Laparotomy

A laparotomy is a surgical procedure in which the abdomen is opened up to look inside for areas of abdominal trauma so that it can be corrected.  The laparotomy is the most commonly performed procedure in a patient with trauma to their trunk. 

A laparotomy is done for two major reasons: 1) trauma, and 2) peritonitis.  Surgery for peritonitis is usually done in a relatively stable patient who has abdominal pain and evidence of infection in the abdomen.  The procedure is done urgently but is not an emergency procedure.  Less commonly, a trauma laparotomy is done in crush injuries to the abdomen where the patient is not stable and needs emergency surgery to correct areas of bleeding before the patient dies of blood loss. 

The focus of a peritonitis laparotomy is to identify a possible ruptured bowel and repair it.  In a crash/trauma laparotomy, the focus is on finding hemorrhaging areas and controlling the bleeding as rapidly as possible. 

Principles of Crash Laparotomy

The core mission of a crash laparotomy is to quickly reach the source of intra-abdominal hemorrhage and to control it effectively.  Everything else is secondary to the primary mission.  If it turns out that the patient is not bleeding rapidly, then the focus can be on repairing holes in the gut in order to prevent infection from occurring later on. 

If for example, there is a bleeding area in the inferior vena cava (the major vein in the abdomen), the surgeon’s job is to put a stitch or two into the tear to control the bleeding with the help of a scrub nurse and the anesthesiologist, who will be giving blood to make up for the blood loss occurring because of the hemorrhage. 

There are several members of the support team in a crash laparotomy.  The first tier of support includes those people who have scrubbed in for surgery and who are sterile and have direct access to the patient on the operating room table.  The middle tier includes the non-sterile circulating nurse and the anesthesia team who help the first tear get the supplies they need and support the patient outside of the sterile field.  The outer tier involves those participants outside of the operating room who provide various resources and technology that exists outside of the operating room itself. 

Some of these support team members are present throughout the surgery and are directly involved in the care of the patient, while others come into play in certain circumstances or at different stages in the laparotomy.  Some things require no time delay, such as when the surgeon needs a special retractor to better see what is going on inside the patient.  Other things have a longer time delay, such as when the doctor orders an x-ray to be done in the operating room while the patient is on the table. 

The most important member of the team is the circulating nurse, who is responsible for getting the things needed by the surgeon that aren’t readily available around the operating room table.  The circulating nurse is responsible for getting those things needed and is responsible for contacting those elements of the support team that are outside the operating room so they can be made available to the surgeon as soon as they are available.  If the circulating nurse must go outside of the operating room to retrieve a special tool, for example, she becomes temporarily unavailable for use by the surgeon for other things, including those things that might be more important than the task the surgical nurse was sent out of the operating room to do. 

Each of the above tiers must work closely together to have the surgery move smoothly and to have the patient go from being unstable, to stable, and finally out of the operating room to a surgical intensive care bed after the surgery is over with. 

Preparation of a Crash Laparotomy

The less stable the patient, the less time is spent on preparing the patient for surgery.  Chest and abdominal x-rays should be taken, especially with penetrating injuries, along with the primary and secondary surveys.  This is often a hectic and disorganized time in the emergency department.  It is up to the surgeon and the operating room team to restore order and to prepare the patient for surgery. 

There is a period of time, known as the “black hole” in which the patient is evaluated, brought to the surgery suite and prepared for surgery when things are happening in the absence of actually controlling the bleeding.  This period of time should be as short as possible.  The surgeon should stay with the patient the whole time, thinking of which things need to be done for the patient and in what order they should be done. 

In torso trauma, the possibility exists for cutting the patient open from the chin all the way down to the knee area.  This area should be prepped for surgery and be available to be exposed by the surgeon if necessary.  This prepares the area for the worst possible scenario in which bleeding can come from just about anywhere and the surgery could happen in any part of the area. 

The Sequence of Events

Every trauma laparotomy involves a generic sequence of events.  It starts with gaining access and exposure to the bleeding area.  Temporarily controlling the bleeding, often using the fingers or hand to stanch the flow of blood.  This is followed by exploration of the area for all areas of possible trauma and decision-making, in which the surgeon decides to definitively correct the surgery or just engages in damage control, stopping the bleeding but not creating a final fix to the problem. 

Access and exposure is best done by making a large incision down the midline of the abdomen and using manual pressure or packing the bleeding area to temporarily stop the bleeding so that the area can be explored without hemorrhaging getting in the way.  The surgeon gets a brief period of time to assess the situation and decide what to do.  It gives the anesthesia team time to give blood if necessary to further stabilize the patient.  Things like additional instruments can be gathered by other members of the support team during this short period of time.  If this initial bleeding is not controlled, the patient continues to bleed and the chance of death due to hemorrhaging continues. 

Methodical exploration of the abdomen should be the ideal but sometimes the surgeon discovers that other things need to be done, such as opening the chest cavity or draining the chest cavity of blood.  The other problems may take precedence over the initial bleeding site so much so that another operation must be planned to definitively control the bleeding in the abdomen. 

If the decision is made to definitively fix the problems in the abdomen, this might mean choosing to repair or remove the damaged organs, reconstructing the normal anatomy of the patient, and closing the patient up without need of further surgery.  Most trauma laparotomies go this way with a need for a single surgery to correct all the problems. 

Damage control surgery means temporary methods are used for stopping bleeding and closure of the patient is temporary with the idea that the patient will be opened up again for definitive repair.  Damage control surgery has a lesser chance of survival and secondary problems so the decision to do this must be done carefully. 

There are conditions known as the “forced bailout” in which damage control is the only option.  This can happen when the surgeon underestimates the extent of the problem or overestimates the ability of the OR team to handle the difficulties.  Packing the wound is necessary in order to stop an irreversible decline in patient function.  This is especially the case in multicavity hemorrhaging that are pushing the patient to the brink of death unless damage control surgery is done to stop whatever parts of the body are hemorrhaging. 

The effective surgeon always plans ahead.  They know the core mission of the operation and know how they plan to take care of everything that is wrong with the patient.  They anticipate and plan ways to stop injuries as they crop up.  The anesthesia team and circulating nurses must also stay ahead of the game so that the proper instruments are ordered from the stock room and blood products are ordered that can be given within a half hour of starting the procedure. 

The surgeon must maintain continuous dialog with members of the rest of the team.  Surgeons are at the helm of the entire process and must be trained in working with teams of others as part of what it takes to help the patient in surgery. 

The surgeon may come across a situation for which he feels incapable of doing.  In such situations, there can be pause points in which the surgical team waits for help from another surgeon.  This is wiser than trying to do something that a surgeon doesn’t feel completely capable of doing. 

Techniques

The best technique is to get a long midline incision to expose the entire abdominal contents.  After going through skin, fat, and muscle, the surgeon can poke a finger into the peritoneal cavity through the very thin layer just above the navel.  A scissors can be used to get at the rest of the peritoneal cavity.  The bowel can then be lifted out of the body and placed upon the surgical field for further study. 

The next step is to pack the abdomen.  This is often done rather blindly without being able to identify the exact sort of bleeding.  Towels are used to pack the abdomen with the bowel still outside the patient’s body.  The liver and spleen are packed separately by being sandwiched between two separate towels on the bottom and top of each organ.  If the patient is bleeding out, the descending aorta can be temporarily clamped so that the bleeding can be slowed and the bleeder identified. 

The surgeon then carefully explores all the solid and hollow organs for injury, repairing or removing parts as necessary.  Simple bleeding areas can simply be repaired as they are found.  Complex bleeding areas must be tackled carefully so that the patient doesn’t bleed out while trying to stop the bleeding.  This may be a time to pause the surgery to wait for outside help to aid in the stoppage of bleeding.  The pause can take as long as thirty minutes.  This gives everyone a chance to catch up by getting necessary supplies or more blood, if needed.  After that, more help can arrive to join the surgical team and can perform the definitive surgery necessary to heal the patient. 

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