Damage Control: Abdominal Closures

Chapter 78 Damage Control: Abdominal Closures



Benjamin Braslow, MD, Bruno Molino, MD, Vicente H. Gracias, MD



INTRODUCTION


Massive hemorrhage ranks second only to central nervous system injuries as the leading cause of prehospital trauma-related mortality.1 Moreover, uncontrolled bleeding stands atop the list of early in-hospital mortality due to major trauma.2 Regarding penetrating trauma patients, increasing use of newer, more powerful automatic firearms, now common in the civilian population, have resulted in more frequent multiple penetrations (often multicavity) with more severe degrees of tissue destruction and bleeding.3 This is even more pronounced in injuries sustained from high-velocity military weaponry now being experienced all too frequently in the global theater of war and terrorism. Advances in prehospital care and trauma bay resuscitations since the mid 1980s has resulted in a greater number of these severely injured patients surviving to the point of necessitating operative intervention. Such patients usually present nearing physiologic exhaustion with profound acidosis, hypothermia, and coagulopathy, the so-called lethal triad of hemorrhage. The “traditional surgical approach” to such patients, in which surgeons would definitively repair all identified injuries at the initial operation, proved inadequate with extremely high mortality despite control of anatomic bleeding. During the peak of gun violence in the late 1980s into the early 1990s, urban American trauma centers gained extensive experience in treating these patients and the concept of “Damage Control” (DC) surgery was born. Borrowed from the Navy, the term “damage control” referred to any and all methods used to keep a badly damaged ship afloat to maintain mission integrity.4 For the trauma surgeon, DC describes the process of abbreviated laparotomy and expedient control of hemorrhage and contamination followed by intraabdominal packing and temporary coverage. From the operating room (OR), the patient is taken to the surgical intensive care unit (SICU) for physiologic resuscitation. Finally, the patient returns to the OR, after physiologic capture, for definitive repair of all injuries and, if possible, abdominal wall closure. To the uninformed observer, the increased morbidity associated with this multistep process might seem like surgical failure or abandonment of proper technique. Despite the associated high morbidity, the DC sequence has proved to be an aggressive and effective strategy to combat the lethal pattern of physiologic failure associated with severe blunt and penetrating injury.5–8



INDICATIONS


Because of the associated morbidity that accompanies the DC process, patient selection and proper timing are crucial. Although major liver injury and progressive coagulopathy remain the most frequent indications, the list continues to expand. In 1997, Rotundo and Zonies9 organized the “key” factors in patient selection for DC into three categories: conditions, complexes, and critical factors. In 1998, Moore and coworkers10 offered their six major indications for abbreviated laparotomy with consideration for institutional available resources and expertise. Ultimately, the decision to proceed with DC principles rests on the surgeon present and is based on the physiology of the patient.


• Inability to achieve hemostasis due to coagulopathy

• Inaccessible major venous injury (pelvis, liver, etc.)

• Time-consuming procedure in a patient with suboptimal response to resuscitaton

• Management of extra-abdominal life-threatening injury

• Reassessment of intraabdominal contents

• Inability to reapproximate abdominal fascia due to visual or abdominal wall edema


THE DC SEQUENCE



DC 0


Once a patient’s injury pattern and physiology are assessed as critical and DC principles are initiated, time becomes critical.




• Consequence



Failure to recognize a patient necessitating early application of DC principles. Aoki and associates in 200111 reported on 68 patients who underwent DC surgery at Ben Taub Hospital. Failure to correct pH above 7.21 by the conclusion of DC I and a PTT greater than 78.7 were predictive of 100% mortality. Likewise, in their review of iliac vascular injuries in 1997, Cushman and colleagues12 reported a fourfold greater risk of dying for the hypothermic patient (preoperative core temperature of ≤34°C). This stresses the importance of early implementation of DC principles to avoid reaching this level of physiologic demise.

Grade 5 complication


• Repair



Truncated scene times for emergency medical services and rapid trauma bay throughput are essential to get the patient to the OR, where hemorrhage control can be best addressed.


• Prevention



Important steps during this phase include obtaining large-bore intravenous (IV) access, rapid-sequence intubation for airway control, gastric decompression (nasogastric tube placement is contraindicated in the presence of facial trauma or basilar skull fractures), chest tube placement (if indicated by absent breath sounds or crepitus), early rewarming maneuvers, and early blood product resuscitation. Large-volume crystalloid resuscitation increases the risk of subsequent edema and dilutional coagulopathy.13 Minimal diagnostic x-rays are required. A chest x-ray after rapid-sequence intubation is useful to confirm tube position and identify immediately treatable hemo- and/or pneumothorax. In the unstable blunt trauma patient, a pelvic x-ray can identify significant pelvic fractures that must be temporarily stabilized to reduce pelvic volume and help tamponade bleeding. Also, for suspected blunt trauma, spinal precautions including a cervical collar must be continued until definitive injury can be excluded. A focused abdominal sonography in trauma (FAST) examination can be helpful in rapidly confirming intraperitoneal bleeding when the physical examination is equivocal and multicavitary trauma is suspected. This technique has supplanted diagnostic peritoneal lavage in many institutions for this purpose. Communication with the blood bank is essential to keep them abreast of the potential for massive transfusion requirements. Likewise, early communication with the anesthesia service is paramount to hasten their preparation for this complicated patient and to initiate prewarming of the OR. A Cell Saver device should be mobilized to the OR for collection and reinfusion of shed autologous blood. Before incision, broad-spectrum antibiotics and tetanus prophylaxis should be administered and a Foley catheter placed.


DC I


The primary objectives of the initial laparotomy are control of hemorrhage, limiting contamination (and the subsequent inflammatory response), and temporary abdominal wall closure to protect viscera and limit heat loss. All of this ideally is accomplished in under 2 hours (about the length of a music CD).



DC I STEPS



Step 1 Positioning and incision

Step 2 Manual abdominal wall retraction and four-quadrant abdominal packing

Step 3 Division of falciform ligament

Step 4 Placement of large self-retaining retractor

Step 5 Sequential removal of packs; abdominal inspection

Step 6 Exposure and control of vascular or solid organ hemorrhage (pack, ligate, shunt, resect)

Step 7 Control of contamination from hollow viscus injury (isolation, resection, repair)

Step 8 Repacking of abdomen

Step 9 Temporary abdominal closure

Step 10 Transport to SICU


Positioning and Incision



Failure to Gain Access to Injured Body Cavities



• Consequence



Failure to adequately prepare and position the patient can result in failure to gain access to injured body cavities and limit the ability to diagnose and treat hemorrhage.

Grade 5 complication


• Repair



The patient is placed supine on the OR table with the right upper extremity extended at a right angle from the torso. The left arm is placed on an arm board with the elbow partially flexed and the arm extended above the level of the head (a modified “taxi-hailing” position). This leaves the left chest widely accessible for emergent thoracotomy if necessary. The patient is prepared from the chin to the knees anteriorly and down to the level of the bed laterally. A vertical midline incision from the xyphoid process to the pubis is ideal. In the setting of a suspected severe pelvic fracture, the inferior limit of this incision can be curtailed to just below the umbilicus. This will prevent loss of tamponade of a retroperitoneal pelvic hematoma.


• Prevention



In anticipation of the potential need for a median sternotomy, resuscitative left thoracotomy, or bilateral tube thoracostomy, no leads or tubing should be present on the anterior or lateral chest wall. Incision should not be delayed while waiting for insertion of invasive monitoring devices (arterial lines and central venous catheters). A posterior heating pad is ideal because a convection warm air blanket becomes impractical.

If the patient has had a previous midline laparotomy, a bilateral subcostal incision can be used. This allows for rapid access to the peritoneal cavity away from the anticipated midline adhesions. These adhesions can then be lysed quickly under direct vision.



Division of the Falciform Ligament and Placement of a Large, Self-retaining Retractor



Iatrogenic Injury to the Abdominal Contents



• Consequence



Once in the abdomen, a large hand-held abdominal wall retractor is used circumferentially to create space for extensive packing of all four quadrants. Iatrogenic injury to the abdominal contents can occur during this rapid, forceful maneuver. Often, bowel loops are compressed between the retractor and the abdominal wall and are bruised or torn or traction injury to the liver occurs.

Grade 2 complication


• Prevention



The hand-held body wall retractor must be initially placed under direct vision as the surgeon or assistant widely pushes down on the abdominal contents to create an area of separation between the abdominal contents and the abdominal wall. The retractor is then slid along the abdominal wall, maintaining the zone of separation. Packs (laparotomy pads) are carefully placed into the gutters and pelvis as the bowels are swept in the opposite direction. Surgeons on opposite sides of the table trade retracting and packing duties as appropriate. The falciform ligament is rapidly divided all the way to the dome of the liver to prevent iatrogenic traction injury to the liver during suprahepatic pack placement. Next, a large self-retaining retractor is placed to liberate all surgical hands available and maximize exposure. Next, packs are removed in a sequential fashion, beginning in the areas least likely to harbor the source of major hemorrhage. This provides space to pack the bowels away from areas of bleeding and create maximal exposure.


Hypotension



• Consequence



Once the peritoneum is opened, any tamponade effect that had been provided by the abdominal wall is immediately lost. This may induce abrupt and severe hypotension. Sometimes, the patient remains profoundly hypotensive after four-quadrant packing is complete.

Grade 5 complication


• Repair



Control of aortic inflow should be obtained. Manual occlusion of the aorta at the diaphragmatic hiatus can be performed quickly by passing one’s hand anterior to the stomach underneath the left hepatic lobe. The aorta can be palpated immediately to the right and posterior to the esophagus. Here, it can be compressed posteriorly against the vertebral body either manually or with an aortic occlusion device. This maneuver has been shown to not only slow intraabdominal bleeding but also augment cerebral and myocardial perfusion while anesthesia catches up on volume replacement and the source of bleeding is identified and controlled.14 If, for some reason, control of aortic inflow cannot be controlled from within the abdomen, an emergent left thoracotomy can be performed and the descending aorta cross-clamped from within the thorax. This adds morbidity to the procedure but, for some surgeons, allows for more rapid control of the aorta.


Sequential Removal of Packs; Abdominal Inspection



Retroperitoneal Hematoma



• Consequence



A centrally located retroperitoneal hematoma is encountered. Injury to a major vascular structure is anticipated.

Grade 5 complication


• Repair



As is true in all vascular surgery, exposure is the key first step. The small bowel is initially eviscerated. This is followed by left and/or right medial visceral rotation to expose centrally located vessels. Often, packing alone is adequate for some vascular injuries, specifically venous. If an injury is amenable to rapid arteriorrhaphy or venorrhaphy, this is the treatment of choice. Of note, almost every vessel in the abdomen can be ligated with limited morbidity.15 However, ligation of the main aorta, external iliac arteries, and proximal superior mesenteric artery are associated with devastating tissue and/or bowel ischemia potentially necessitating limb amputation or extensive small bowel resection. Temporary intraluminal shunts are relatively easy to place and maintain end-organ perfusion. They are secured in place using silk ties or Rumel tourniquets. The largest shunt that fits easily within the vessel should be used. Argyle carotid shunts and Javid shunts work well on medium-sized vessels, whereas chest tubes may be used when larger conduits are required (aorta or inferior vena cava). Literature on DC shunting of abdominal vessels is sparse and mostly limited to case reports; nevertheless results are encouraging.16,17 The feasibility of major abdominal and pelvic vein shunting in critically injured patients is controversial because published patency rates are low. However, it has been proposed that temporary shunting may help control short-term edema during acute high-volume resuscitation. In the context of DC surgery, there is no justification for wasting time with pelvic vein shunting or reconstruction.18 When ligation is performed, the clinically significant edema rate does not appear to be different from that of repaired veins if leg elevation, compression stockings, and liberal use of fasciotomies are utilized.19 Tense laparotomy pad packing and/or inflatable balloon catheters (e.g., Foley or Fogarty catheters) can be utilized for persistent hemorrhage from inaccessible locations or uncontrollable vessels. They may be placed directly into the missile or knife tract or directly into the defect in the injured vessel.


Solid Organ Injury



• Consequence



Ongoing bleeding from solid organ injury.

Grade 4 complication


• Repair



With respect to solid organ injuries, prolonged repair for bleeding must be avoided. Splenic and renal hemorrhage is best managed with prompt resection, especially when the patient is approaching physiologic exhaustion. Tight packing anteriorly and posteriorly initially controls bleeding from liver parenchyma. Ongoing deep parenchymal bleeding is then controlled by compression of the porta hepatis (Pringle’s maneuver), followed by a finger fracture technique to expose deep vessels for suture ligation or clip application.20 More complex injuries (e.g., transhepatic gunshot wounds with long narrow columns of injury and active bleeding) require more innovative techniques like the insertion of a Penrose drain ligated distally, secured to and inflated over a red rubber catheter.21

Any and all topical hemostatic agents can be applied as well including fibrin glue. A “liver tampon” made up of several sausage-sized pieces of absorbable gelatin sponge (Gelfoam) soaked in thrombin solution and wrapped loosely in a sheet of oxidized cellulose (Surgicel) is a recommended hemostatic modality. This device is then stuffed into the parenchymal defect followed by additional packing. This effectively tamponades bleeding and creates a hemostatic milieu.22 Tampons composed of other absorbable hemostatic materials available to the surgeon are also feasible.



• Prevention



After the completion of DC I, all cases of complex hepatic injury should be interrogated with angiography. Even in those cases in which hemostasis is seemingly achieved, there can be a high incidence of ongoing intrahepatic arterial bleeding or traumatic arteriovenous fistula, which requires therapeutic embolization.


Control of Contamination from a Hollow Viscus Injury (Isolation, Resection, Repair)



Ongoing Intraabdominal Contamination



• Consequence



Ongoing intraabdominal contamination from a hollow viscus injury.

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  4. Bronchial and Vascular Sleeve Lobectomy

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Damage Control: Abdominal Closures

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