep the team focused Communicate
Room time to incision can make or break outcome
Communicate
Chin to knees, table to table
Four bars… side, side, top, bottom

6. Operative Sequence
Access and exposure Temporary hemorrhage control Exploration Definitive Repair Damage Control

7. Gaining Access “Hey diddle diddle, right down the middle” Three passes
Skin and subcutaneous tissue
Land on the linea alba
Divide the fascia, expose preperitoneal fat
Push through the peritoneum just cranial to umbilicus
Cut peritoneum, divide falciform ligament

8. Gaining Access Avoid iatrogenic injury Previous laparotomy scar?
Left liver, small bowel, bladder
Avoid pelvic hematoma
Previous laparotomy scar?
Bilateral subcostal incision

9. Once Inside… Evisceration Blunt trauma Penetrating trauma
Up and to the right, remove clot/blood
Blunt trauma
Empiric, yet directed packing
Penetrating trauma
Direct hemorrhage control
Exsanguinating hemorrhage
Supraceliac aorta

10. Empiric Packing Right upper quadrant—Above and below liver
Right gutter
Left upper quadrant—Above and medial to spleen
Left gutter
Pelvis
Survey solid organs, look back at the eviscerated bowel, start making decisions…

11. Survey the Battlefield
Divide the peritoneal cavity at the transverse mesocolon
Supramesocolic
Liver, stomach, spleen
Inframesocolic
Small bowel, colon, bladder, female reproductive organs

12. Inframesocolic Exploration
Lift transverse mesocolon cranially
Run the gut
Visualize the pelvis and female reproductive organs
The posterior portions of the transverse mesocolon, hepatic, and splenic flexures are common sites for missed injuries

13. Supramesocolic Exploration
Move transverse colon caudad
Inspect and palpate
Liver, GB, right kidney
Stomach to GE junction and diaphragms
Duodenum
Spleen, left kidney
Lesser sac (LEFT less vascular)

14. Retroperitoneum 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

15. Left (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

16. Left (Mattox maneuver)
Midline supramesocolic area, aorta, branches
Kidney up or kidney down?
Periaortic tissue
Left lumbar vein
Branch of left renal vein, crosses left lateral aorta immediately below left renal artery

18. Right (Kocher and friends)
Classic Kocher
Duodenum from CBD to SMV
Extended Kocher
Infrahepatic IVC, renal hilum, right iliacs
Cattell-Braasch
Medial side of cecum, incise line of fusion small bowel mesentery and posterior peritoneum to ligament of Treitz

20. Adult Decision-Making Time
Combined major vascular/hollow viscus
Penetrating injury to the “surgical soul”
High-grade liver injury
Pelvic fracture with expanding hematoma
Injuries requiring surgery in another cavity

21. Temporary Closure Best practice? Contain and protect the bowel
Avoid damage to skin or fascia
Close skin over temporary closure method to maintain fascial domain

22. Vascular Control Zone 1 Zone 2 Zone 3 Supramesocolic—Proximal aorta
Inframesocolic—Infrarenal aorta
Zone 2
Proximal control of renal pedicle
Zone 3
Expose bifurcation, control common iliacs, distal external iliacs

23. Vascular Control Portal area Retrohepatic area
Pringle maneuver
Retrohepatic area
Do not open hematoma unless ruptured, pulsatile, or rapidly expanding
Learn how to stay out of trouble, not get out of trouble

24. Supraceliac Aorta Exposure
Incise gastrohepatic ligament
Left lobe of liver cephalad
Stomach caudad
Esophagus and periesophageal tissue lateral
Clamp or compress, not repair

25. Vena Cava Suprahepatic—Yikes! Infrahepatic
Median sternotomy with pericardiotomy
Infrahepatic
Right to left medial visceral rotation
Leave the kidney down

26. Pancreas Divide portion of the gastrocolic ligament
Kocher maneuver (proximal, head, uncinate)
Mobilize spleen medially (distal)

27. Summary Points
Get in with three sweeps of the knife and an educated finger
Stay away from old scars
Eviscerate early
Blunt trauma—empiric packing
Penetrating trauma—eviscerate and go for the bleeder

28. Summary Points Explore the infra- and supramesocolic compartments
Keep retroperitoneal exploration targeted and limited
Feel the muscles of the back with your fingertips
Right-sided medial visceral rotation in 3 steps
Cattell-Braasch—CBD to ligament of Treitz

29. Summary Points
After careful, but rapid exploration, decide… damage control or definitive repair
Contain and protect the underlying viscera
Maintain domain
Complex problems require simple operative solutions…
Top Knife: The Art and Craft of Trauma Surgery Copyright © January 2005
Asher Hirshberg MD and Kenneth L. Mattox MD