66.3 Laparotomy for abdominal injuries

If you suspect that a patient might have an abdominal injury, don’t be afraid to do a laparotomy, and don’t delay. An occasional negative laparotomy is better than always waiting for some obvious indication of an abdominal injury. He will not die from a big incision, but he will die if you overlook a serious injury. If necessary, watch him carefully for at least 24 hours. The commonest causes of a haemoperitoneum are injuries to a patient’s spleen, liver, and mesentery. So search for them in that order. Even if you find no free blood or intestinal contents, he may still have a small perforation, which is temporarily sealed off. So search his abdominal organs carefully.

Try to find and treat all the patient’s injuries. Don’t try to do this through an incision which is much too small. Although he may only have a tiny bullet hole in his abdominal wall, you will probably need a long incision to find all the harm it has done. Adequate exposure may save your time and his life.

Severe haemorrhage can be difficult to control. The secret is to control it temporarily with pressure, packing, and patience—especially patience. Then, slowly and carefully try to find the bleeding site. This is much better than frantic efforts to clamp bleeding points, regardless of the blood that is being lost while you try to do this. If bleeding is so severe that blood wells up in the wound, try packing, and pressure, if necessary on a major vessel. Be patient, and find another assistant to help you. Good relaxation will make the bleeding site easier to find; so will packing away the viscera, extending your incision, and tilting the table.

FIND AND TREAT ALL INJURIES
’PRESSURE, PACKING AND PATIENCE’

LAPAROTOMY FOR AN ABDOMINAL INJURY

Here are the common steps in any abdominal injury. Read on for the care of particular injuries. If the patient has a penetrating injury, consult Section 66.2 first.

INDICATIONS FOR LAPAROTOMY Always do an early laparotomy for: (1) Signs of internal bleeding, as shown by a rising pulse rate, restlessness, and pallor. (2) Increasing guarding, tenderness (including rebound tenderness) or rigidity (regardless of the bowel sounds). (3) All bullet and grenade wounds. (4) Herniation of a patient’s viscera through his diaphragm, or his abdominal wall, even if there is only a tag of omentum protruding. (5) Thoraco–abdominal wounds. (6) Haematemesis, blood in his gastric aspirate (provided this is not obviously from his mouth or nose), or rectal bleeding. (7) Penetrating anal or vaginal injuries. (8) Positive findings on paracentesis or gastric lavage, or an increasing girth.

Many stab wounds don’t need a laparotomy (66.2).

CAUTION! (1) More harm is done by not exploring than by doing so. (2) You will not know the extent of an abdominal injury until you get inside the patient’s abdomen, so, if referral is possible, you may be wise to resuscitate a patient with fluid and blood and refer him.

RESUSCITATION Set up a really good intravenous drip (A 15.2). Cross–match several units of blood. If this is scarce, and the patient’s condition allows it, don’t give it until you have clamped the bleeding vessel. Meanwhile give him Ringer’s lactate or saline; if necessary, give him 3 or 4 litres of fluid over an hour or two as in Section 53.2.

CAUTION! Operate as soon as you have got the maximum benefit from resuscitation. But if bleeding exceeds all your efforts at blood replacment, operate urgently to control it.

EQUIPMENT A general set (4.11). Use long instruments to enable you to work deep in the patient’s abdominal cavity. Have the equipment for autotransfusion ready (16.11). Effective suction is essential.

Find a strong assistant to help with traction.

GASTRIC ASPIRATION If you have not already aspirated the patient’s stomach, do so and leave the tube in. An empty stomach will make splenectomy easier. In bladder injuries, pass a Foley catheter and leave that in too.

PEROPERATIVE ANTIBIOTICS If the patient’s peritoneal cavity does become infected, Gram negative bacilli and anaerobes will probably be responsible—see Section 2.7. Timing is critical. Give him chloramphenicol with metronidazole. Give these intravenously as soon as you suspect contamination of his peritoneal cavity from rupture of his gut. Give them with the premedication.

If laparotomy shows no contamination, stop them immediately.

If contamination of the peritoneum occurs during surgery, but is not going to continue, as with resection of the colon, stop the patient’s antibiotics after 12 hours.

If there is established infection, as with a perforation of 8 hours duration or more, continue antibiotics for 5 days.

CAUTION! (1) It is much more important to start antibiotics early than to continue for long. Starting them after the patient returns to the ward is certainly too late. (2) This perioperative regime is always indicated if the operative field is, or will be, significantly contaminated. (3) Avoid gentamicin because it interferes with the reversal of some relaxants (A 14.3).

If a patient is drowsy from a head injury, and needs a laparotomy, don’t be deterred from giving him a general anaesthetic.

If a patient’s respiration is embarrassed because there is much blood in his pleural cavity, drain it under local anaesthesia, before you anaesthetize him. If an intercostal drain does not improve his respiration adequately, he should, ideally, have a thoracotomy before his laparotomy.

If he is so weak that he will not withstand a general anaesthetic, you may have to operate under local anaesthesia.

OTHER WOUNDS If a patient has serious wounds on his back explore these first. The problem if you leave them until last, is that he may not tolerate lying on his front after a long abdominal operation.

INCISIONS FOR BLUNT INJURIES Aim to get inside the patient’s abdomen fast; you can tie bleeding vessels in his abdominal wall later. In general, make a midline or right rectus retracting or rectus splitting incision. Vertical extensions to an incision are easier to close than horizontal ones. So, if necessary, extend a vertical incision from a patient’s xiphoid to his pubis. If you want even more exposure, make a T–shaped incision into either flank.

If the injury is in the patient’s lower left chest, and the signs indicate a ruptured spleen, make a left upper paramedian incision. If exposure is inadequate, extend it towards his left costal margin.

If necessary, with any incision, tilt the table to make access easier.

INSIDE AN INJURED ABDOMEN

Have the sucker ready as you get inside the patient’s abdomen. Watch for a puff of gas as you open it. This indicates an injury of his gut. If the gas smells faecal, he has injured his colon.

If there is blood in his left hypochondrium, you can be almost sure that he has ruptured his spleen.

If there is blood in his right hypochondrium, his liver is probably ruptured.

If there is blood in the middle of his abdomen, his mesentery may have been injured.

If there is bile in his peritoneal cavity (66.18), examine his gall bladder, his duodenum, the rest of his upper small gut, his cystic duct, his common bile duct, and his hepatic ducts.

If there is blood, intestinal juice, and bile in his peritonal cavity, he has probably torn his small gut.

Quickly suck away any free blood and intestinal contents. If you are going to use the blood for autotransfusion, see Section 16.11.

CAUTION! If the blood in his peritoneal cavity is contaminated by bile or intestinal or pancreatic secretions, don’t use it for autotransfusion.

CONTROL BLEEDING Do this before you examine the patient’s viscera. If necessary: (1) Grasp or put a clamp across his splenic pedicle. (2) Clamp his mesentery. (3) Pinch the vessels in the free edge of his lesser omentum with your finger in his epiploic foramen.

Suck out the blood from his abdomen.

EXAMINING THE VISCERA IN AN ABDOMINAL INJURY

Examine the patient’s abdominal organs systematically. Diagram D in Fig. 66-7 shows one pathway for doing so. Most surgeons have their own routine. Whatever routine you choose, be sure to examine everything.

Unless you find some major bleeding, such as from a ruptured spleen, complete your examination before starting to do any repairs. If you find an injury to the patient’s small gut or mesentery, clamp it with a soft intestinal clamp, so that you can easily find it, making sure that it does not leak while you continue your search.

If there is any possibility of an injury to the posterior wall of the patient’s stomach or the peritoneum behind it, detach his omentum from the anterior surface of his colon. It has almost no blood vessels. Open his lesser sac, and look at the back of his stomach, the back of his transverse colon, and the front of his pancreas.

If you have reason to suspect that the second part of his duodenum might be injured, (for example, you might see a retroperitoneal haematoma) incise the parietal peritoneum lateral to it, elevate his duodenum, and inspect its posterior wall.

Look for retroperitoneal bruising over the patient’s ascending and descending colon.

If necessary, you can reflect his ascending or descending colon by making incisions in his paracolic gutters, and reflecting part of his colon forwards, as in K, and L, Fig. 66-8.

If necessary, you can reflect his duodenum forwards, as in M, Fig. 66-8.

CAUTION! Don’t be content with finding only one injury. He may have many, especially if he has a gunshot injury.

RETROPERITONEAL INJURIES Management depends on the site of the injury.

If the patient has a retroperitoneal haematoma in his flank, it is probably coming from his kidney (67.1). If possible, leave it. Don’t open any retroperitoneal haematoma, unless you are obliged to.

If he has a haematoma near his duodenum or colon, these organs are probably injured retroperitoneally and need to be explored, if possible without contaminating the adjacent peritoneal cavity.

For haematomas of the mesentery and pelvic mesocolon, goto Section 66.10.

GUNSHOT WOUNDS Search meticulously for entry and exit wounds in anything that might have been injured. Small bullet wounds in the gut may seal themselves off temporarily. Bullet holes in the colon may be covered with a sheet of omentum which you must lift to find them.

INJURIES TO PARTICULAR VISCERA A a blunt injury is likely to have injured these organs in order of decreasing frequency: the spleen (66.6), the liver (66.7 ), the mesentery (66.10), the small gut (66.9), the colon (66.11), the kidneys (67.1), or the duodenum and Pancreas (66.16 and 66.17).

CLOSING THE ABDOMEN AFTER A LAPAROTOMY

The danger of peritonitis will be reduced if you remove as much pus, intestinal contents, faeces, and blood as you can. So irrigate the patient’s peritoneal cavity with warm saline before you close it. See Section 6.2. If you don’t have any warm saline, mop it out as best you can.

CAUTION! Bleeding must be completely controlled.

When you have closed the patient’s peritoneum, irrigate the structures of his abdominal wall thoroughly, and close it with tension sutures of monofilament or stainless steel. if necessary, close it in a single layer.

If there is much infection, and you expect the wound to disrupt, close the muscles of his abdominal wall with interrupted stainless steel wire or deep tension sutures, and his skin by delayed primary closure, as in Section 9.7.

If infection is present, or you expect it to develop, insert one or more drains through separate incisions. Use wide bore tubes, such as 30 Ch catheters and lead them into sterile bags or bottles (9.7).

RECORDS Sign the patient’s notes to the effect that you have examined, and either dealt with or found normal, his diaphragm, stomach, spleen, liver (both surfaces), large gut (including his splenic and hepatic flexures), entire small gut, rectum, bladder, pancreas, kidneys, ureters, and a woman’s gynaecological organs. Many surgeons prefer this order of examination to that in Fig. 66-7, and some have a rubber stamp made to this effect.

POSTOPERATIVE CARE Monitor the patient’s haemoglobin, and correct his anaemia by transfusion. Continue intravenous fluids and nasogastric suction until bowel function is restablished. His bowel may be paralysed for many days, so monitor his fluid and electrolyte balance carefully. Watch for pelvic and subphrenic abscesses (6.3).

EXPLORE THE ABDOMEN IN A LOGICAL WAY