Chapter 15 Operative Exposure in Abdominal Trauma: Trauma Laparotomy

This chapter will discuss trauma laparotomy, including the incision, basic operative mobilization, and surgical exposure maneuvers.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe the goals of a trauma laparotomy.
2. Describe the zones and contents of the retroperitoneum.
3. Demonstrate exposure and control of the supraceliac aorta at the diaphragm.
4. Demonstrate right-to-left medial visceral rotation (Cattell-Braasch maneuver).
5. Demonstrate mobilization of duodenum (Kocher maneuver).
6. Demonstrate left-to-right medial visceral rotation (Mattox maneuver).

General Considerations

• The vasculature of the abdomen is located in three zones (Figure 1).
• All hematomas in Zone 1, which is further subdivided into supramesocolic and inframesocolic areas, require surgical exploration.
• Zone 2 hematomas from penetrating injury are typically explored; hematomas from blunt injury are usually explored only when they are expanding.
• Zone 3 hematomas from penetrating injury require surgical exploration, while exploration of hematomas from blunt injury should be avoided if at all possible.

Goals of Trauma Laparotomy

• Control of potentially life-threatening bleeding
• Identification of injuries
• Control of contamination
• Repair of injuries when appropriate

Incision

• The patient should be placed supine and prepped from the chin to the knees and from table to table laterally. This will allow for extension into the chest and for harvest of veins from the legs for vascular repairs, if needed.
• Make sure you have appropriate equipment, such as adequate suction (two suction devices, with cell saver if available), numerous laparotomy pads, vascular and bowel instruments, retractors (e.g., Bookwalter or Omni-Tract®), appropriate staplers, and supplies for temporary abdominal closure.
• The trauma laparotomy incision runs from xiphoid process to pubic symphysis.
• This incision provides access to all intra-abdominal contents, including the retroperitoneal vascular structures.
• The entire length of the incision is opened down to the fascia prior to entry into the peritoneum.
• The peritoneum should be opened last. If a patient has significant hemoperitoneum, entering the peritoneum prematurely will obscure the field with blood and delay exposure.
• Good communication with anesthesia is important prior to opening the abdomen.

Control of Hemorrhage

• The peritoneum is rapidly opened, and any blood and clots are rapidly evacuated. If there is ongoing bleeding, the four quadrants of the abdomen are packed using two or three packs per quadrant.
• Packing is not about quantity but about quality. The small bowel should be eviscerated prior to packing, which may be inadequate if the bowel is left in place.
• Once the abdomen is packed, the packs in the quadrants that are least likely to be the source of bleeding should be removed first. If you go first to the quadrant that you suspect is the source, you may miss another potentially life-threatening source of bleeding in another quadrant.
• Initial control of hemorrhage may require rapid proximal control of the aorta immediately upon entering the abdomen.
• If ongoing hemorrhage involving a major vascular structure is present, additional surgical exposure maneuvers may be required, including the following:
• Exposure and control of the supraceliac aorta at the diaphragm
• Right-to-left medial visceral rotation (Cattell- Braasch maneuver)
• Mobilization of the duodenum (Kocher maneuver)
• Left-to-right medial visceral rotation (Mattox maneuver)
• Control of the abdominal aorta at the root of the mesentery
• Control in the chest via a resuscitative thoracotomy, as discussed in chapter 10
• Temporary control might also be obtained in select cases using resuscitative endovascular balloon occlusion of the aorta (REBOA), as discussed in chapter 22.
• The decision to control the aorta at the hiatus or to perform a medial visceral rotation on either side should be based on the suspected injuries and which maneuver is most likely to allow adequate exposure for subsequent vascular control and repair.

Exposure and Proximal Control of the Aorta at the Diaphragm

Considerations

• When hemorrhage or hematoma is present in the upper portion of Zone 1 (the central supramesocolic area), an injury to the aorta, celiac axis, superior mesenteric artery, or renal arteries may require proximal control of the supraceliac aorta at the diaphragm.

Technique

• The liver is retracted to the right to expose the gastrohepatic ligament (lesser omentum), which is opened vertically (Figure 2). The distal esophagus and stomach are retracted to the patient’s left.
• The aorta can be initially occluded by compression against the vertebral bodies using an assistant’s fingers or an aortic occluder (a commercial device, a sponge stick, or a Richardson retractor).
• Definitive clamping of the supraceliac aorta first requires blunt dissection on either side of the aorta at the hiatus (Figures 3 and 4).
• The aorta below the diaphragm is invested in thick neurofibrous tissue, which makes application of a clamp difficult.
• Splitting or sharp division of the muscles of the right crus of the diaphragm (Figure 5) facilitates clamping of the aorta.
• The aorta is further dissected anteriorly and laterally to accommodate a vascular clamp. It is not necessary to encircle the aorta to place the clamp, as this may result in injury to posterior arterial branches.
• An atraumatic vascular clamp is placed on the aorta, using the spine and the paraspinal muscles as the posterior landmarks (Figures 6 and 7). The clamp must be placed securely, as it can easily be dislodged while working in the abdomen. It is often helpful to have an assistant hold the clamp in place.
• The clamp should be released as soon as more distal control of bleeding has been achieved.

Right-to-Left Medial Visceral Rotation (Cattell-Braasch Maneuver)

Considerations

• Right-to-left medial visceral rotation provides excellent exposure of injuries to the structures of the right retroperitoneum, including the duodenum, head of the pancreas, right kidney and its vessels, ureter, inferior vena cava (IVC), and right iliac vessels.

Technique

• The first step of right-to-left medial visceral rotation (Cattell-Braasch maneuver) is to incise the parietal peritoneum at the white line of Toldt, from the base of the cecum to the hepatic flexure (Figure 8). The dissection plane
• between the right colon and the abdominal wall is avascular and, once entered, can be extended rapidly with blunt dissection.
• If there is an IVC injury, performing a medial visceral rotation may unroof a contained hematoma with significant bleeding. One must plan for this possibility and be prepared to obtain rapid control of the IVC.
• The second step of the Cattell-Braasch maneuver is to mobilize the hepatic flexure of the colon and perform a Kocher maneuver to fully visualize the sweep of the duodenum and the head of the pancreas.
• The final step of the maneuver is to rotate the cecum and small bowel up and out of the pelvis in a right-to-left, inferior-to-superior fashion. Completion of the maneuver should enable the displacement of the patient’s cecum to near the patient’s left shoulder.
• The completed Cattell-Braasch maneuver (Figure 9) provides excellent visualization of the retroperitoneal structures in the right mid abdomen and pelvis.

Left-to-Right Medial Visceral Rotation (Mattox Maneuver)

Considerations

• The entire aorta, from the diaphragmatic hiatus to the iliac vessels, can be visualized using this maneuver.
• This maneuver is challenging in a cadaveric specimen due to the tissues being stiff and fused together. In living patients with an injury, the hematoma will do much of the dissection work (Figure 10).

Technique

• The white line of Toldt, along the descending colon, is incised using either sharp or blunt dissection (Figure 11). In this bloodless plane, the entire left colon is mobilized and rotated up and out of the abdomen toward the midline.
• The spleen is also mobilized upward and medially, taking care to divide any lateral attachments such that the spleen and tail of the pancreas can be rotated up off the retroperitoneum. Care should be taken not to injure the spleen or the tail of the pancreas.

• The left colon, spleen, tail of the pancreas, and stomach are reflected medially, bringing the dissecting hand into a plane anterior to the left kidney.
• The “classic” Mattox maneuver includes mobilization of the left kidney (Figure 12) and is performed when there is an injury posterior to the kidney or to the aorta below the renal pedicle.
• More commonly performed is a modified Mattox maneuver in which the left kidney is not mobilized (Figure 13).
• The completed left-to-right medial visceral rotation (Mattox maneuver) provides exposure of the abdominal aorta from the diaphragm down, allowing access to the celiac trunk, the origin of the superior mesenteric artery, the origin of the inferior mesenteric artery, and the vascular pedicle of the left kidney (Figure 14).
• These anatomic relationships are better illustrated in Figure 15.

Exposure and Control of the Infrarenal Aorta

Considerations

When the hemorrhage or hematoma involves only the infrarenal aorta, an alternative to the Mattox maneuver is to directly expose and proximally control the aorta at the root of the mesentery, just below the renal vessels.

Technique

• The small bowel is retracted superiorly to expose the root of the mesentery, and the peritoneum overlying the infrarenal aorta is opened (Figure 16).
• Further sharp and blunt dissection is used to identify the infrarenal aorta, which can be
• clamped to achieve proximal control (Figure 17).
• Distal vascular control is similarly achieved over the distal aorta or the iliac arteries, depending on the clinical situation, taking care to identify and avoid injury to the ureters (Figure 17).