Trauma laparotomy

Question 1

What is Stage 1 of the five stages?

Answer 1

Patient selection

Criteria include haemodynamic instability, metabolic instability, coagulopathy, surgical injury, environment, and logistics.

Question 2

What are the haemodynamic instability criteria for Stage 1?

Answer 2

Systolic <90 for >60 mins and/or temperature <35

Indicates a need for urgent intervention.

Question 3

What are the metabolic instability criteria for Stage 1?

Answer 3

pH <7.2, BE >5, Lactate >5

These values indicate severe metabolic derangement.

Question 4

What defines coagulopathy in Stage 1?

Answer 4

PT >16s, PTT >60s, abnormal TEG or ROTEM

Indicates impaired coagulation status.

Question 5

What types of surgical injuries warrant Stage 1 intervention?

Answer 5

Major liver, inaccessible major vessels, inability to perform definitive repair, suboptimal patient circumstances

These factors complicate surgical management.

Question 6

What environmental factor indicates a need for Stage 1 intervention?

Answer 6

> 10U RBC requirement

Suggests significant blood loss and resuscitation needs.

Question 7

What logistical issues may require Stage 1 intervention?

Answer 7

Multiple patients/mass casualty, patient requires transfer to another service

Indicates resource and management challenges.

Question 8

What is the focus of Stage 2?

Answer 8

Operative haemorrhage and contamination control

Involves surgical techniques to manage bleeding and infection.

Question 9

What is the first step in Stage 2 for controlling hemorrhage?

Answer 9

Evacuate blood and pack all quadrants

Aims to manage blood loss effectively.

Question 10

What maneuver is used to occlude inflow in Stage 2?

Answer 10

Pringle’s maneuver

Helps control hepatic blood flow during liver surgery.

Question 11

What methods are used to control contamination in Stage 2?

Answer 11

Staple defects, drain biliary/GU systems, drain pancreatic injuries, copious wash

Aims to minimize infection risk.

Question 12

What is the goal of Stage 3?

Answer 12

Physiological restoration in ICU

Focuses on stabilizing the patient’s condition post-surgery.

Question 13

What are the key components of physiological restoration in Stage 3?

Answer 13

Restores body temperature, optimizes oxygen delivery, corrects acidosis, inotropic support, corrects clotting profile, monitors for IAH, tertiary survey

Comprehensive care for recovery.

Question 14

What is the time frame for Stage 4 intervention?

Answer 14

Within 24-48 hours, ideally within 24 hours

Early intervention is crucial for recovery.

Question 15

What is performed during Stage 4?

Answer 15

Re-look laparotomy, lateral stoma if required

Aims to reassess and address any remaining issues.

Question 16

What is the focus of Stage 5?

Answer 16

Abdominal closure

Finalizes the surgical intervention process.

Question 17

When should abdominal closure ideally occur?

Answer 17

Majority during 1st relook, all within first 7-10 days

Timeliness is important for recovery.

Question 18

What aids are used in delayed closure during Stage 5?

Answer 18

NPWT +/- mesh-assisted closure

Techniques to promote healing and closure.

Question 19

What are the five stages of trauma laparotomy?

Answer 19

Stage 1 = Patient selection
Stage 2 = Operative haemorrhage and contamination control
Stage 3 = Physiological restoration in ICU
Stage 4 = Definative surgery
Stage 5 = Abdominal closure

Question 20

What are the principles of trauma laparotomy?

Answer 20

Damage control
Limit contamination
Abbreviation of the injury process through temporisation

Question 21

List the six factors that may influence patient selection

Answer 21

Haemodynamic instability despite haemostatic resuscitation (syst <90 for >60mins and/or temp <35)

Metabolic instability (PH<7.2, BE >5, Lactate >5)

Coagulopathy (PT>16s, PTT >60s abn TEG or ROTEM

Surgical injury – Major liver, inaccessible major vessels, inability to perform definative repair in timely fashion or suboptimal patient circumstances

Environment - >10U RBC requirement

Logistics – multiple patients/mass casuality, pt requires transfer to another service

Question 22

Stage 2 = Operative haemorrhage and contamination control - list the five steps

Answer 22

Full incision

Control Heamorrhage:

Control contamination

Copious wash

Temporary closure

Question 23

What are the 8 steps involved in controlling haemorrhage?

Answer 23

Evacuate blood and pack all quadrants

Move to least blood soaked area first

Control arterial and venous bleeding

Tamponade using packs (liver/pelvis)

Occlusion of inflow eg pringles manoeuvre

Repair accessible vessels

Shunt larger arteries/veins not repairble

+/- embolisation

Question 24

What are the four steps involved in controlling contamination?

Answer 24

Staple defects in lumens

Externally drain biliary system
Externally drain GU system

Widely drain pancreatic injuries

Question 25

Stage 3 = Physiological restoration in ICU - list the seven components to consider here

Answer 25

Restores body tempreature Optimise oxygen delivery Correct acidosis Innotropic support if required Correct clotting profile Monitor for IAH Tertiary survey

Question 26

Stage 4 = Definative surgery - what are the three steps here?

Answer 26

Within 24-48hrs (ideally within 24hrs) Re-look laparotomy Lateral stoma if required

Question 27

Stage 5 = Abdominal closure

Answer 27

Majority during 1st relook but all should be in first 7-10 days Delayed closure assised by NPWT +/- with mesh assisted closure

Question 28

Recite operative viva for trauma laparotomy

Answer 28

Drape clavicle to knee Large incision Evacuate clot Eviscerate small bowel Examine for any major bleeding Haemostatic packing Under left diaphragm Left paracolic gutter Pelvis Right paracolic gutter Subhepatic space Above and lateral to liver Remove packs one at a time, starting at area least likely to be bleeding Apply pressure, compress organ that is bleeding Allow anaesthetist to ‘catch up’ Perform definitive packing and haemorrhage control Packs should provide sufficient pressure to tamponade venous bleeding but preserve arterial flow Copious washout Replace small intestine Perform temporary abdominal closure if required

Question 29

List six indications for trauma laparotomy

Answer 29

Haemodynamic instability Inability to achieve haemostasis – inaccessible major vessel injury Cold coagulopathy/ acidotic Time consuming procedure needed in under resuscitated Massive transfusion Multisystem injury (vascular, solid, hollow)

Question 30

List 8 markers of diminished physiological reserve

Answer 30

Systolic BP < 75 Base excess > -8 pH < 7.25 Temp < 35 ISS > 25 Lactate > 5 INR > 1.5, APTT > 60 All – 85% MR

Question 31

What should happen within 2 hours of a trauma arriving in ED that requires laparotomy?

Answer 31

Laparotomy Should take < 1 hour Trauma Rapid control of haemorrhage Pack & then remove from area of least likely to most likely Control enteric contamination Careful inspection of injuries Definitive repair of injuries Damage control Haemorrhage control Contamination control – staple off Pack & (temporary) close DON’T VAC Drain Back to ICU

Question 32

What should happen in hours 2-36 post trauma laprotomy?

Answer 32

Back to ICU 2-36 hours Rewarm Physiological correction Acidosis Coagulopathy

Question 33

What should happen 24-48 hours post trauma laparotomy?

Answer 33

24-48 hours Remove packs Definitive surgery

Question 34

What should happen 1-8 weeks post trauma laparotomy?

Answer 34

Definitive reconstruction