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Surgical Therapy for Penetrating Abdominal Trauma

Practice Essentials

Although nonoperative intervention is increasingly used in selected patients, surgical therapy for penetrating abdominal trauma remains an essential part of overall management.
The indications for operative intervention include the following:

Development of hemodynamic instability

Development of increasing pain, peritoneal findings (eg, point tenderness, involuntary guarding, rebound tenderness)

Diffuse and poorly localized pain that fails to resolve

The image below depicts a tangential gunshot wound to the liver.

Penetrating abdominal trauma. Tangential gunshot w

Penetrating abdominal trauma. Tangential gunshot wound to the liver.

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Preoperative details

Surgical intervention begins with preparation of the patient in the operating room, as follows:

The patient is placed in the supine position with arms extended

The entire chest, abdomen, and pelvis, including the upper thighs, are prepped and draped

Fluids and blood products should be readily available (and administered via warm lines)

Warming devices should be placed on the patient’s upper and/or lower extremities

Entering the abdominal cavity can release tamponade, resulting in a precipitous drop in blood pressure, so the anesthesia team must be informed when the midline incision is made

Intraoperative details

Essential components to the trauma laparotomy include the following:

Control of bleeding

Identification of injuries

Control of contamination

Reconstruction (if possible)

Procedure

Initial control of bleeding is accomplished with 4-quadrant packing using laparotomy pads

The abdominal wall is retracted, the falciform ligament is taken down, and packs are placed above the liver and the spleen and in both sides of the pelvis after the bowel is swept cephalad

Once anesthesia has been given time to catch up with fluid resuscitation, the packs are removed one quadrant at a time, starting away from the sites of apparent bleeding

All areas are examined for injuries; each solid organ and the entire bowel are inspected

Contamination is controlled with the use of clamps, staples, or suture closures

Depending on the character of the defect(s), resection may be necessary

If the patient is stable enough to continue the operation, reconstruction may then be performed

Occasionally, patients with penetrating abdominal trauma develop such significant metabolic acidosis and coagulopathy that proceeding with the reconstruction phase of the laparotomy is not possible. In these cases, the operation is considered damage-control surgery, and the abdomen is closed rapidly.

Often, a temporary closure with an intravenous fluid bag or mesh (occasionally with a vacuum dressing) is used, as the patient has undergone massive fluid resuscitation and the bowel has become quite edematous, precluding primary closure of the abdomen. The patient is then transported to the intensive care unit for continued resuscitation and warming. Reconstruction then takes place upon return to the operating room in 24-48 hours.

Colon injuries

Primary repair of colonic injuries may be considered if the patient is hemodynamically stable and if the injury is fairly small with minimal fecal contamination. A diverting colostomy should be performed if the patient has any of the following:

Multiple injuries

Requirement for significant blood product resuscitation

Acidosis, hypothermia, and coagulopathy

A large defect (>50% of the circumference) and considerable fecal spillage

Other organ injuries

Diaphragm – Lower-grade injuries may be repaired either via laparotomy or with laparoscopic or thoracoscopic techniques

Liver – The key rules are gaining adequate exposure and obtaining hemostasis

Spleen – On the basis of the patient’s hemodynamic status, comorbidities, and operative access, the surgeon will plan for splenorrhaphy or splenectomy

Kidney – If at all possible, the kidney is salvaged with renography, using pledgeted sutures and wrapping, and capsular reapproximation; if nephrectomy is deemed necessary because of the severity of injury or instability of the patient, an intraoperative intravenous pyelogram is performed to confirm function of the contralateral kidney

Stomach – Exposure and thorough inspection is necessary, facilitated by opening of the gastrocolic ligament; injuries extending into the lumen may be repaired quickly with a stapling device

Diaphragm – For exploration, the Kocher maneuver is used to mobilize the duodenum, along with the pancreatic head and distal common bile duct; primary repair of injury is the goal, with protection of the repair using closed-suction drainage; diversion procedures are often used for protection

Pancreas – Pancreatic duct status and injury location are determinants in the management; lacerations or contusions without ductal injury can be treated conservatively, while more severe injuries may require partial or complete pancreatectomy

Damage-control surgery

Damage control surgery involves abbreviated laparotomy after control of surgical hemorrhage and enteric spill, with physiologic resuscitation in the intensive care unit and staged abdominal reconstruction.

Damage-control techniques include the following:

Perihepatic or intra-abdominal packing and towel clip closure of the abdomen

Therapeutic decompressive celiotomy

Prophylactically leaving open the abdominal fascia after laparotomy

Postoperative details

Patients should be monitored closely in the surgical intensive care unit after trauma laparotomy. Many patients will remain intubated and require ventilatory support. Attention should be paid to the following:

Warming the patient

Continuing fluid and blood product resuscitation

Replacing electrolytes

Monitoring drain outputs

Patients with evidence of ongoing bleeding may benefit from angiographic evaluation for possible embolization; some require reexploration for control of hemorrhage

Patients who have undergone damage-control procedures or have temporary abdominal closures must return to the operating room within 24-48 hours for definitive repair

Complications

Prevention is important for the following complications:

Deep vein thrombosis and pulmonary embolism

Stress ulceration and bleeding

Pressure ulcers

Atelectasis

Ventilator-associated pneumonia

Catheter-related sepsis

ICU psychosis

Early postoperative complications include the following:

Ongoing bleeding

Coagulopathy

Abdominal compartment syndrome

Later complications include the following:

Acute respiratory distress syndrome

Pneumonia

Sepsis

Intra-abdominal fluid collections

Wound infections

Enterocutaneous fistulae

Small bowel obstruction

Incisional hernias

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