Trauma Exploratory Laparotomy

Use broad-spectrum preoperative antibiotics.

Type and cross-match for blood.

Place a nasogastric tube.

Place a Foley catheter.

Prepare and drape the chest, abdomen, and both lower extremities up to the knees.

Make a midline incision from the xiphoid process to the pubis.

If possible, avoid entering the abdomen using the old abdominal surgical incision.

Make a bilateral subcostal incision (rooftop incision) in patients with multiple previous abdominal incisions.

Enter the peritoneal cavity just proximal to the umbilicus, because in this area the peritoneum is very thin with minimal preperitoneal fat.

Eviscerate small bowel loops up and to the patient’s right in order to avoid traction injury on the mesentery.

Eviscerate the transverse colon cranially.

Blunt trauma

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  Perform abdominal packing in each quadrant of the abdominal cavity.

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    Above and below the right lobe of the liver

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    Right paracolic gutter

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    Superior and medial surface of the spleen

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    Superior surface of the left lobe of the liver

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    Left paracolic gutter

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    Pelvis

Penetrating trauma

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  Perform direct control of the bleeding with sutures or clamps.

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  Aortic clamping if indicated (described below)

Sources of bleeding in abdominal trauma

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  Intraperitoneal structures

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  Retroperitoneal structures

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  Combination of intraperitoneal and retroperitoneal structures.

Intraperitoneal source of bleeding

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  Common sources in blunt trauma

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    Solid-organ injuries such as liver and spleen

    

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    Mesenteric vascular injuries

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      Distal superior mesenteric artery (SMA) and branches of the celiac trunk result in intraperitoneal bleeding.

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      Proximal SMA and celiac trunk are retroperitoneal structures.

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    Small bowel injuries

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    Retroperitoneal bleeding communicating to the peritoneal cavity

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  Common sources in penetrating trauma

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    Liver

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    Small bowel

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    Diaphragm

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    Colon

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    Intraperitoneal or retroperitoneal vascular injury

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    Additional injury based on the trajectory of the weapon used

Retroperitoneal source of bleeding

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  Blunt and penetrating trauma due to retroperitoneal vascular injuries

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  Exposure techniques (described below)