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Intraperitonealblood
Thepatientmayhavesufferedabluntorpenetratinginjuryornoinjury
at all; in the latter case he is suffering from spontaneous intra-
abdominal hemorrhage (abdominal apoplexy), an uncommon entity
theetiologyofwhichissummarizedin Table11.1.
You may have been expecting the presence of free intraperitoneal
bloodfromtheclinicalfindingsofhypovolemicshock,ortheresultsofCT,
ultrasoundorperitoneallavage.Youractiondependsonthemagnitudeof
hemorrhage and the degree of resulting hemodynamic compromise.
When the abdomen is full of blood, and the patient unstable,you
shouldactswiftly.
Controlthesituation:
Enlargeyourinitialincisiongenerously(avoidtheliverandbladder).
Liftoutthesmallbowelcompletely(nothysterically…tearingthemesentery).
Evacuate the blood as fast as possible — always have two large suckers ready.
However,inmassivehemoperitoneumitisbettertoscoop
out the blood with hand/towels/kidney dish, because
suckersgeteasilyblocked
.
Packthefourquadrantstightlywithlaparotomypads.
Evacuation of massive hemoperitoneum temporarily aggravates
hypovolemia. It releases the tamponade effect and relieves intra-
abdominalhypertension( Chapter 33), resulting in suddenpooling of
bloodinthevenouscirculation.Atthisstage,compresstheaortaatits
diaphragmatic hiatus, or through the lesser omentum, and let the
anesthetistcatchupwithfluidandbloodrequirements.
Be patient, do not rush; with your hand or a Deever retractor
(carefully!)compressingtheaorta,theabdomentightlypacked,and
the patient’s vital organ perfusion improving, you have almost all
thetimeintheworld.Donotbetempted at this stage to continue
withthe operation,whichcan resultinsuccessfulhemostasis ina
deadpatient.Relaxandplanthenextmove,rememberingthatfromnow
on you can afford to lose only a limited amount of blood before the
viciouscycleofhypothermia,acidosis,andcoagulopathy—the‘triangle
ofdeath’—willfurtherfrustrateeffortstoachievehemostasis.
Primarysurvey(seealso Chapter32)
Nowyouarereadytoidentifyandtreatthelife-threateninginjuries.The
initial direction of your search will be guided by the causative
mechanisms.In penetratinginjurythebleedingsourceshouldbein
thevicinity of the missileorknife track; in blunttrauma,bleeding
will probably originate from a rupturedsolid organ— the liver or
spleen,thepelvicretroperitoneumoratearinthemesentery.
Unpack, suck and repack each quadrant consecutively noting where
there is blood reaccumulation (active bleeding) or hematoma. Having
accurately identified the source (or sources) ofbleeding, start definitive
hemostasis,therestoftheabdomenbeingpackedaway.Simultaneously,
ifthesituationpermits,controlcontaminationfrominjuredbowelusing
clamps,staplersortapes,orrepackingindesperatesituations.
Stay tuned constantly to events behind the blood-brain barrier
(BBB)—whichisthescreenbetweenyou and the anesthetists. Wake
them up fromtime to timeand ask how the patient is doing. Take this
opportunityalsotoexplainhowandwhatyouaredoing.Communication
amongmembersofthemedicalteaminthissituationisvital.Whileyou
are busy repairing the iliac vein the patient may be developing a
pericardialtamponadeor pneumothorax. So avoid tunnelvision and
keepyourantennasupallthetime!
Secondarysurvey
Nowtheexsanguinatinglesionispermanentlyortemporarilycontrolled
and the patient’s hemodynamics have stabilized. With less adrenaline
floating around you and the patient, youcan divert yourattention to all
therest, andlook aroundmore precisely.Withgrowingexperienceyour
abdominal exploration will become more efficient but never less
thorough,as ‘missed’abdominal injuries continue to bea common
source of preventable morbidity. The practicalities of systemic
abdominalexplorationaredescribedbelow.
Intraperitonealcontaminationorinfection
•
First you register the offensive fecal smell or fecal-looking fluid
that denotes the abundance of anaerobic bacteria and usually an
infective source in the bowel. Note, however, that neglected
infections from any source can be pseudofeculant due to the
predominanceofanaerobes.
•
When, on opening the peritoneum gas escapes with a hiss, be
awarethataviscushasperforated.Inthenon-traumasituationthis
usuallyimpliesperforatedpepticulcerorsigmoiddiverticulitis.
•
Bile-stainingofthe exudatepoints topathology inthebiliarytract,
gastroduodenumorproximalsmallbowel.
•
Darkstout-beerfluidandfatnecrosishintsatpancreaticnecrosis
orinfectionin thelesser sac.JohnHunter(no,not theauthorof
Chapter 15) observed that “the gastric juice is a fluid somewhat
transparent,andalittlesaltishorbrackishtothetaste”butwedonot
suggestyougothatfar!Whateverthenatureofcontaminationor
pus,suckandmopitawayassoonaspossible.
Generally,biledirectsyouproximallyandfecesdistally,but‘simple’pus
can come from anywhere. When its source remains elusive, start a
systematic search keeping in mind all potential intraperitoneal and
retroperitonealsources‘fromtheesophagustotherectum’.Bepersistent
with your search. We recall a case of spontaneous perforation of the
rectum in a young male, twice explored by experienced surgeons who
failedtoappreciatetheminuteholedeepintherectovesicalpouch.Itwas
found(byalowlyresident)duringathirdoperation.
Occasionally, however, the origin of contamination or secondary
peritonitisisnotfound.AGramstaindisclosingasolitarybacterium—as
opposedtoafew—suggeststhediagnosisofprimaryperitonitis,since
secondaryperitonitis (e.g. secondaryto a visceral pathology)is always
polymicrobial.Moreaboutthisin Chapter13.
Thedirectionandpracticalitiesofexploration
This depends on the reason for the laparotomy; let’s start with a
generalplan.
Theperitonealcavitycomprisestwocompartments:the supracolic
and the infracolic compartment. The dividing line is the transverse
(meso)colon, which in a xipho-pubic midline incision is located
approximatelyinthecenteroftheincision(alittleabovethebauchnabel
or the belly button). It is important to develop and adhere to a fixed
routineofabdominal exploration, which will include bothcompartments.
Ourpreferenceistobeginwiththeinfracoliccompartment:thetransverse
colon is being retracted upwards,the small bowel eviscerated, andthe
rectosigmoid identified. Exploration begins with the pelvic reproductive
organs in the female, and then attention is turned to a systematic
inspectionandpalpationoftherectosigmoid,progressinginaretrograde
fashiontotheleft,transverseandthen rightcolonandcecum,including
inspection of the mesocolon. The assistant follows theexploration with
successivemovementsofahand-heldretractortoretracttheedgeofthe
surgicalincisionandtoenablegoodvisualizationofwhicheverabdominal
structure is the focus of attention. Exploration then proceeds in a
retrogradefashionfromtheileocecalvalvetotheligamentofTreitz,with
specialcarebeingtakentoinspectboth‘anterior’and‘posterior’aspects
ofeachloopofbowelaswellasitsmesentery.
Attention is then turned to the supracolic compartment. The
transversecolonispulleddown,andthesurgeoninspectsandpalpates
the liver, gallbladder, stomach (including the proper placement of a
nasogastrictube), andspleen. Specialcareshouldbetakento avoid
iatrogenicdamagetothespleencausedbypullinghardonthebody
of the stomach or the greater omentum. A complete abdominal
exploration also includes entry into the lesser peritoneal sac, which is
best undertaken through the gastrocolic omentum. This omentum is
usuallyonlyathinavascularmembraneontheleftside,andthisshould
therefore be the preferredentry routeinto thelesser sac. Take care to
avoidinjury to thetransversemesocolon whichmaybe adherent tothe
gastrocolicomentum.Amisdirectedsurgeoncanbeconvincedthatheis
entering the lesser sac when in fact he or she is cutting a hole in the
transverse mesocolon. If ‘vascular’, the gastrocolic omentum is divided
between ligatures (or Ligasure™, ifyou like and can afford...), bringing
the body and tail of the pancreas into full view.Shouldyou decide to
enterthelessersacthrough the lesser omentum be careful to not
divideanypulsatilevesselcoursingwithinthelessersacasitmay
be the aberrant left hepaticartery originating from the left gastric
artery!
Exploration of retroperitoneal structures involves two key
mobilizationmaneuvers,whichshouldbeemployedwheneveraccessto
theretroperitoneumisdeemednecessary:
•
‘Kocher’smaneuver’is mobilization of the duodenal loop and the
head of the pancreas by incising the thin peritoneal membrane
(posteriorperitoneum)overlyingthelateralaspectoftheduodenum
and gradually lifting the duodenum and pancreatic head medially.
This maneuver is also the key to surgical exposure of the right
kidneyanditshilumandtherightadrenalgland.Kocher’smaneuver
may be extended further lateral and caudad, around the hepatic
flexure and along the ‘white line’on the lateral aspect of the right
colonallthewaydowntothececum.Thisextensionallowsmedial
rotationoftherightcolonandaffordsgoodexposureoftherightsidedretroperitonealstructuressuchastheinferiorvenacava,iliac
vesselsandtherightureter.Furtherextensionofthisincisionangles
aroundthe cecumand continuesin asuperomedialdirectionalong
the line of fusion of the small bowel mesentery to the posterior
abdominalwall.Thusitispossibleto mobilizeandreflectthesmall
bowel upwards, the so-called Cattell-Braasch maneuver. This
affords optimal exposure of the entire inframesocolic
retroperitoneum,includingtheaortaanditsinfrarenalbranches.
•
The second key mobilization maneuver is called the ‘left-sided
Kocher’ or ‘medial visceral rotation’ (also called by some the
‘Mattox maneuver’) and is used especially to gain access to the
entire length of the abdominal aorta and to the left-sided
retroperitonealviscera.Dependingon thestructures tobe exposed
thismaneuverbeginseitherlateraltothespleen(splenophrenicand
splenorenalligament)workingcaudallyorin the‘whiteline’of Toldt
lateraltothejunctionofthedescendingandsigmoidcolon,working
upwards. The peritoneum is incised and the viscera,including the
left colon, spleen and tail of pancreas are gradually mobilized
medially. The left kidney can either be mobilized or left in situ,
dependingonthesurgicaltargetoftheexploration.
Incases ofspontaneoushemoperitoneum,you’ll haveto lookfor a
ruptured aortic, iliac or visceral arterial aneurysm, ectopic pregnancy,
bleeding hepatic tumor, spontaneous rupture of an enlarged spleen, or
anyoftheothercauseslistedin Table11.1.
In penetrating trauma you’ll follow the entry-exit track, taking into
consideration the missile’s energy, velocity and potential to fragment.
Whereverthereisanentrywoundinaviscusorbloodvessellook
fortheexitone! Thelattermaylieconcealed onthelesser sacwallof
the stomach, the retroperitoneal surface of the duodenum, or the
mesentericedgeofthesmallbowel.Missinganexitwoundisoftena
deathsentencetoyourpatient!
It is the blunt abdominal injury, however, that requires the most
extensive and less directed search, from the surface of both hemidiaphragmstothepelvis,fromguttertogutter,onallsolidorgans,along
thewholelengthofthe gastrointestinaltract, andin theretroperitoneum
(asdiscussedin Chapter32).Theexactsequenceofexplorationis
lessimportantthanitsthoroughness.
Useyourcommonsense
Are you alreadysnoring? Alittle boring, eh? So wake up and listen:
becausethisbookis aimedalsoattraineeswehadtobecompleteand
describethe‘classicalabdominalexploration’.Butfrankly,ifthepatientis
bleedingfromarupturedliverwewouldexploretheupperabdomen,but
if the infracolic compartment looks pristine and dry we would leave it
alone.Souseyourcommonsense: donotlook forovariancysts ina
patient with a bleeding spleen. Like Dr. Leo Gordon said: “When
commonsenseinterfereswithaprotocol,followcommonsense.”
Whataboutretractors?
Usewhateverisavailableatyourinstitution.Inmostcircumstanceswe
preferoneofthehand-heldretractorsinthehandsoftheassistant.But
not all assistantsare as passiveor active as you wish them to be. As
Arthur E. Hertzler wrote: “If I ever deliberately commit murder I shall
select an inattentive and awkward assistant as my victim.I shall select
one who has assisted enough to delude himself into thinking he could
himself do the work better than the surgeon who is operating. This
usually reaches the high point at about the third week of the intern’s
experiences.”
In some situations a ‘passive’ fixed retractor (a.k.a. a ‘mute intern’)
should be used — especially when operating in the pelvis or upper
abdomen.ThegoodoldBalfourretractorisusefulwhendoingamidline
laparotomy.Ofcourse,yourhospitalmayhaveoneofthosefancymulti-
arm retractors (called the Omni-Tract® or whatever) or the ingenious
Bookwalter®ringretractor;somesurgeonsliketousethem—particularly
thosewhodonot haveresidentsbuthavetorelyonsleepynurses.We
tryto usethose typesof mechnicalretractorsselectively:oftenthetime
neededtoplacethemislongerthantheoperationandwehateoperating
with a sharpmetal frame piercing our paunch. But when you expect a
deep and long dissection — a fixed, smart retractor can change your
operationfromastruggletopurefun.
Additionalpoints:gradingtheseverityofinjury
Abdominalexplorationfortraumaendswithastrategicdecisionabout
the subsequent steps. Forget at this stage the many available organ
injury scales, which are of academic value only; from the operating
surgeon’spointofviewthereareessentiallytwopatternsofvisceral
damage:‘minortrouble’and‘majortrouble’:
•
‘Minor trouble’ involves easily fixable injuries, either because the
injuredorganisaccessibleorthesurgicalsolutionisstraightforward
(e.g. splenectomy, suture of mesenteric bleeders, or a colon
perforation).Thereisnoimmediatedangerofexsanguinationorloss
ofsurgicalcontrol.Underthesecircumstancesyoucanimmediately
proceedwithdefinitiverepair.
•
‘Majortrouble’ is whenthe spontaneouscondition orinjury isnot
easilyrectifiedbecauseofcomplexityorinaccessibility(e.g.ahighgrade liver injury, a major retroperitoneal vascular injury in the
supracolic compartment, or destruction of the pancreatoduodenal
complex).HerethesecretofsuccessistoSTOPtheoperationwhen
temporary(usuallydigitalormanual)controlofbleedingisachieved.
Taketimetooptimizethesurgical attackontheinjuredorgan.
Updateall membersofthe operatingand anesthesia teamson the
operativeplan.Allowyouranesthetisttousethetimetostabilizethe
patienthemodynamicallyandtoobtainmorebloodproducts.Usually
youhavetothinkforyourteam—don’tassumethatallareawake.
However,bearinmindthatjustasyouarea‘modern’surgeonthere
arenow‘modern’anesthetists,andtheyareaninvaluableresource
inthemanagementofsuchpatients.Takecarenottoalienatethese
excellent practitioners! Order an autotransfusion device and a full
range of vascular and thoracotomy instruments to be brought in.
Thisisalsotheappropriatetimetoseekmorecompetenthelp,and
to plan the operative strategy, including additional exposure and
mobilization. Such preparation is crucial for the survival of your
patient.
Remember: Very often the initial exploration of the abdomen in the trauma patient is
incomplete, because the patient’s critical condition creates a situation where every minute
countsandinjuriesaresimplyrepairedastheyareencountered.Underthesecircumstances
youmustcompletetheexplorationbeforeterminatingtheprocedure.
Finally, primum non nocere (first do no harm). This applies
everywhereinmedicinebutisofparamountimportanceduringabdominal
exploration.Theinjuredorinfectedcontentsoftheperitonealcavitymay
be inflamed, swollen, adherent, friable and brittle. Careless and sloppy
manipulation and separation of viscera during exploration commonly
induceadditionalbleedingandmayproduceadditionalboweldefects,or
enlarge the existing ones. And as always, new problems translate into
additionaltherapiesandmorbidity.
Thisiswhatmakesemergencyabdominalsurgerysoexcitingand
demanding: the ever looming catastrophe and the anxiety about
whetheryouareable,ornot,totackleitcompetently.
“When the doctor isin doubt and thepatient in danger,
makeanexploratoryincisionanddealwithwhatyoufind
asbestasyoucan.”
RobertLawsonTait
1
AsherHirshberg,MD,contributedtothischapterinthefirsteditionofthisbook.
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