Trauma Crash Laparotomy.pptx

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1. Trauma: Crash Laparotomy

2. Access & Exposure Incision: Long Midline from Xiphoid to Pubis Major Pitfall: Iatrogenic Injury to Left Liver, Bowel or Bladder Options to Avoid Scars: Extend Incision Superiorly/Inferiorly to Enter Virgin Territory Chevron Incision (Bilateral Subcostal, Double Kocher, Rooftop) Mercedes Incision Enter Fast & Eviscerate Bowel Early Access & Exposure

3. Approach Blunt Trauma: Begin with Empirical Packing Penetrating Trauma: Begin by Directly Attacking the Bleeding *Some Recommend Empiric Packing in All Trauma Cases Temporary Bleeding Contro l

4. Packing Pack Early – Relies on Ability to Form Clot Technique: “From Within” – Packed into a Cavity Applying Outward Pressure “From Without” – Create a Sandwich to Reapproximate Disrupted Tissue Planes Empiric Packing Sites: Right Side – Over/Under Liver & Along the Right Gutter Left Side – Over/Medial to Spleen & Along the Left Gutter Pelvis

5. Rapid Supraceliac Control (If Exsanguinating) Approach: Divide Gastrohepatic Ligament Normally Avascular Watch for Replaced Left Hepatic Artery Reflect Stomach/Esophagus to the Left to Visualize the Aorta May Require Division of the Diaphragmatic Crura Bluntly Dissect the Aorta Occlude Aorta Using: Manual Compress Against Spine Aortic Root Compressor/T-Bar Aortic Clamp – Consider Umbilical Tape to Hold Up Clamp Distal Thoracic Aorta Through the Abdomen Thick Fibrous Attachments as Abdominal Aorta Passes Thorough Diaphragm Other Possible Options: Thoracotomy with Thoracic Aortic Control Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) – Controversial

6. Exploration Once Bleeding Temporarily Controlled Order of Exploration: 1. Inframesocolic 2. Supramesocolic 3. Lesser Sac 4. Retroperitoneum *Some Report Different Orders of Exploration – Exact Order is Not as Important as Making Sure to Preform it the Same Way Every Time & to Not Miss Any Injuries

7. Inframesocolic Exploration Lift Transverse Colon Cranially Run Bowel from Ligament of Treitz to Rectum Transverse Colon & Hepatic/Splenic Flexures are Notorious for Missed Injury Inspect Bladder & Pelvis

8. Supramesocolic Exploration Pull Transverse Colon Caudally Inspect from Right-to-Left Palpate Liver, Gallbladder & Right Kidney Then Stomach & Duodenum Finally, Palpate Spleen & Left Kidney

9. Lesser Sac Exploration Bluntly Dissect Through the Greater Omentum (Left Side Less Vascular) Inspect Posterior Stomach & Pancreas

10. Retroperitoneum Exploration Keep Retroperitoneal Exploration Targeted & Limited Clinical Suspicion Based on Missile Trajectory or Presence of Hematoma Maneuvers: Mattox Cephalad Transverse Mesocolon Reflection Kocher Cattell-Braasch *Understand that There is Significant Overlap with the Maneuvers & They Should be Tailored to the Individual Patient

11. General Abdomen: Maneuvers & Retroperitoneal Exposure

12. Mattox Maneuver “Left-Sided Medial Visceral Rotation” Procedure : Mobilize Descending Colon at White Line of Toldt Extend Incision Lateral Around the Spleen Using Hand Sweep from Below-Up and Medial Dissection Plane Directly on the Posterior Abdominal Wall Rotate All Structures to the Midline Visualize: Entire Abdominal   Aorta Proximal Celiac Axis & SMA Left Renal Artery Limits IVC Exposure Risk: Splenic Injury or Avulsion of Left Descending Lumbar Vein off Renal Vein

13. Procedure: Incise Posterolateral Peritoneal Attachments of Duodenum Place Hand Behind Duodenum/Pancreatic Head and Retract Medially Visualize: Duodenum (D1, D2, Proximal D3) & Pancreas Suprarenal IVC Right Renal Hilum Risk: Right Gonadal Vein Injury Kocher Maneuver

14. Inframesocolic Division Used in Vascular Surgery as the Preferred Operative Approach for a Transperitoneal Open AAA Repair Procedure: Reflect Transverse Mesocolon Cephalad Eviscerate Small Bowel to Right Incise Retroperitoneum Along Midline From Ligament of Treitz , Left of Aorta Extend Caudally to the Right of the Aorta Visualize: Inframesocolic Aorta More Targeted/Limited Than Mattox if Supramesocolic Access is Unnecessary Pitfalls: IMV Injury with Initial Cut IMA/Sigmoid Mesentery Injury

15. Decision (Definitive Repair vs. Damage Control ) Damage Control Definition Definition: Surgery to Stabilize with Delayed Definitive Repair Goals: Arrest Hemorrhage Limit Contamination Maintain Blood Flow Temporary Abdominal Closure Operative Time Limited to Minimize Further Hypothermia, Coagulopathy and Acidemia

16. Damage Control Indications Severe Physiologic Insult Acidosis ( pH < 7.2 ) Base Deficit > 14-15 Lactate > 5 Temp < 34-35 Coagulopathy (Clinical Evidence or INR > 1.5) Intraoperative Ventricular Arrhythmia High Blood Loss Unable to Control Bleeding by Conventional Methods Blood Loss > 4 L Blood Transfusion > 10 U

17. Injury Pattern 5 Different Injury Patterns Difficult to Assess Major Venous Injury Massive Hemorrhage from the Pancreatic Head Major Liver or Pancreaticoduodenal Injury with Hemodynamic Instability Pancreaticoduodenal Devascularization or Massive Disruption with Involvement of Ampulla or Distal CBD Need for Staged Reconstruction Need to Reassess Bowel Viability Unable to Close Abdominal Wall Without Tension Signs of Abdominal Compartment Syndrome While Attempting Closure

18. Damage Control Phases DC-0: Preoperative DC-I: Initial Operation DC-II: Resuscitation DC-III: Definitive Repair DC-IV: Delayed Soft Tissue Reconstruction (If Needed)

19. TERIMA KASIH

20. Trauma: Crash Laparotomy

21. Access & Exposure Incision: Long Midline from Xiphoid to Pubis Major Pitfall: Iatrogenic Injury to Left Liver, Bowel or Bladder Options to Avoid Scars: Extend Incision Superiorly/Inferiorly to Enter Virgin Territory Chevron Incision (Bilateral Subcostal, Double Kocher, Rooftop) Mercedes Incision Enter Fast & Eviscerate Bowel Early Access & Exposure

22. Approach Blunt Trauma: Begin with Empirical Packing Penetrating Trauma: Begin by Directly Attacking the Bleeding *Some Recommend Empiric Packing in All Trauma Cases Temporary Bleeding Contro l

23. Packing Pack Early – Relies on Ability to Form Clot Technique: “From Within” – Packed into a Cavity Applying Outward Pressure “From Without” – Create a Sandwich to Reapproximate Disrupted Tissue Planes Empiric Packing Sites: Right Side – Over/Under Liver & Along the Right Gutter Left Side – Over/Medial to Spleen & Along the Left Gutter Pelvis

24. Rapid Supraceliac Control (If Exsanguinating) Approach: Divide Gastrohepatic Ligament Normally Avascular Watch for Replaced Left Hepatic Artery Reflect Stomach/Esophagus to the Left to Visualize the Aorta May Require Division of the Diaphragmatic Crura Bluntly Dissect the Aorta Occlude Aorta Using: Manual Compress Against Spine Aortic Root Compressor/T-Bar Aortic Clamp – Consider Umbilical Tape to Hold Up Clamp Distal Thoracic Aorta Through the Abdomen Thick Fibrous Attachments as Abdominal Aorta Passes Thorough Diaphragm Other Possible Options: Thoracotomy with Thoracic Aortic Control Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) – Controversial

25. Exploration Once Bleeding Temporarily Controlled Order of Exploration: 1. Inframesocolic 2. Supramesocolic 3. Lesser Sac 4. Retroperitoneum *Some Report Different Orders of Exploration – Exact Order is Not as Important as Making Sure to Preform it the Same Way Every Time & to Not Miss Any Injuries

26. Inframesocolic Exploration Lift Transverse Colon Cranially Run Bowel from Ligament of Treitz to Rectum Transverse Colon & Hepatic/Splenic Flexures are Notorious for Missed Injury Inspect Bladder & Pelvis

27. Supramesocolic Exploration Pull Transverse Colon Caudally Inspect from Right-to-Left Palpate Liver, Gallbladder & Right Kidney Then Stomach & Duodenum Finally, Palpate Spleen & Left Kidney

28. Lesser Sac Exploration Bluntly Dissect Through the Greater Omentum (Left Side Less Vascular) Inspect Posterior Stomach & Pancreas

29. Retroperitoneum Exploration Keep Retroperitoneal Exploration Targeted & Limited Clinical Suspicion Based on Missile Trajectory or Presence of Hematoma Maneuvers: Mattox Cephalad Transverse Mesocolon Reflection Kocher Cattell-Braasch *Understand that There is Significant Overlap with the Maneuvers & They Should be Tailored to the Individual Patient

30. General Abdomen: Maneuvers & Retroperitoneal Exposure

31. M A T T O X M A NE UV E R Mobilizes the splenic flexure of the colon inferio -medially and then allows mobilization of the kidney, spleen and pancreas superior- medially. Completely exposes the anterior and lateral aspect of the aorta, gives direct access to the celiac trunk, superior and inferior mesenteric arteries

32. M O D I F I E D M A T T O X M A NE UV E R Modified mattox maneuver is performed by allowing the kidney to remain in Gerota’s fascia and selecting a dissection plane that includes the spleen and the pancreas. These organs are then rotated superiorly and medially. This approach give excellent exposure of the celiac trunk, and the superior mesenteric artery. It also gives ready access to the left renal pedicle vessels .

33. M O D I F I E D M A T T O X M A NE UV E R Mobilization of the left colon along Toldt’s line. Reflection begins at the distal descending colon and extending the incision past the splenic flexure, around the posterior aspect of the spleen, behind the gastric fundus, and ending at the oesophagus .

34. M O D I F I E D M A T T O X M A NE UV E R The spleen and pancreas are also mobilized. With reflection of the spleen, pancreas, and colon anteriorly toward the midline, the anterior aspect of the aorta is exposed along with the origins of the left renal, superior mesenteric, and celiac arteries. The aortic hiatus (left crus) may need to be incised to provide additional cephalad exposure

35. NB; If access to the posterior aspect of the aorta is required, the left kidney is mobilized outside Gerota’s fascia, along with the other viscera.

36. P I T F A LL S O F M A T T O X M A N U E V E R Splenic injury Avulsion of Left descending lumbar vein (comes off L renal vein )

37. Involves incision of the ligament of Treitz and mobilization of the fourth portion of the duodenum superiorly and to the right The left renal vein serves as a reference to identify the superior extent of dissection. INFRARENAL AORTIC EXPOSURE

38. EXPOSURE OF VENOUS STRUCTURE RIGHT MEDIAL VISCERAL ROTATION Kocher’s maneuver Extended Kocher's maneuver Super-Extended Kocher ( Cattell - Braasch Manuever )

39. Identify duodenum Incise posterior peritoneum immediate lateral Reflect the duodenum and pancreatic head from retroperitoneum Allows access to infrahepatic IVC, distal CBD, duodenum, pancreatic head, right renal hilum K O C H E R M A N EU V E R

40. EXTENDED KOCHER MANEUVER Carry the classic Kocher incision caudally along white line of Toldt Access to entire infrahepatic IVC, right kidney/R hilum, right iliac vessels

41. Extended Kocher+ incise line of fusion of small bowel mesentary to posterior peritoneum Swing small bowel and right colon out of abdomen Cattell - Braasch Manuever ( Super- Extended Kocher)

42. Exposes entire inframesocolic retroperitoneum , infrarenal aorta, IVC, L renal hila, L iliac vessels, superior mesenteric vessels. CATTELL-BRAASCH

43. The right colon, duodenum, and head of the pancreas are mobilized to expose the vena cava, the iliac veins, and the right renal artery and vein. The renal artery is exposed by retracting the vein either cephalic or caudal . CATTELL-BRAASCH

44. Control of vena cava. Pressure using digital compression or sponge sticks should be sufficient to control most venous injuries and avoids circumferential dissection .

45. Pitfalls of Cattell-Braasch Maneuver Injury to the SMV at the root of the mesentry

46. TERIMA KASIH