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The Operation
B
The Incision
1
Moshe Schein
Incisions heal from side to side, not from end to end, but length does matter.
When entering the abdomen, your finger is the best and safest instrument.
The patient now lies on the table, anesthetized, and ready for your knife.
Before you scrub, carefully examine the relaxed abdomen. Now, you can feel things
that were impossible to feel in the tense and tender belly. You may feel a distended
gallbladder in a patient diagnosed with an acute appendicitis or an appendiceal
mass in a patient booked for a cholecystectomy. Yes, this may also occur in the era
of ultrasound and computed tomography (CT).
Traditionally, abdominal entry in an emergency situation or for exploratory
purposes has been through a generous and easily extensible vertical incision, especially a midline one. Generally, the trans linea alba midline incision is swiftly
effected and relatively bloodless. On the other hand, transverse incisions are a
little more time and blood consuming but are associated with a lower incidence of
wound dehiscence and incisional hernia formation. In addition, transverse incisions are known to be “easier” on the patient and the patient’s lung function in the
postoperative period. Vertical paramedian incisions largely belong to history.
Keeping this in mind, we should be pragmatic rather than dogmatic and
tailor the incision to the individual patient and his or her disease process. We
should take into consideration the urgency of the situation, the site and nature of
the condition, the confidence in (or uncertainty about) the preoperative diagnosis, and the build of the patient.
Common sense dictates that the most direct access to the specific intraabdominal pathology is preferable. Thus, the biliary system is best approached
through a transverse, right subcostal incision. Transverse incisions are easily
lengthened to offer additional exposure; a right subcostal incision can be extended into the left side (as a “chevron”), offering an excellent view of the entire
abdomen. When a normal appendix is uncovered through a limited, transverse,
muscle-splitting, right lower quadrant incision, one can extend it by cutting the
10
1
Asher Hirshberg, MD, contributed to this chapter in the first edition of the book.
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_10, © Springer-Verlag Berlin Heidelberg 2010
85
86 Moshe Schein
muscles across the midline to deal with any intestinal or pelvic condition.
Alternatively, when an upper abdominal process is found, it is perfectly reasonable to close the small right iliac fossa incision and place a new, more appropriate, one. Two good incisions are better than one, poorly placed.
The midline incision—bloodless, rapid, and easily extended—affords superior exposure and versatility; it remains the classic “incision of indecision” when the
site of the abdominal catastrophe is unknown and is the safest approach in trauma.
This is an occasion to mention that an emergency laparotomy without a diagnosis is not a sin. Do not surrender to the prevailing dogma that the patient cannot
enter the operating theater without a ticket from the CT scanner. A clinical acute
abdomen—when other diagnoses have been ruled out (see > Chaps. 3 and 4)—
remains an indication for laparotomy when the abdominal wall is the only structure separating the surgeon from an accurate diagnosis. Having said this, mainly
to satisfy and pacify those of you who work under adverse circumstances, we have
to admit that preoperative abdominal imaging (see > Chap. 5) is of great help in
choosing the correct incision. For example, in a patient needing splenectomy for
a delayed rupture of the spleen, we would place a left subcostal incision rather
than a midline one. The CT has shown us that this is an isolated splenic injury, and
there is no need to explore the rest of the abdomen.
At What Level Must the Midline Incision Start, and How Long
>
Should It Be? (
The macho surgeons of previous generations often screamed: “Make it long.
It heals from side to side, not from end to end.” Today, in the era of minimal-access
Fig. 10.1)
Fig. 10.1. “Which incision?”
10 The Incision 87
surgery, we are familiar with the advantages of shorter incisions. In the absence of
any obvious urgency, enter the abdomen through a short incision and then extend
as necessary, but never accept less-than-adequate exposure or strive for keyhole
surgery. Begin with an upper or lower midline incision, directed by your clinical
assessment; when in doubt, start near the level of the umbilicus and “sniff” around
from there, then extend toward the pathology. Just remember what the famous
Swiss surgeon Theodor Kocher said more than 100 years ago: “The incision must
be as long as necessary and as short as possible.”
Should You Extend Your Incision Into the Thorax?
Very rarely should the incision extend into the thorax. In the vast majority of
cases, infradiaphragmatic pathology is approachable through abdominal incisions.
The combination of a subcostal and upper midline incision offers an excellent exposure for almost all emergency hepatic procedures, with the exception of retrohepatic venous injuries, for which insertion of a transatrial vena cava shunt necessitates
a median sternotomy—usually a futile exercise anyway. Thoracoabdominal incisions are mainly reserved for combined thoracoabdominal trauma.
Knife or Diathermy?
A few studies suggest that the diathermy is a few minutes slower than the
knife, while the knife sheds a few more drops of blood; otherwise, results are comparable. We use either. In extreme urgency, gain immediate entry with a few swift
strokes of the knife; otherwise, diathermy is convenient, especially when performing transverse muscle-cutting incisions. Adequate hemostasis is a crucial surgical
principle but do not go overboard chasing individual erythrocytes and avoid reducing the subcutaneous fat or skin to charcoal. The hypothesis that “You can tell
how bad the surgeon is by the stink of the Bovie [electrocautery] in his OR” has not
been proven by a double-blind randomized trial but makes sense nonetheless.
Subcutaneous hemostatic ligatures behave like a foreign body and are almost never necessary. In fact, most incisional “oozers” stop spontaneously, after a
few minutes, under the pressure of a moist lap pad or a temporary hemostat. It is
also unnecessary to “clean” the fascia by sweeping the fat laterally: the more you
dissect and “burn,” the more inflammation and infection-generating dead tissue
you create!
Keep in Mind Special Circumstances
If a stoma is anticipated, then place the incision away from its planned location. Abdominal re-entry into the “hostile abdomen” of a previously operated
88 Moshe Schein
patient can be problematic; you may spend more time, sweat, and blood, but the
real danger is creating inadvertent enterotomies in intestine adherent to the previous incisional scar. This is a common cause of postoperative external bowel
fistula (> Chap. 50). The prevailing opinion is to use the previous incision for re-
ent ry, if possible. When doing so, however, start a few centimeters below or above
the old incision and gain entry to the abdomen through virgin territory. Then,
insert your finger into the peritoneal cavity and navigate your way safely in, taking down adhesions to the abdominal wall, which hamper the insertion of a selfretaining retractor. Essentially, you are finished “getting in” when you are able to
place a self-retaining retractor to open the abdomen wide. In a dire emergency or
when you expect the abdomen to be exceptionally scarred, it may be prudent to
stay away from trouble and create an entirely fresh incision. In this situation,
beware of parallel incisions in close proximity to one another because the intervening skin may be at risk of necrosis, particularly if the first incision is relatively
recent.
Pitfalls
When in haste, do not forget that the liver lies in the upper extremity of the
long midline incision and the urinary bladder at its lowermost. Be careful not to
damage either.
When approaching the upper abdomen, divide and ligate the round hepatic
ligament. Leave it long; it could be used to elevate and retract on the liver. Take
the opportunity to divide the bloodless falciform ligament, which runs from the
anterior abdominal wall and the diaphragm to the liver. If left intact, it may
“tear” off the liver, causing irritating bleeding.
When performing any transverse incision across the midline, do not for-
get to ligate or transfix the epigastric vessels just behind the rectus abdominis
muscles. They may retract and cause a delayed abdominal wall hematoma.
In the very obese patient, in the upright position, the umbilicus commonly
reaches the level of the pubis. After elevating the fat panniculus, you can place a
lower midline incision between the pubis and umbilicus, but after the operation
it will be macerated by the sweaty (and smelly) panniculus. Thus, in the superfat,
a supraumbilical midline incision would provide better access into the lower
abdomen.
“Pray before surgery, but remember God will not alter a faulty incision.” (Arthur
H. Keeney)
“When the doctor is in doubt and the patient in danger, make an exploratory incision
and deal with what you find as best as you can.” (Robert Lawson Tait, 1845–1899)
Abdominal Exploration:
Finding What Is Wrong
Moshe Schein
Never let the skin stand between you and the diagnosis. (We understand that this
is an old and venerated surgical aphorism but we don’t wish to encourage reckless
pursuit of diagnosis, do we?—The Editors)
“In surgery, eyes first and most; fingers next and little; tongue last and least.”
(Humphrey George Murray, 1820–1896)
Not uncommonly—especially with the increased use of diagnostic imaging—
when opening the abdomen, the surgeon knows what to expect inside; the clinical
picture or ancillary tests direct the surgeon to the disease process. In some instances, however, the surgeon explores the unknown, led on only by the signs of
peritoneal irritation, assuming that the peritoneal cavity is flooded with blood or
pus. Usually, the surgeon speculates about the predicted diagnosis but always
remains ready for the unexpected. This is what makes emergency abdominal surgery so exciting and demanding—the ever-looming catastrophe and the anxiety
about whether you are able to tackle it competently. Yes, even in the days of computed tomography (CT) and magnetic resonance imaging (MRI), the abdomen
can be full of surprises.
1
11
Abdominal Exploration (> Fig. 11.1)
Although the specific sequence and extent of abdominal exploration are to be
tailored to the clinical circumstances, the two principal stages of any exploration are:
Identification of the specific pathology that prompted the laparotomy
Routine exploration of the peritoneal cavity
Essentially, there is a sharp distinction between a laparotomy for nontraumatic conditions such as bowel obstruction, inflammation, or peritonitis and
laparotomy for trauma with intra-abdominal hemorrhage, the latter rarely being
due to spontaneous, nontraumatic intra-abdominal causes.
1
Asher Hirshberg, MD, contributed to this chapter in the first edition of the book.
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_11, © Springer-Verlag Berlin Heidelberg 2010
89
90 Moshe Schein
Fig. 11.1. “Hey Doc, did you find anything?”
So, you incise the peritoneum, what now? Your action depends on the urgency
of the situation (condition of the patient), the mechanism of the abdominal pathology (spontaneous vs. trauma), and the initial findings (blood, contamination, or
pus). Whatever you find, follow the main priorities:
Identify and arrest active bleeding
Identify and control continuing contamination
At the same time, do not be distracted by trivia. Do not chase isolated red
blood cells or bacteria in a patient who is bleeding to death. For example, do not
repair minor mesenteric tears in a patient who is busy exsanguinating from a
torn inferior vena cava. This is not a joke—surgeons are easily distracted.
Intraperitoneal Blood
The patient may have suffered a blunt or penetrating injury or no injury at
all; in the latter case, the patient is suffering from spontaneous intra-abdominal
hemorrhage (abdominal apoplexy), an uncommon entity. Its etiology is summarized in > Table 11.1.
You may have been expecting the presence of free intraperitoneal blood
from the clinical findings of hypovolemic shock or the results of CT, ultrasound,
or peritoneal lavage. Your action depends on the magnitude of hemorrhage and
the degree of resulting hemodynamic compromise. When the abdomen is full of
blood and the patient unstable, you should act swiftly.
11 Abdominal Exploration: Finding What Is Wrong 91
Control the situation:
Enlarge your initial incision generously (avoid liver and bladder)
Lift out the small bowel completely
Suck out blood as fast as possible (always have two large suckers ready)
Pack the four quadrants tightly with laparotomy pads
Table 11.1. Causes of spontaneous intra-abdominal hemorrhage (“abdominal apoplexy”)
Vascular
Ruptured abdominal aortic aneurysm
Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic,
pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left
gastric, ileocolic [may be associated with Ehlers-Danlos syndrome])
Intraperitoneal rupture of varices associated with portal hypertension
Spontaneous rupture of the iliac vein
Gynecological
Ruptured ectopic pregnancy
Spontaneous rupture of the pregnant uterus with placenta percreta
Postpartum ovarian artery rupture
Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus
luteum, ovarian cancer)
Pancreatitis
Erosion of adjacent vessels involved in the process of severe acute pancreatitis,
chronic pancreatitis, or pancreatic pseudocyst
Liver
Rupture of benign (typically adenomas) or malignant hepatic tumors
Spleen
Spontaneous rupture
Adrenal
Spontaneous hemorrhage: normal gland or secondary to tumor
Kidney
Spontaneous rupture: normal kidney or secondary to tumor
Anti-coagulation
Patients on anticoagulation are prone to spontaneous retroperitoneal or
intraperitoneal bleeding, often prompted by unrecognized minor trauma
Unrecognized or denied trauma
Patient “forgot” the kick to the left upper quadrant, which broke the spleen
Miscellaneous
Acute ruptured cholecystitis
Mediolytic arteritis of an omental artery
Periarteritis nodosa
92 Moshe Schein
Evacuation of massive hemoperitoneum temporarily aggravates hypovolemia. It releases the tamponade effect and relieves intra-abdominal hyperten-
sion (>Chap. 40), resulting in sudden pooling of blood in the venous circulation.
At this stage, compress the aorta at its diaphragmatic hiatus and let the anesthetist
catch up with fluid and blood requirements.
Be patient, do not rush forward; with your fist on the aorta, the abdomen
tightly packed, and the patient’s vital organ perfusion improving, you have almost
all the time in the world. Do not be tempted to continue with the operation, which
can result in successful hemostasis in a dead patient. Relax and plan the next
move, remembering that from now on you can afford to lose only a limited amount
of blood before the vicious cycle of hypothermia, acidosis, and coagulopathy, “the
triangle of death,” will further frustrate efforts to achieve hemostasis.
Primary Survey
Now, you are ready to identify and treat the life-threatening injuries. The
initial direction of your search will be guided by the causative mechanisms. In
penetrating injury, the bleeding source should be in the vicinity of the missile or
knife tract; in blunt trauma, bleeding will probably originate from a ruptured solid
organ—the liver or spleen—or the pelvic retroperitoneum.
Unpack, suck, and repack each quadrant consecutively, noting where there
is blood reaccumulation (active bleeding) or hematoma. Having accurately identified the source (or sources) of bleeding, start definitive hemostasis, the rest of
the abdomen being packed away. Simultaneously, if the situation permits, control
contamination from injured bowel using clamps, staplers or tapes, or repacking
in desperate situations.
Stay tuned constantly to events behind the blood–brain barrier (BBB),
which is the screen between you and the anesthetists. Wake them up from time
to time and ask how the patient is doing. Take this opportunity also to explain
how and what you are doing. Communication among members of the medical
team in this situation is vital. While you are busy repairing the iliac vein, the
patient may be developing a pericardial tamponade or pneumothorax.
Secondary Survey
Now, the exsanguinating lesion is permanently or temporarily controlled,
and the patient’s hemodynamics have stabilized. With less adrenaline floating
around you and the patient, you can divert your attention to all the rest and look
around more precisely. With growing experience, your abdominal exploration will
become more efficient but never less thorough as “missed” abdominal injuries
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