27
Trauma Laparotomy:
Principles and Techniques
INTRODUCTION
Performing a complete and efficient emergency exploration
of the abdominal cavity is an essential skill of the trauma sur-
geon. Trauma laparotomy is a commonly performed proce-
dure after both penetrating and blunt abdominal trauma. The
operation must be performed in a systematic and thorough
fashion with primary objectives including control of hem-
orrhage, control of contamination from the gastrointestinal
tract, and identification of all injuries followed by definitive
repair or damage control management. Definitive repair of
injuries may or may not be performed at the initial operation;
it is up to the surgeon to devise a plan to address all injuries in
a comprehensive and time-sensitive manner.
The word “laparotomy” comes from Greek origin, with
lapara signifying the flank or abdomen, and tomoz mean-
ing to cut. In modern trauma surgery, the word laparotomy
is used interchangeably with celiotomy, which also stems
from the Greek word koilia, belly. Both words imply open-
ing of the peritoneal cavity for access to its contents. After
either penetrating or blunt forces, laparotomy is indicated
for hemodynamic instability, peritonitis, evisceration, posi-
tive or questionable radiographic findings of organ injury,
a positive diagnostic peritoneal tap (or lavage), and in some
cases, a persistent fall in hematocrit. In a hemodynamically
stable patient with a gunshot wound, a tangential bullet tra-
jectory may dictate intervention, whereas a stab wound to
the flank may have a variety of treatment options other than
laparotomy. Given the many indications for celiotomy, there
is some variability in celiotomy technique, with physiologic
stability of the patient dictating the urgency of the steps of
the procedure.
This chapter provides an overview of the trauma laparot-
omy. The first part of the chapter describes the principles of
the trauma laparotomy as well as the preparation and team
effort that must occur for a successful operation. A detailed
description of the technical steps and key maneuvers of a
laparotomy, as well as considerations for damage control and
the practical aspects of temporary abdominal closure follows.
Complications of trauma laparotomy and the nontherapeutic
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Moore_Ch27_p0523-0538.indd 523
laparotomy will be discussed. The final part of the chapter
addresses special types of abdominal exploration, including
planned and unplanned reoperations after initial laparotomy
as well as bedside laparotomy.
PRINCIPLES
The Core Mission
In a trauma laparotomy, the core mission is to identify the
greatest threat to the patient’s life and alleviate that threat
as quickly as possible. In a trauma situation, the most com-
mon threat to life is exsanguination, and thus the mission is
to stop the bleeding. The success of the operation depends
on the team’s ability to identify, expose, and control hem-
orrhage, while simultaneously resuscitating the patient with
appropriate blood products, fluids, and electrolytes to main-
tain intravascular volume, correct coagulopathy, and counter-
balance physiologic insult. If the patient is not hemorrhaging,
the mission is shifted to one of accurately identifying and
addressing contamination from bowel injuries. Lastly, but no
less important is addressing other injuries, including injuries
to the genitourinary tract, pancreas, spleen, and liver.
Prehospital transport, emergency department triage, and
the early presence of a trauma surgeon all play a role in the
success of the mission, since time to definitive control of
bleeding is the major determinant of outcome. Once the
indication for laparotomy has been established in the hemo-
dynamically unstable patient, there should be a focused effort
by the entire medical team to get the patient to the operating
room as quickly as possible.
Length of time spent in the emergency department has
been shown to correlate with mortality in hypotensive trauma
patients requiring laparotomy and in those with a posi-
tive FAST exam.1,2 Hypotensive patients with penetrating
abdominal trauma may benefit from bypassing the trauma
bay completely and going directly to the operating room,
thus minimizing time to incision and definitive hemorrhage
control.
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 524 Section III Management of Specific Injuries
Preparation
Preparing a patient for a trauma laparotomy begins in the
trauma bay. The less stable the patient, the less time should be
allocated to preoperative preparations. In the hemodynami-
cally unstable trauma patient, activities in the trauma bay
should be limited to the primary and secondary survey, chest
decompression for significant hemopneumothorax, obtaining
intravenous access and initiating blood transfusion, placing
direct pressure on sites of external hemorrhage, pelvic sheet-
ing (if mechanism dictates), and obtaining a blood specimen
for type and cross. At our institution, a blood gas, base deficit,
lactate, and a thromboelastogram are obtained on all high-
level trauma activations to quantify and qualify physiologic
and coagulopathic insult in order to guide resuscitation.
Plain films of the chest, abdomen, and pelvis have been
long advocated as adjuncts to the primary survey, and each
has a special role, but not all three are needed at all times.
Pelvis x-rays can be reserved for high-energy blunt force, and
plain abdominal films when bullet trajectory is in doubt, par-
ticularly in the setting of multiple gunshot wounds.
Certain bullet trajectories carry special significance. A
thoracoabdominal trajectory has been shown to predict a
higher morbidity. Trajectory across the abdominal midline in
a hypotensive patient is an early predictor of the need for
FIGURE 27-1 Prepping from chin to knees: the sterile operative field for trauma provides access to the neck, chest, abdomen, and groins. It
allows the surgeon to plan for the unexpected during the procedure, providing access into an adjacent cavity and access to the groins for vein harvest
or vascular control.
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Moore_Ch27_p0523-0538.indd 524
damage control and a marker for increased mortality.3 X-rays
may be examined in the operating room as not to delay trans-
port and time to incision.
Once arriving in the operating room, priorities prior to
incision include positioning and prepping the patient, ensur-
ing large-bore intravenous access and Foley catheter place-
ment, obtaining blood products, temperature control of the
room and the patient, and the administration of perioperative
antibiotics. This requires an organized effort between the sur-
geon, anesthesiologists, and the nursing team. Introductions
should be made when time permits. Communication with
the entire operating room team regarding objectives, opera-
tive plan, anticipated pitfalls, and necessary equipment is
essential. Rapid transfuser devices, thermal control garments,
electrocautery, suction, sequential compression devices, and
appropriate padding are all required and should be a standard
part of advanced preparation.
Trauma patients should initially be positioned in the
supine position with arms fully abducted at a 90° angle
(Fig. 27-1). If the patient is unstable, prepping and draping
may occur before or simultaneously with intubation. At this
time, other members of the team can work on venous and
arterial access and the other issues noted above. This allows
for immediate commencement of the operation should the
patient decompensate further with induction of anesthesia.
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 Chapter 27
The groin is isolated with a sterile towel, leaving room
to access the femoral vessels if needed. Typical draping for
trauma laparotomy should be performed with exposure from
chin to knees. The posterior axillary line is the limit of drap-
ing laterally. Anesthesia is allowed access the head and arms
while the surgeon maintains access to the neck, chest, abdo-
men, bilateral groins, and saphenous veins.4 A wide sterile
field allows the surgeon to be prepared for a variety of scenar-
ios, and specifically the dreaded worst-case scenario, as in a
single gunshot wound to the abdomen that tracks superiorly
into the great vessels of the chest.
In the clearly exsanguinating patient, sterility remains
desirable, but is not essential. Protection from blood-borne
infectious agents is essential at all times. In instances where
the patient has rolled to the operating room with a skilled fin-
ger holding hemostasis, the assistant’s hand may be prepped
into the field until surgical control is achieved. In the rela-
tively stable patient, prophylactic antibiotics should be given
prior to incision, and a proper time-out should be performed.
Role of the Surgeon
During a trauma laparotomy, the surgeon plays many dif-
ferent roles that must be quickly integrated. They conduct
the operation with the core mission as primary objective
and have a plan on how to achieve it, but always with a high
index of suspicion for associated injuries and occult sources
of hemorrhage.
The surgeon must physically perform the operation in a
technically proficient manner while supervising the other
members of the team. Attention to the fine details of the case
as well as to big-picture physiology of the patient is neces-
sary. The surgeon must anticipate the steps of the operation in
advance as to prepare the anesthesiologists and scrub nurses,
while having a clear vision of the end-point of the operation
(eg, “Next we are going to perform splenectomy, staple off the
bowel injuries and be in the SICU in under an hour with a
temporary abdominal closure in place. Please let them know
we will be coming and have a rapid transfuser ready.”). Early
on, a decision must be made regarding the operative profile
of the case: specifically whether to perform damage control
or a definitive repair, and the sequence of operative priorities.
These considerations will be discussed later in the chapter.
The trauma laparotomy is not performed by the surgeon
alone. It is a concerted effort from the surgeon, the anes-
thesiologists, the nurses, the blood bank, and others. For
the operation to be a success, continuous dialogue must be
maintained amongst the entire team regarding the broad pic-
ture of what is being done and how the plan is evolving. The
anesthesiologists should keep the operating surgeon updated
on hemodynamics and volume status, dysrhythmias, and
need for vasopressors, as well as on the presence of acidosis,
coagulopathy, and hypothermia. It is with these variables of
physiologic reserve that the surgeon must make critical deci-
sions regarding the operative profile. Likewise, the patient
may be bleeding from another visceral cavity, for example
hemorrhaging from a chest tube, and this may be only noted
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Moore_Ch27_p0523-0538.indd 525
Trauma Laparotomy: Principles and Techniques 525
by those away from the operative field. In turn, the surgeon
must communicate with anesthesia upon opening the abdo-
men with potential release of tamponade, the presence of
massive bleeding, and regarding the clamping and unclamp-
ing of major vessels which may alter hemodynamics and
arterial pH. These examples illustrate that a safe operation
necessitates open communication lines between the surgeon
and the anesthesiologist across the sterile drapes. Likewise,
the scrub and circulating nurse have responsibilities regard-
ing availability of needed devices and supplies, suction and
irrigation, sutures and staplers, and family contacts or new
information regarding the patient’s medical history.
A final responsibility of the operating surgeon is to know
when to get help. When a technical challenge arises that
requires more specialized assistance, the appropriate thing
to do is to call for help. The decision to stop and call for
additional help often reflects sound judgment, humility, and
ultimately puts patient safety in utmost regard.
Throughout the course of the operation, appropriate break
points occur which allow the surgeon the opportunity to reex-
amine the big picture and alter the operative profile, assess
hemodynamics and coagulopathy, and summon consultants
or assistance when needed. The first such opportunity arises
when temporary hemostasis has been achieved with ligation,
packing, or a shunt. Another valid pause in the operation exists
after exploring the abdomen and finding a large retroperitoneal
hematoma, allowing time to consider other operative approach
options, including angiography. Control of gastrointestinal
tract leaks should next allow a pause to consider if definitive
hand-sewn repair or damage control is the best approach. Prior
to abdominal closure is yet another time to consider the next
steps in management, the timing of orthopedic or other opera-
tions, and the best disposition for the patient.
TRAUMA LAPAROTOMY
Sequence of Operation
The trauma laparotomy generally follows a reproducible
sequence of steps that are expected to provide a goal-directed,
efficient, and thorough approach to the abdomen (Fig. 27-2).5
A typical trauma laparotomy includes the task of gaining
access into the peritoneum, early control of bleeding and con-
tamination, a thorough exploration of the abdominal cavity,
and then either a damage-control approach with temporary
abdominal closure or definite repair; the patient’s hemody-
namic and physiologic profile should guide this decision.
This sequence reflects the objectives and priorities of the
procedure; however, the ability to vary this sequence based on
exigent operative findings is the hallmark of a good trauma
surgeon. For example, if upon entry into the abdomen, a liter
of bright red blood is suctioned from the peritoneum with an
avulsed spleen identified as the source, priority will first be
given to the splenectomy as the most imminent threat to life.
In this case, complete exploration would be deferred until the
hemorrhage has been controlled, and then returning to the
standard sequence and objectives should follow.
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 526 Section III Management of Specific Injuries
Access and Temporary bleeding control
exposure
FIGURE 27-2 A schematic depiction of the generic sequence of steps in a trauma laparotomy.
After entry into the abdomen in the hemorrhaging
patient, the early objective is hemostasis. Initial steps include
bowel evisceration to allow for better exposure of bleed-
ing sites (Fig. 27-3). Note we do not advocate a routine
“4-quadrant packing” as the first step. It is our contention
that this packing is not adequate to tamponade bleeding, it
may injure delicate structures (splenic ligaments; friable or
injured mesentery), and simply masks ongoing bleeding.
Evisceration and exposure should be the first steps, directed
at the sites of bleeding. Control of bleeding should be rapidly
obtained with a finger, suture, sponge stick, or directed pack-
ing. Once temporary hemorrhage control has been obtained,
a break in the operation should occur, giving the entire team
time to regroup. The surgeon can take a moment to assess the
severity of the injury, reformulate the plan of action and call
FIGURE 27-3 Complete evisceration of the small bowel on entering
the peritoneal cavity is a key maneuver that is often forgotten by the
inexperienced. Gathering all bowel loops outside the abdomen allows
easy entry into the peritoneum and improved exposure of injuries.
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Moore_Ch27_p0523-0538.indd 526
Definitive repair
Decision
Exploration
Damage control
for additional instruments or assistance if needed. The nursing
team has time to obtain appropriate suture, instruments, and
trays and organize for the next portion of the procedure. Anes-
thesia has time to catch up on blood loss and correcting coagu-
lopathy. Effective temporary hemostasis is a critical objective
early in the operation, without it the surgical team is denied the
above advantages and the operation continues at a frantic pace.
The methodical exploration of the abdomen allows the
surgeon to catalog all injuries and devise a comprehensive
plan of action. Ultimately the repair of one injury may hinge
on the repair of a second injury, and therefore the plan should
generally not be finalized until all damage is assessed. The
need for good decision making abounds in a trauma lapa-
rotomy, and the principles of hemorrhage control followed by
contamination control with attention to coagulation physiol-
ogy should help direct the surgeon.
A critical judgment to be made by the surgeon is that of
the operative profile: damage control versus definitive repair.
The decision to perform damage control surgery can be made
before the operating room for the patient in shock, or it can be
made intraoperatively once injury severity has been assessed.
Damage control implies utilizing a modified, abbreviated
operative course designed to control hemorrhage and control
gross contamination, a temporary abdominal closure, and a
plan for reexploration and definitive repair once the patient
has been resuscitated. The purpose is to avoid a permanent
physiologic insult from which the patient cannot recover; this
insult has been termed to as the “bloody, viscous cycle” and
consists of coagulopathy, acidosis and hypothermia.6
Gaining Access to the Peritoneum
The trauma exploratory laparotomy is most commonly per-
formed through a midline incision from xiphoid to pubis.
This incision affords wide exposure of intraperitoneal and
retroperitoneal organs and may easily be extended into a
sternotomy as needed. Most general and trauma surgeons
are comfortable with this incision and can use the midline to
enter the abdomen quickly.
Incising down through skin and soft tissue can be made
with a few strokes of the knife. Staying in the midline, the
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 Chapter 27
white decussating fibers of the anterior rectus sheath are
encountered. The linea alba is divided sharply, revealing
preperitoneal fat and the peritoneum which lies beneath.
The peritoneum may be entered bluntly above the umbili-
cus, or is entered sharply with a pair of Metzenbaum scis-
sors while pinching the peritoneum up to avoid injuring
the bowel. This is best performed near the xiphoid with
the lateral segments of the liver providing some protection
beneath. Iatrogenic bowel injuries can be catastrophic and
care must be taken to prevent them. Once the peritoneum
is deemed free of adhesions, the peritoneum may be freely
opened with electrocautery, or when speed is essential, with
a pair of Mayo scissors.
In the patient with a prior abdominal incision, it is saf-
est to enter the abdomen away from the preexisting scar in
order to avoid adhesions. Alternatively, a bilateral subcostal
incision (chevron) or even a flank incision may be utilized
to circumvent a midline scar. While these options provide
adequate access to isolated areas of the abdomen, they are
much less desirable for complete exploration of the abdomen
and pelvis. In addition, these incisions are likely to take more
time and have their own significant morbidity, therefore the
midline incision is preferred whenever possible.
Early Goals: Hemostasis and
Control of Contamination
The patient’s hemodynamic status dictates the course and
urgency of the laparotomy. Once the peritoneum has been
opened in the bleeding patient, two pooled suction catheters
are utilized to rapidly evacuate blood from the peritoneum.
The bowel is then eviscerated and hemorrhage control or
directed packing is performed. Likely sources of bleeding are
bowel mesentery, solid organs, or the great blood vessels. The
solid organs are quickly inspected and palpated for injury.
When liver hemorrhage is identified, packing should occur
laterally, superiorly, and inferiorly to the liver. Splenic hem-
orrhage should be managed with immediate splenectomy
in most circumstances. Mesenteric bleeding is managed by
clamps and ligature as the first step, with later evaluation of
bowel viability.
Retroperitoneal and great vessel injuries are more
challenging. An aid to their management is an understand-
ing of the anatomy of the three zones of the retroperito-
neum. Zone I is the central zone of the retroperitoneum,
bounded by the kidneys laterally and extending from the
diaphragmatic hiatus to the bifurcation of the inferior
vena cava and aorta. This zone can be further divided by a
supramesocolic or inframesocolic location. It is inspected
by lifting the transverse colon and gently retracting it
either caudally or cranially. Bleeding or hematoma in this
area signifies great vessel injury, including aorta, vena cava,
and celiac axis vessels or superior mesenteric artery, vein
or portal vein injury. Zone II is located laterally from the
kidneys to the paracolic gutters, and hematoma in this area
usually signifies injury to the renal artery or vein. Zone III
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Trauma Laparotomy: Principles and Techniques 527
of the retroperitoneum includes the pelvis, encompassing
the iliac arteries and veins.
If packing controls hemorrhage, a pause in the operation
can occur, allowing the team to regroup, restore the patient’s
blood volume, obtain equipment and mentally ready for the
next portion of the operation. The surgeon’s next immediate
priorities include locating the injured vessel or organ, expos-
ing the injury, and then deciding on temporary or definitive
repair.
If bleeding is not controlled with packing, or if it manifests
as an expanding Zone I retroperitoneal hematoma, proximal
control should be obtained with occlusion of the suprace-
liac aorta with a trained finger or sponge stick compressing
the aorta against the vertebral bodies. The supraceliac aorta
can be then exposed by first retracting the lateral segments
(II and III) of the liver toward the patient’s right. The gastrohe-
patic ligament is incised. The esophagus can then be laterally
displaced, which should expose the aorta. The aorta should
be dissected anteriorly and laterally to allow for passage of a
vascular clamp. Division of the left crus of the diaphragm will
also help to expose the proximal aorta at the hiatus. While
suture ligation of most bleeding intra-abdominal vessels is the
norm, primary repair of the aorta, vena cava, and very proxi-
mal superior mesenteric artery (and rarely the portal vein)
should be part of the hemorrhage control plan. Adjuncts can
include packing, clamps, or balloon catheter tamponade.
Hollow viscus injuries are repaired or the injured bowel
segment is resected, with or without re-anastomosis. Once
initial hemorrhage and gastrointestinal spillage have been
controlled, the decision to reconstruct complex gastrointes-
tinal and vascular injures is weighed against the decision to
place a temporary abdominal closure and come back once the
patient is fully resuscitated.
Exploring the Peritoneal Cavity
The peritoneal cavity is explored in the same fashion each
time, as not to overlook any injuries. As previously described,
Zones I, II, and III of the retroperitoneum are examined for
hematoma early in the procedure. The anterior aspect of the
stomach is examined in its entirety from the gastroesopha-
geal junction to the pylorus. The lesser sac is then opened by
dividing the gastrocolic omentum, and the posterior aspect
of the stomach and the anterior aspect of the pancreas are
inspected.
From the pylorus, the gastrointestinal tract can be exam-
ined from proximal to distal. If the duodenum has been
mobilized with a Kocher maneuver, the anterior and poste-
rior aspects of the duodenum can be visualized. The small
bowel is then run in a methodical fashion, examining the
circumference of the bowel and identifying any abnormali-
ties. As a segment of small bowel is lifted for examination,
the corresponding mesentery is also inspected for hematoma.
Serosal injuries or full-thickness perforations of the small
bowel may be contained with a Babcock clamp or over sewn
with a rapid whipstitch as they are encountered. Once the
terminal ileum is encountered, the appendix, ascending,
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 528 Section III Management of Specific Injuries

transverse, descending, and sigmoid colon are inspected. It

may be necessary to mobilize the colon along the white line
of Toldt to examine the retroperitoneal aspect, particularly in
cases of penetrating trauma where the trajectory is suspicious.
The liver, spleen, kidneys, and gallbladder are palpated for
injury. In the pelvis, the genitourinary organs are inspected
for injury. Finally, the diaphragm is inspected carefully as a
site of potential missed injury. Structures appearing bruised
or those located close to a missile trajectory should be fully
mobilized and carefully examined for injury.

Medial Visceral Rotations

In the presence of a retroperitoneal hematoma, the decision on
whether or not to explore the hematoma must be made. Zone
I retroperitoneal hematomas require surgical exploration.
Penetrating injuries to Zone II are generally explored, while
blunt injuries are only explored if the hematoma is expanding.
Zone III, the pelvis, should only be explored in the case of
penetrating injury. Blunt injury to Zone III is best dealt with
via an interventional approach or preperitoneal packing.
The medial visceral rotations are maneuvers utilized to
expose key retroperitoneal structures, including the great
vessels and their branches, the kidneys, and the duodenum.
Both maneuvers are based on a technique of mobilizing intra-
peritoneal structures off of the posterior abdominal wall, and
mobilizing them medially to allow access to the retroperito-
neum. The decision to perform such maneuvers should be
based upon anatomic location of hematoma and suspected
injuries. FIGURE 27-4 The full Cattell–Braasch maneuver provides broad
A right medial visceral rotation, also known as the Cattell- exposure of the retroperitoneum. The only two areas of the retroperi-
Braasch maneuver, is used to expose the intra-abdominal toneum that remain inaccessible are the retrohepatic vena cava and the
inferior vena cava, the right renal pedicle, and the right iliac suprarenal aorta. The latter is accessible with the Mattox maneuver.
artery and vein (Fig. 27-4). The ureter, head of the pancreas,
and duodenum will also be exposed. The Cattell-Braasch
begins with mobilization of the hepatic flexure of the right to the iliac vessels. Before opening the retroperitoneum, prox-
colon and a full Kocher maneuver to mobilize the duodenum imal control at the supraceliac aorta should be obtained. A
and pancreatic head along the peritoneal reflection. This is left medial visceral rotation is initiated by dividing the spl-
further carried down the right colon along the paracolic gut- enorenal ligament. The left peritoneal reflection, or the white
ter by dividing the white line of Toldt. The exposure ends by line of Toldt, is then divided from the splenocolic flexure
dividing the avascular plane which exists between the root down the paracolic gutter to the distal sigmoid colon. The
of the mesentery and the peritoneum. The small bowel and left colon, spleen, stomach, and pancreas are then mobilized
right colon are then retracted medially, allowing visualization to the midline, just anterior to Gerota’s fascia surrounding
of the inferior vena cava. the kidney. The abdominal aorta is thus exposed, along with
Another technique that can be used to expose the retro- the celiac axis, the superior mesenteric artery, the left renal
hepatic vena cava is extension of the midline incision across artery and vein, and the left iliac artery and vein. In the clas-
the costal margin into an intercostal space of the right chest. sic Mattox maneuver, the kidney is included in the mobiliza-
The diaphragm can thus be incised to expose the vena cava tion, which allows for access to the posterior aspect of the
and hepatic veins. Proximal control of the inferior vena cava kidney and the aorta below the renal pedicle. Otherwise, the
is best achieved from inside the chest. left renal vein would restrict access to the anterior aorta. Care
Injuries to the aorta present most commonly as exsan- must be taken to avoid iatrogenic injury to the spleen when
guinating hemorrhage or as pulsatile hematomas in Zone I placing traction on the descending colon.
of the retroperitoneum. To explore a Zone I or a Zone II
retroperitoneal hematoma on the left, a left medial visceral
rotation, the Mattox maneuver, is performed (Fig. 27-5).
Approach to Hemorrhage
The left-sided organs are mobilized off the aorta, which allows Hemorrhagic shock is the most common immediate cause of
for broad exposure of the aorta from the diaphragmatic hiatus death in patients with abdominal vascular injuries. Assessment

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 Chapter 27 Trauma Laparotomy: Principles and Techniques 529

© Kenneth L. Mattox, M.D.

FIGURE 27-5 A full left-sided medial visceral rotation for trauma (Mattox maneuver) provides access to the abdominal aorta and is the only
way to rapidly expose the suprarenal aortic segment in the presence of a central retroperitoneal hematoma. The inset shows the correct plane of
dissection that is immediately on the muscles of the posterior abdominal wall. The presence of a large retroperitoneal hematoma greatly facilitates
the maneuver. (Copyright © Kenneth L. Mattox, MD.)

of hemorrhage begins in the trauma bay with the vital signs
and physical examination. In an unstable patient, a FAST
exam which is positive for abdominal fluid should direct the
patient (and surgeon) up to the operating room as quickly
as possible. In the penetrating trauma patient who loses vital
signs and has had cardiopulmonary resuscitation for less than
fifteen minutes, a resuscitative thoracotomy with aortic cross-
clamp is the initial maneuver to prevent further hemorrhage
into the abdomen and preserve flow to the brain.7
In the patient who survives to the operating room, the
peritoneum is opened through a midline laparotomy and
blood is quickly evacuated from the peritoneum, gener-
ally with a combination of suction, manual evacuation of
clot, and directed and careful packing. The bowels are then
eviscerated. The surgeon should quickly assess hemorrhage
severity and potential sources, and an immediate plan must
be made at this time.
Hemorrhage from the liver is best treated with manual
compression followed by tight packing lateral, superior, and
inferior to the liver (Fig. 27-6). If packing controls hemor-
rhage, packs should be left in place. If bleeding is not con-
trolled, a Pringle maneuver is the next step. This maneuver
occludes the portal vein and the hepatic artery, effectively
making the liver anoxic; it does not address hepatic venous
bleeding, nor retrohepatic vena caval injury. To perform the
Pringle maneuver, the anterior edge of the liver is reflected
cephalad. A finger is placed through the foramen of Winslow,
and with a pinching movement, the portal triad may be con-
trolled. A vascular clamp or Rommel occlusive loop can then
replace the surgeon’s hand (Fig 27-7). It is not known exactly
how long it is safe to leave the Pringle on, but intermittent
release of the clamp every 30 minutes should suffice to main-
tain perfusion to the liver.
The approach to bleeding from a pedicled organ like the
spleen and kidney is best approached with vascular control
at the pedicle followed by repair or resection of the involved
organ. Details are found in these respective chapters.
Pelvic veins are the most common cause of Zone III
retroperitoneal hematoma following blunt trauma. Open-
ing these hematomas can induce uncontrolled hemorrhage
and is generally only done for exsanguination or critical limb
ischemia. The decision options for managing pelvic retroperi-
toneal bleeding are affected by the availability of expertise in
preperitoneal packing, angioembolization, and urgent exter-
nal fixation (see chapter on Pelvic Trauma). When confronted
by a previously unsuspected expanding Zone III hematoma
during a trauma laparotomy, the best management might
well be to move rapidly to angioembolization. In our institu-
tion, packing of the preperitoneal pelvic space with external
fixation of the pelvis is employed in patients with hemody-
namically significant pelvic fractures. This can be performed
in conjunction to exploratory laparotomy when indicated.
Treatment options for vascular injury include vessel liga-
tion, primary repair, vein patch, interposition grafting, and

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 530 Section III Management of Specific Injuries
FIGURE 27-6 Hemostasis of the liver can be achieved via manual
compression followed by tight packing laterally, superiorly and infe-
riorly. If bleeding is halted with packing, packs should be left in place
and the abdomen closed with a temporary closure. (Used by permis-
sion from Walter Biffl, MD.)
FIGURE 27-7 The Pringle maneuver occludes the hepatic artery, the
portal vein, and the common bile duct. The surgeon’s hand is replaced
by a vascular clamp. Hepatic venous bleeding will not be addressed with
this maneuver. (Used by permission from Walter Biffl, MD.)
temporary intravascular shunting. Vessel ligation, shunting,
and occasionally small primary repairs can be used in damage
control situations. Primary repair of the vessel should be per-
formed whenever time (and the nature of the wound) permits.
Debridement to healthy tissue is performed prior to any repair.
Whenever possible, closure of a vascular injury should be
performed in a transverse fashion with a running permanent
monofilament suture in a lateral arteriorrhaphy, or in an end-
to-end anastomosis. Stenosis of the vessel is often accepted in
favor of hemorrhage control, but when time permits, stenosis
may be avoided with vein patch. In all cases, tenets of vascular
surgery including proximal and distal control, adequate inflow
and outflow, and a tension-free anastomosis should be followed.
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The decision to ligate or repair a vessel depends on the
nature of the vessel and the risk of ischemia with ligation.
Ligation of the celiac artery and the internal iliac artery may be
done with low risk of morbidity as good collateral circulation
exists. On the contrary, ligation of the common iliac artery
and the external iliac artery carry the risk of amputation.
Aortic injuries mandate repair. Injuries to the suprarenal
inferior vena cava also mandate repair. Any vein below the
renal vein may be ligated if repair is unsafe. Tying off the
external iliac vein, common iliac vein, or even the infrare-
nal inferior cava is acceptable in critical situations, although
lower extremity edema leading to a compartment syndrome
may result. In these cases, four compartment fasciotomy
should be performed on the ipsilateral limb. Injuries to the
iliac veins may be amenable to a primary repair after proximal
control at the bifurcation and distal control in the femoral
canal is obtained.
Repair of the portal vein with carefully placed monofila-
ment suture should be attempted when possible, although
portal triad vascular injuries remain one of the most lethal
of intra-abdominal injuries, usually due to exsanguination.8
Portal vein ligation should be used as a last resort, as ligation
leads to massive intestinal edema. When employed, this strat-
egy should be used in conjunction with an open abdomen
and a planned second look procedure.
Injury to the mesenteric vessels may present as shock with
active hemorrhage, ischemic or necrotic bowel, or as mesenteric
hematoma. A left medial visceral rotation is the optimal way to
expose the superior mesenteric artery and vein, but division of
the pancreas with distal pancreatectomy is another acceptable
approach. The proximal superior mesenteric artery or vein must
be repaired to preserve blood flow to the small bowel. Injuries
to the superior mesenteric artery beyond the pancreas can be
addressed with vessel ligation in conjunction with bypass graft-
ing from the distal aorta, as would be performed for superior
mesenteric artery thrombosis. Caution should be used when
placing interposition grafts near a major pancreatic injury, as
a pancreatic leak could lead to a complete disruption of the
anastomosis.9 Injury to the mesenteric vessels necessitating vas-
cular repairs and large mesenteric hematomas may compromise
blood flow to the intestine. In these circumstances, a planned
second-look laparotomy within 24 hours is prudent.
Shunting may be considered in damage control situations
with an acidotic, hypothermic, polytrauma as an alternative
to vessel ligation. Shunting is a method to temporarily bridge
injured vessels with a prosthetic conduit, rapidly restor-
ing blood flow and controlling hemorrhage. This technique
allows definitive repair to be deferred until the patient has
been fully resuscitated, and addresses both hemorrhage and
critical ischemia. In patients with injury to the common or
external iliac arteries, shunting has been shown to reduce the
rate of amputations and fasciotomies.10
The Pruit-Inahara shunt (LeMaitre Vascular, Burlington, NJ)
is a double-lumen device that has a balloon on each end to
secure the shunt in place. Ties and clamps which may dam-
age the vessel are not needed. It also includes a side port
thorough which contrast, tissue plasminogen activator, or
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 Chapter 27
papaverine may be injected. Nasogastric tubing, intravenous
tubing, pediatric feeding tubes, or thoracostomy tubes may
be utilized as shunts for larger vessels, as most commercial
shunts are too small to utilize in larger vessels such as the
aorta or iliacs. The choice of shunt depends mainly on the size
of vessel injured, as size-match between shunt and vessel is a
primary factor in shunt success.
Before shunting, thrombectomy with proximal and distal
embolectomy should be performed with Fogarty catheters to
ensure adequate inflow and outflow. It is not necessary to sys-
temically anticoagulate patients with temporary intravascular
shunts. Patency and flow through the shunt can be demon-
strated with on-table angiography.
Complications of shunting include shunt thrombosis, dis-
tal embolization, shunt dislodgement, and infection. The ideal
time to shunt removal has not been definitively identified—
optimally, removal and definitive repair occurs before shunt
thrombosis but after complete resuscitation of the patient.
When segments of critical vessels are destroyed or resected,
interposition grafts of polytetrafluoroethylene (PTFE) (Gore-
Tex, Newark, DE) or Dacron can be used to bridge the defi-
cit. In clean or minimally contaminated cases, tissue coverage
with omentum or muscle may be utilized to protect the graft.
Autogenous great saphenous vein can also be harvested as
conduit, particularly in instances of bowel perforation and
contamination.
Damage Control Considerations
Over the last three decades principles of damage control have
been widely adopted and applied to both the military and
civilian approach to the critically injured trauma patient.
Damage control refers to an abbreviated laparotomy in an
unstable trauma patient with goals of controlling hemorrhage
and gastrointestinal spillage. A temporary abdominal closure
is employed with a planned return to the operating room
in 24–48 hours for a second look procedure and definitive
repair of injuries. Damage control has become a fundamental
concept in modern day trauma surgery.
The concept of damage control was first introduced to the
trauma community in 1908, when Dr J. Pringle described
the technique of utilizing suture over gauze to control
portal venous bleeding in the trauma patient.11 In 1983,
Dr H. Harlan Stone described rapid termination of the trauma
laparotomy after intra-abdominal packing for nonhepatic
trauma once clinical evidence of coagulopathy was noted. He
supported delayed, definitive surgery once the patient was
fully resuscitated.12 The damage control sequence was later
named in the early 1990s by Dr Michael F. Rotondo and
colleagues at the University of Pennsylvania. They described a
three-stage approach to damage control: the first, laparotomy
with rapid hemostasis and control of contamination with a
temporary closure of the abdomen, the second stage of resus-
citation and restoration of normal physiology in the intensive
care unit, and the third stage, reexploration, definitive repair,
and closure. With a retrospective review, he found that sur-
vival was improved with abbreviated laparotomy techniques
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Moore_Ch27_p0523-0538.indd 531
Trauma Laparotomy: Principles and Techniques 531
in patients with combined major vascular injury and two or
more visceral injuries. These patients were then taken back to
the operating room once their coagulopathy, acidosis and/or
hypothermia were corrected.13
The primary objective of damage control surgery is avoid-
ance of a permanent physiologic insult, the “bloody viscous
cycle” of trauma—acidosis, coagulopathy, and hypothermia—
from which a patient cannot recover. The “bloody viscous
cycle,” also known as the lethal triad, was first described in
1981 by Dr Gene Moore and the Denver General group.7
Severely injured patients displaying such physiology are at
heightened risk of mortality.
Once the bloody viscous cycle has set in, it can be nearly
impossible for one to recover from the insult. Damage con-
trol techniques should be used in the patient likely to enter
into the bloody viscous cycle, rather than after the patient
is in physiologic extremis. In these instances, rapid restora-
tion of normal physiology takes precedence over restoration
of normal anatomy.
The decision to perform damage control is ultimately left
to the judgment of the surgeon. There are instances in which
damage control may be decided on even before the operat-
ing room, for example, a patient in a profound shock state
or with multisystem/multicavity trauma. Parameters such as
an intraoperative pH of <7.20, a temperature of 93°F, and
a blood loss of 10 units or more strongly suggest utilizing
damage control.14 Once in the operating room, wounding
patterns such as combined major vascular injury and gastroin-
testinal injury may warrant damage control. The decision for
abbreviated laparotomy should be made proactively, before
the patient manifests acidosis, coagulopathy, or hypother-
mia. Intraoperative signs of the bloody viscous cycle include
diffuse oozing from all surfaces, edematous bowel, or dusky
appearing viscera.
If the decision is made too late, the patient will not be able
to recover from physiologic insult, and will enter a downward
spiral leading to death.
The damage control sequence is three-stage process. The
first stage is the initial emergency trauma laparotomy, with
goals being hemostasis, the shunting of major vascular inju-
ries, and control of contamination from gastrointestinal, biliary,
and genitourinary injuries. Splenectomy may be performed
as needed, and injuries to solid organs such as the liver and
kidney are tightly packed. Small injuries to the bowel may be
over sewn with a whipstitch. Injuries to the gastrointestinal
tract are often stapled off with a gastrointestinal anastomosis
stapler, with the bowel left in discontinuity and anastomosis
or reconstruction delayed until the definitive repair. Suspected
pancreatic injuries should be drained. The fascia is left open
with a tension-free temporary abdominal closure to facilitate
reexploration. Methods of temporary abdominal closure will
be described later in the chapter.
If there is concern for ongoing bleeding from solid organs
such as the liver, spleen, or kidney, consideration should be
given to angiography and embolization in the interventional
radiology suite. Hybrid operating rooms have all the features
of a traditional operating room, but in addition capabilities
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 532 Section III Management of Specific Injuries
for angiography, endovascular interventions, and fluoroscopy.
These hybrid rooms are becoming more popular in large cen-
ters and allow multiple teams to intervene on a patient at once.
After the goals of hemostasis and gastrointestinal spillage
are achieved, the patient should be promptly transported to
the surgical intensive care unit for phase II, resuscitation.
Mechanical ventilatory support is provided. Hemodynamics,
urine output, and serial lab parameters such as lactate and
base deficit are used as quantifiable markers of shock to guide
fluid resuscitation. Rewarming with forced-air warmers, radi-
ant heat, and heated fluids is also performed. Transfusion
of blood, plasma, platelets, and cryoprecipitate is guided by
coagulation labs and serial thromboelastography until coagu-
lopathy has been reversed. Drains and tubes are monitored
for signs of bleeding. In preparation for phase III, a thorough
head-to-toe tertiary exam should be performed.
Once the patient has been fully resuscitated, phase III, or
reexploration with definitive repair can occur. Back in the
operating room, packs are removed and definitive gastrointes-
tinal anastomoses and vascular reconstructions are performed.
The abdomen is then completely explored for other injuries.
If at any point the patient becomes hemodynamically unsta-
ble, the damage control sequence can be reinitiated.
When possible, a tension-free fascial closure is performed.
In cases of ongoing contamination, bleeding requiring repack-
ing, or concern for bowel viability, the abdomen may be left
open again for subsequent reexploration. When the abdomen
cannot be fully closed due to loss of domain or bowel edema,
a sequential abdominal closure with retention sutures may be
employed. When all attempts to close the fascia have failed,
complex closure methods with mesh may be utilized.
Temporary Abdominal Closure
Temporary abdominal closure allows the surgeon a quick and
easy reentry into the abdomen for subsequent explorations
after damage control surgery, and can be reapplied as needed
before definitive closure. The temporary abdominal closure
ideally will contain the viscera, protect the bowel, provide
early identification of intra-abdominal complications, and
preserve healthy fascia for subsequent closure.
There are a variety of techniques utilized to perform tem-
porary abdominal closure. Utilization of towel clips to being
the skin together is the simplest and fastest method. Towel
clips should be placed 1 cm apart and should then be cov-
ered with a sterile towel and a piece of Ioban (Ioban, St Paul,
MN). A running suture in the skin is another easy method to
bring the skin together, but takes longer to apply. Drawbacks
to these methods include injury to the skin and possible evis-
ceration of the bowel between clips. These skin-only closures
do not allow for fascial expansion and have a higher rate of
abdominal compartment syndrome, and thus have fallen out
of favor (Fig. 27-8).
Another inexpensive temporary closure method is
the Bogotá bag. This technique is credited to surgeons
in Columbia who had vast experience with catastrophic
abdominal trauma in the setting of limited resources. A
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Moore_Ch27_p0523-0538.indd 532
FIGURE 27-8 The abdomen has been partially closed with a skin-
only closure. (Used by permission from Clay Cothren Burlew, MD.)
3-L intravenous fluid bag is utilized to cover the abdominal
contents. It can be sewn into the skin or the fascia. It allows
for a tension-free abdominal wall closure. Drawbacks to the
Bogotá bag include the risk of ripping the bag and eviscera-
tion, traumatizing the fascia with suture, and loss of domain.
Our institution utilizes a perforated subfascial 1010 Steri-
Drape (3M Health Care, St Paul, MN) with two Jackson-Pratt
drains placed over the 1010 to be used as sumps, followed
by an Ioban drape to close the open abdomen. A sterile blue
towel may be placed over the 1010 drape to further protect the
bowel (Fig. 27-9). This method allows easy inspection of the
bowel through the transparent closure. Jackson-Pratt drains
are placed to suction for control of abdominal effluent. Use
of a transparent closure device allows for examination of the
bowel for ischemic changes. In addition, the suctioned efflu-
ent can be monitored for bloody or bilious drainage. The open
abdomen may drain several liters over one day, and control of
effluent with a vacuum device helps to keep the patient dry.
Commercial vacuum-assisted management devices for the
open abdomen, such as the ABThera open abdomen negative
pressure therapy system (KCI, Inc, San Antonio, TX) have
been designed to promote healing by constant negative pres-
sure applied to the wound. The ABThera is associated with
less loss of domain, but at an increased cost.
Patients with open abdomens need not be kept paralyzed
and sedated through the course of their operations. In fact,
patients may be extubated, enterally fed, and ambulated. In
those patients without bowel injury, enteral feeding is asso-
ciated with a longer duration of open abdomen but signifi-
cantly improves fascial closure rates, decreases complications,
and decreases mortality.15
After the abdomen has been left open, the problem
becomes, “Can we close the fascia, and if so, how?” Once all
packs and foreign bodies have been removed from the abdo-
men, vascular reconstruction is complete and the gastrointes-
tinal tract is in continuity, fascial closure can be attempted.
Primary fascial closure is performed whenever possible, as
long as it is performed in a tension-free fashion.
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 Chapter 27 Trauma Laparotomy: Principles and Techniques 533

A B C
FIGURE 27-9 The three steps of performing a temporary abdominal closure. (A) The bowel is covered with a sterile 1010 drape. (B) A sterile
towel is placed to protect the bowel and two Jackson-Pratt sump drains are placed to remove effluent from the peritoneum. These are placed to bulb
or wall suction. (C) The closure is completed with a large Ioban drape. (Photo credit: Walter Biffl, MD.)

Several studies have shown that definitive fascial closure

should be performed as early as possible to avoid morbid-
ity and mortality. Earlier returns to the operating room are
associated with increased rates of successful closure and
decreased intra-abdominal complications.16 Early abdomi-
nal closure shortens hospital and intensive care unit length
of stay and diminishes cost. Finally, those patients whose
abdomens are closed within a week, report higher quality
of life, improved emotional health and are more likely to
return to work than those closed after a week.17 Factors
associated with failure to achieve delayed primary closure
include the number of reexplorations necessary, the devel-
opment of intra-abdominal infections, bloodstream infec-
tions, acute renal failure, enteric fistula, and ISS greater
than fifteen.18
When the fascia cannot be closed all at once, sequential
fascial closure can be employed. Sequential closure may be
performed with a sponge “sandwich,” as used at our institu-
tion (Fig. 27-10). This technique consists of multiple white
sponges (KCI International, San Antonio, TX) covering the
bowel with the fascia held under tension with full-thickness
no. 1-polydioxanone sutures. A black sponge is placed over
the white sponge with an occlusive dressing and the vacuum
is placed to suction. This addresses the need to keep the fascia
under tension to prevent fascial retraction and loss of domain.
The patient is returned to the operating room every other
day to perform sequential fascial closure with interrupted no.
1-PDS suture. Prior to definitive closure, the need for enteral
access is addressed.19 Whenever possible, omentum should
be placed between the bowel and the abdominal wall before FIGURE 27-10 A sequential closure is performed on the second
takeback operation. The lower fascia has been closed in a tension-free
closure.
manner. A white VAC sponge is placed over the bowel and fascial
In some cases, despite all efforts, the fascia cannot be closed. retention sutures are placed. A black sponge will be placed over top
When a primary fascial closure is not possible, options include and an Ioban drape will seal the closure. (Used by permission from
closure with a permanent prosthetic, closure with autologous Clay Cothren Burlew, MD.)

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 534 Section III Management of Specific Injuries
tissue, or closure with a temporary prosthetic and anticipating
a hernia. An absorbable mesh, such as a vicryl mesh (Ethicon,
Somerville, NJ), may be employed in closure, with eventual
skin grafting to cover the mesh in 2–3 weeks when granula-
tion has occurred. This method accepts a very high likelihood
of ventral hernia in favor of temporarily closing the abdomen.
Vicryl has a high tensile strength and a very low rate of infec-
tion. This mesh will eventually reabsorb, or can be removed
at time of skin grafting. Coverage of these open wounds with
autologous skin grafting should be performed as early as pos-
sible after granulation has grown through the mesh. These
wounds are similar to full-thickness burns and represent a
major catabolic drain for the patient, and the unprotected vis-
cera are susceptible to injury and fistulization.
A permanent prosthetic, such as a Marlex mesh (Davol Inc,
Cranston, RI) or a Prolene mesh (Ethicon, Somerville, NJ) may
also be employed to bridge the fascial deficit. They become
well-incorporated into the body but carry a risk of infection,
adhesion formation, seroma, and fistulization. Permanent pros-
thetics should not be utilized in a contaminated abdomen, for
if a permanent prosthetic becomes infected it must be removed.
Composite meshes utilize different materials in one product in
order to take advantage of the various properties of different
materials. They have improved tissue incorporation and create
less inflammatory reaction, but they are more expensive. Bio-
logic mesh, such as a porcine intestinal submucosa (Surgisis,
Cook, Bloomington, IN) or a human acellular dermis such as
Alloderm (Lifecell, Branchburg, NJ) are ideal for contaminated
wounds as they have no risk of infection, but are very expensive
and have a small but significant rate of hernia recurrence.
In complex cases, definitive reconstruction of the
abdominal wall can be performed with myofascial advance-
ment, rotational flaps, or lateral rectus release (component
separation).
COMPLICATIONS OF TRAUMA
LAPAROTOMY
Although damage control laparotomy and temporary closures
are performed to decrease mortality for the severely injured,
significant morbidity may result. Complications after trauma
laparotomy can involve any organ system of the body and
including the pulmonary system (atelectasis, pneumonia),
the cardiovascular system (myocardial infarction, deep venous
thrombosis, arrhythmia), the gastrointestinal system (fistulae,
ileus, anastomotic leak, pancreatitis), and the skin and soft
tissue (loss of domain, hernia, wound infection).
This section will focus on five potentially devastating com-
plications after trauma laparotomy: fascial dehiscence and
evisceration, abdominal compartment syndrome, enterocuta-
neous fistula, missed injury, and retained foreign body.
Fascial Dehiscence and Evisceration
Dehiscence occurs when previously closed fascia pulls apart.
Evisceration occurs when intra-abdominal contents leave
the peritoneal cavity and escape through an opening in the
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Moore_Ch27_p0523-0538.indd 534
fascia. Factors contributing to fascial dehiscence include
technical error, closure under tension, and wound infec-
tion.20 Additional risk factors for dehiscence include obesity,
pulmonary disease, hemodynamic instability, sepsis, poor
nutritional status, malignancy, ascites, and steroid use.21
Unfortunately, dehiscence may complicate any exploratory
laparotomy. Dehiscence with evisceration mandates urgent
return to the operating room. Principles of operative man-
agement include debridement to healthy fascia, control of
any intra-abdominal sepsis, and a tension-free fascial closure.
More complex methods of abdominal closure, as described
above, may be employed when tension-free closure cannot
be obtained. Prophylactic abdominal retention sutures may
be useful in decreasing evisceration rates, but ultimately their
benefit remains debatable within the literature.
Abdominal Compartment Syndrome
Patients requiring trauma laparotomy are at increased risk for
intra-abdominal hypertension (IAH) and abdominal com-
partment syndrome (ACS).22 Intra-abdominal hypertension
is defined by intra-abdominal pressures greater than 10 mm
Hg. Abdominal compartment syndrome is a clinical entity
which reflects impaired organ function as a consequence
of intra-abdominal hypertension, and is usually defined as
intra-abdominal pressures greater than 20 in the presence of
elevated airway pressures or renal impairment. Factors which
increase the risk of ACS include large-volume resuscitation,
bowel distention, bowel edema, the presence of packing, and
ongoing hemorrhage into the abdomen. Abdominal com-
partment syndrome can still occur in an abdomen that has
undergone temporary abdominal closure.
ACS is a clinical diagnosis. On physical examination, the
abdomen will be tight and distended. Intra-abdominal hyper-
tension can lead to direct compression of the inferior vena cava,
and as a result, increased central venous pressure, increased pul-
monary wedge pressure, decreased cardiac preload, and increased
afterload can be noted. The lungs must work to expand against
a tense abdomen and this elevates peak airway pressures as mea-
sured by the ventilator. Compression of the renal veins leads to
an oliguria which is unresponsive to fluid resuscitation.
Diagnosis should be based on clinical findings in conjunc-
tion with a measurement of a bladder pressure. The trend of
the bladder pressure may be more helpful than the absolute
number. More importantly, the patient’s physiologic profile
and degree of organ dysfunction should hold more value in
assessing ACS than the absolute bladder pressure measure-
ment. It is commonly accepted that bladder pressures greater
than 26–30 mm Hg should prompt decompression, but the
absolute intra-abdominal pressure leading to a compartment
syndrome is not definitively known and may vary per patient.
Treatment for abdominal compartment syndrome is
emergent decompression of the abdomen via midline lapa-
rotomy incision with placement of a tension-free temporary
abdominal closure. Repeat closure of the fascia should not be
performed. Decompression may be performed in the operat-
ing room or at the bedside.
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 Chapter 27
Enterocutaneous and
Enteroatmospheric Fistulae
An open abdomen after a damage control sequence is asso-
ciated with increased incidence of enterocutaneous fistula.
A fistula is an abnormal connection between two epithelial-
ized organs. Factors contributing to the formation of fistu-
las include deserosalization, erosion of the bowel against a
prosthetic mesh, missed traumatic or iatrogenic injury to the
bowel, and anastomotic breakdown. In the patient with an
open abdomen, bowel ischemia and inflammation, bowel
obstruction, increased manipulation of the bowel, desiccation
of the bowel, and the presence of intra-abdominal infection
can also contribute to fistula formation. Prevention of a fis-
tula can be attempted by placing omentum over the bowel,
minimizing injury to the serosal layer of the bowel, keeping
the bowel moist when the abdomen is open, and obtaining
fascial closure as early as possible. Some surgeons prefer to
cover exposed bowel with Vaseline gauze to prevent direct
contact during dressing changes while moving towards defini-
tive closure. Commercially available vacuum-assisted closure
devises have specialized materials for this specific use as well,
all with the idea of less micro-trauma to the bowel wall. Intra-
operatively, a sound technical repair and a diligent exploration
to avoid missed injures will also minimize fistula occurrence.
Principles of enterocutaneous fistula management include
protecting the skin and controlling effluent with wound care,
aggressive nutritional support, managing fluid and electrolyte
imbalances, and potentially operating to resect the fistula.
Once a fistula forms, it is a difficult problem to manage, as
spontaneous closure is uncommon. In select patients, fibrin
glue and acellular dermal matrix can occasionally seal a small
fistula. Fistula resection should be planned once nutritional
status has been optimized and intra-abdominal sepsis has
been controlled. Preoperative planning should attempt to
anatomically locate the fistula.
An enteroatmospheric fistula occurs when the fistula arises
immediately under a mesh or skin graft and is open to the
atmosphere. This is a unique and challenging problem as no
vascularized tissue exists over the fistula tract, which decreases
the possibility of spontaneous healing. Continuous drainage
of enteric succus over the exposed loops of bowel can lead to
ongoing peritonitis and sepsis. The enteroatmospheric fistula
cannot be simply resected in the setting of dense abdominal
adhesions, also known as a “frozen abdomen.” The presence
of such fistulae delays fascial closure and can lead to ongoing
sepsis, electrolyte imbalance, malnutrition, prolonged ICU
and hospital stays, and increased mortality.
Missed Injury and Retained
Foreign Bodies
Missed injuries and retained foreign bodies can be devastat-
ing to patient health and contribute to increased mortality.
These problems are embarrassing to the entire team involved,
particularly the surgeon, and can have significant medicolegal
repercussions.
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Moore_Ch27_p0523-0538.indd 535
Trauma Laparotomy: Principles and Techniques 535
A missed injury is any traumatic insult that is overlooked
during initial assessment, diagnostic imaging, or an injury
not identified during exploratory laparotomy. Missed inju-
ries may present as bleeding, peritonitis, sepsis, or pain. In
the trauma bay, failure to completely expose the patient or
perform a thorough primary and secondary survey with
attention to axillae and perineum may contribute to over-
looked signs of trauma. The tertiary exam performed out of
the acute resuscitation but still within 24 hours of admission
is designed to pick up on injuries not initially identified. At
the time of tertiary exam, the patient should be sober and
alert when possible. Pain from distracting injuries should be
controlled and the patient should be questioned for any new
complaints.
Incorrect reads on imaging studies and false negative tests
can also contribute to an inaccurate assessment of injury. In
the trauma team with a low index of suspicion, a false sense of
security with a negative study may cause harm.
Injuries can also be missed at the time of operative abdom-
inal exploration. Injuries to the colon, diaphragm, and geni-
tourinary tract are the most common missed intra-abdominal
injuries.23 Errors in technique and judgment can contribute
to an imperfect exploration, as may hemodynamic instability
and distracting injuries.
After penetrating trauma, accurate identification of all
external wounding sites is the first step in identifying any
internal injury. Bullet trajectory should be assessed with a
complete and thorough internal exploration along the tract.
An uneven number of bullet holes should alert the surgeon
to a retained missile. A single bullet hole in the abdomen
may signify a bullet in the abdomen, chest, or pelvis. X-rays
performed prior to operation can sometimes identify bullet
location in these cases.
After trauma laparotomy, there are various factors which
may contribute to a retained foreign body. The emergent
nature of the procedure precludes the routine counting of
instruments. During the initial entry and packing of the
abdomen, it is easy to lose track of the number of lapa-
rotomy pads placed in the abdomen when the focus is on
lifesaving hemorrhage control. The presence of multiple
teams operating in multiple body cavities may also contrib-
ute to the potential for instruments to be left behind. In
one retrospective analysis, emergency surgery, unplanned
change in procedure, and body mass index of the patient
were found to be significantly associated with risk of foreign
body retention.24
Fortunately there are a few simple things which can be
done to circumvent the retained foreign body. Before prepar-
ing to close fascia, the surgeon should perform a thorough
search of the peritoneum for laparotomy pads and instru-
ments. When a patient’s abdomen is left open and packed,
it is helpful to note the number and location of packs left
inside the abdomen on the operative note. Prior to exiting
the operating room after definitive closure of any body cavity
after multiple operations or with an incorrect count, an x-ray
should be performed and assessed by a radiologist and the
surgeon to look for retained foreign bodies.
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 536 Section III Management of Specific Injuries
Paramount to the management of any missed injury or
retained foreign body is prompt identification. Once the
missed injury has become evident to the team, full disclosure
to the patient and family must occur. A hospital’s risk man-
agement team may help to manage and mitigate this difficult
situation.
NONTHERAPEUTIC LAPAROTOMY
A nontherapeutic laparotomy is a laparotomy in which no
intra-abdominal injuries are identified and therefore no
interventions are performed, including suture, debride-
ment, or drainage. Despite the evolution of multislice com-
puterized tomography, diagnostic peritoneal aspiration and
lavage, and the focused abdominal sonogram for trauma,
the decision to perform laparotomy for trauma is not always
straightforward. On occasions where imaging or physical
examination is equivocal or when the imaging does not cor-
relate with the patient’s clinical state, there is not always
a clear decision algorithm. In these instances, the risk of
a nontherapeutic laparotomy must be weighed against the
risk of a delay in diagnosis.
There is controversy about the relative morbidity of a non-
therapeutic laparotomy. Potential complications include, but
are not limited to cellulitis, wound infection, dehiscence, ileus,
deep-vein thrombosis, and myocardial infarction. It appears
long-term risks such as bowel obstruction and hernia are
low.25 Repercussions after a missed injury may pose a greater
threat than the repercussions of a negative laparotomy.26
The greater acceptance of minimally invasive techniques
for trauma has reduced the negative laparotomy rate.
Thoracoscopy or laparoscopy for penetrating trauma can be
used in select hemodynamically stable patients with tho-
racoabdominal stab wounds to rule out diaphragm injury.
Laparoscopy is a useful tool in the evaluation of left-sided
thoracoabdominal gunshot wounds, gunshot wounds with
suspected extraperitoneal trajectory, and for assessment of
peritoneal violation after stab wounds to the flank and ante-
rior abdomen.27
RELAPAROTOMY
Urgent Relaparotomy for Hemorrhage
Urgent relaparotomy for hemorrhage is generally performed
in the hemodynamically unstable patient with ongoing trans-
fusion requirements. In those patients with a temporary
abdominal closure with a sump device, large volumes of san-
guinous drainage may be used as a trigger to return to the
operating room. For the surgeon, the decision to return to the
operating room is not always straightforward and should be
made with an assessment of original injury pattern, potential
for missed injury, and the patient’s overall coagulopathic pro-
file in mind. Ultimately there is minimal benefit to returning
a patient to the operating room for coagulopathic, or nonsur-
gical bleeding. In that patient, transport and reopening can
be detrimental to a patient who truly needs rewarming and
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Moore_Ch27_p0523-0538.indd 536
correction of coagulopathy and acidosis. It is the patient with
“surgical bleeding” from inadequate packing, technical failure
of suture ligatures, bleeding anastomoses, or a missed injury
who may potentially benefit from a return to the operating
room.
The relaparotomy sequence for hemorrhage is similar
to that of the original laparotomy: reopening of the lapa-
rotomy wound, evisceration, and a thorough exploration
of the abdomen. Hemostasis is achieved with a well-placed
finger, pack, or suture, followed by definitive repair. These
patients should be left with a temporary closure as they have
a high rate of abdominal compartment syndrome after mas-
sive transfusion.
Urgent Relaparotomy for
Intra-Abdominal Infection
An urgent relaparotomy for intra-abdominal infection is a
morbid operation performed for a variety of potential indi-
cations. In the right clinical situation, succus or bile com-
ing from abdominal drains after a temporary abdominal
closure indicates a missed injury or anastomotic dehiscence.
In the closed abdomen, drains are occasionally placed near
an anastomosis or tenuous repair. Enteric or bilious effluent
into these drains may be the first harbinger of anastomotic
leak or dehiscence. A septic clinical picture indicates that the
drain is not sufficiently controlling the leak and the patient
warrants return to the operating room. Infected biloma,
hematoma, or abscess cavities that are multiloculated or not
amenable to percutaneous drainage also necessitate return to
the operating room.
Once back in the operating room, regaining access to the
abdomen can be a challenging and difficult problem. After
a few days, the abdominal cavity becomes entrapped and
immobile secondary to adhesions and contamination. In
these situations, the bowel is hard to free and is often highly
edematous and easily injured. After entry into the abdomen is
achieved, the second goal is to identify the source of ongoing
contamination and control it. A variety of treatment options
exist, but repairs are fraught with potential complication.
When possible, simple suture closure of a bowel leak or per-
foration often puts part of the bowel under tension. Second-
ary to the inflamed nature of the bowel surrounding the leak,
this simple method has a high likelihood of failure. Resection
and reanastomosis is a better option when enough bowel can
be mobilized, although any new anastomosis remains at high
risk for failure in this situation. Tube drainage is generally not
favored for the risk of continued leak around the tube, and
in addition the tube can serve to enlarge the enterotomy and
maintain patency.
Another treatment option exists with proximal diversion.
Injuries to the duodenum and proximal jejunum may be
addressed with pyloric exclusion and a gastrojejunostomy. A
diverting ileostomy would permit more distal repairs in the
ileum and large bowel to heal while diverting enteric con-
tents. The technical options for reoperation for sepsis are out-
lined in Table 27-1.
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 Chapter 27
TABLE 27-1: Technical Options for Source Control During Relaparotomy for Uncontrolled Abdominal
Infection
Technical option
Resection and anastomosis
Resection and exteriorization
Proximal diversion
Tube drainage
Vacuum-assisted management
Planned Reoperation
A planned reoperation should take place when the patient
has been adequately rewarmed, acidosis has been corrected as
denoted by resolution of base deficit and normalizing lactate
levels, and coagulopathy has been normalized as evidenced by
thromboelastography and clinical signs of coagulation. These
parameters signify a return of healthy physiology. Once aci-
dosis, coagulopathy, and hypothermia have been corrected,
then and only then should planned reexploration with defini-
tive repair occur.
Most patients are adequately resuscitated by 24–48 hours
after initial operation, but a patient should be assessed for return
to the operating room as soon as physiologic parameters have
normalized. Packs should be changed or removed as early as
possible as they are a nidus for infection. Definitive gastrointes-
tinal anastomoses and vascular reconstructions are performed
once hemodynamics are adequate, as signified by an absence of
vasopressor requirement. Once all injuries have been repaired
and functional anatomy restored, the abdomen is completely
explored for other injuries and fascia is closed in a tension-free
manner. For those patients requiring additional trips to the
operating room, temporary closure may be reemployed.
BEDSIDE LAPAROTOMY
Resuscitative laparotomy may be performed at the bedside
in the intensive care unit for those patients with respiratory
or cardiovascular instability rendering them unable trans-
port to the operating room. In general, escalating vasopres-
sor requirements or high levels of ventilatory support with
high fraction of inhaled oxygen or high levels of positive end-
expiratory pressure preclude safe transport to the operating
room. Procedures which may be performed at the bedside
include decompressive laparotomy for abdominal compart-
ment syndrome, washout and fascial closure, exploration for
suspected intra-abdominal sepsis, perforation, or ischemia,
and exploration for hemorrhage, although the latter should
be performed with extreme caution. Patients who are not in
extremis should be brought to the operating room for the
safety, sterility, and added resources it provides.
Willingness from the surgeon, anesthesia, and nursing staff
is essential for success of the bedside laparotomy. A portable
electrocautery and suction should be arranged. Drawbacks
to bedside surgery include suboptimal sterility and lighting,
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Moore_Ch27_p0523-0538.indd 537
Trauma Laparotomy: Principles and Techniques 537
Comment
Rarely feasible for early leaks
Almost never feasible due to foreshortened mesentery
Occasionally lifesaving (edematous abdominal wall is obstacle)
Contraindicated
Useful option for exposed fistula (caution if unprotected suture lines)
lack of access to instrument trays and trained operating room
staff, and the challenge of operating over a larger bed with
less space. Despite these disadvantages and high associated
mortality, resuscitative laparotomy at the bedside can be the
best option to perform a potentially lifesaving operation for a
critically ill trauma patient.
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