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23 Practical Approach toREBOA
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201
23.7 Military Considerations ofREBOA
All endovascular procedures can be roughly divided into
simple and complex. REBOA, consisting of percutaneous
or open arterial access and straightforward insertion and
ination of the balloon catheter, certainly belongs to the
former category. As with simple, reliable and effective surgical technique, it is likely to be feasible in military settings as such. Basically, REBOA can be done at every
forward medical treatment facility echelon of care from a
Role 1 to 3.
A Role 2 (forward surgical teams) or Role 3 (combat support hospital) facility represents an environment where such
a procedure can be used as a bridging haemostatic technique
in a similar way as in civilian trauma centres. However, there
are some major differences in austere environment such as
lack of imaging modalities, monitoring and endovascular
armamentarium. Also, the resuscitative capabilities are less
advanced, and the endovascular experience of forward medical facility personnel is likely lesser compared to civilian
counterparts.
In military setting, the decision to use REBOA must be
done with consideration for unforeseen delays in evacuation and other combat-related changes in the operating
environment. There should be a low threshold for cancelling balloon occlusion in such situations, alongside with
preplanned bail out tactics. Yet, if decision to use REBOA
has been made, a close casualty monitoring is mandatory
with focus on local puncture site complications and systemic reperfusion injury after prolonged (>30min) occlusion. Furthermore, the aftercare and monitoring become
especially challenging if the patient is undergoing strategical evacuation. In a such case, both the balloon catheter and
the sheath must be removed, and reliable vascular closure
technique should be applied before patient transportation.
In austere and military environment, the puncture site complications can be life- and limb-threatening if left unnoticed. Such complications may overwhelm the very limited
surgical capacity in forward medical facilities and must
therefore be minimized by meticulous operation techniques
and protocols.
There is very limited and obscure data demonstrating feasibility and efcacy of Role 1 REBOA implementation,
where battleeld REBOA is followed by damage control surgery close to the battleeld. The military out-of-hospital
REBOA, as a part of advanced resuscitation care (ARC), en
route tactical evacuation, and at Role 1 procedures, warrant
further investigation and in-depth analysis for future reasonable implementation.
23.8 Future Considerations ofPractical Use
ofREBOA
Due to the increasing use of REBOA, both the knowledge on
patient selection and understanding how and when to use or
not to use it during the resuscitation of exsanguinating patient
are increasing. The technological breakthrough of dedicated
REBOA catheters has not stopped yet, and more advanced
devices for controlling the balloon placement, partial occlusion, prevention of balloon overination and targeted blood
pressure control are being developed. The increasing experience may indicate in the future that the practical use of
REBOA will be more front-loaded and should be initiated in
earlier stages of resuscitation. Also, there has been a slow
ongoing tactical shift from total occlusion towards partial
occlusion. It is yet to be shown whether these other than total
occlusion tactics will actually improve the REBOA results.
Inferior vena cava bleeding is a critical injury and carries
ultimately high risk of death. Especially, the juxtahepatic
venous injuries (either retrohepatic vena cava or central major
hepatic vein) are extremely challenging to manage with open
surgery. For so far, there are few incidental case reports on
using balloon occlusion of the inferior vena cava in treating
abdominal major vein injuries. This method is called resuscitative endovascular balloon occlusion of the vena cava
(REBOVC). Animal studies are being conducted on simultaneous use of REBOA, REBOVC and Pringle manoeuvre in
case of juxtahepatic bleeding. The early experimental results
are looking promising, and inferior vena cava balloon occlusion, used with simultaneous REBOA, may turn out as a possible adjunct in treating severe retrohepatic venous bleedings.
By now, the REBOA catheter has been used to occlude the
aorta. In addition to varying levels of occlusions, the idea of
using a large lumen balloon catheter to occlude and at the same
time to provide a direct transfusion route into a central circulatory system is interesting. This method called selective aortic
arch perfusion (SAAP) is an endovascular- extracorporeal perfusion resuscitation technique designed specically to treat cardiac arrest. SAAP catheter occlusion balloon provides
simultaneous afterload support for the heart and facilitates a
relatively isolated resuscitative perfusion of blood through the
catheter to the heart and brain. Animal data suggests that in traumatic cardiac arrest, SAAP can provide thoracic aortic balloon
occlusion for control of haemorrhage, rapid volume replacement in haemorrhage-induced hypovolemia to restore normovolaemia and perfusion of the heart and brain to achieve ROSC.
The coming years will show whether these techniques
prove to be practical enough to nd their way into clinical
use.
202
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L. Handolin et al.
23.9 Conclusion
REBOA is a potent tool for treating a critically injured patient.
However, it is only a device which serves as a bridge to damage control surgery, and its implementation requires both careful patient selection and wide overall situational awareness.
The overuse of REBOA will yield unnecessary complications,
and the balloon deployment as a “last resort” will not facilitate
better results. In penetrating trauma, REBOA is contraindicated in injuries above the xiphoid process. The practical use
of REBOA mandates knowing the elementary basics, practical
devices and techniques, as well as organized and systematic
training for the whole team involved. The future research is
needed to help us understand the role of REBOA more
carefully.
Important Points
• REBOA is a bridging temporary technique to support cardiovascular system and control haemorrhage in exsanguinating haemodynamically unstable patients.
• Aortic occlusion has major physiological compromising
sequelae; the balloon occlusion time must be minimized
exceedingly no longer than 30 min for zone 1 and
45–60min for zone 3.
• REBOA necessitates a clear plan for denitive haemorrhage control; surgery must be initiated within 15–20min
after balloon deployment.
• REBOA is a team approach: close communication with
an anaesthetist and a whole trauma team is necessary.
• REBOA is a complex invasive procedure: it may cause
disastrous complications if not appropriately used.
• Appropriate training, common sense and following an
institutional protocol may prevent most of REBOArelated complications.
Suggested Reading
Brenner M, Moore L, Dubose J, Scalea T. Resuscitative endovascu-
lar balloon occlusion of the aorta (REBOA) for use in temporizing
intra-abdominal and pelvic hemorrhage: physiological sequelae and
considerations. Shock. 2020;54(5):615–22. https://doi.org/10.1097/
SHK.0000000000001542.
Bulger EM, Perina DG, Qasim Z, Beldowicz B, Brenner M, Guyette F,
etal. Clinical use of resuscitative endovascular balloon occlusion of
the aorta (REBOA) in civilian trauma systems in the USA, 2019: a
joint statement from the American College of Surgeons Committee
on trauma, the American College of Emergency Physicians, the
National Association of emergency medical services physicians and
the National Association of emergency medical technicians. Trauma
Surg Acute Care Open. 2019;4(1):e000376. https://doi.org/10.1136/
tsaco- 2019- 000376.
Hörer T. Resuscitative endovascular balloon occlusion of the aorta
(REBOA) and endovascular resuscitation and trauma management
(EVTM): a paradigm shift regarding hemodynamic instability. Eur
J Trauma Emerg Surg. 2018;44(4):487–9. https://doi.org/10.1007/
s00068- 018- 0983- y.
Hörer T, The EVTM group. Top Stent- The art of EndoVascular hybrid
Trauma Management. c/o KärlThorax kliniken: Örebro University
Hospital; 2017. ISBN 978-91-639-2522-1
Matsumura Y, Matsumoto J, Kondo H, Idoguchi K, Ishida T, Kon
Y, et al. Fewer REBOA complications with smaller devices and
partial occlusion: evidence from a multicentre registry in Japan.
Emerg Med J. 2017;34(12):793–9. https://doi.org/10.1136/
emermed- 2016- 206383.
Matsumura Y, Matsumoto J, Kondo H, Idoguchi K, Ishida T, Okada Y,
etal. Early arterial access for REBOA is related to survival outcome
in trauma. J Trauma Acute Care Surg. 2018;85(3):507–11. https://
doi.org/10.1097/TA.0000000000002004.
Morrison JJ, Morrison JJ, Galgon RE, Jansen JO, Jansen JO, Cannon
JW, etal. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg Feb. 2016;80(2):324–34.
https://doi.org/10.1097/TA.0000000000000913.
Pieper A, Thony F, Brun J, Rodière M, Boussat B, Arvieux C, Tonetti
J, Payen JF, Bouzat P. Resuscitative endovascular balloon occlusion of the aorta for pelvic blunt trauma and life-threatening hemorrhage: a 20-year experience in a level I trauma center. J Trauma
Acute Care Surg. 2018;84(3):449–53. https://doi.org/10.1097/
TA.0000000000001794.
Theodorou CM, Anderson JE, Brenner M, Scalea TM, Inaba K, Cannon
J, etal. Practice, practice, practice! Effect of resuscitative endovascular balloon occlusion of the aorta volume on outcomes: data from
the AAST AORTA registry. J Surg Res. 2020;253:18–25. https://doi.
org/10.1016/j.jss.2020.03.027.
Thrailkill M, Gladin K, Thorpe C, Roberts T, Choi J, Chung K, Necsoiu
C, Rasmussen T, Cancio L, Batchinsky A.Resuscitative endovascular balloon occlusion of the aorta (REBOA): update and insights
into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med. 2021;29(1):8.
https://doi.org/10.1186/s13049- 020- 00807- 9.2021.
Video-Assisted Thoracic Surgery
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inPenetrating Chest Trauma
FrançoisPons, Henride Lesquen, CharlotteBaltazard,
andGuillaumeBoddaert
24
24.1 Indications
Hemodynamic instability is an absolute contraindication for
VATS. Unstable patients should undergo open surgery:
emergency thoracotomy and/or laparotomy in the supine
position. Indications for VATS in stable patients are based
upon initial ndings and the patient evolution. They can be
immediate or delayed (Table24.1).
• Immediate (immediately or within a couple of hours following the wound):
– Signicant hemothorax (>1 or 1.5 L at chest tube
insertion).
– Continuous bleeding (>300cm3/h within the rst 3h
after chest tube insertion).
– Suspected diaphragmatic injury (quite probable when
the entrance wound is inferior to the nipple line or the
scapula tip).
– Suspicion of a penetrating heart wound (stable patients
with penetrating injuries in cardiac proximity and
doubtful pericardial ultrasound examination). The procedure aims at ruling out any pericardium or heart
wound, which can decompensate at any time.
– Withdrawal of a stab in situ under direct vision.
• Delayed (up to several days after the trauma) in case of:
– Retained or clotted hemothorax. The goals of VATS in
the management of these retained collections are (1)
evacuation and culture of the collection, (2) release of
F. Pons (*) · G. Boddaert
Ecole du Val de Grâce, Paris, France
Department of Thoracic Surgery, Percy Military Hospital,
Clamart, France
H. de Lesquen
Department of Thoracic Surgery, Sainte-Anne Military Hospital,
Toulon, France
C. Baltazard
Department of Thoracic Surgery, Percy Military Hospital,
Clamart, France
the trapped lung with decortication, and (3) drainage
of the chest cavity and lung re-expansion.
– Prolonged air leak and/or recurrent pneumothorax.
– Secondary empyema (often secondary to an incom-
pletely drained hemothorax).
– Chylothorax.
– Foreign-body extraction such as bullets, wires, etc. It
should be discussed depending on the proximity of the
vascular structures and on the predictable operative
difculties.
24.2 Preoperative Preparation
The aim of the treatment is twofold: (1) to inspect and accurately diagnose the injuries (hemothorax, chest wall, lung,
diaphragm, pericardium) and (2) to proceed accordingly,
evacuating a hemothorax, ensuring hemostasis, suturing a
diaphragmatic defect, treating a pulmonary lesion, etc. The
extent of the lesions and the operator’s expertise will decide
whether to hold on to VATS or convert to open
thoracotomy.
24.2.1 Anesthesia
General anesthesia using a double-lumen endotracheal tube
is recommended in order to facilitate the ipsilateral lung collapse and optimize the view in the thoracic cavity. When
selective endotracheal intubation fails, the exploration is
made much more difcult, and most of the time, you should
better convert to an open thoracotomy.
24.2.2 Positioning ofPatient
Penetrating chest injuries may involve various organs; some
of them are best dealt with by laparotomy (abdominal viscus), sternotomy, or thoracotomy (heart, contralateral hemi-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_24
203
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Table 24.1 Indications for VATS in penetrating chest trauma
Clinical picture (stable)
Signicant hemothorax or
continuous bleeding
Residual hemothorax + Delayed (third,
Persistent pneumothorax,
air leak
Suspicion of diaphragmatic
injury
Suspicion of
hemopericardium
Post-traumatic empyema ++ Delayed Treatment Well
Foreign body ++ Immediate Treatment Admitted Supine or
Chylothorax + Delayed Treatment Admitted,
Interest in penetrating
trauma
+ Immediate Diagnosis: source of the
+ Delayed (third
++ (wound under the
nipple horizontal line)
++ (wound in the
“cardiac box”)
Time of
thoracoscopy Diagnosis or treatment Indication Position
Discussed,
bleeding, complete exploration
Treatment: evacuation of clotted
hemothorax, hemostasis
Treatment Well
seventh day)
Treatment Well
day)
Immediate Diagnosis Well
Treatment (sometimes)
Immediate Diagnosis (conversion if
hemopericardium)
Delayed
careful
admitted
admitted
admitted
Discussed,
careful
admitted
rare
F. Pons et al.
Supine
Lateral
decubitus
Lateral
decubitus
Supine
Supine
Lateral
decubitus
lateral
decubitus
Lateral
decubitus
thorax, massive bleeding). Patient positioning is therefore
paramount in view of a possible thoracic, abdominal extension, and more therapeutic options.
• The lateral decubitus position is the easiest approach to
perform VATS, but as laparotomy or sternotomy requires
different patient positioning, the surgeon should eliminate
diaphragmatic or pericardiac lesions before. In practice,
we mainly recommend lateral position for delayed thoracoscopic exploration.
• The supine position (Fig.24.1) makes the VATS slightly
more difcult, but this setting allows accesses in all directions as and when required. Elevate the injured chest with
a cushion, with the arm folded over the head. If necessary,
tilt the operating table up to 30° in order to improve the
exposure. Should you need to proceed through a sternotomy or a laparotomy, you just have to remove the cushion
and replace the arm in abduction.
24.2.3 Setup andEquipment
The operator stands at the site of the injured chest, his assistant next to him, and the scrub nurse facing him. Formal thoracotomy instruments are prepared and available on an
auxiliary table.
The equipment is as follows:
• Two or three trocars (10 mm, sometimes 5 mm), one
10mm 0° optical (a 30° optical may facilitate the visualization of chest wall lesions)
• One irrigation-suction cannula
• Bipolar diathermy forceps
• Coagulating scissors
• Lung grasping forceps (Duval type, endoscopic or open
surgery forceps)
• Articulated endostaplers with reloads
A large hemothorax should ideally be drained before gen-
eral anesthesia. The tube is then removed just before the
procedure.
24.3 Operative Technique
24.3.1 Port Sites
• Use 10mm ports as it allows you to swap the optical from
one site to another.
• Avoid placing the rst port in the wound as it may reactivate bleeding.
• The rst port site depends on the place of the wound; in
most cases, you should place the rst port at the level of
the tip of the scapula, posterior to the midaxillary line
around the fth intercostal space. It may then be necessary to aspirate blood pouring throughout the port before
inserting the optical if the thorax has not been drained
before. The inspection immediately focuses on the internal orice(s) of the chest wound and on adjacent lung
lesions.
• A second port should rapidly follow, either through the
seventh or eighth intercostal space, the previous drain ori-
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Monitor
Monitor
Fig. 24.1 Team allocation and port positions
ce, or through the wound itself (Fig. 24.1). Drain the
hemothorax under direct vision, swapping instruments if
necessary to achieve a systematic and meticulous
inspection.
• A third port disposed in an appropriate triangulation will
allow the insertion of a retractor or forceps and careful
mobilization of the lung.
24.3.2 Exploration
This stage may be demanding and stressful. Impaired vision
is frequent as the hemothorax absorbs the light and gives the
disturbing impression that the patient is still bleeding. You
should keep composed and constantly share information
with the anesthetist. As long as the patient is stable, you can
pursue the thoracic washout, aspirating the blood and clots
from the apex to the diaphragmatic cul-de-sac. To remove
large clots, you can use lung forceps as for open surgery
(Kelly or Duval) introduced through the port without trocar
(Fig.24.2) or a 10mm suction cannula. Once evacuation of
Injury
Fig. 24.2 To remove large clots, you can use lung forceps as for open
surgery (Kelly or Duval) introduced through the defect without trocar
the hemothorax has been achieved, you should systematically examine the lung, the diaphragm, the pericardium, and
the internal aspect of the chest, inventory all lesions, and
decide whether the treatment will remain thoracoscopic or
converted into a sternotomy or a thoracotomy.
206
Optical
Exit wound
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F. Pons et al.
24.3.3 Parietal Hemostasis
If an intercostal artery bleeds, you can achieve hemostasis
with bipolar diathermy, completed if necessary, with a hemostatic gauze packed in the orice. Clips are often unsuccessful. Anterior or lateral wounds may require an enlargement
of the wound and a stitch under direct or video-assisted
vision or conversion into an open thoracotomy.
24.3.4 Pulmonary Injuries
You should remember that the treatment of a pulmonary
injury must be a lung-sparing technique. Inspection determines the site of the wound, its size and depth, the appearance
of the adjacent parenchyma, the severity of the bleeding or
the air leakage, etc.
• A peripheral wound is ideally stapled: grasp the injured
lung and apply one or two series of staples in the adjacent
normal parenchyma (Fig.24.2). The resected lung is then
extracted under direct vision through the port.
• In case of a dry wound, possibly transxing, do not catheterize or manipulate as bleeding may reoccur. Refrain
yourself from any deleterious manipulation and prefer
abstention.
• Pulmonary contusions without breach should just be left
well alone.
• Massive bleeding through a deep pulmonary opening is
rarely encountered at this stage due to prior hemodynamic
instability. In the exceptional case that this occurs, conversion into open thoracotomy is mandatory.
• Some authors reported video-assisted lobectomies in penetrating chest trauma. We share with others the opinion
that it should remain the exception to spare as much
parenchyma as possible. Most importantly, the patient is
hardly ever hemodynamically unstable when lobectomy
is required; therefore, VATS is contraindicated.
• An insufcient air leak control may be improved with an
application of surgical sealant or collagen patch.
associated abdominal injury is present, based upon the
abdominal entry wound site, the peritonitis signs, and the
intra-abdominal viscus lesions on ultrasound or CT scan,
you should prefer an abdominal approach. When there is
only a thoracic wound (especially for a posterior or lateral
stab wound), VATS is recommended to rule out a diaphragmatic injury.
Carefully examine the area facing the wound entry into
the thoracic cavity, and push down the hemidiaphragm to
visualize the posterior cul-de-sac where a small wound can
be missed (Fig.24.3). If you nd a diaphragmatic injury, a
laparotomy should be considered to diagnose and treat
associated intra-abdominal injury. Thoracic approach is
easier than abdominal to repair posterior DI particularly if
you consider laparoscopy. As a result, you may choose the
thoracic approach if you are familiar with this access or if
laparotomy is not indicated. You can repair the diaphragm
either under thoracoscopic vision or through a
mini-thoracotomy.
• Video-assisted repair of a DI: interrupted sutures or a run-
ning suture of nonabsorbable material with a round bod-
ied needle is applied using two ports (one for the forceps,
one for the needle holder) (Fig.24.4). Endothoracic knot-
ting may be difcult and time-consuming specically for
posterior lesions.
• Repair through a utility thoracic incision (Fig.24.5): the
diaphragmatic breach can be exposed and then grasped
and sutured through a limited thoracotomy centered on
the DI or through the enlarged thoracic wound.
port
In conclusion, the main target is to achieve hemostasis.
Small residual air leaks may be tolerated as it will dry out
with the chest tubes. Keep in mind that massive pulmonary
bleeding may lead to thoracotomy and those pulmonary contusions are not as such an indication of resection, as the lung
parenchyma has surprising capabilities of healing.
24.3.5 Diaphragmatic Injury (DI)
Diaphragmatic injury is suspected when the entrance wound
is located below the nipple line or the scapula tip. When an
Fig. 24.3 Thoracoscopic visualization of a defect in the diaphragm
Pericardium
nerve
Diaphragm
Deflated
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Fig. 24.4 Video-assisted repair of a diaphragmatic injury
207
pericardial window to rule out hemopericardium. Identify
the phrenic nerve, and grasp the pericardium (most of the
time posteriorly to it on the left and anteriorly on the right)
(Figs. 24.6 and 24.7). Endoscopic forceps may not be as
effective as expected to hold the pericardiac sac, in which
case the use of formal forceps (Bengolea or Roberts) directly
inserted in an intercostal space will be of great help. A
1–2cm incision in the pericardium is sufcient to diagnose a
Fig. 24.5 Direct suture through a small utility thoracotomy suture
24.3.6 Pericardial Eusion
lung
Phrenic
Fig. 24.6 Pericardiotomy after identication of the phrenic nerve.
Note that a horizontal incision may be safe especially when the nerve
cannot be seen
In our opinion, this procedure is diagnostic and has to be
limited to the cases for whom there is a doubt of pericardial
effusion. A wound may directly be visible, or an effusion
may be seen through a stretched pericardium. In this case, be
careful and inform the anesthetist of a probable heart wound
leading to immediate sternotomy or anterolateral thoracotomy. When pericardial effusion is not obvious, perform a
Fig. 24.7 Video-assisted pericardiotomy. P pericardium, PN phrenic
nerve, L lung, D diaphragm
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hemopericardium. Some authors recommend abstention
when minimal bleeding is met. We do not share the same
view and strongly advocate immediate conversion to thoracotomy or sternotomy. When pericardiac effusion is eliminated, then the pericardial window should be left open.
24.3.7 End ofProcedure
Insert at least one chest tube through the inferior port under
direct vision. The lung is then progressively reinated, showing possible air leaks. Close the remaining incisions.
24.4 Delayed VATS
These procedures are performed 3 or 4days (or later) after
the trauma. They are consequently carried out as elective
procedures. We will just emphasize on the main steps:
F. Pons et al.
• Anesthesia: a double-lumen endotracheal tube is also
necessary.
• Patient setting: likewise, to elective thoracic surgery, the
lateral decubitus position is the position of choice.
• Trocar positioning: the optical trocar is placed in the fth
intercostal space slightly posterior to the scapular angle.
One or two additional ports will then be positioned
depending on the procedure.
The main steps are (1) exploration, (2) evacuation of a
clotted hemothorax (sometimes old clots will need to be
fragmented and extracted bit by bit; a gentle dissection and
peeling with sponge sticks and ring forceps usually allow the
rind to be removed from the visceral and parietal pleura, thus
completely releasing the trapped lung), and (3) re-expansion
of the lung to identify air leaks that will be treated as
described above with stapler, sealant, and collagen patches.
• Foreign-body extraction (Fig.24.8): it needs rst to be
precisely localized on CT scans to discuss the feasibility
of a VATS extraction and above all anticipate the risks of
bleeding. Location under uoroscopy may be of great
help. When it is in close proximity to a main vessel, then
thoracotomy will probably be the way forward.
• Post-traumatic chylothorax: this is a rare complication
that may require surgery when the medical treatment is
unsuccessful. VATS will aim at identifying the lymphatic
vessel and ensure lymphostasis with diathermy, endo-
clips, or biologic glues.
Provided that the surgeon sticks to some basic principles,
VATS in a stable patient with penetrating trauma of the chest
allows a comprehensive exploration of the thoracic cavity
Fig. 24.8 Video-assisted extraction of a bullet (white arrow) near the
posterior diaphragmatic cul-de-sac
and the performance of simple procedures, which will ensure
a better outcome in terms of morbidity, mortality, and duration of hospital stay.
Important Points
• Hemodynamic instability is an absolute contraindication
for VATS.
• Double-lumen endotracheal intubation is strongly
recommended.
• Think of abdominal or thoracic extension: prefer the
supine position for immediate VATS.
• Do not use the wound for the rst trocar.
• You can use the wound or a tube incision for the other
trocars.
• The treatment of pulmonary injuries must be a lungsparing technique.
• Repair of a diaphragmatic injury is often easier through a
small utility thoracotomy.
Acknowledgment The current chapter is a revision of the original
chapter written by François Pons, Federico Gonzalez, Jean P.Arigon,
and Guillaume Boddaert in the previous edition of the book.
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Diagnostic Peritoneal Lavage (DPL)
https://t.me/medicina_free
Unplugged
KeneeshiaWilliams andTerenceO’Keee
25
The original technique for performing a diagnostic peritoneal lavage (DPL) was rst described by Root etal. back in
1965. For many years, it was the diagnostic test of choice to
detect the presence of blood in the abdominal cavity. With
the advent of the computerized tomography (CT) scanner
and later the focused assessment with sonography for trauma
(FAST) exam, it now enjoys a more limited use. Moreover,
diagnostic peritoneal aspiration (DPA) has largely replaced
DPL.DPA employs a technique similar to the DPL; however
uid is not infused. This approach is most useful to determine quickly if the cause of hypotension in a patient is due to
an intra-abdominal source, if FAST is not available or is
unreliable. There is an advantage to this technique if the
patient needs a CT scan, as there will be less confusion if the
abdomen is not lled with lavage uid. If the aspirate is positive, it is extremely accurate, but the false-negative rate is
signicantly higher than a full DPL with lavage, and a negative result should be interpreted with caution. Although DPL
is rarely utilized, DPL can still be performed rapidly, is 98%
sensitive, and is able to detect bowel injury.
A note of caution must be expressed regarding the speed
with which this procedure can be performed in the real
world; because of the limited use of DPL, it may be difcult
to nd the necessary equipment, and the lack of technical
familiarity may extend the time it takes to get a denitive
result. The supply chain disruptions of the last few years
have also impacted the ability to adequately source a full
DPL kit, making it more likely that some improvisation is
necessary to perform the procedure, and so sourcing the necessary pieces of equipment will add additional time.
Increasing obesity within the trauma population will also
K. Williams (*)
Department of Surgery, Trauma/Critical Care, Wellstar Kennestone
Regional Medical Center, Marietta, GA, USA
e-mail: Keneeshia.williams@emory.edu
T. O’Keeffe
Department of Surgery, Trauma/Critical Care, Augusta University,
Augusta, GA, USA
e-mail: TOKEEFFE@augusta.edu
make the placement of the catheter challenging, the infusion
of saline is not always rapid, and the laboratory where the
uid is sent to will often take up to 30 min to report the
results. Therefore, the theoretical rapidity of this test may
run up against some signicant real-world roadblocks.
Notwithstanding the above, the safe and rapid performance of a DPL should continue to be part of the diagnostic
skillset of the trauma surgeon.
25.1 Open or Closed?
The technique as originally described consisted of placing a
catheter through the abdominal wall into the peritoneal cavity and aspirating for gross blood or bile with subsequent
infusion of a liter of saline into the abdomen, followed by
removal and analysis of the efuent.
Both open and percutaneous techniques have been
described, the choice being at the preference of the operator,
with the closed technique generally being quicker; however,
the open technique may at times be safer. Both procedures
use the infraumbilical approach, which should be altered
only for atypical circumstances such as a pelvic fracture or
pregnancy (to prevent decompression of pelvic hematomas
or avoid the gravid uterus, respectively). Prior to performing
a DPL, it is considered preferable to place a gastric tube and
Foley catheter to decompress the stomach and bladder. The
former may be omitted in the awake patient if it will cause
too much discomfort but should always be placed in an
unconscious patient. Relative, but not absolute, contraindications to the performance of a DPL include prior surgery,
advanced cirrhosis, coagulopathy, and morbid obesity. The
only absolute contraindication is an obvious need for surgery, e.g., evisceration or peritonitis.
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E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_25
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