MAKING THE INCISION

The abdomen and retroperitoneum are generally explored via a generous midline incision. The incision should be made from the xiphoid to pubis, unless a specific already-diagnosed injury is to be treated. This gives the greatest access to all of the structures in the abdomen and retroperitoneum. Several additional options exist in order to reach specific areas. A thoracoabdominal approach gives access to certain structures high in the abdomen. This generally involves a seventh or eighth interspace anterolateral thoracotomy that is brought down to the sternum. The ribs are divided flush with the sternum. The diaphragm is then taken down off the chest wall radially. Approximately one to two inches should be left on the chest wall for diaphragmatic reconstruction later. On the left side, the diaphragm should be taken down all the way to the aorta. A left-sided thoracoabdominal approach is probably the best exposure for the supraceliac aorta. A right-sided thoracoabdominal incision increases the exposure of the posterior portion of the right lobe of the liver. Exposure of the retrohepatic cava is also enhanced with the use of a right-sided thoracoabdominal approach.

Occasionally, the midline incision is extended up into a medium sternotomy. This gives access to the anterior mediastinal structures. If an atriocaval shunt is to be used to treat a retrohepatic caval injury, a sternotomy is probably the best approach. In addition, if one wishes to control the inferior vena cava within the pericardium to achieve complete vascular isolation of the liver, a sternotomy or a right-sided thoracoabdominal incision will give the surgeon adequate access to perform that maneuver.

Exposure of the deep pelvic vasculature can also be difficult through a standard laparotomy. Several options exist to increase that exposure. A groin incision allows for vascular control of the common femoral artery and vein at the level of the inguinal ligaments. A combination of a full laparotomy and groin incision can aid in repair of a vascular injury immediately adjacent to the inguinal ligaments. Another option is to perform a retroperitoneal incision similar to those used for renal transplant. This hockey stick incision comes down through the retroperitoneum and exposes the distal iliac artery and vein. Distal pelvic vascular repair can then be accomplished via the combined incisions. While rare, if a transplant incision is combined with a midline incision, the bridge of skin, subcutaneous tissue, and fascia between the two incisions can become ischemic and infarct.

EXPLORING THE ABDOMEN

As the fascia is divided at the time of laparotomy, it is helpful to look at the peritoneum. If it is bulging, and has a bluish discoloration, that generally means there is a tense hemoperitoneum that will be released as the peritoneum is opened. Blood should be aspirated into a cell saver circuit. The most commonly injured organs after blunt trauma are the liver and spleen. They can be quickly assessed for injury by palpating the right upper quadrant and left upper quadrant. The surgeon can then sweep the small bowel and colon medially, which identifies any large retroperitoneal hemorrhage. If the base of the small bowel mesentery is examined, any mesenteric injury can be identified.

It is imperative to fully mobilize the spleen in order to be able to fully inspect all surfaces. This allows for intelligent decision making as to whether splenectomy or splenorrhaphy will be wise (Figure 1). All of the ligamentous attachments must be divided in order to get the spleen up to the anterior abdominal wall.

Figure 1 Full mobilization of the spleen, allowing for inspection of all surfaces.

A similar strategy is important when inspecting the injured liver. The falciform ligament should be taken down all the way to the level of the vena cava. Both triangular ligaments must be completely incised. This leaves the liver suspended only on the hepatic veins and the portal structures. This allows the surgeon to rotate the liver up out of the deep recesses of the right upper quadrant, which is especially important when evaluating injuries to the posterior right lobe. In addition, one should evaluate whether sternotomy and/or right thoracotomy with takedown of the diaphragm will be needed for added exposure.

Most blunt liver injuries are now treated nonoperatively. Bleeding from higher-grade liver injury is often persistent and of significant volume. In these cases, manual compression by direct pressure or packing will often temporize the bleeding. The Pringle maneuver is often diagnostic, and it achieves temporary hemostasis. The Pringle maneuver involves placing a non-crushing vascular clamp across the hepaticoduodenal ligament, thereby occluding both portal venous and hepatic arterial inflow. Once the clamp is applied, the liver can be reinspected and repair undertaken under better circumstances. If bleeding persists despite portal compression, the surgeon must suspect a retrohepatic inferior vena cava injury, hepatic vein injury, or anomalous hepatic arterial anatomy (10%–25%). The main or right hepatic artery comes off the superior mesenteric artery (SMA) in 10%–20% of cases, as the accessory right hepatic artery comes off the SMA in about 5% of cases. In addition, an anomalous left hepatic artery comes off the left gastric artery in nearly 5% of cases.

While often quite effective, the Pringle maneuver has some drawbacks. The Pringle maneuver produces global ischemia of the liver, potentially worsening hepatic function in the postoperative period. While there is some evidence that the liver can withstand several hours of warm ischemia during elective hepatic resection, the same may not be true for the patient in shock. The Pringle maneuver can also be cumbersome, limiting exposure. In addition, in severe liver injuries there almost always is a component of hepatic venous injury limiting the utility of the Pringle maneuver.

In more severe cases of liver injury, one may also consider the Heaney maneuver, which involves complete vascular isolation of the liver. In this technique, vascular clamps are placed on the cava, above and below the liver. When combined with the Pringle maneuver and/or supraceliac aorta clamping, this should provide for a relatively dry field in order to attempt to definitively repair the liver, and the hepatic venous injury. While this can be effective, it may be difficult to dissect out the suprahepatic vena cava in order to place a clamp, unless the diaphragm has been divided or the pericardium opened via a thoracotomy or sternotomy. The infrahepatic cava must be occluded distal to the junction of the renal vein. If the clamp is placed too low, flow from the renal vein into the cava will perpetuate bleeding and continue to make exposure extremely difficult. Occasionally, complete vascular isolation can be combined with a venous bypass circuit to allow for venous return to the heart (Figure 2).

Figure 2 Hepatic venous exclusion and venovenous bypass.

(Courtesy of ATOM, L. Jacobs, MD, Cine-Med, 2004.)

Perhaps the greatest downside to the use of complete vascular isolation is the rapid and profound decrease in venous return to the heart. In these critically ill patients, this can occasionally produce cardiovascular collapse and/or cardiac arrest. If the technique is to be used, all resuscitation lines must be placed in the upper extremity or the mediastinal veins.

An intermediate solution to injuries with a hepatic vein component is manual compression medial to the injury. This should control all inflow to the injured segment. The injured liver can then be debrided. The hepatic vein can then be identified and ligated when pressure is relaxed. The more central hepatic arterial and portal venous branches can be ligated as well using the same temporary relaxation of hand held pressure (Figure 3).

Figure 3 Liver after right debridement hepatectomy. Note the hemoclips on the cut surface.

The anterior portions of the duodenum and the head of the pancreas are in the abdomen. The posterior portion of the duodenum and the head of the pancreas are in the retroperitoneum. A full Kocher maneuver (incising the lateral peritoneal reflection and completely mobilizing the duodenum and pancreas) is necessary to evaluate both structures for injuries. The body of the pancreas lies within the lesser sac. It is necessary to widely open the lesser sac to examine the posterior stomach, as well as the anterior aspect of the body of the pancreas. This is best accomplished by dividing the gastrocolic omentum.

The gastrocolic omentum can be divided all the way up the greater curvature of the stomach to the level of the gastroesophageal (GE) junction. This requires taking the short gastric vessels adjacent to the spleen. When the gastrocolic omentum has been completely divided, the surgeon has good access to the lesser sac, allowing inspection of the posterior wall of the stomach. It is necessary to carefully inspect the stomach, particularly around the area of the GE junction in order to avoid missing small injuries. If necessary, the intra-abdominal portion of the esophagus can be mobilized on a Penrose drain to aid in exposure. We attempt to triangulate the stomach using sponge sticks to flatten out both the anterior and posterior aspect of the stomach adjacent to the GE junction. This allows for complete inspection and avoids missing a subtle injury high up on the stomach.

The area of the porta contains the hepatic artery, portal vein, and common bile duct. The portal structures are covered with peritoneum. When the peritoneum is opened, the common bile duct is generally the first structure encountered. The hepatic artery can be identified by its palpable pulse and the thrill usually present within it. The portal vein lies posterior to the common bile duct. Each of these can be individually isolated and examined for injury.

It is necessary to completely evaluate the small intestine to avoid missing an injury. Complete evaluation of the bowel involves running the small bowel using a hand over hand technique. The bowel should be flipped with each inspection to be sure both sides have been completely evaluated. Spreading the bowel out allows for inspection of the corresponding mesentery. Once major vascular injuries and solid visceral injuries are controlled, the small bowel should be examined next. We generally re-examine the small bowel before closing to avoid missing an injury.

EXPLORING THE RETROPERITONEUM

The retroperitoneum is generally divided into three zones (Figure 4). Zone one is the central portion of the retroperitoneum containing the aorta, vena cava, and the major branch vessels, as well as the superior mesenteric vein and splenic vein. Any retroperitoneal hematoma in zone one is generally explored.

Figure 4 Retroperitoneal hematoma. Zone one: mandatory exploration. Zone two: explore in all penetrating injury and blunt injury with expanding or pulsatile hematoma. Zone three: explore in penetrating injury only.

(Courtesy of ATOM, L. Jacobs, MD, Cine-Med, 2004.)

Zone two is the lateral perinephric area above the pelvis. Zone two houses the kidney, ureters, and renal artery and vein. In general, zone two hematomas are explored after all penetrating injuries. Zone two hematomas in blunt trauma can be managed expectantly unless there is a known injury requiring operation such as a ruptured ureter or if the hematomas are expanding or pulsatile.

Zone three houses all pelvic organs. This includes the common and external iliac artery as well as the hypogastric artery. The lower portion of the sigmoid colon is in zone three as well as the distal ureters. Zone three hematomas are explored in penetrating injury only. In general, surgical exploration of a pelvic retroperitoneal hematoma after blunt trauma is discouraged. The hypogastric artery is short and branches into a large number of small vessels. Unroofing the pelvic hematoma risks loss of tamponade. Other techniques such as external compression or angiographic embolization generally are a wiser course to treat bleeding in zone three following blunt trauma.

There are several surgical maneuvers to allow access to the retroperitoneum. These involve medial visceral rotation on either the left or right side. The viscera can be rotated medially by incising the white line of Toldt. A small incision can be made in the white line and then the white line may be divided using the cautery or a pair of scissors over a finger inserted into the retroperitoneum to protect the deeper structures. The incision should be brought around the hepatic or splenic flexure of the colon. We generally hold the colon up with a hand and then sweep the retroperitoneal contents downward either with a laparotomy sponge, sponge stick, or hand. This protects the mesentery of the colon and allows for raid access to the retroperitoneum.

The original left medial visceral rotation maneuver was described by Creech and DeBakey in 1956. It involves taking down the white line of Toldt of the left colon all the way to the splenic flexure and sweeping the spleen, tail of the pancreas, and stomach medially to the hip or the aorta, celiac axis, and superior mesenteric artery.

The so-called “Mattox maneuver” involves medial visceral rotation on the left side (Figure 5). The left colon is mobilized as described previously. This brings the surgeon down into the retroperitoneum. At the base of the mesentery, the surgeon will then encounter the aorta. The aorta can be followed up on its lateral margin at 3:00 quickly as there are no branches until one encounters the left renal artery and vein.

Figure 5 Aortic exposure: Mattox maneuver.

(Courtesy of ATOM, L. Jacobs, MD, Cine-Med, 2004.)

The Mattox maneuver involves mobilizing the kidney with the remainder of the viscera (see Figure 5). We generally prefer to leave the kidney in situ and mobilize it later if necessary. The splenic flexure must be completely mobilized into the lesser sac. The spleen and tail of pancreas can be mobilized which exposes the aorta up to the level of the hiatus. This is our preferred method of achieving aortic control at the level of the diaphragm. Often, the diaphragmatic crura come down lower than the surgeon expects. It may be necessary to divide the diaphragmatic fibers to control the supraceliac aorta.

We strongly believe that supraceliac aorta control must be accomplished by completely encircling the aorta. Blindly placing a clamp either from the anterior or lateral aspect of the aorta almost certainly results in the clamp slipping off. We mobilize the esophagus off the aorta anteriorly and insert a finger from the left side around to the right. It is then possible to bluntly dissect the fibers holding the aorta down to the spine. With a finger completely encircling the aorta, it is then possible to gently place the cross-clamp around the aorta and clamp the aorta. The left-sided medial rotation also provides good access to the left renal artery and vein. If exploring a patient for a penetrating injury to the pelvis, left-sided medial visceral rotation allows aortic control above the bifurcation. This is also a reasonable exposure to control the superior mesenteric artery at its origin. If one must expose a longer length of the supermesenteric artery, we generally combine a lesser sac exposure with the left-sided medial rotation.

Supraceliac aortic control can also be obtained via a lesser sac approach (Figure 6). The lesser sac is opened widely by dividing the gastrohepatic ligament or lesser omentum, and then dissects down onto the superior aspect of the pancreas. The pancreas is mobilized and the esophagus and stomach bluntly dissected. This will bring the surgeon down onto the aorta. Again the diaphragmatic crura may have to be divided in order to gain good access to the aorta. With the aorta exposed, a cross-clamp can be applied.

Figure 6 Proximal aortic control.

We prefer the left-sided visceral rotation for several reasons. There are a number of esophageal branches coming off of the anterior aorta. The lesser sac approach risks injuring these as the dissection is somewhat blind. In addition, we have found it more difficult to completely encircle the aorta through the lesser sac. Using this approach, the clamp is generally applied somewhat blindly down onto the aorta and risks slipping off.

A right-sided medial visceral rotation, the so called Cattel-Braasch maneuver, exposes the right-sided retroperitoneal structures (Figure 7). The right colon is mobilized in a technique exactly similar to what was described on the left side. Similarly, the dissection should be brought around the hepatic flexure and into the lesser sac. The duodenum and head of pancreas should be completely mobilized via a Kocher maneuver. This brings the surgeon down onto the inferior vena cava (IVC). The IVC can be controlled and traced up to the confluence of the left and right renal vein. There is a short suprarenal segment of the cava and then the vena cava becomes retrohepatic in location.

Figure 7 Cattel-Braasch maneuver or right-sided medial visceral rotation. Kocher maneuver. Mobilize the right colon along the equivalent of the white line of Toldt.

(Courtesy of ATOM, L. Jacobs, MD, Cine-Med, 2004.)

The Cattel-Braasch maneuver is ideal exposure for the vena cava and the right kidney with its vasculature. When combined with the Kocher maneuver, the duodenum and head of the pancreas can be completely explored. In addition, the right-sided pelvic vasculature can be exposed via this maneuver. The Cattel-Braasch maneuver gives better access to the pelvic vasculature than does a left-sided approach. The mesentery of the left colon can limit exposure with the Mattox maneuver. As there is no mesentery to obscure the view, the Cattel-Braasch maneuver gives wider exposure.

The mesentery of the small bowel can also be incised and lifted up off the aorta and vena cava in a maneuver similar to that used by vascular surgeons during aortic surgery. When combined with the Cattel-Braasch maneuver, it gives the widest exposure of the retroperitoneal vasculature from the aorta and cava down into the pelvis.

Retroperitoneal arterial injuries are handled using the standard technique. Proximal and distal control must be obtained, and a decision made about direct repair, bypass grafting, or shunting. Injuries to the external iliac artery at the junction with the common iliac and hypogastric arteries can sometimes be managed by using the proximal hypogastric artery as a conduit. The hypogastric artery is mobilized out of the pelvis and ligated. An end-to-end anastomosis then can be performed between the hypogastric and the external iliac artery.

Retroperitoneal venous injuries can be among the most difficult to treat, particularly if located at the confluence of the vena cava and external iliac vein or in the juxtarenal IVC. Many techniques have been described for temporary vascular control including the use of sponge sticks, vascular clamps, and direct finger pressure to control bleeding. We have preferred the use of intestinal Allis clamps (Figures 8, 9, and 10). The vascular injury is first controlled with digital pressure and an Allis clamp is applied at the apex of the injury vessel. The clamps are then sequentially stacked for the length of the injury. The clamps can then be lifted. This allows for restoration of venous return to the heart. A decision can be made about ligation or repair. Vascular ligation can be accomplished by running a suture onto the clamp.

Figure 8 Temporary venous control is obtained with digital pressure. Intestinal Allis clamps are stacked and the vein repaired by running a suture under them.

(From Henry SM, Duncan AO, Scalea TM: Intestinal allis clamps as temporary vascular control for major retroperitoneal venous injury. J Trauma 51:170–172, 2001.)

Figure 9 Temporary venous control is obtained with digital pressure. Intestinal Allis clamps are stacked and the vein repaired by running a suture under them.

(From Henry SM, Duncan AO, Scalea TM: Intestinal allis clamps as temporary vascular control for major retroperitoneal venous injury. J Trauma 51:170–172, 2001.)

Figure 10 Temporary venous control is obtained with digital pressure. Intestinal Allis clamps are stacked and the vein repaired by running a suture under them.

(From Henry SM, Duncan AO, Scalea TM: Intestinal allis clamps as temporary vascular control for major retroperitoneal venous injury. J Trauma 51:170–172, 2001.)

Exposure of the superior mesenteric vein (SMV) within the lesser sac can be extraordinarily problematic. The SMV courses behind the pancreas and joins the splenic vein to become the short portal vein. SMV injuries often present with torrential blood loss.

Occasionally, the pancreas can be mobilized up off the SMV and the injury isolated. There are many small branches off the SMV that must be individually ligated. If these are torn, the bleeding only becomes more difficult to control. Occasionally, identification of the location of an SMV injury is impossible, particularly if it is directly behind the pancreas or adjacent to the confluence of the splenic vein. In those cases, we generally divide the pancreas at the level of the SMV. This is done by gently inserting a finger behind the pancreas and mobilizing the pancreas off the SMV. A GIA stapler can be guided using a Penrose drain and the pancreas divided. This gives excellent exposure to the SMV proper and its junction with the splenic and portal veins. Virtually any injury can be identified and repaired. The distal pancreatic remnant can be resected later or inserted into a loop of jejunum depending on the surgeon’s preference.

Exposing the pelvic vasculature is a particular challenge (Figure 11). It is essential to identify the aorta proximally and be sure of its identification. Young patients in profound hemorrhagic shock can become intensely vasospastic. The common iliac artery may be mistaken for the external iliac artery or even the aorta. With the aorta and cava clearly identified and controlled, the surgeon must sequentially expose the common, external and hypogastric arteries. All of these should be individually controlled. The ureter runs through the retroperitoneum and into the pelvis at the confluence of the iliac arteries. This is a constant anatomic relationship. The ureter should be identified and protected during any pelvic exposure.

Figure 11 Pelvic vascular anatomy. Note the ureter coursing over the iliac bifurcation.

The pelvic veins are very large and fragile. They generally course behind the arteries. Iatrogenic injury to these can be devastating. Even if patients are in deep shock, the surgeon must be deliberate enough to avoid adding to the problem. Temporary venous control can be obtained by packing and the veins individually identified and looped.

FUTURE CHALLENGES

Operative trauma cases are declining. Nonoperative management has become the norm for the vast majority of blunt solid visceral injuries. Even operative cases following penetrating injury are fewer in number and are concentrated in a few centers. How then will we train the surgeons of the future to understand these complex anatomic relationships and operative techniques?

The average general surgeon spends little time in the retroperitoneum, the lesser sac, or near the GE junction. Conditions that were once treated operatively are now treated nonoperatively because of better pharmacological agents and minimally invasive endoscopic techniques. General surgical procedures are increasingly being performed via a laparoscope. Finally, the average general surgery resident finishes his or her residency with fewer than 700 operative cases, a number far fewer than residents performed in the past. While community surgeons may opt to transfer moderately injured patients to a higher level of care, it simply is not feasible if the patient is hemodynamically unstable.

Clearly we must devise a different training scheme so that surgeons of the future are prepared to deal with operative trauma. A number of solutions have been proposed. Simulators offer some advantages, although the technology is not yet robust enough to replace hands-on operating. Cadaver courses can be helpful, allowing the surgeon to understand anatomic relationships. Unfortunately, cadaveric tissues handle much differently than in a hemorrhaging trauma patient. The cadaver course is a static experience; it has none of the urgency of operating on a real-life trauma surgery.

We have embraced the Advanced Trauma Operative Management course (ATOM). This was developed in Hartford, Connecticut, by Dr. Lentworth Jacob. The students must repair injuries in a 50-kg swine. These injuries encompass all organ systems in the abdomen and some in the chest. For instance, the student must successfully repair the bladder, ureter, and the pancreas as well as more common liver, spleen, and bowel injuries. The final two scenarios involve a large injury to the inferior vena cava and a right ventricular stab wound.

The course is conducted in a full operating room atmosphere with real instruments, drapes, and scrub tech. It does not take long to forget that this is an animal exercise and fall into the rhythm of repairing injury. While other options will almost certainly occur in the future, we believe that at present the ATOM course is the best option available.

SUMMARY

A complete knowledge of anatomic relationship in the abdomen and retroperitoneum is absolutely essential to being able to rapidly and effectively control hemorrhage and repair injuries. It is critical that the general surgeon understand these and be comfortable with them before being called to see a patient with a serious torso injury. Operative trauma case volume is shrinking. Thus, surgical residents are exposed to fewer and fewer trauma operations. Other training paradigms exist, and we strongly urge that these be incorporated into residency training and special courses at postresidency to be sure that surgeons of tomorrow are adequately prepared to meet the challenge of operative trauma surgery.