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R. Lati
48.7.1.2 Underlay Placement
Underlay graft placement (Fig.48.10) has now become the
main technique in all high-risk and complex ventral hernia
defect reconstructions in my practice. It is more involved, but
once it is mastered and perfected, it does not add signicant
operative time. Although it is believed that that underlay
graft placement is associated with lower incidence of seroma,
in our practice the determining factor is the thickness of the
pannus over the fascia. You need to free the abdominal wall
entirely from any adhesions, as far laterally as possible posteriorly, and of course you need to free the anterior wall from
the subcutaneous tissue (see creation of mucocutaneous
aps).
Placement of the interrupted sutures should ensure complete stretching of the mesh once sutures are tight. During
this stage of the operation, cover the intestines with moist
pad and place the mesh on the moist pad with clear orientation superior-inferior left-right marking. Sutures are placed
using the “parachuting” technique under direct vision at all
times, starting one at each corner, superior, followed by
inferior, and then lateral sutures. The suture is rst placed
anteriorly through and through the abdominal wall, then on
the posterior to anterior surface of the mesh, and returned
back posterior to anterior abdominal wall direction. You
should have approximately 1–2-cm space between sutures.
If sutures are placed close to each other, you will cause
ischemia of large amount in the muscle, and if there is bigger distance between sutures, you run the risk of loosing
the tension of the sutures. The direct-vision parachuting
technique minimizes the potential for bowel injury during
xing of graft on the abdominal wall. When lateral component release is used, sutures in the anterior abdominal wall
are placed as far laterally as possible and must include the
medial edge of the external oblique fascia that has been
previously released. Doing so prevents bulging laterally at
the release component site, which the patient might take the
bulging as a new hernia. It is important to ensure that
sutures are close enough to each other to prevent intestinal
herniation between the sutures. Several techniques of
“underlay” placement have been described, including retrorectus and sublay, as well as release of posterior aspect of
the rectus. If the peritoneum is intact and not violated from
stoma placement or any other reason, retrorectus, and preperitoneum mesh placement may have the advantages
described above.
While retromuscular mesh repair has gained popularity, a
number of associated complications have been reported,
including surgical site infections (SSI) in 19.6% of cases,
and the overall recurrence rate was 16.9%. In one study, the
highest rate of recurrence (25%) occurred when hernia was
repaired with biologic mesh, followed by synthetic mesh
(16.2%), and bio-absorbable mesh (17.1%). The lightweight
mesh use was associated with 22.9% vs. mid-weight mesh
(10.6%) (p= 0.045). The only predictor of recurrence was
the presence of an SSI (p<0.01). Similarly, after multivariate analysis, diabetes, hernia width>20cm, and the use of
biologic mesh were statistically associated with the development of a surgical site occurrence (SSO) (p<0.05). Notably,
the mere presence of contamination was not independently
associated with wound morbidity (p=0.11). SSO and SSI
rates anticipated by a recent risk prediction model were
50–80% and 17–83%, respectively, compared with our actual
rates of 20–46% and 7–32%.
48.7.1.3 Bridge Mesh Placement
When there is a major loss of abdominal wall domain,
approximating the medial edges of the abdominal wall may
be impossible, despite performing bilateral anterior or posterior compartment release. In this situation, the only remaining option is to use mesh as a bridge (Fig. 48.11). The
technique is similar to placing a mesh underlay. Cover the
intestines with moist pad and make sure the mesh orientation
is optimal. You need to have a 3–5-cm mesh under and lateral
to midline fascia. One should avoid tacking the mesh on the
edge of the fascia, given the risk of herniation or suture failure. If at all possible, the “bridge” should be covered with
native skin and subcutaneous tissue. However, when mesh is
used as a bridge and there is no skin or subcutaneous tissue
to cover the mesh, then the use of a wound vacuum-assisted
closure (VAC) with continuous irrigation is very useful to
keep the mesh moist and to speed up the process of granulation for later skin grafting.
48.7.2 Postoperative Complications
Based on the extent of the operation and dissection, the postoperative course can be quite complicated. Wound infection,
necrosis of mucocutaneous aps, seroma, and long-term
open wounds are common, and the patient should be prepared for these possibilities in advance.
Important Points
• The management of complex abdominal wall defects following damage control surgery continues to evolve and
still poses a major challenge.
• Successful abdominal wall reconstruction relies primarily
on good judgment, careful perioperative preparation,
expertise in performing the surgical technique, a multidisciplinary approach, and close follow-up.
• Underlay mesh prosthesis placement, preferably retrorectus with TAR, has become a technique of choice.
• For grossly contaminated wounds, abdominal wall reconstruction can be done with a biologic mesh prosthesis.
48 Beyond Damage Control Surgery: Abdominal Wall Reconstruction andComplex Hernia Repair
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409
• Physiology of the patient, defect size, its location, and
level of contamination are considerations that inuence
the management of abdominal wall defects.
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Abdominal Esophagus andStomach
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ChelseaR.Horwood andClayCothrenBurlew
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49.1 Initial Evaluation intheTrauma Bay
The initial management of seriously injured patients consists
of the primary survey, concurrent resuscitation, the secondary
survey, diagnostic evaluation, and prioritized denitive care.
Although trauma to the abdominal esophagus and stomach
may not be a direct threat to life within the “golden hour,”
associated thoracic or vascular injuries may result in hemodynamic compromise. As with all trauma patients, the primary
survey is utilized rst in management. Appropriate initial
evaluation of the trauma patient begins with “ABCs” (airway
with cervical spine protection, breathing, and circulation).
Utilizing “CAB” (circulation, airway with cervical spine protection, and breathing) is also appropriate initial management
with no difference in mortality compared to the classic
“ABCs.” Remember that due to its location high in the abdomen, any patient sustaining trauma to the esophagus or stomach is at risk for thoracic injury as well aortic trauma.
Therefore, after ensuring a patent and secure airway, you
should search for evidence of a thoracic injury and ensure
adequate oxygenation and ventilation. A combination of
physical exam, focused abdominal sonography for trauma
(FAST), and chest radiography should determine if the patient
has an associated pneumothorax (tension, open, or simple),
hemothorax, or cardiac tamponade. Furthermore, the abdominal aorta lies directly behind the esophagus and stomach, and
the injury is often temporarily tamponaded by the dense nerve
tissue surrounding the supraceliac aorta. Finally pancreatic
injuries are associated with penetrating stomach wounds.
Indications for laparotomy vary slightly for different pen-
etrating and blunt mechanisms. As a rule, minimal evaluation is required prior to laparotomy for gunshot or shotgun
wounds (GSW) that penetrate the peritoneal cavity, because
over 90% of patients have signicant internal injuries.
C. R. Horwood (*) · C. C. Burlew
Department of Surgery, University of Colorado School of
Medicine, Denver, CO, USA
e-mail: Chelsea.horwood@cuanschutz.edu;
clay.burlew@cuanschutz.edu
However, select patients with abdominal GSWs can safely
be managed nonoperatively in select cases. Specically, nonoperative management for abdominal GSWs can be performed in centers where serial abdominal exams are able to
be performed, the patient is able to participate in abdominal
examination, the patient is hemodynamically stable, high
resolution contrast computed tomography (CT) scans are
available, and there is no evidence of peritonitis on exam.
Right upper quadrant, ank and back GSWs are the most
common locations that permit nonoperative management.
In contrast to GSWs, stab wounds (SW) that penetrate the
peritoneal cavity are less likely to injure intra-abdominal
organs. You can explore under local anesthesia in the emergency department (ED) anterior abdominal SWs (from costal margin to inguinal ligament and bilateral mid-axillary
lines) in patients without evidence of shock or peritonitis to
determine if the fascia has been violated. Injuries that do not
penetrate the peritoneal cavity do not require further evaluation, and the patient is discharged from the ED.Although the
optimal diagnostic approach for those patients with fascial
violation (i.e., a positive local wound exploration) has been
debated, the most recent guidelines regarding abdominal
stab wounds (SW) from the Western Trauma Association
(WTA) require either ultrasound, diagnostic laparoscopy, CT
scanning, or serial examination. Diagnostic peritoneal lavage
(DPL) is no longer included in the diagnostic management of
abdominal SWs and is considered mostly for historic relevance unless there is a need in remote access or resource
poor areas. In our experience, serial examinations and laboratory evaluation is the most commonly employed
management.
Abdominal SWs of three body regions require a different diagnostic approach: thoracoabdominal/upper abdomen SWs, anterior, and back/ank SWs. You should try
and rule out occult injury to the diaphragm in patients with
SWs to the lower chest, particularly the left side. SWs to
the RUQ in stable patients without peritonitis can undergo
CT scanning to determine trajectory and connement to
the liver for potential nonoperative care. SWs to the ank
© 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_49
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C. R. Horwood and C. C. Burlew
and back should undergo triple-contrast CT to detect
occult retroperitoneal injuries of the colon, duodenum, and
urinary tract.
49.2 Abdominal Exploration
andIdentication ofInjuries
Abdominal exploration in adults is performed using a midline
incision. The length of the initial incision should be based on
hemodynamic status and presumed missile or knife trajectory. The incision can always be extended for further exposure. For children under the age of 6 years, a transverse
incision may be advantageous. The incision is faster with a
scalpel compared to an electrosurgical unit; ignore incisional
abdominal wall bleeding until you control the intra- abdominal
sources of hemorrhage. Evacuate liquid and clotted blood
promptly with multiple laparotomy pads and suction so that
you can identify the major source(s) of active bleeding. After
localizing the source of hemorrhage, direct digital or vascular
clamp occlusion (vascular injury) or laparotomy pad packing
(solid organ injury) is used to control bleeding.
Once you control overt hemorrhage, you turn your attention to identifying sources of enteric contamination. The
stomach should be inspected from the pylorus to the gastroesophageal junction (GEJ) with both anterior and posterior
aspects of the stomach inspected. This requires opening the
lesser sac and lifting the stomach cephalad for complete
visualization. Full decompression of the stomach with a
nasogastric tube facilitates mobilization. If the trajectory of
the injury is in the region of the GEJ, one should mobilize the
esophagus circumferentially away from the diaphragmatic
crus with care to avoid injury to the anterior and posterior
vagus nerve branches. Mobilization of the lateral segment of
the left lobe of the liver facilitates exposure of the GE junction. Dividing the short gastric vessels will aid in mobilization of the gastric fundus and prevent iatrogenic injury to the
spleen. The serosa of the stomach can be tightly adherent to
the splenic capsule of the upper pole; therefore, take care
with dissection. The most common missed gastric injury is
the posterior wound of a through-and-through penetrating
wound. Retroperitoneal exploration should be done promptly
with any posterior defect of the esophagus or stomach.
Injuries can also be overlooked if the wound is located within
the mesentery of the lesser curvature or high in the posterior
fundus. To delineate a questionable injury, you can digitally
occlude the stomach at the pylorus while you instill methylene blue-colored saline via the nasogastric tube.
Alternatively, you can insufate the stomach via the nasogastric tube while submerging the stomach in saline; any
leakage of air bubbles will identify a missed injury. If the
“leaking or bubbling” injury cannot be found, intraoperative
esophagogastroduodenoscopy (EGD) may be required.
Following identication of injuries, the use of damage control techniques versus primary repair of injuries is based
upon the patient’s intraoperative physiologic status.
Administer antibiotics to all injured patients undergoing a
laparotomy. You should determine the type of antibiotic by
the anticipated source of contamination in the abdomen;
additional doses should be administered during the procedure based on blood loss and the half-life of the antibiotic.
You may consider extended postoperative antibiotics for
patients with signicant intra-abdominal contamination with
delayed recognition.
49.3 Treatment ofSpecic Injuries
Specic treatment of injuries can be further guided by the
American Association for the Surgery of Trauma (AAST)
grading of gastric injury (Table49.1).
Most grade I injuries should be managed with unroong
of the hematoma to rule out any full-thickness injuries.
Simple gastric injuries (grade II or III) can be oversewn with
a running single-layer suture line or closed with a stapler.
Prior to closure, you must debride devitalized tissue. If you
chose a single-layer closure, take full-thickness bites with a
2-0 PDS suture to ensure hemostasis from the wellvascularized gastric wall (Fig.49.1). If the injury is in proximity to the pylorus, be careful not to narrow the channel
with your repair. Performing an associated pyloroplasty with
transverse repair may be warranted. A tangential injury to the
anterior wall of the stomach can be both excised and closed
simultaneously with a stapler. Using Babcock clamps to
approximate the edges of the gastrotomy, place the stapler
beneath the opening in the gastric wall (Fig.49.2). You may
be able to perform a wedge resection using a GIA stapler for
small defects in the body of the stomach (Fig. 49.3a, b).
Table 49.1 Stomach injury scale
GradeaDescription of injury ICD-9 AIS-90
I Contusion/hematoma 863.0/.1 2
Partial thickness laceration 863.0/.1 2
II Laceration <2cm in GE junction or
pylorus
<5cm in proximal 1/3 stomach 863.0/.1 3
<10cm in distal 2/3 stomach 863.0/.1 3
III Laceration >2cm in GE junction or
pylorus
>5cm in proximal 1/3 stomach 863.0/.1 3
>10cm in distal 2/3 stomach 863.0/.1 3
IV Tissue loss or devascularization
<2/3 stomach
V Tissue loss or devascularization
>2/3 stomach
From Moore etal. (1995), with permission
GE gastroesophageal
a
Advance one grade for multiple lesions up to grade III
863.0/.1 3
863.0/.1 3
863.0/.1 4
863.0/.1 4
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Fig. 49.1 Gastric injuries may be repaired with a running single-layer
closure; full-thickness bites of the stomach will ensure hemostasis from
the well-vascularized gastric wall
Fig. 49.3 (a, b) Small defects in the body of the stomach may be repaired by performing a wedge resection using GIA staplers
Fig. 49.2 Tangential injuries to the anterior wall of the stomach can be
both excised and closed simultaneously with a TA stapler. Babcock
clamps are used to approximate the edges of the gastrotomy, placing the
TA stapler beneath the opening in the gastric wall
Alternatively, you may need to perform a partial gastrectomy
for complex or destructive injuries (grade IV or V) to the
central body or antrum of the stomach (Fig.49.4a); resections of the body, distal antrum, or pylorus may be reconstructed using a Billroth I or II procedure, based upon local
anatomy and a tension-free anastomosis technique
(Fig.49.4b). You should add a drainage procedure such as a
pyloroplasty in patients with injuries that damage both
nerves of Latarjet or vagi.
GEJ injuries are usually more challenging to repair. For
simple anterior stab wound to the abdominal esophagus, you
should repair these with a transverse single layer of interrupted PDS sutures. You can then perform either a partial or
full fundoplication to buttress your repair (Fig.49.5). If the
injury is a through-and-through injury, primary repair may
result in a stenotic segment. Consider resecting the injured
segment and pulling up the stomach for a primary end-to-end
anastomosis; a wide Kocher maneuver will ensure your
anastomosis is tension free, and performing a pyloroplasty is
necessary due to transection of the vagi (Fig. 49.6).
Nasogastric tubes should be placed intraoperatively following repair, and correct positioning should be conrmed by
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C. R. Horwood and C. C. Burlew
the operating surgeon. Depending on the type of repair, a
feeding gastrostomy or jejunostomy tube should be performed along with wide drainage of the area.
In recent years, there has been advancement in endoscopic
stent use for potential repairs of esophageal injuries.
Esophageal stents have been shown to be particularly useful
in the management of mid-esophageal injuries. Compared to
open repair, esophageal stents are associated with a decrease
in time to oral intake, morbidity, length of stay, and cost. With
advancement in technology, hybrid stents, and anti- reux
valve systems, stent placement at the GEJ is feasible.
However, GEJ stents are still typically utilized for surgical
complications and anastomotic leaks postperatively given the
b
slightly higher risk of migration and post-placement reux.
Further advancements in endoscopic techniques including endoscopic clips and endoscopic suturing have been uti-
B1
lized for repair of iatrogenic and malignant perforations of
the esophagus and stomach. Injuries to the esophagus and
stomach that have been repaired with endoclip devices have
shown similarity to improved rates of morbidity and mortality. However, to date, only case reports have shown successful management of penetrating stomach injuries with
endoclip and endoscopic suturing. Given the success in the
management of various pathologies and advances in endoscopy, endoscopic closure offers possible new treatment algorithms for stable patients with isolated injuries to the stomach
and GEJ injuries. Similarly, endoluminal wound vacuum
assisted closure (vac) therapy has been utilized for GEJ perforations and leaks. To date, there are no studies to evaluate
B2
this modality in trauma; however, these techniques should be
considered in the future given the reduced rates of mortality
and high closure rates.
In the multisystem trauma patient, one should consider
enteral access via a jejunostomy or a naso-jejunal tube placed
in the operating room. Following gastric repair, avoid insertion of a gastrostomy tube as it will likely put tension on the
suture/staple line. If abdominal closure is indicated after
addressing the patient’s injuries, irrigate the abdomen with
warm saline and close the midline fascia with a running
Fig. 49.4 Complex injuries to the central body or antrum of the stomach may require a partial gastrectomy (a) with reconstruction using
either a Billroth I or II anastomosis (b)
heavy monolament suture. Close the skin selectively based
upon the amount of intra-abdominal contamination.
Fig. 49.5 Anterior traumatic
gastrotomies may be repaired
using a single-layer closure
followed by a buttressing
partial fundoplication
Wrap to
reinforce
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Fig. 49.6 Complex injuries
at the gastroesophageal
junction often require
excision of the injured
segment with a primary
end-to-end
esophagogastrostomy; if the
vagus nerves are transected, a
pyloroplasty is performed
Exit
wound
abc
415
Pyscoplasty
Fig. 49.7 Temporary closure of the abdomen is attained by covering
the viscera with a fenestrated, subfascial 10:10 steri-drape (a). Two
Jackson-Pratt drains are placed along the fascial edges (b). The steri-
49.3.1 Damage Control Surgery Techniques
Damage control surgery techniques should be considered in
any patient with a temperatureof <35°C, arterial pHof <7.2,
base decit of <15mmol/L (or <6 mmol/L in patients over
55years of age), severe coagulopathy (i.e. INR or PTT>50%
of normal and/or abnormal thromboelastography), or abnormal physiology including vasopressor requirements. The
goal of damage control surgery is to control surgical bleeding and limit gastrointestinal spillage. The operative techniques employed are temporary measures, with denitive
repair of injuries delayed until the patient is physiologically
replete. Gastric lacerations can be controlled with a rapid
whipstitch of 2-0 prolene. Segmental damage to the stomach
drape and drains are covered using an Ioban, allowing closed suction to
control reperfusion-related ascitic uid egress while providing adequate
space for bowel expansion (c)
can be controlled using a GIA stapler, with resection of the
injured segment, leaving the proximal and distal ends of the
stomach in discontinuity.
Before returning to the surgical intensive care unit (SICU),
close the abdomen temporarily. Multiple methods to temporarily close the abdomen have been utilized; however, negative pressure wound therapy (NPWT) appears to be superior
in outcomes. Currently, Ioban closure of the abdomen is performed for initial temporary closure (Fig. 49.7a–c) at our
institution. In this technique, the bowel is covered with a
fenestrated subfascial 10:10 steri-drape (3M Health Care, St.
Paul, MN) and 2-#10 Jackson-Pratt drains are placed along
the fascial edges; this is then covered using an Ioban, allowing closed suction to control reperfusion-related ascitic uid
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C. R. Horwood and C. C. Burlew
egress while providing adequate space for bowel expansion
to prevent ACS.Return to the OR in 12–24h for denitive
repair of injuries is planned, once the patient’s physiology is
restored, including normothermia, normalization of coagulation studies, and correction of metabolic acidosis.
49.4 Postoperative Care
Following repair of gastrointestinal injuries, nasogastric
tubes are used to decompress the stomach, preventing tension on the gastric repair, for the rst 24–48 postoperative
hours. Early enteral nutrition, within 72h, is encouraged to
reduce postoperative complications, including septic complications. Overzealous jejunal feeding can lead to small
bowel necrosis in the patient recovering from profound
shock, and patients should be closely monitored in the early
postoperative period. While there is some reluctance to initiate EN in patients with an open abdomen, a multicenter
study by the Western Trauma Association demonstrates that
EN is feasible and is associated with a marked increase in
fascial closure and a decrease in complications and mortality. Prior to starting an oral diet in extubated patients, contrast esophagography for gastroesophageal junction repairs
is often performed.
In general, wounds sustained from trauma should be
examined daily for progression of healing and signs of infection. Midline laparotomy wounds are inspected 48h postoperatively by removing the sterile surgical dressing. If your
patient develops high-grade fever, inspect wounds sooner to
exclude an early necrotizing infection (Fig. 49.8). If you
identify a wound infection—evidenced by erythema, pain
along the wound, or purulent drainage—open the wound
widely by removing skin staples. After ensuring the midline
fascia is intact with digital palpation, the wound is initially
managed with twice-daily wet-to-dry dressing changes and
consideration for NPWT placement.
The most common intra-abdominal complications following gastric injury repair are anastomotic failure and abscess.
Sepsis with abdominal tenderness is the most common clinical
presentation. CT scanning will identify the integrity of the
repair (free air and contrast extravasation indicate breakdown
of the suture or staple line) and identify inammatory uid
collections or abscesses (Fig. 49.9). Percutaneous versus
endoscopic versus operative therapy will be based on the location, timing, and extent of the collection.
Important Points
• Evaluation of the trauma patient begins with the standard
“ABCs” (airway with cervical spine protection, breath-
ing, and circulation) versus “CAB” (circulation, airway
with cervical spine protection, and breathing).
• Operative evaluation should include exploration the retro-
peritoneum for all thru-thru penetrating injuries. Bowel
wall-associated hematomas should be unroofed to rule
out adjacent enteric injury.
Fig. 49.8 Intraoperative photo of necrotizing omental infection
Fig. 49.9 CT imaging
showing pneumoperitoneum
and portal venous gas
concerning for anastomotic
failure
49 Abdominal Esophagus andStomach
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• The most common missed gastric injury is the posterior
wound of a through-and-through penetrating wound. To
fully evaluate the stomach for injuries, the lesser sac
should be opened, and the stomach lifted cephalad for
complete visualization.
• To delineate a questionable injury, the stomach can be
digitally occluded at the pylorus, while a methylene
blue- colored saline is instilled via the nasogastric tube.
Alternatively, you can insufate the stomach via the
nasogastric tube while submerging the stomach in
saline; any leakage of air bubbles will identify a missed
injury.
• If a gastric injury is suspected but cannot be found, intraoperative endoscopy should be employed.
• Prior to repair of a gastric injury, devitalized tissue must
be debrided.
• Gastric repair should not narrow the pyloric channel; performing a pyloroplasty with transverse repair may be
indicated.
• If a penetrating injury damages both nerves of Latarjet or
vagi, a drainage procedure such as a pyloroplasty should
be added to your primary procedure.
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Duodenum
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GeorgeC.Velmahos
50
Table 50.1 Duodenal injury grading
Grade Description
I Hematoma of one portion or partial thickness laceration
II Hematoma of more than one portion or laceration <50%
of circumference
III Laceration 50–75% of circumference
IV Laceration >75% of circumference or involving ampulla
V Massive destruction of pancreaticoduodenal complex
Modied from the original version and simplied
The management of duodenal trauma remains challenging not
only because of the organ’s close anatomic relationship with
vascular structures and other organs but also because of its retroperitoneal location which may mask the initial symptoms and
cause delays in diagnosis with dire consequences. The grading
of the duodenal injuries has been developed by the American
Association for the Surgery of Trauma and provides a straightforward way to communicate the severity of injury and plan the
operation. A simplied version is shown in Table50.1.
50.1 General Rules ofOperative Strategy
You should always use a midline laparotomy to approach
duodenal injuries. Other incisions usually compromise the
ability to explore the rest of the abdominal cavity adequately
and are more time-consuming to open and close. There are
two extremely important issues to which you should pay
attention at the beginning of the operation:
(a) Mobilize the duodenum fully by a Kocher maneuver
(Fig.50.1). The duodenum must be brought at the surface of the abdominal wound. Avoid working in the
G. C. Velmahos (*)
Division of Trauma, Emergency Surgery and Surgical Critical
Care, Department of Surgery, Massachusetts General Hospital,
Harvard University Medical School, Boston, MA, USA
e-mail: gvelmahos@partners.org
depths of the abdominal cavity. For non-trauma operations, the Kocher maneuver is typically limited to the
C-loop of the duodenum. I strongly discourage this.
Because it is rare that only the duodenum is injured
and because adjacent structures are involved and need
exploration, you should mobilize the right colon and
the duodenum widely toward the midline. Incise the
peritoneum at the ileocecal junction and carry the
incision with scissors lateral to the cecum and
descending colon along the white line of Toldt. Use
your ngers to create tissue planes as you incise the
soft tissues layer by layer, and gently retract the colon
medially. Stay away from the mesocolic vessels to
avoid inadvertent bleeding and interruption of blood
supply to the colon. Navigate laterally around the
hepatic exure and mobilize it similarly toward the
midline. At this point, you have the entire colon elevated from the duodenum, which is lying attached to
the retroperitoneal space. Incise the peritoneum
around the lateral surface of the duodenal C-loop, and
gently mobilize the duodenum (with the attached pancreatic head) toward the midline too. Your Kocher
maneuver should be wide and include the entire duodenum from its rst to its fourth portion. The duodenum and pancreatic head should be easily inspected
anteriorly (Fig. 50.2a) and posteriorly (Fig. 50.2b).
The inferior vena cava lying posteriorly and slightly
laterally to the second portion of the duodenum should
also be inspected for hematomas. There is no need to
skeletonize it, if no hematoma exists. Similarly, the
portal triad can be inspected for hematomas—
although again not necessarily requiring full dissection in the absence of suspicion for injury. Only if the
duodenum is mobilized in this extensive fashion, you
will be sure to never miss an injury and have the ability to x it comfortably if one is present.
(b) Control temporarily the duodenal injury (DI), but
explore the entire abdominal cavity before performing a
permanent repair. Although an atraumatic clamp or
quick suture can be temporarily placed to control con-
© 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_50
419
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