Laparotomy and

Abdominal Trauma

LAPAROTOMY
Def. an incision made on abdominal wall to explore
visceral organs.
Types
Based on location
Midline
Paramidline
Subcostal
Supra/infaumblical
Based on purpose
Diagnostic vs therapeutic

It also allows confirmation or correction of the

preoperative diagnosis in a patient presenting with an
acute abdomen.

LAPAROTOMY
Avoid laparotomy in pancreatitis.
Be thoroughly familiar with the midline incision,
which is:

simple,
causes relatively little
bleeding and
performed rapidly,
Closed quickly and
extended easily
See text for details of the procedure

LAPAROTOMY
Make an incision in the upper abdomen to expose:

The gallbladder
Stomach
Duodenum
Spleen
Liver.

Use a lower abdominal incision for patients with:

Intestinal obstruction
Pelvic problems.

Make an incision from the upper to lower abdomen

to:
Evaluate all abdominal organs in a trauma laparotomy.

LAPAROTOMY
Abdominal findings

Possible cause

Greenish fluid and gas

Per foration of stomach or duodenum

Free bowel contents and gas in

peritoneum

Bowel per foration

Free blood in peritoneum: with trauma

Injury to liver, spleen or mesentery

Free blood in peritoneum: female, no

history of trauma

Ruptured ectopic pregnancy

Purulent exudate

Appendicitis, diver ticulitis or

perforation of the bowel

Distended loop of bowel

Intestinal obstruction or paralytic ileus

ABDOMINAL TRAUMA
When a patient presents with abdominal injuries,
give priority to the primary survey:
Establish a clear airway.
Assure ventilation.
Arrest external bleeding.
Set up an intravenous infusion of normal saline or RL.
Insert a nasogastric tube and begin suction and
monitor output.
Send a blood sample for haemoglobin
measurement and type and crossmatch.

ABDOMINAL TRAUMA
Insert a urinary catheter, examine the urine for blood
and monitor the urine output.
Perform the secondary survey: a complete physical
examination to evaluate the abdomen and to establish
the extent of other injury.
Examine the abdomen for bowel sounds,
tenderness, rigidity and contusions or open wounds.
Administer small doses of intravenous analgesics,
prophylactic antibiotics and tetanus prophylaxis

ABDOMINAL TRAUMA
If the diagnosis of intra-abdominal bleeding is
uncertain, proceed with diagnostic peritoneal
lavage.
Laparotomy is indicated when abdominal trauma
is associated with
obvious rebound, frank blood on peritoneal lavage
hypotension and a positive peritoneal lavage.

Serial physical examination, ultrasound and Xrays are helpful in the equivocal case.

ABDOMINAL TRAUMA
X-ray the chest, abdomen, pelvis and any other
injured parts of the body if the patient is stable.
Lateral decubitusabdominal X-ray : If you
suspect a ruptured viscus,
free intraperitoneal air is seen .

Diagnostic peritoneal lavage

After the primary survey, resuscitation and
secondary survey have been completed, the
findings indicating intra-abdominal bleeding or
lacerated viscera may not be adequate to confirm
diagnosis.
Serial physical examination can be supplemented
with diagnostic peritoneal lavage (DPL) to
make a decision on whether trauma laparotomy
should be performed.

Penetrating injuries
Penetrating injuries follow gunshot wounds and
wounds induced by sharp objects such as knives or
spears
Laparotomy with intra-abdominal exploration is
indicated when the abdomen has been penetrated,
regardless of the physical findings
Signs of hypovolaemia or of peritoneal irritation
may be minimal immediately following a
penetrating injury involving the abdominal viscera.

Blunt injuries
Blunt injuries result from a direct force to the abdomen
without an associated open wound; they most commonly
follow road traffic accidents or assaults
Following blunt injury, exploratory laparotomy is indicated in
the presence of:

Abdominal pain and rigidity

Free abdominal air, seen on a plain X-ray (lateral decubitus or upright chest)

Following blunt abdominal trauma, signs that may indicate

intra-abdominal bleeding include:

Referred shoulder pain

Hypotension

Oliguria associated with suprapubic pain suggests bladder

rupture.

Injuries to the diaphragm

Penetrating trauma to the upper abdomen and
lower chest can result in small perforations to the
diaphragm which can be closed with simple or
mattress 2/0 sutures.
Blunt trauma can result in a large rent in the left
diaphragm (the liver protects the diaphragm);
Diagnostic features:
the presence of viscera in the chest, by auscultation
chest X-ray,.

RUPTURED SPLEEN
In tropical countries, enlargement of the
spleen due to malaria or visceral
leishmaniasis is common.
The affected spleen is liable to injury or
rupture as a result of trivial trauma.
Delayed rupture can occur up to three weeks
after the injury

RUPTURED SPLEEN
Diagnostic features of a ruptured spleen include:
History of trauma with pain in the left upper
abdomen (often referred to the shoulder)
Nausea and vomiting
Signs of hypovolaemia
Abdominal tenderness and rigidity and a diffuse
palpable mass
Chest X-ray showing left lower rib fractures and a
shadow in the upper left quadrant displacing the
gastric air bubble medially.

RUPTURED SPLEEN
Consider conservative management, particularly in children, if
the patient is haemodynamically stable and
you are able to monitor them closely with

bedrest,
intravenous fluids,
analgesics and
nasogastric suction.

If the patients condition deteriorates, perform a splenectomy.

Perform a laparotomy if you suspect a ruptured spleen and the
patient is hypovolaemic.
Repair or remove the spleen.

See text for details of the procedure.

SMALL INTESTINE
In nonviable small intestine:

Bowel will be black or deep blue without peristalsis

Mesenteric veins may appear thrombosed
Arterial pulsation may be absent
The serosa will have lost its shiny appearance.

Make the decision to resect a part of the small intestine

after you have inspected the entire gut.
If there is a perforation in the intestine, repair the wound
with
a purse string invaginating suture or
transverse two layer invaginating closure.

SMALL INTESTINE
When several wounds are close together, or if the
gut is ischaemic, resect the damaged loop and
make an end-to-end anastomosis.
Reasons for resection include:
Traumatic perforation
Gangrene
Tear of the mesentery with an ischaemic loop of
bowel.

See text for details of the procedure

COLON
Treatment of colon injuries is dependent upon the location:
Transverse colon injuries with exteriorization of the site of injury
as a colostomy
Descending colon injuries with exteriorization of the injury site
through a colostomy; drain the paracolic gutter and the pelvis
Ascending colon injuries with resection of the entire right colon;
make an ileostomy and transverse colostomy do not attempt to
repair the injury directly
An alternative in the treatment of colonic injury or perforation is
to defunction the lesion by creating a colostomy or an ileostomy
upstream from the lesion, and placing a large latex drain near
that lesion
Patients with colonic trauma require antibiotics.

Selecting the type of colostomy

Loop colostomy: is the easiest (Figure 6.48A)
Double barrel colostomy : with the two free ends, If you
have to resect a piece of colon, (Figures 6.48B)
End colostomy : (Figure 6.48C) when the distal stump is
too short to exteriorize after the gangrenous or injured
loop has been resected; this is particularly useful in the
sigmoid colon and proximal rectum
End ileostomy : after right colon resection when
anastomosis is not performed.

Techniques
Determine the site for the colostomy at surgery.
Make an incision separate from the main wound in the quadrant of
the abdomen nearest to the loop to be exteriorized.
Use the greater omentum as a guide to locate the transverse colon.

Loop colostomy
Bring out the loop of colon without kinking or
twisting it (Figure 6.49).
Make an opening in the mesocolon just large enough
to admit a piece of glass rod.
Push the rod halfway through the opening and attach its
ends to the ends of a piece of polythene tubing (Figure
6.50, 6.51).
As an alternative, insert a catheter through the mesocolon
and join the ends with sutures of 2/0 thread.

Close the wound around the exteriorized loop of gut.

Loop colostomy
The opening in the colon may be made
immediately, provided that extreme care is taken
to prevent mechanical contamination of the
wound.
Alternatively defer making the opening for 8 to 24
hours when there is less risk of wound contamination.
Make a cruciate incision in the apex of the loop with a
knife or diathermy (Figure 6.52).
Pack petroleum gauze and gauze swabs around the
colostomy.

Double-barrelled colostomy
Resect the gangrenous loop of colon as described
for resection of the small intestine (see page 6
10).
Mobilize the remaining colon so that the limbs to be
used for the colostomy lie without tension.

Bring the two clamped ends of bowel out through

a stab wound or gridiron incision and keep them
clamped until the laparotomy incision has been
closed (Figure 6.53).

Double-barrelled
colostomy
Then remove the clamps and fix the full thickness of the gut
edge to the margin of the stab wound.
Approximate mucosa to skin edge with interrupted 2/0
absorbable suture (Figures 6.54, 6.55).
If a bag is not available, cover the colostomy with generous
padding.

End colostomy
Bring out the proximal end of the colon through a
gridiron incision (Figure 6.56).
Close the distal stump of colon without further attempt
at mobilization using two layers of stitches:
an inner, continuous stitch of 2/0 absorbable suture
an outer seromuscular layer of interrupted 2/0 polyglycolic or
non-absorbable suture (Figures 6.57 to 6.60).

Attach a 56 long non-absorbable suture to the distal

stump so that it can be found more easily at the time of
re-anastomosis

End colostomy
Drop this end of bowel back into the pelvis. Finally,
stitch the proximal end to the margin of the stab
wound.
Colostomy bags greatly ease the long-term care of the
stoma

RETROPERITONEUM
Haematoma
A retroperitoneal haematoma may indicate trauma to a major
vessel.
If the patient is stable it should not be opened or disturbed.
However, to save life,control and repair of a major vessel should
be attempted at the district hospital.

Kidney
Do not expose the kidney unless there is life-threatening bleeding.
An expanding or pulsating haematoma is evidence of such
bleeding.
Stop the bleeding at the site of the tear with stitches.
Consider the need for specialized surgery.

RETROPERITONEUM
Duodenum
Blunt trauma to the upper abdomen can result in retroperitoneal
rupture of the duodenum.
Air in the retroperitoneum is diagnostic.
The retroperitoneum is opened with blunt dissection and the
duodenal perforation closed transversely in two layers.
This repair should be protected with a nasogastric tube and, after
thorough cleansing of the retroperitoneum, a drain should be
placed near but not on the duodenal repair.

RETROPERITONEUM
Pancreas
Confirm an injury to the pancreas by opening the
lesser sac through the gastrocolic (greater) omentum.
The only safe procedure at the district hospital is to
put a drain at the site of injury.
The drain should traverse the lesser sac and come
out in the flank.
Specialized surgery may be necessary.
Make arrangements for referral when the patient is
stable.

RUPTURE OF THE BLADDER

Extraperitoneal rupture
Extraperitoneal rupture is most commonly associated
with fracture of the pelvis, resulting in extravasation
of urine (Figure 6.60).
The patient may pass only small drops of blood when
attempting to pass urine.
A significant feature is swollen soft tissues of the
groin extending to the scrotum, due to extravasated
urine.

RUPTURE OF THE
BLADDER
Intraperitoneal rupture
Intraperitoneal rupture is often the result of a
direct blow to the bladder or
a sudden deceleration of the patient when the bladder is
distended, for example in a road traffic accident.

Presentation
pain in the lower abdomen,
tenderness and guarding
failure to pass urine.

Rx of RUPTURE BLADDER
Extraperitoneal rupture,
construct a suprapubic cystostomy;
if the rupture is large, also place a latex drain

Intraperitoneal rupture,
close the rupture and drain the bladder with a large urethral
catheter or a suprapubic drain;
if the rupture is large, also place a latex drain

Evaluate your patient carefully to ensure that other injuries

are not missed.
A ruptured bladder is an indication for a full trauma
laparotomy to rule out other abdominal injuries.
See text for details of the procedure.

Aftercare
Administer antibiotics for the first five days and give
adequate fluids to maintain the urinary output.
The drain can be removed when urine or blood drainage has
ceased.

For extraperitoneal rupture,

clamp the catheter for increasing periods of time, beginning on
about the fifth day.
The patient with a suprapubic catheter may start passing
urine during this period; if so, remove the catheter.

In cases of intraperitoneal rupture,

remove the urethral catheter after about two days of
intermittent clamping, provided that no problems result.