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308
M. Harris and J. A. Sciacca
• Injury grade, amount of free uid, and pseudoaneurysm have not been shown to predict failure of nonoperative management
Diagnostic Studies
• Diagnostic Peritoneal Lavage (DPL) or Aspiration
– Relatively obsolete with advancements in imaging and
movement towards diagnostic laparoscopy
– High clinical suspicion of intra-abdominal injury with
negative FAST
– Lacks specicity
– Can be useful in the absence of a CT scan (rural hospi-
tal) or with unreliable abdominal exam due to altered
mental status
– Positive if 10mL blood aspirated or aspirate cell count
positive
Resuscitation
• Two large-bore peripheral IVs (18 or 16 gauge)
• Transfuse blood products if the patient is hypotensive
(consider uncrossed whole blood)
• Activate massive transfusion protocol
Mechanism Considerations
Blunt
• Multiple injuries
• Prioritize injuries that will kill the patient rst—hemorrhage is the number one cause of mortality within the rst
24h in severely injured trauma patients
• More amenable to nonoperative management
Penetrating
• Less common
• Laparotomy has been the gold standard
• Can consider angioembolization in hemodynamically
stable patients depending on the degree of injury on CT
imaging with no other signs of intra-abdominal injuries.
Operative Management
• Paradigm shift with nonoperative management becoming
commonplace
• Goal is to preserve splenic function (cell line production,
immune health)
Indication to Go to the OR
1. Hemodynamically unstable with positive FAST or perito-
nitis, NO imaging, and go to OR
2. Patients with multiple associated injuries who won’t tolerate hypotension or cannot undergo reliable serial
abdominal exams (TBI)
3. Facilities in which intensive monitoring cannot be performed, or angiography is not available
4. Penetrating injuries are more likely to prompt operative
management
5. Failure of nonoperative management (multiple transfusions (>6 units pRBC within 24 h), ongoing hemodynamic instability after embolization, etc.)
Technical Considerations
• Patient supine
• Prep from neck to knees
• Broad-spectrum antibiotics
• Midline laparotomy incision
• Pack all four quadrants, removing from the area that does
not appear to be hemorrhaging rst
Damage Control Laparotomy
• The goal is to avoid the “lethal triad” (hypothermia, aci-
dosis, coagulopathy)
• Stop bleeding and control contamination
• Balanced resuscitation (1:1:1 pRBC:FFP:Platelets)
• Temporary abdominal closure
• Vacuum-assisted therapies such as utilizing AbThera,
skin-only closures with towel clips or running sutures,
Bogota Bag techniques, etc.
Splenic Salvage
Can be considered in patients who are hemodynamically
stable. These techniques have fallen out of favor, however.
If you have a hemodynamically unstable patient, remove
the entire spleen.
• Splenorrhaphy (suture repair of the spleen)
Reapproximate splenic tissue and capsule when
possible
Mattress pledged sutures with absorbable suture
• Partial splenectomy
Based on segmental blood supply
Hilar vessels supporting the damaged portion of the
spleen are ligated and divided
Remove the non-viable portion and suture over the raw
surface
• Topical hemostatic agents
• Argon beam coagulator
Splenectomy Technique
• Divide attachments
• Vascular ligaments:
Gastrosplenic—contains short gastric vessels
Splenorenal—contains splenic artery and vein, along
with the tail of the pancreas
94 Splenic Trauma
309
• Avascular attachments:
Splenophrenic, splenocolic
• Mobilize spleen to midline
• Place lap pads behind the spleen to assist in elevating
it medially and anteriorly
• Divide short gastric vessels in the gastrosplenic ligament
• Ligate and divide hilar vessels (suture ligation, ligation
between clamps, vascular staple loads)
• Hilar vessels in splenorenal ligament
• Be mindful not to injure the tail of the pancreas
• Check for hemostasis in three major areas
• Inferior surface of diaphragm, greater curvature of
stomach and region of short gastric vessels, region of
the hilum
Operative Considerations
• Ligate short gastric vessels, avoiding injury to the gastric
wall
• Pancreatic tail is near the hilar resection
To Drain or Not to Drain
• No drain after splenectomy
• Only place drain if concerned for pancreatic injury
Non-operative Management
1. Has become the gold standard for blunt splenic trauma in
hemodynamically stable patients
2. Consider an initial attempt at non-operative management
in a hemodynamically stable patient without other
abdominal organ injuries requiring surgery
3. Nonoperative management should only be attempted in a
facility capable of intensive monitoring, serial labs, angiography, access to blood products, and an immediately
available OR and surgeon
4. Patient/injuries must be amenable to serial abdominal
exams, labs, and repeat imaging
5. Hemodynamically stable pediatric patients
Angiography/Angioembolization
• Stable patient or patient who responds appropriately to
resuscitation
• CT imaging with large volume hemoperitoneum, contrast
blush, or pseudoaneurysm
• Consider empiric embolization for AAST grades IV and
V injuries
• Improves success rate of nonoperative management
• Blood ow to the spleen is maintained via collateral circulation, preserving immune function
• Hybrid suite can provide a safe environment for embolization with a rapid transition to splenectomy if needed
Selective Angioembolization
• Intentional cessation of blood ow to a segmental arterial
branch
• Splenic artery divides into many small branches; there-
fore, occlusion of an arterial branch only affects the
corresponding splenic segment
• Useful for segmental bleeding/injury
• Decreases risk of ischemic complications to the rest of the
spleen
Nonselective Angioembolization
• Reduce splenic perfusion while maintaining blood supply
via collaterals
• Useful for multifocal bleeding/injury
• Quicker, therefore, faster hemostasis, decreased contrast
load, and reduced radiation exposure
• Site of embolization must be distal to the dorsal pancreatic artery to avoid ischemic pancreatic tail
Complications
• Complications at the arterial puncture site
• Hematoma, pseudoaneurysm, arteriovenous stula,
dissection
• Splenic abscess
• Inadvertent embolization of pancreatic artery
• Postembolization syndrome
• Daily fevers, abdominal pain, nausea, vomiting, loss of
appetite
Vaccinations
• Post-splenectomy immunization against encapsulated
bacteria
• Streptococcus pneumoniae, Haemophilus inuenzae,
Neisseria meningitidis
• Should be given 14days after splenectomy
• If patient is discharged before 14days after splenectomy,
vaccinate prior to discharge
• Not indicated after splenic artery angioembolization
• Overwhelming Post-splenectomy Infection (OPSI) syndrome has low incidence but high mortality
Common Curveballs
• Trauma patients often have multiple injuries; avoid tunnel
vision
• Failure of nonoperative management
• Delayed splenic rupture
• Overwhelming Post-splenectomy Infection (OPSI)
• Subphrenic abscess
310
M. Harris and J. A. Sciacca
• Missed bowel injury intraoperatively with septic shock in
the postoperative period
• Pancreatic or gastric injury during operation
• Complications of angioembolization
• Rebleeding, splenic necrosis, delayed rupture, iatro-
genic vascular injury
Clean Kills
• Not knowing post-splenectomy management
• Not knowing splenic salvage techniques
• Not performing complete trauma workup
• Not having clear criteria for nonoperative management
• Being unfamiliar with post-splenectomy vaccinations
Summary
The spleen is one of the most common organs injured in
trauma. An injury scoring scale can be used to classify
the anatomy of the injury, but management is dependent
on patient presentation and response to treatment.
Intervention for splenic injuries can be both operative
and nonoperative, with the goal of restoring stability and
preserving physiology when possible. The management
of splenic trauma requires a multidisciplinary approach,
taking the patient’s hemodynamics, concomitant inju-
ries, injury severity on imaging, and hospital resources
into consideration.
Bibliography
Blunt splenic trauma. The American Association for
the Surgery of Trauma. 2012. https://www.aast.org/
resources- detail/8764001f- b3b2- 425e- 89c5- 5284d417de1e.
Coccolini F, Montori G, Catena F, Kluger Y, Bif W, Moore EE, Reva
V, Bing C, Bala M, Fugazzola P, Bahouth H, Marzi I, Velmahos G,
Ivatury R, Soreide K, Horer T, ten Broek R, Pereira BM, Fraga GP,
etal. Splenic trauma: WSES classication and guidelines for adult
and pediatric patients. World J Emerg Surg. 2017;12:40. https://
wjes.biomedcentral.com/articles/10.1186/s13017- 017- 0151- 4.
Corcos A, Six C, Britt LD, Peitzman A. Abdominal trauma. In: The
trauma manual: trauma and acute care surgery. essay, Lippincott
Williams & Wilkins; n.d.. pp.425–458.
Guan Y-S, Hu Y. Clinical application of partial splenic embolization.
ScienticWorldJournal. 2014;2014:961345. https://pubmed.ncbi.
nlm.nih.gov/25538966/.
Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS,
Guillamondegui OD, Jawa RS, Maung AA, Rohs TJ, Sangosanya
A, Schuster KM, Seamon MJ, Tchorz KM, Zarzuar BL, Kerwin
AJ. Selective nonoperative management of blunt splenic injury:
an Eastern Association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl
4):S294–300. https://pubmed.ncbi.nlm.nih.gov/23114484/.
The spleen. In: Fischer’s mastery of surgery. essay. Lippincott Williams
& Wilkins; n.d. pp.1650–1670.
Tran S, Wilks M, Dawson J. Endovascular management of splenic
trauma. Surg Pract Sci. 2022;8:100061. https://www.sciencedirect.
com/science/article/pii/S2666262022000067.
Nutrition
BradfordBormann andJonathanImran
95
Chronic Malnutrition, Outpatient
Nutritional status is often overlooked in the initial evaluation
of a patient. However, nutrition impacts the function of
nearly every organ system, and improper nutrition will have
signicant, if not grave, effects systemically if underdiagnosed or undertreated. Consistently and effectively assessing
the nutritional status of patients should be a cornerstone of
practice for every surgeon.
How theQuestion May BeAsked
A 72-year-old female is being seen in the clinic for postprandial abdominal pain, food fear, and unintentional weight
loss. For 18 months, she has had regular periumbilical
abdominal pain following an estimated 50% of her meals.
She has a past medical history of peripheral arterial disease,
claudication, and a 50-pack-year smoking history. She has
lost 47 pounds in the last 6weeks. CTA of the abdomen pelvis demonstrates SMA stenosis. You are concerned that she
may have chronic mesenteric ischemia (CMI). She is asking
about managing her recent weight loss.
How do you identify and treat malnutrition in the outpa-
tient setting?
How toAnswer
• Does the patient have any other medical or surgical history related to their diet changes?
• Presenting weight and body mass index (BMI)? How
does this compare to prior records?
Physical Exam
• Does the patient appear to be cachectic, or have protuberant/palpable bony prominences like ribs?
• Does the patient appear fatigued, lethargic, or even
altered?
• Does the patient lack a robust red/pink color in the
conjunctiva?
Nutritional Assessment
• Malnutrition Universal Screening Tool (MUST) helps
to risk-stratify people for malnutrition (Elia 2003). See
Table95.1:
• Based on MUST score, patients with low risk for clinical
malnutrition (a score of 0) should receive annual assessments for malnutrition (i.e., an annual history and physical with a family physician)
• Medium risk patients (MUST score of 1) should be reevaluated every 2–3 months and should be advised to
keep a food diary/regular weight to monitor weight gain
relative to the diet.
• High-risk patients (MUST score of 2+) should be referred
to a dietitian or institutional nutritional support team.
These patients should be seen monthly.
History
• What is the patient’s current diet? What does she eat, how
often, and how much?
• Has the patient tried any adjustments to their diet? Have
they worked?
B. Bormann (*) · J. Imran
Department of Surgery, ChristianaCare, Newark, DE, USA
e-mail: bradford.bormann@christianacare.org;
jonathan.imran@christianacare.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_95
Table 95.1 The Malnutrition Universal Screening Tool (MUST)
0 points 1 point 2 points
BMI >20 18.5–20.0 <18.5
Unexplained weight loss <5% 5–10% >10%
Add 2 points if the patient is severely ill and unlikely to have PO
intake for 5+ days.
Score of 0=low risk; 1=medium risk; 2+=high risk
311
312
B. Bormann and J. Imran
Chronic Malnutrition, Inpatient
Just as adequate nutrition is critical in the outpatient setting,
adequate nutrition in the inpatient setting can be the difference between a successful course and one riddled with complications. At all times, surgeons should determine the
optimal strategy for macronutrient delivery to the patient. If
possible, enteral feeding, either per os or via enteric access,
is preferred. If enteral feeding is not an option (for example,
the patient has a high-grade small bowel obstruction), parenteral nutrition is an acceptable alternative.
A 27-year-old male with a history of Crohn’s disease has
been admitted to the colorectal surgery service for management of an acute Crohns are. He has a CT scan demonstrating
active inammation of the terminal ileum, with an associated
intra-abdominal abscess. He cannot receive any enteral nutrition due to abdominal pain, nausea, and vomiting. How would
you like to provide nutritional support to this patient?
What is the optimal nutritional management of the critically ill inpatient?
History
• What is baseline nutritional status?
• When was the last time the patient tolerated substantial
PO intake?
• History of recent weight gain or loss?
• Any medical or surgical history predisposing the diet to
malnutrition?
Physical Exam
• Evidence of temporal wasting
• Any loss of body fat, muscle mass
• Evidence of peripheral uid accumulation
• Decreased grip strength
Diagnostic Tests
• Obtaining daily weight measurements is essential in mak-
ing sure your patient has adequate nutrition (be wary,
however, that non-nutritional components like third-
spaced uids can inate patient weight without improving
nutritional status).
• Prealbumin (2-day half-life, normal is 15–35), albumin
(18-day half-life, normal is 3.5–5.5).
• The ASPEN Criteria is a peer-reviewed tool both to
diagnose malnutrition and to identify its severity
(McClave etal. 2016), demonstrated in Table95.2:
Treatment/Management
• Patients should receive a nutrition consult if their Albumin
is <3.0, BMI<18.5, if they have had unplanned weight
loss >10% in 6months, or if they have been eating <50%
of their normal diet in the week prior to surgery.
• The three essential routes of nutritional supplement
include: per os, enteric tube, and parenteral nutrition (central or peripheral).
• The clinician must determine both the amount of and contents of supplemental nutrition.
• As a rough estimate, the mild-to-moderately ill adult
requires 25kcal/kg per day.
• This can be adjusted for a given diagnosis by applying the
appropriate Harris–Benedict energy multiplier to this
base calorie requirement (for example, orthopedic trauma
incurs a 1.35 multiplier to the baseline energy
requirement).
Managing Nutrition intheSetting
ofanEnterocutaneous Fistula
Nutritional management of the enterocutaneous stula
(ECF) is a tricky clinical balancing act. On the one hand, the
patient must have sufcient nutrition to heal tissue and bring
the stula under control. On the other, feeding the gut can
potentially increase output from the stula and make spontaneous closure difcult or even nearly impossible.
A 56-year-old man with a history of perforated small
bowel diverticulitis underwent exploratory laparotomy, lysis
of adhesions, and small bowel resection with primary anastomosis. He is discharged in fair condition and 2weeks later
presents to the ED with a chief complaint of green drainage
from his midline laparotomy site. A CT scan was obtained,
which demonstrates a small abscess near the anastomosis
with a tract to the midline. You remove the staples and note a
small nonhealing aspect of the incision with green drainage
from the base of the wound. The patient is admitted to the
hospital, and you are considering the nutritional management of this patient in the setting of EC stula.
How do you manage nutrition in a patient with ECF?
History
• What has been draining? How much? How long ago was
a possible contributory procedure?
• What, if anything, has the patient done to alter/control the
output? Has it helped?
Table 95.2 The ASPEN criteria for severe acute and chronic
malnutrition
Severe Acute Malnutrition >7.5% total weight loss in
3months; <50% intake over 5days
Severe chronic malnutrition >20% total weight loss over one
year; <75% for >1month
Physical
• CT with IV and oral contrast of the abdomen and pelvis is
generally a great place to start, as it will indicate the location of a stula within the GI tract, obstruction, collections, and presence of a fascial defect.
95 Nutrition
313
• Is the patient at risk for, or perhaps even currently experiencing, malnutrition? This is a great time to screen for
malnutrition.
Diagnostic Tests
• Assess for malnutrition (can use the MUST score here) at
the time of ECF diagnosis. Frequent reassessment (i.e.,
once a month) is recommended for patients with ECF, as
the risk of developing malnutrition is very high.
Treatment/Management
• Patients with low-output stulas (<500 mL daily) can
safely start an oral diet. Patients with high-output stulas
(>500mL daily) may need enteral nutrition supplemented
with parenteral nutrition.
• Recommend 1.5–2.0g/kg/day protein, up to 2.5g/kg/day
for high output stulas. This will facilitate wound
healing.
• Somatostatin analogs like octreotide may help reduce output from high-output stulas and increase the rate of
spontaneous closure.
• Home TPN can be used with stula output is manageable
(<500 mL), or in high-output stulas not amenable to
operative takedown.
Refeeding Syndrome
Rapid reintroduction of critical nutritional components
causes a dramatic state of anabolism to recover lost nutrients,
and this results in a decrease in K, Mg, PO4−, Cl−, and thiamine. Rapid depletion of these electrolytes or vitamins can
lead to cardiac dysfunction, weakness, encephalopathy, and
failure to wean from a vent. Whenever you are introducing
nutrition to a patient who has had little or no sustenance for
a sustained period, refeeding syndrome must be on your
differential.
An 81-year-old female is admitted to the ICU after a
ground-level fall. She was found down at home after an
unknown period. She has a subdural hematoma and was
admitted for close monitoring of neuro status. She has a BMI
of 18kg/m
days after initiation of nutrition, the patient becomes lethargic, with new bradycardia and hypotension.
What is Refeeding syndrome, and how is it managed?
History
• How long has this patient gone without meaningful
caloric intake?
• What was their baseline level of nutrition before they
developed their current illness?
• Is there another possible cause of their altered mental
status?
2
. Enteral tube feeding has been initiated. Three
Physical Exam
• Is the patient receiving either PO, enteral, or parenteral
nutrition?
• Has the patient developed a new altered mental status?
Diagnosis
• The ASPEN Consensus Denition of Refeeding
Syndrome will help identify this pathology in patients
(Da Silva etal. 2020):
• Decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10–20% (mild),
20–30% (moderate), or >30% and organ dysfunction
resulting from a decrease in any of these and/or due to
thiamine deciency (severe)
• Occurring within 5 days of reinitiating or increasing
caloric intake
• How will you manage this patient?
– Stop feeding if Refeeding Syndrome is suspected.
– Obtain a Basic Metabolic Panel, including phospho-
rus/magnesium measurement. This will discern the
essential electrolyte deciencies to aid in the
diagnosis.
– Deciencies in phosphate, chloride, magnesium are
suggestive of Refeeding Syndrome.
– Replete electrolytes and consider thiamine supplemen-
tation as indicated.
– Multisystem support as needed for cardiopulmonary
compromise.
– Restart enteral nutrition if appropriate.
– Improvement in the cardiopulmonary manifestations
of Refeeding Syndrome with supplementation of elec-
trolytes suggests the diagnosis was accurate.
Bonus Points
• Calculating TPN
– To the chagrin of many surgical residents, calculating
TPN begins with some basic math. You must deter-
mine the macronutrient requirements of the patient
based on several simple formulas, all of which deter-
mine nutritional requirements as a proportion of the
patient’s body weight.
How to Calculate the Grams of Protein, Fats, and
Carbohydrates required in a daily volume of TPN:
1. Total daily calories required: 25kCal×body weight in
kg
2. Total daily calories should then be divided into Protein
and Non-protein calories
(a) Required daily Protein mass, in grams:
1.5g×body weight in kg
• Daily protein calories: protein mass×4g.
314
B. Bormann and J. Imran
• This is the portion of your total daily calories
that should be delivered by protein.
(b) Required Non-protein calories
• Subtract protein calories (calculated above)
from total daily calories (calculated above) ->
this is the Non-protein portion of your total
daily calories, delivered by fats and
carbohydrates.
• Multiply non-protein calories by 0.7 -> this
tells you how many calories should be delivered from carbohydrates. Divide this number
by 3.4 to determine total daily grams of dextrose, or divide by 4 to determine total daily
grams of carbohydrates.
• Multiply non-protein calories by 0.3 -> this
tells you how many calories should be delivered from fats. Divide this number by 9 to
determine the total daily grams of fat.
3. In total, this strategy will help you determine the
grams of protein, carbohydrates, and fats a patient
should receive daily while receiving TPN.
Words ofWisdom
Nutritional status is an essential factor in the health prole of
every patient. Patient reserves of macronutrients like proteins and lipids are key determinants of their ability to with-
stand illness and injury and, in turn, to successfully endure
both operative and nonoperative treatment. Often, providers
treat “malnutrition” and “undernutrition” as synonymous
terms, but literature has shown that patients can suffer malnutrition whether they eat regularly at a calorie decit or
excess. The bottom line is that assessing and optimizing
nutrition in every patient is a key part of effective clinical
practice (Townsend etal. 2016).
Bibliography
Da Silva JSV, Seres DS, Sabino K, Adams SC, Berdahl GJ, Citty SW,
Cober MP, Evans DC, Greaves JR, Gura KM, Michalski A, Plogsted
S, Sacks GS, Tucker AM, Worthington P, Walker RN, Ayers P,
Parenteral Nutrition Safety and Clinical Practice Committees,
American Society for Parenteral and Enteral Nutrition. ASPEN consensus recommendations for refeeding syndrome. Nutr Clin Pract.
2020;35:178–95.
Elia M.Screening for malnutrition: a multidisciplinary responsibility.
Development and use of the malnutrition universal screening tool
(‘MUST’) for adults. Redditch: BAPEN; 2003.
McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR,
Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci
GA, Gervasio JM, Sacks GS, Roberts PR, Compher C, Society
of Critical Care Medicine; American Society for Parenteral and
Enteral Nutrition. Guidelines for the provision and assessment of
nutrition support therapy in the adult critically ill patient. J Parenter
Enter Nutr. 2016;40:159–211.
Townsend JCM, Beauchamp RD, Evers BM, Mattox KL.Sabiston text-
book of surgery, 20th ed. Elsevier—Health Sciences Division; 2016.
Thoracic Trauma
OdessaR.Pulido andTanyaEgodage
96
Way Question May BeAsked
A trauma alert is called for a 34-year-old male patient who
sustained a stab wound to the infraclavicular chest at third
intercostal space. The patient is found to have decreased leftsided breath sounds, with a BP of 80/40mmHg, a heart rate
of 136, and a respiratory rate of 31.
How toAnswer
• Start with Advanced Trauma Life Support (ATLS)
protocols.
– Airway: beware of circulatory collapse during induction.
– Breathing: listen for breath sounds (this may be dif-
cult to assess in the trauma bay).
– Circulation: does this patient have peripheral pulses?
(Assess pulses in extremity for which there may be
a concern for subclavian artery injury, and compare
to contralateral limb.)
Do they have appropriate access? IV access in
upper extremity contralateral to injury.
Consider intraosseous access if unable to obtain
intravascular access immediately.
– Disability: if penetrating wound, assess neurovascular
function in that extremity.
– Exposure: important in penetrating traumas, so as not
to miss small injuries.
• Adjuncts to primary survey
– CXR
Pneumothorax
Hemothorax
Widened mediastinum
Apical cap
Deviated trachea
– E-FAST
Lung sliding
– FAST
Tamponade
• Continue reassessment of hemodynamics throughout the
resuscitation
– If unstable, restart at the beginning of ATLS algorithm
and proceed.
• Physical exam
– Distended neck veins with hypotension?
Concern for obstructive shock (tamponade or tension pneumothorax).
– Paradoxical chest wall movement?
Concern for ail chest. May require early intubation.
– Injury to “the box”
The boundary is dened by the clavicle superiorly,
nipple laterally, and xiphoid process inferiorly, but
may also include the “extended box” which extends
further to the lateral left hemithorax.
Management
Thoracostomy Tube
• Indication
– Pneumothorax
– Hemothorax
– Conduct thoracostomy emergently if the patient is
hypotensive. Needle thoracostomies in trauma do not
reliably enter the chest. Consider nger or tube
thoracostomy.
O. R. Pulido
Division of Trauma and Acute Care Surgery, Department of
Surgery, University of Nevada Las Vegas, Las Vegas, NV, USA
T. Egodage (
Division of Trauma and Acute Care Surgery, Department of
Surgery, Cooper University Health Care, Camden, NJ, USA
e-mail: egodage-tanya@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_96
*)
Resuscitative Thoracotomy
• Indication
– Output >1500 mL upon tube placement or 200 mL/h
for 2–4h.
– If the patient remains hypotensive following the tube
thoracostomy, consider a second tube and repeat CXR.
315
316
O. R. Pulido and T. Egodage
If unresolved hypotension with hemothorax, may
require emergent thoracotomy.
– Penetrating thoracic trauma patient with less than
15min of prehospital CPR.
– Penetrating nonthoracic trauma patients with <5 min
of prehospital CPR.
– Blunt trauma with signs of life.
• Steps
1. Left anterolateral incision through the fourth or fth
intercostal space. (Incision should extend from the
right side of sternum into patient’s left axilla).
2. Open pericardium in longitudinal fashion to avoid
injury to the phrenic nerve.
3. Deliver the heart.
4. Divide pulmonary ligament—beware of inferior pulmonary vein. May not need to do this if you can access
the aorta.
5. Clamp aorta supra-diaphragmatically (as near to diaphragm as possible).
Other Types of Thoracic Exposure and Access
• Pericardial window
– Concern for hemopericardium and ultrasound not
technically feasible.
– Penetrating wound to cardiac box, or transmediastinal,
with left hemothorax (cardiac injury may decompress
into left chest).
– Can perform subxiphoid or transdiaphragmatic
pericardiotomy.
– Resect xiphoid or lift with Kocher or army-navy retrac-
tor. Bluntly dissect in the substernal plane. Identify
pericardium, grasp between two Alis clamps, and
incise with scissors.
– If under tension, will not be able to grasp pericardium
and must open with a knife. This is indicative of
tamponade.
– Place red rubber catheter into pericardium and irrigate
to evaluate efuent.
• Median Sternotomy
– Provides access to heart and great vessels.
– Only indicated if the patient is hemodynamically nor-
mal (otherwise perform thoracotomy).
– Steps:
1. Make an incision over the center of the sternum and
ensure that you score the midline.
2. A Lebsche knife or electric saw can be used to
divide the sternum after clearance of interclavicular ligament and soft tissues behind the manubrium is assured. With Lebsche knife, go caudal
to cranial fashion. For sternal saw, perform in the
craniocaudal direction.
• Anterolateral thoracotomy: resuscitative thoracotomy,
access to lung or posterior heart
• Steps:
1. Make an incision within fourth or fth intercostal
space and divide the pectoralis major, pectoralis minor,
and serious anterior muscle.
2. Intercostal muscles are then divided at the most superior portion of the rib in order for a Finochietto retractor to be placed.
• Posterior-lateral thoracotomy
– Access to lungs and proximal bronchi
– Not to be used in hemodynamically unstable patients
due to positioning required and lack of access to the
rest of the thorax
– Right-sided: trachea, main-stem bronchi, proximal/
mid-esophagus
– Left-sided: Left ventricle, descending aorta, distal
esophagus
– Steps:
1. Place the patient in a lateral decubitus position with
lower leg exed at knee and upper leg straight. An
axillary roll should be placed under the axilla.
2. An incision is made in the 6th–7th intercostal space
from the anterior axillary line to below the tip of the
scapula and toward the midway between the spine
and medial border of the scapula. The latissimus
dorsi and serratus anterior will be encountered and
can be divided.
• Clamshell: need for extension of left anterolateral inci-
sion in order to see the contralateral side to evaluate bilateral lungs, great vessels, heart, and mediastinum
• Steps:
1. Usually used to extend a standard anterolateral thoracotomy to contralateral side.
2. Incision is continued contra laterally to the fourth or
fth intercostal space.
3. Bilateral internal mammary arteries may be transected
and will need to be ligated to prevent further
hemorrhage.
Pericardiotomy with Cardiac Injury
• Indication
– Cardiac tamponade
Signs: Beck’s triad of mufed heart sounds, hypotension, jugular venous distention (rarely appreciate all three in the acute setting). Hypotension with
positive cardiac FAST preoperatively or injury traversing anterior mediastinum. If patient has true
tamponade, use knife to enter pericardium as it will
remain under tension.
• Steps
1. If through a median sternotomy→perform pericardiotomy at midline by elevating the pericardium and
making an incision.
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2. If through a left lateral thoracotomy→the pericardiotomy is done superior and parallel to the phrenic
nerve (in craniocaudal fashion).
3. Repair cardiac wound with monolament suture. Can
use pledget or pericardium as a pledget.
4. If juxta coronary injury, perform horizontal mattress
suture and ensure that coronary is not kinked.
• For posterior wounds, elevate heart serially with packs or
place suture or clamp on the apex and lift slowly.
• For arterial wounds, do not require pledge. Can place
clamp and suture with monolament.
Great Vessel Injury
• To gain better access, divide innominate vein, which
crosses in the superior mediastinum, anteriorly.
• Use vascular clamp or manual control.
• For arterial injuries, temporize with intraluminal shunt or
Fogarty balloon.
• For injuries in aortic arch, may need CT surgery and car-
diopulmonary bypass.
• Pulmonary vein more forgiving than pulmonary artery.
Hilar Injury
• Divide inferior pulmonary ligament but beware of pulmo-
nary vein.
• Possible to use hilar twist, but clamp or manual control
may be better.
• Vascular load stapler for the hilar transection.
Parenchymal Injury
• Continuous low-volume hemorrhage or audible air leak.
• Do not retract perpendicular to injury.
• Temporary closure with Duval clamp.
• Can perform nonanatomic resection or tractotomy to
incorporate the wound.
• Umbilical tape or Rummel tourniquet to aid in
dissection.
• Pneumonectomy is poorly tolerated. Dobutamine or nitric
oxide may be helpful if you do have to perform this.
Consider early ECMO.
Closure
• Temporary closure should include rapid en-masse run-
ning suture of skin.
• Beware hemorrhage from internal mammary arteries or
chest wall.
• Temporary chest cover with Ioban dressing may be used.
• Vacuum device should be placed on LOW suction if used.
Diaphragmatic Repair
• Indication
– Traumatic diaphragmatic hernias
• Goals
– Reduction of hernia contents
– Watertight closure
• Steps
1. Exposure of right hemidiaphragm → transect falci-
form ligament with downward traction of liver.
2. Exposure of left hemidiaphragm→downward retrac-
tion of spleen and greater curvature of stomach.
3. Delineate edges of diaphragmatic laceration and grasp
with Allis clamps.
4. Approximate edges with PDS or chromic suture.
Curve Balls
• Thoracoabdominal injury—may have visceral herniation.
Need to explore abdomen and thorax.
• Patient with concomitant traumatic brain injury (TBI).
Rule out thoracic and abdominal hemorrhage by exploration and achieving hemostasis to avoid secondary insults
to TBI.
• Patients with widened mediastinum—these are contained
aortic injuries, address concomitant life-threatening injuries rst.
• Aortic injury locations—ligamentum arteriosum, dia-
phragmatic hilum.
• Treatment of postoperative thoracic duct leak.
• Thoracic duct injury—treat with diet free of long-chain
fatty acids, and drainage.
Clean Kills
• Not following ATLS sequence
• Not taking patient with cardiac box injury to OR
• Failure to recognize a blunt cardiac injury
• Failing to do an indicated thoracotomy
• Bringing an unstable patient to the CT scanner
Summary
Your goal is to determine the most life-threatening injuries, and perform interventions to correct shock.
Hemorrhagic shock is the most common etiology of shock